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Beyond the EHR—Creating an Integrated Population Health Management Strategy

In recent years, the industry has focused a lot of attention on using the EHR as the center of today’s healthcare delivery. While EHRs add value at the point of care, enabling caregivers within a care setting to chart and manage patient information and to administer organizational operation, we can’t stop there. Extending the applicability of the EHR through other population health management solutions will help us look beyond the point of care to get to the real goal—improving how we manage patients—by focusing on the between-care activities and settings to significantly impact patient outcomes. This approach will help us bridge the gaps and pull the maximum value from the EHR in the larger picture of longitudinal care.

An EHR is a good record keeper, documenting the care provided to a patient within the four walls of an organization. But as soon as you step out of the confined domain of the physician, medical practice, hospital, or health system to manage the health of a population, you’ll need to communicate with service providers across the care continuum who are also involved in the patient’s care. These providers may have different types of software and administrative systems, and some may not even use EHRs. To be effective, you’ll need a tool that does a different type of work—one that enables collaboration and the documentation and tracking of not only what is happening now, but what needs to happen in the future to support a patient’s health.

Successful value-based care models require providers across the community—including an entire range of social services in addition to medical and behavioral health providers—to participate as an interdisciplinary team to address the entirety of each patient’s needs. The care team contributes to a body of knowledge contained in universal care plan, and collaborates via common tools and orchestrated workflow to optimize care delivery. These tasks cannot be accomplished by EHRs alone—true population health management requires a tool that can not only document facts and actions as they occur, but provide a platform for ongoing collaboration and proactive care management that will prevent encounters and reduce emergency department usage and hospitalizations.

The best population health management tools can coexist with EHRs, aggregating health information and seamlessly moving it back and forth as needed to support workflow. A high degree of interoperability is necessary to integrate information from disparate providers, reducing friction between systems and providing a comprehensive view of both the patient and the entire population. Remember that it’s not a competition between EHRs and population health management solutions—the goal is to extend the value of the EHR through another population health management solution that enables providers to be proactive and predictive, bridging the gaps and connecting disparate providers so they can collaborate to provide better care for the patient.

How providers approach PHM matters. A patchwork of existing technologies or a tool that simply documents care as it happens will not enable teams to treat the “whole person” rather than a condition. You’ll need to proactively identify the patients to focus on, determine what care to provide across medical, behavioral and social patient needs, and orchestrate the care across various settings. And, you’ll need to integrate disparate information from across the community so you can analyze and tune your care model, identify additional patients, evaluate how the care coordination programs are performing, and improve outcomes.  An ideal population health management solution combines care coordination with robust analytics and smooth interoperability to provide the insights to make patient care more effective and efficient while reducing risk.

Going beyond the EHR to create an integrated population health management strategy will result in improved clinical outcomes, more effective care teams, better financial results, and ultimately healthier populations.

Want to learn more? Check out our white paper.

At-Risk Populations—Understanding Who We Serve

Delivering effective care to high-risk populations is challenging. As the costliest patients to treat, at-risk patients—typically those with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions—strain the entire healthcare system, requiring treatment from many different providers and a large investment of time and resources. If patients are unemployed, uninsured, or uneducated, the impact of their conditions is magnified. These forces result in an epidemic of poor health in our disadvantaged communities.

A strained healthcare system does not deliver the highest quality care, and in some geographies, struggles to even adequately serve the people who need it most. The effects of this are seen in the health statistics in cities across the nation—for example, in 15 zip codes in North Philadelphia, life expectancy of children is 20 years shorter compared to their counterparts in wealthier zip codes.

While underlying health conditions are significant factors for these vulnerable patients, there are many other things that contribute to these statistics. Complex and overlapping social, economic, physical environment, and societal issues such as alcohol and drug use, income and job security, housing conditions, transportation challenges, and much more can interfere with treatment plans and create a significant negative effect on health.

With so many people impacted by these systemic barriers to wellness, we need to make more of an effort to fix the problem. Many organizations are trying to do their part through a variety of programs, such as combatting childhood obesity through better eating choices and fitness programs in schools—but despite the good intentions we aren’t seeing enough results that translate into measurable or significant improvement of health outcomes across the population. Getting to the root causes of these issues will help us turn the tide so that these vulnerable populations are not just receiving healthcare, but are on a path to deal with their issues so that they can recover and remain healthy.

It’s important to understand that the healthcare system does not operate in isolation. A doctor may prescribe the highest quality evidence-based medicine available, but after people are treated, they leave the medical facility and go back out into an environment that may prevent them from fulfilling their treatment plan. The specific challenges vary, including everything from a lack of access to healthy foods, to the inability to take time off work for appointments, to pill rationing because a patient can’t pay for a prescription or get to the pharmacy for a refill. But the bottom line is that if we don’t understand and address what our patients are facing in their daily lives, they won’t get the most out of their healthcare.

Another hurdle is that the accessibility of healthcare and even the cultures of these populations sometimes work against the system. For example, the emergency department (ED) is the most expensive form of healthcare—but is also the one place where service will not be denied if you don’t have the right kind of insurance or aren’t on the current roster of patients. If a population tends to go to the ED no matter what the issue is, the cost will always be excessive, driving up the cost of treatment and taking resources that could be used to do other valuable work. So, to solve healthcare, we have to not only treat, but change the culture by impacting lives and how populations think. That’s where community partnerships come in—engaging with community organizations who can influence behavior and act as agents of the healthcare system may be able to affect the success of healthcare delivery.

To solve healthcare, we need to think more broadly, understanding what patients are facing and what their lives are like so we can treat the whole person rather than just their medical symptoms. Enlisting patients as partners in care rather than expecting them to adhere to a prescribed path will provide insight into the people and their circumstances, only some of which are controllable. Developing relationships with the right partners to address those factors that stand in the way of good outcomes and coordinating among these partners will help ensure that these at-risk patients receive the right treatment at the right time to improve their health.

Optimizing healthcare delivery through population health management—in essence solving the problems of delivering healthcare to these at-risk patients—is a first step in trying to eliminate the problem as a whole.

 

Developing Evidence-Based Care for Social Determinants

While we know that outcomes can be materially impacted by non-clinical factors like social determinants of health, the industry’s strong focus on medical factors have long pushed social determinants to the backseat. It is clear that population health management is most effective when it is comprehensive and community-based, extending beyond the walls of a single care establishment to encompass all relevant services, including medical, behavioral, and socioeconomic factors. But what will truly make a difference to patients is being able to prescribe how to address the social determinants in a normalized manner that will consistently improve patient outcomes.

As an organization transitions to value-based care and makes decisions on the interventions and level of intensity needed to address a patient’s social determinants of care, the ability to measure results—and draw insights from those results that can be used to improve outcomes—is critical. What will truly put social determinants onto the map is developing evidence-based care in the social realm—with the same rigor of common terminology, infrastructure to manage and move information, and prescribed workflow based on an accepted body of knowledge that supports demonstrable and repeatable success.

Elevating the importance social determinants of health is difficult. The environment is very complex, with many types of disparate organizations that need to be coordinated to improve the physical health of patients. Common tools that capture descriptions of social factors and the protocols and interventions that address them do not exist, making it difficult to find a common language to develop a shared body of knowledge. Without a clear path to payment, there is little incentive for organizations to push forward. And because social determinants vary from region to region, the best practices of one organization may not transfer to others.

So is it a big enough factor to be important? The answer is a resounding yes. And it matters even more in today’s healthcare environment as organizations across the nation shift to value-based care.

Value-based care involves connecting a variety of different medical encounters in a protocol that should successfully treat a condition. But what it doesn’t take into account is that every time a patient leaves the controlled environment of a medical provider, they enter a social context that has to be dealt with. It’s within this social context that social determinants of health come into play. We need to be able to bridge the gap between the medical and social realms to get patients to where they need to be.

To get there, we need a care model that goes beyond the reactive management of care—simply healing people who are sick—to a proactive model that helps prevent people from getting sick. This approach requires providers to understand the patient outside the medical office—and be able to address their social issues using partnerships within the community that help keep the patient on track. By creating a community-based care plan that connects medical, behavioral, and social service providers, we can coordinate what we are going to do for a patient in the future—plus give everyone a say in how we do it together so we can harmonize our efforts.

Drawing information from the interdisciplinary team, we’ll not only have insight into what determines health, the factors that are involved, and what to do about it, but develop interventions that can be applied across the interdisciplinary care team to the broader population. Over time, providers can normalize what actions are being taken, measure results, validate care steps, and build models that determine efficacy. This will lead to an empirical set of evidence-based activities for social determinants of care that can be prescribed at the point of care. The end result will be more efficient and effective collaboration with a measurable reduction in admissions and emergency department usage.

The shift to value-based care and population health management is an opportunity for all of us together to raise the awareness of social determinants of health, and promote the care planning, coordinated care teams, and common tools that will enable providers to treat the whole person instead just medical conditions. Laying a foundation that is empirically based will pave the way to make true progress toward evidence-based care for social determinants of health.

Addressing the Healthcare Crisis in Philadelphia’s Poorest Neighborhoods (Part 1)

How the Digital Health Initiative of Philadelphia Began

Named the “poorest big city in America,” Philadelphia has plenty of challenges, and one of the most damaging is the impact on our poor communities in the area of healthcare. Philadelphia County has more than 500,000 Medicaid enrollees, and care for these vulnerable populations strains the entire healthcare system, diverting resources from other areas of investment that would otherwise benefit our region. Poverty costs us jobs, new business development, tourism, and other growth opportunities.

Read more “Addressing the Healthcare Crisis in Philadelphia’s Poorest Neighborhoods (Part 1)” >

Value-Based Care—The Future of Health Care: Part 2 of 2

This blog is part 2 of a discussion of value-based care—the new paradigm in which care is no longer delivered only by doctors and nurses, but by an entire community of providers that treat the “whole” patient rather than just treating the disease. The focus is on treating the entirety of a patient’s needs to bring about better health outcomes—which means that communication and care plans no long reside solely within a doctor’s office. To achieve this objective, the industry is migrating to a de facto set of standards that it is believed will take us down the right path. Read more “Value-Based Care—The Future of Health Care: Part 2 of 2” >

Value-Based Care—The Future of Health Care: Part 1 of 2

Value-based care creates a new paradigm—one in which care is no longer delivered only by doctors and nurses, but by an entire community of providers that treat the “whole” patient rather than just treating the disease. Communication and care plans can no longer live inside the four walls of a doctor’s office, but must integrate information from the community to fully address the needs of the patient and of the population. Further, those members of a patient’s care team must work together to deliver an effective and coordinated treatment experience. This blog—part 1 of a 2-part series—introduces the idea of value-based care, and discusses how integrating care coordination with robust analytics into a single platform provides the big picture of patient care, enabling efficient, collaborative care for diverse teams to treat complex populations. Part 1 is an introduction, intended for those starting to explore the idea of value-based care. Stay tuned for Part 2, which will be a deeper dive into some of the key issues facing the industry.

Read more “Value-Based Care—The Future of Health Care: Part 1 of 2” >

Care Coordination and Analytics Together

Remember the days when you had to use two different platforms for phone calls and for calendaring and task management? In today’s iPhone/Android laden world, such a separation seems heretical. Yet in healthcare’s hot new niche of population health management, we see that same heresy in the artificial, and suboptimal divide between care coordination/management software and analytic software. Read more “Care Coordination and Analytics Together” >

Care Coordination Automation: Tracking Success, Part 4

Collaborative Care technologyOur previous posts have discussed the details of managing care team assignment and composition that’s customized for the whole patient as well as managing patient and population care systems. Now, we move onto the fourth and final discussion topic in this series for supporting a care coordination program using technology: measurement & reporting.

The last step in any effective process is to monitor progress, analyze results and make adjustments accordingly. But in order to track program success, you must start by implementing a measurement strategy that’s unified. Read more “Care Coordination Automation: Tracking Success, Part 4” >

Care Coordination Automation: Management Cycles, Part III

whole patient careIn our previous posts, we’ve discussed whole patient care and the use of technology to build coordinated care teams. Now it’s time to delve deeper and address how to leverage technological tools when treating and managing patients in a collaborative care setting.

Developing the right care plan for each patient requires the dedication of a multidisciplinary team, innovative technologies and an intimate connection with patients. Whole patient care means assembling a comprehensive network of healthcare providers – behaviorists, administrators, social workers, general physicians, payer care managers and specialists – and then assigning patients to the teams best suited to treat their individual conditions. Read more “Care Coordination Automation: Management Cycles, Part III” >

Care Coordination Automation: Use Your Technology, Part II

care coordination technology solutionsWe’ve been talking about using health information technology to leverage both algorithmic automation and expert-human execution for your coordinated care and population health management program. Our last post introduced the first step to effective and efficient collaborative care: Population Determination & Outreach. After defining the patient population in need of care coordination and successfully reaching out to this group, it’s time for the second stage: Care Team Assignment & CompositionRead more “Care Coordination Automation: Use Your Technology, Part II” >

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