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.