Taking Steps Toward Technology-Supported Population Health Management

By Richard A. Royer, Chief Executive Officer, Primaris

Right now, there are multiple forces driving physicians toward population health management. For one thing, chronic disease — both the prevalence of chronic illness and the cost of treating it — is giving clinicians reasons to divert attention away from episodic care and focus more on managing the ongoing health of patients. In addition, evolving payment models are beginning to reward healthcare providers for quality and efficiency — and that is financially motivating doctors to zero in on population health.

This shift towards prevention-heavy care means physicians need to understand how to access and use data to assess health risks of groups and individuals. It also means physicians need to be able to leverage technology to create proactive care programs for different patient groups — for example, healthy patients, at-risk persons, and those with chronic conditions. The first step to all of this is recognizing technology gives doctors the ability to manage the health of their entire patient population in ways they could not achieve manually.

Managing population health involves creating various sub-populations within a larger patient base, then matching patients into efficient care programs that meet their clinical needs. While it takes a big push initially to implement population health strategies and ongoing effort to manage the health of patients, the prevention, disease management, and cost wins pay off for patients and for providers. The following steps show a basic population health outline doctors can follow to improve care quality, patient experiences, and efficiency.

1. Use an EHR system to collect patient data: Using an EHR system well is essential for population health management. EHRs are the best way to store and quickly retrieve valuable patient data. When EHR systems are optimized, each patient’s electronic record contains a comprehensive health history that can be used to signal next steps in patient care. EHR technology needs to match the processes and workflows that have already been established in a practice — which means software should be customized. To avoid frustration, providers need to look beyond using an off-the-shelf solution that is not aligned with how their practice functions.
2. Analyze collected data and assess the overall patient population: Before a population’s health can be managed, the population needs to be defined. This requires data from individual patients and data for the whole population. By pulling together data and analyzing it, medical teams can gain an understanding of the makeup of the overall population, what percentage of patients share common conditions like diabetes, heart disease, obesity, and so on. Data can also show what patients are at a high risk for being hospitalized, what patients need extra monitoring, or how large of a healthy population there is that simply needs preventive care. Having a good understanding of the makeup of an overall patient population makes it easier to address the needs of various groups of patients. 
3. Segment patients into groups based on clinical, claims, and demographic data: Once the larger patient population is defined, smaller subpopulations will emerge. Using data filters makes segmentation quick and easy to do electronically. Figuring out where patients belong based on their clinical needs enables healthcare providers to deliver continuous, patient-centered care. So, healthcare teams need to place patients into groups of like individuals.
4. Match people into care management programs that meet their clinical needs and are operationally efficient: A general care plan is needed for each subpopulation. For example, healthy patients (a group that has traditionally been left alone until they required acute care) should have a plan that proactively promotes routine tests, immunizations, and other preventative services. Pregnant women need a plan that includes blood glucose checks and screening for gestational diabetes, children need plans to keep them up to date on vaccinations, and chronically ill patients need plans that address their periodic servicing needs. A single care plan that can easily be customized and applied to many patients within the same subpopulation leads to more efficient and effective care for entire groups of people.
5. Engage patients on a regular basis and continuously work to help them maintain their health: The whole purpose of assigning patients to care management programs is to continuously work with them to maintain their health. Thoughtful use of technology and automation makes it possible for medical teams to extend support, provide services and connect with patients more regularly. It’s a lot easier to rely on an electronic system that can prompt doctors, care coordinators, and other staff to take specific actions than it is to manually keep track of data and act on it. The point is, population health management takes continuous effort and consistent patient outreach.

As mentioned earlier, chronic disease (which is the leading cause of death and disability in the U.S.) is pushing providers to get more serious about population health management. Preventing issues related to chronic disease is good for both patients and providers. Patient-centered preventive care helps reduce the need for acute services. Since it costs more to treat a disease than to prevent a disease this alleviates financial pressure as well. Prevention not only reduces care costs, but it improves health outcomes and patient experiences. But again, prevention across a patient population requires data. Providers must be able to collect, analyze and apply data from an entire patient population, otherwise they will be flying blind when attempting to improve quality, outcomes, costs, etc.

For healthcare providers, it pays to invest in technology that enables them to identify patients with target conditions and fix gaps in care. By defining patient populations and sorting patients into high, moderate, and low-risk categories, doctors can more clearly identify opportunities for clinical improvement and take actionable steps that improve outcomes for an entire portfolio of patients.

About The Author
Richard A. Royer has served as the chief executive officer of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006 he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the board of directors as treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience he has held positions as chief executive officer at Cuyahoga Falls, OH, General Hospital; executive director of Columbia Regional Hospital in Missouri; and founder and president of Avalon Enterprises, a medical financial consulting firm.