Managing The Health Of Populations In Uncertain Times

By Michael Nissenbaum, president and CEO, Aprima Medical Software

If I could sum up today’s healthcare environment in a single word it would be “uncertainty.” The House just passed a bill to “repeal and replace” the Affordable Care Act, though the content of this legislation could change significantly before it goes through the Senate. In the meantime, the direction of the country’s healthcare system will continue to be a bit cloudy — though not totally foggy.

What does appear fairly clear is healthcare will continue its shift from fee-for-service reimbursement to payment models based on quality and value. Additionally, technology-driven quality reporting and interoperability will remain important objectives, as will the need for faster and friendlier user experiences for providers and staff alike. HHS is pushing to tie quality to 50 percent of traditional fee-for-service measures by 2018, and already 60 percent of commercial plans include a quality performance component. With this transition, physicians are increasingly aware of the need to monitor patient health, manage costs, and take proactive measures to keep their patients healthy.

Population health management (PHM) requires clinicians not only address existing acute and chronic conditions, but expand their focus beyond the care and treatment of patients with known problems to include all the individuals in their patient population that may have indications of potential conditions. Managing the health of a patient population requires a proactive approach to ensure healthy patients remain healthy and to continually monitor the status of at-risk patients. To do this efficiently and cost-effectively, providers need technology to help aggregate and analyze patient data across entire patient populations, to facilitate care coordination, and to enable patient communication and education.

Electronic Health Records
While the adoption of electronic health records (EHRs) is often demonized as being burdensome to the provider, attempting to manage a patient population by paper is a non-starter. A physician can certainly deliver quality patient care one-on-one without an EHR; however, the proactive management of thousands of patients is overwhelming without the right technology tools. At a minimum, physicians need an EHR solution to collect and store patient data in order to effectively analyze and manage the health of their patient population.

For example, consider a practice that wants to minimize health complications among its diabetic patients by encouraging regular blood testing. The staff must first identify all of the practice’s diabetic patients, then verify the date of their last test, ensure the results came back and are recorded, and ultimately reach out to those patients who don’t have current results. Without an EHR, the identification process alone would be tedious and time-consuming; with most EHRs, practices can easily query to find patients based on specific criteria, eliminating staff time and immediately narrowing the focus to just those in need.

Often such reports can be scheduled to run automatically and can even trigger messages to be sent to the patient. Alternatively, the data can feed to the appropriate staff members for follow-up if a more personal touch is desired. Even if a practice could accomplish this manually for the example above, to truly handle an entire population the above pattern must repeat itself over and over for numerous conditions such as hypertension, heart disease, etc., not to mention annual well visits and diagnostic tests such as mammograms or other early detection initiatives.

Communication
Technology also facilitates timely (or contemporaneous) communication between providers and patients. A practice that has identified at risk patients who are delinquent on testing or follow-up would historically need to manually call every patient or mail them letters. With the use of technology, this can all be handled with an automated reminder, or with a secure online patient portal to send messages, along with educational materials that highlight the importance of managing their condition. More and more patients are demanding online access to their medical information and their healthcare providers. Also, studies have shown the use of secure bi-directional and bi-lingual patient portals improves patient satisfaction.

Documentation And Reporting
Regardless of the communication method, practices need to document their outreach activities in order to qualify for bonuses under various quality-based incentive programs, such as the Merit-based Incentive Payment System (MIPS) and Chronic Care Management (CCM). The practice’s EHR should support the ability to create patient-specific care plans, track a patient’s progress using key performance indicators, and create automated reports that detail a practice’s quality-related activities. The bottom line is no matter how well you deliver care, you only get credit for what you document.

Care Coordination And Interoperability
Effective PHM also requires care coordination and collaboration across the continuum. When a primary care provider refers a patient to a specialist, for example, care is enhanced if the specialist has the patient’s pertinent medical record information, including their current list of problems and medications. Record-sharing between providers also minimizes test duplication, plus helps clinicians identify gaps in care. In order to efficiently share clinical records between providers, practices need technology that supports the interoperable exchange of data between disparate systems. Interoperability is an area that has progressed dramatically in the recent past, and while there is still a long way to go to make it seamless and complete, it continues to promise significantly more efficiency and value for everyone involved, including the patient.

Data Aggregation And Integration
PHM relies on information compiled from multiple sources. In order to measure, analyze, and monitor patient health, providers need the ability to easily and quickly aggregate and integrate data in a meaningful way, as well as having the information presented in an intuitive and insightful format. To monitor the effectiveness of their practice, physicians should have easy access to the information, ideally with an option to view data in a chart or graph. Everything from electronic prescribing with the ability to do real time medication reconciliation, to sending an order and receiving the results back electronically, to transition-of-care (sending/receiving patient records), is a care team effort where everyone wins when done effectively.

Certainty In The Midst Of Uncertainty
Despite the many uncertainties in healthcare today, I feel certain that we will continue to see an emphasis on keeping patient populations healthy and on the delivery of high-quality outcomes and cost-effective care. I also believe that having the right technology in place is a critical component to success for both patients and providers!