shifting to value population health management...

PHYTEL | WHITEPAPER

Shifting to Value

Authors:Richard Hodach, MD PhD MPH Karen Handmaker, MPP

Population Health Management Technologies for Accountable Care

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com2 Copyright ©2013 Phytel Inc. All rights reserved.

As population health management takes center stage in healthcare transformation, it’s becoming clear that the medical neighborhood must be better organized to improve care coordination and ensure that all patients receive the right care at the right time. The hub of the medical neighborhood—which includes primary care physicians, specialists, hospitals, post-acute care providers, ancillary services, social service agencies, and public health departments—is the patient-centered medical home, which guides patients through the system. Health IT is the glue that connects the providers in the medical neighborhood to each other and to their patients.

Care teams perform the work, not only of managing care for individual patients, but also of population health management. Besides the clinicians within a practice who provide patient care, the care team should be expanded to include all of the providers who deliver care to a particular patient. When electronically connected, this extended care team can continuously send and receive updates and can easily exchange views on a patient’s condition and treatment.

Whether the medical neighborhood is organized by clinically integrated networks, health information organizations, or accountable care organizations, it requires interoperable EHRs and advanced data aggregation, analytic and automation tools to manage population health effectively.

The ten most effective health IT tools for population health management are as follows:

• Electronic health records • Referral tracking

• Patient registries • Patient portals

• Health information exchange • Telehealth/telemedicine

• Riskstratification • Remotepatientmonitoring

• Automated outreach • Advanced population analytics

These applications can be categorized as population-level solutions or patient-level applications. The core of both categories is the patient-centric registry, a frequently updated collection of patient data that drives both population-level analysis and care management. Patient registries are the central database for population health management in the medical neighborhood. Populated by clinical and administrative data, they’re used for patient monitoring, patient outreach, point of care reminders, care management and other purposes. Theycanalsobeusedforhealthriskstratification,caregapidentification,qualityreporting,andperformanceevaluation.

At the patient level, population health management requires an organization to reach out to and engage all patients who have care gaps, whether or not they visit their providers. Physicians and care managers must also be alerted about those care gaps, and they must have a mechanism for intervening with patients who need routine care, as well as high-risk patients who require immediate attention. Traditional manual methods are too labor-intensive and time-consuming to do all of this consistently and comprehensively. So healthcare organizations must deploy automation tools and integrate them with registries and other data sources to make sure that patients receive appropriate services.

Among the automation solutions that have been shown to be most effective in population health management are automated messaging systems for patient outreach; automated systems for alerting care teams about patient needs; and online health risk assessments, customized educational materials, and self-care recommendations. Telehealth and telemonitoring can help monitor the health status of high risk patients and can give all patients remote access to their care teams when they need it.

Anyone that is involved in healthcare transformation—including healthcare system and insurance executives and frontline providers—should read this paper to get an in-depth view of where healthcare is heading and how it will get there. The more that healthcare professionals understand about the medical neighborhood and population health management, the faster they can move the ball forward.

Summary

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com Copyright ©2013 Phytel Inc. All rights reserved. 3

Page 4Introduction

Page 5What is population health management?

Page 6Population Health Management and the Medical Home

Page 7The Care Team in the PCMH and PCMN The Extended Care Team In the Medical Neighborhood

Page 8Organizing the Medical Neighborhood

Page 9Health Information Technology: The Nervous System of PHMInformation-Sharing in the Medical NeighborhoodPopulation Health Management Tools

Page 10Population Level HIT ApplicationsPatient-Centric Registries

Page 11Claims and Financial AnalyticsRiskStratification

Page 13Advanced Population Analytics

Page 14Patient Level HIT ApplicationsIndividual Engagement

Page 15Care ManagementVirtual and Remote Monitoring

Page 16Team-Based Care Collaboration

Page 18Conclusion

Page 19Notes

Contents


The U.S. health care system faces numerous challenges in adopting a population-based approach to health care delivery. This transformation will require a critical shift from the current approach, which focuses mainly on individual patients and episodes of illness, to an approach that emphasizes the health needs of an entire patient population. Providers will need to be aware of their patients’ interactions with other providers and health organizations (hospitals, specialists, mental health, behavioral health, and long-term care), as well as non-medical factors that affect their health and capacity to self-manage, including geography, socioeconomic status, and risky behaviors like smoking, poor nutrition, violence, and substance abuse.

Population health hasbeendefinedas“thehealth outcomes of a group of individuals, including the distribution of such outcomes within the group.”1Theterm“population”canrefer to geographic regions, such as nations or communities, but it most often describes aspecificsubgroupofpatients.Examplesinclude a population of patients with a specificdisease(e.g.,allofthediabeticpatients in a practice), a group with gaps in care (e.g., all female patients without up-to-date breast cancer screening), or simply, all of the people who identify Dr. Smith as their personal doctor.2

While the term population health might be seen as implying a disassociation or a distancing from the individual patient,

the opposite is true. The population health approach to care delivery strongly emphasizes patient engagement, quality improvement, and the coordination of care for individuals across care settings.

Improving population health is one of the principles of the Institute for Healthcare Improvement’s Triple Aim, which seeks to improve the experience of care, improve the health of populations, and reduce the per capita costs of care.3 The Centers for Medicare and Medicaid Services (CMS), along with many private payers and healthcare organizations, regards the Triple Aim as the key goal of healthcare reform.

Despite the importance of the population health approach, however, it will not be widely adopteduntilnewfinancialincentivesinhealthcare evolve and become prevalent. A key barrier is the dominant fee-for-service payment system, which rewards healthcare providers for patient encounters and the volume and complexity of the services performed during those visits. This model discourages providers from caring for patients outside of face-to-face encounters or proactively seeking out patients with gaps in their preventive or chronic disease care. The current transition from fee-for-service to a budgeted payment model in which healthcare providerstakefinancialandclinicalresponsibility for care is expected to facilitate adoption of the population health model.

Additional barriers to the new approach

include the lack of an infrastructure in most healthcare organizations for improving population health; the inability of most electronic health record (EHR) systems to generate the data or provide the analytics required for population health; and the fragmentation of healthcare in most communities. Because of this state of disorganization, there is little coordination ofcarewithinthe“medicalneighborhood,”which includes primary care physicians, specialists, hospitals, rehab and long-term-care facilities, home health agencies, pharmacies, labs, and imaging centers. Until these entities coordinate care and communicate, not only with each other but also with patients, social service agencies, and public health departments, the optimization of population health will remain a distant goal.

For a medical neighborhood to optimize population health, it must be organized around the patient-centered medical home (PCMH), a primary care delivery model that is patient-centered, comprehensive, coordinated, accessible, and committed to quality and safety.1 The PCMH coordinates the care of each patient across the spectrum of care settings with the help of health information technology. The objective of this paper is to explain how this can be done in the patient-centered medical neighborhood (PCMN) and associate important health IT infrastructure elements with key functions required for effective population health management.

For a medical neighborhood to optimize population health, it must be organized around the patient-centered medical home (PCMH), a primary care delivery model that is patient-centered, comprehensive, coordinated, accessible, and committed to quality and safety.1

Introduction


What is population health management? Thedefinitionofpopulation health management (PHM) encompasses both the population to be managed and

the approach chosen to accomplish that goal. For the purposes of this paper, we are going to use the Agency

forHealthCareResearchandQuality’s(AHRQ)definitionof“practice-basedpopulationhealth,”orPBPH:“We

definePBPHasanapproachtocarethatusesinformationonagroup(‘population’)ofpatientswithinaprimary

carepracticeorgroupofpractices(‘practice-based’)toimprovethecareandclinicaloutcomesofpatients

within that practice.” 4

Patient engagement is also critically important in PHM. The Care Continuum Alliance (CCA), an associationofstakeholderscommittedtoPHM,definespopulationhealthimprovementasamodel“featuringaphysician-guidedhealthcaredeliverysystemdesignedtodevelopandengageinformedand activated patients over time to address both illness and long term health. Care Continuum Alliance members believe that managing health requires the active, integrated involvement of all health care professionals coordinated with the patient and their caregivers and families.” 5

Key components of the CCA model include health risk assessments, health promotion programs, patient-centric health management goals and education, self-management interventions aimed at influencingthetargetedpopulationtomakebehavioralchanges,andongoingcommunicationsbetweenpatients and physicians, ancillary providers, and health plans.

Care teams are also a key part of the PHM approach. Shifting the care model from an episode-based model to a person-centered population health model requires a team of providers who diligently monitor quality and outcomes, care for patients based on conditions and risk levels, and proactively manage patientswhomayotherwise“slipthroughthecracks”bydelayingoravoidingcarealtogether.

The ability to achieve the goals of population health management, however, only becomes possible when health information technology applications underpin and drive the fundamental activities of practices,providersandcareteams.The2010AHRQreportfirstidentifiedfivedomainsofPHMthatdepend on HIT applications. Although this framework was developed to operate at a practice level, these domains—all of which require the use of IT—can be considered at a number of levels: patient, provider, practice, integrated health system and the medical neighborhood.

The ability to achieve the goals of population health management, however, only becomes possible when health information technology applications underpin and drive the fundamental activities of practices, providers and care teams.


A fully developed PHM approach requires a number of capabilities and functions, including an organized system of care, care teams, coordination across care settings, access to primary care, patient self-management education, a focus on health behavior and lifestyle changes, and the use of linked EHRs and patient registries.

Population Health Management and the Medical HomeThe goals of population health management are compatible with the goals of the patient-centered medical home (PCMH). Like PHM, the PCMH is a completely different kind of care delivery model than that which most providers are used to. Both emphasize the need to proactively keep people healthy instead of just providing care when they’re sick; shift the focus from acute care to preventive and chronic care; are predictive and proactive, rather than reactive; are continuous, rather than episodic; are whole-person-oriented, rather than case-oriented; and offer care to all patients, not just those who present for care. An individual primary care practice can achieve some of these goals, but population health management as a whole requires a foundation established by the PCMH model, which becomes the hub for collaboration within the medical neighborhood.

AHRQdefinesthepatient-centeredmedicalhome as an approach to the delivery of primary care that has the following characteristics:

• Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.

• Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.

• Accessible: Patients are able to access serviceswithshorterwaitingtimes,“after hours” care, 24/7 electronic or telephone access, and strong communication through health IT innovations.

• Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

• Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.6

A fully developed PHM approach requires a number of capabilities and functions that are not yet found widely in the U.S. healthcare system, although there are many examples emerging as the number of PCMH practices, ACOs and clinically integrated networks continues to grow. These critical capabilities include an organized system of care, care teams, coordination across care settings, access to primary care, patient self-management education, a focus on health behavior and lifestyle changes, and the use of linked EHRs and patient registries.7


The Care Team in the PCMH and PCMN Perhaps the medical home’s most significantcontributiontopopulationhealthmanagement is the emphasis on a care team model. A team-based model of care ensures that all patients from the lowest risk level to the highest risk level are cared for in the right place, at the right time, and in the manner most appropriate for the patient. A medical home care team offers 24/7 access and alternatives to traditional face-to-face visits, including e-consults, group visits, and patient portals. The care team’s responsibilities may include activities such as pre-visit planning, self-management counseling and creating complex chronic care plan for a patient with multiple illnesses

and medications recently discharged from the hospital. High-performing care teams often include a combination of clinical and non-clinical staff. It is not uncommon for some staff to have multiple roles and for otherstobe“embedded”byahealthplanor“shared”acrossmultiplepracticesites.Careteams,invariousconfigurations,may include nurses, care coordinators, medical assistants, social workers, diabetes educators, nutritionists and/or health coaches who are dedicated to supporting patients as they navigate the health system and strive to achieve their care plans goals.

To support the objectives of PHM, the care team also ensures that proactive processes are in place to manage the health care needs of all patients—even those who have not scheduled visits, paying special attention to subpopulations of patients with chronic diseases, complex conditions, and behavioral health issues. These population management activities can require the sophisticated use of electronic health records and other population health management tools to identify and track cohorts of patients by risk level, adherence to care plans, appropriate medication use, and achievement of therapeutic targets. Onceidentified,careteamscanalsoleverage technology-assisted tools to reach out to patients via phone, secure messaging, or email to encourage them to schedule

neededappointments,refillimportantprescriptions or check in with their doctor following a hospital admission or emergency room visit.

The Extended Care Team In the Medical NeighborhoodTo coordinate care and patient support beyondthe“walls”ofthemedicalhome,HIT applications can be used by care teams to document and share information electronically and bi-directionally with providers (primary care and specialists), caregivers, hospitals, home health agencies,

community resources and others in the larger medical neighborhood. All of the providers caring for a patient should be regarded as part of an extended care team that is connected electronically and can continuously send and receive updates on the patient’s condition. This care team should work off a single care plan that can be expandedandmodifiedasthepatientmovesfrom one care setting to another. Further, a well-functioning medical neighborhood would feature seamless sharing of clinical information, reduced duplication and waste, enhanced continuity of care, shared decision making and strong community linkages. When all this happens, the medical neighborhood care team becomes even more patient-centered.

One compelling reason why PHM requires this close collaboration between the medical home and the medical neighborhood is that patients with complex, high-cost illnesses must be managed by multiple specialists. For example, a cardiologist may manage a patient’s heart disease, but that same patient may also have advanced diabetes and emphysema requiring the attention of other specialists. The primary care physician who serves as the patient’s medical home may not be able to address these conditions fully, but he or she should lead the care team that is providing holistic, comprehensive care to the patient.

To support the objectives of PHM, the care team also ensures that proactive processes are in place to manage the health care needs of all patients—even those who have not scheduled visits, paying special attention to subpopulations of patients with chronic diseases, complex conditions, and behavioral health issues.


In today’s fragmented environment, however, it is highly likely that primary care and specialist providers treating these complex patients may not all be aware of each other’s involvement and, even if they are aware, they may be on separate electronic medical systems and in different networks or health systems. AHRQ notes that these and the following challenges greatly complicate care coordination and the development of medical neighborhoods and effective extended care teams:

• No(orfew)financialincentivesorrequirements for care coordination

• Limitedfinancialintegrationacrossproviders

• Practice norms that encourage clinicians to act in silos rather than coordinate with one another

• The complexity of coordination for high-need patients

• Patient self-referrals of which the PCMH is unaware

• Limited health IT infrastructure and interoperability8

Organizing the Medical NeighborhoodThere are several ways to organize a medical neighborhood into a high-functioning system capable of managing populations and their health. A hospital system, a physician group, or an independent practice association can form a clinically integrated network (CIN) that adheres to a single set of clinical protocols and has the health IT infrastructure required for care coordination, care management, and patient engagement.9

Alternatively, a health information organization (HIO) can leverage the connectivity it provides to participants by adding a layer of automation and analytic tools.10-11

Accountable care organizations (ACOs), which are groups of providers committed to improving

quality and lowering costs, can also organize the medical neighborhood into a network capable of managing population health.12 But ACOs—like CINs and HIOs--need primary care practices that follow PCMH principles to coordinate care and help patients navigate the healthcare system. In the view of many observers, the PCMH is an indispensable building block of the ACO.

In an ACO, the population to be managed includes all of the people who receive their care from the providers that participate in the ACO. (For purposes of the Medicare shared savings program,beneficiariesenrolledintheACOmustreceive most of their primary care from an ACO participating provider.) But many of these patients get some of their care outside the ACO, and population health management encompasses interventions that fall into non-traditional categories, such as social services, nutrition, and wellness programs.13 The ACO’s medical neighborhood includes not only the providers whom patients encounter in various care settings, but also many other actors in the community and sometimes outside of it.14

The healthcare stakeholders that have the most experience in PHM are payers, which have longsoughttoinfluencepatientsandprovidersto improve outcomes and lower costs. Both government and private insurers and employers have engaged in various aspects of PHM, including disease management and health promotion. Recently, a number of health plans have formed partnerships with large provider organizations to form ACOs or ACO-like entities. In some cases, the plans are taking the lead in online patient engagement activities and/or are placing care coordinators in physician practices. In addition, as we explain later, many payers are providing claims data that can be extremely valuable to providers that are doing PHM.

There are several ways to organize a medical neighborhood into a high-functioning system capable of managing populations and their health.


Health Information Technology: The Nervous System of PHMComprehensive, reliable coordination of care in a medical neighborhood is impossible without health information technology. HealthIT“isaprimary,ifnotthemostimportant support tool available” for medical neighborhoods, according to the AHRQ report.15 This report further points out:

HealthIThassignificantpotentialfor facilitating physician efforts to coordinate patient care in the medical neighborhood…Interoperable electronic health records enable PCCs [primary care clinicians] and specialists to share information, such as a patient’s medical history, current problem and medication lists, diagnostic testing and laboratory results, and care plans.

The AHRQ paper also notes that electronic health records need to become truly interoperable and must link with the public health data infrastructure to achieve their potential in the medical neighborhood. But this only scratches the surface of what health IT can do in population health management.

With data supplied by registries and enterprise data warehouses, analytic software can be used to stratify the population by health risk, identify care gaps and set priorities for care planning. Automation tools can facilitate care management, patient outreach, health risk assessment, web-based education, remote patient monitoring, and other PHM functions.16

In addition, ACOs and other organizations that seek to manage population health need analytics to measure performance across the entire medical neighborhood. With providers who are part of an ACO or a clinically integrated network, the challenge is to integrate data from many disparate clinical andfinancialsystemssothatanalyticscanbe applied to it. To track care provided outside of the network, health plan claims data will also be required.17

It should be noted that while AHRQ calls for theuseof“interoperable”EHRs,systemsfrom different vendors are unlikely to be capable of exchanging discrete data directly in the foreseeable future. Instead, healthcare organizationsandHIEscreate“dataliquidity”by aggregating and normalizing data from disparate EHRs—which is another form of interoperability.

Information-Sharing in the Medical NeighborhoodA wide range of health IT capabilities are needed to knit together the medical neighborhood in ways that facilitate PHM. This starts with the ability of providers to communicate with one another electronically. One way to do that is through health information exchanges (HIEs) that connect providers across communities. Another is to use the direct secure messaging protocol to transfer clinical data back and forth between providers. Both approaches have drawbacks that are discussed later.

Beyond the sharing of information among providers and between providers and patients, PHM requires analytic and automation tools for care managers to assess the health status of patients, collaborate on care planning, and engage patients more fully in their own care. Moreover, when an ACO or a clinically integrated network takes financialriskforcare,itmusthavetoolsforevaluatingbothclinicalandfinancialperformance.18

Population Health Management ToolsThe commercially available PHM solutions described below can be categorized as population or patient level functions to emphasize new and enhanced activities required to fully implement population health management. Population level tools integrate multiple data sources, apply evidence-based and predictive modeling algorithms, and generate actionable performance reporting. Patient level tools use the output from population level applications to inform patient engagement andcareteamworkflows.Inmostcasesthese applications are complementary to electronic health records (EHRs), which, by and large, are not designed for PHM.19

EHRs, practice management systems, and other clinical and administrative systems can provide much of the structured data required for PHM. But as we’ll see, other data sources and capabilities must also be included.

Comprehensive, reliable coordination of care in a medical neighborhood is impossible without health information technology.


Population Level HIT ApplicationsPatient-Centric RegistriesTraditionally, a registry is a list of all the patients in a physician’s practice who share a characteristic, such as a certain condition (diabetes, asthma, hypertension) or medication regimen. As HIT capabilities have improved, registries are now built to be patient-centric—providing a full view of all information associated with a single patient—buttheinformationcanbefilteredbyoneormanycriteriasuchasdiagnosis,medications,age,payer,lab results and more. Dynamic registries help the care team keep better track of these patients by providing care reminders and by identifying patients who are overdue for certain kinds of care, or who are not adhering to care plans. Registries can be integrated with other tools such as automated messaging systems that remind appropriate patients to schedule appointments with their provider.

Patient registries form the central database for PHM in the medical neighborhood. Populated by clinical and administrative data, they are used for patient monitoring, patient outreach, point-of-care reminders, care management, public health reporting, and other purposes. When combined with analytic tools, they can be usedforhealthriskstratification,caregapidentification,qualityreporting,andperformanceevaluation.

Registries can also provide feedback to physicians to benchmark their own performance and support their continuous improvement efforts. And a registry can be the online platform that allows all providers caring for the same patient to collaborate and coordinate care across the medical neighborhood.

Payer

Managing Populations, Maximizing Technology

Population in the Community Patient EngagementAutomated OutreachPatient Portals

Distance MonitoringTelehealth/ TelemedicineRemote Patient Monitoring

Care ofa patient

Primary CareOffice

Patient Population of the Primary Care Office

Referral Tracking/HIEs

Others who supply/require information and coordination

Specialty Care Hospital Radiology, Lab, Rx

Claims and CostRisk Stratification

Care ManagementClinical AnalyticsClinical Decision SupportPatient-Centered Registry

Ten Recommended Health IT Tools to Achieve PHM:• Electronic health records

• Patient Registries

• Health Information Exchange

• Risk Stratification

• Automated Outreach

• Referral Tracking

• Patient Portals

• Telehealth/Telemedicine

• Remote Patient Monitoring

• Advanced Population Analytics

Figure A. Technologies for Population Health Management in a PCMH-N


A registry lists each patient’s demographic characteristics, diagnoses, lab values, medications, and other pertinent data. Applied to the individual patient, a registry can show when the person was last seen, who provided what care to that patient, the patient’s current health status, and when the patient is due to visit again. Applied to a population, the registry can show, for example, how all of a particular provider’s patients with type 2 diabetes are doing, which diabetic patients are out of control, or how well an entire organization is treating patients with that condition.

Analytic applications can compare the data in a registry with nationally recognized clinical protocols or guidelines accepted by an organization’s providers. Such tools can identify care gaps, help stratify the population by health risk, and generate outreach messages to patients in need of preventive or chronic care. These analytics can also be used to generate reports on subpopulations, such as patients with uncontrolled hypertension, and to alert providers and care managers that particular patients need attention. In addition, care teams can leverage registry reports to prioritize interventions with high-risk patients, create pre-visit care plans, and customize educational materials to patients in certain categories.

A registry that draws its data exclusively from a single practice or healthcare organization is inherently limited because it includes only information generated by that entity. A more effective registry would contain data from all of the providers caring for each patient. However, the owner of

the registry would have to aggregate the information from these providers and then normalize all of the data to a single format so that it can be displayed and analyzed. It’s also essential to scrub and validate this data to assure its integrity before it is used to manage care or evaluate performance.

Claims and Financial Analytics One way for a healthcare organization to obtain information on patients who receive care from outside provider networks is to obtain paid claims data from health plans. Healthplansareincreasinglyfindingways to share this data with providers to help them reduce variations in care and manage population health. Some payers, as mentioned earlier, are even collaborating with providers to form ACOs.20

Claims data is less actionable than clinical data because it can lag the date when services were provided to patients by a monthormore.Italsohasdeficienciesbecause the information is based on payment and excludes clinical lab results and other pertinent information captured in the clinical record. For example, a claim for a test ordered to rule out a diagnosis might include that diagnosis on a claim, but the patient might not have that condition.

Claims information can also help an organization calculate the total cost of providing particular kinds of care. A practice managementsystemorahospitalfinancialsystem is not designed to furnish that kind of information. But claims data, when combined with analytics, can supply an approximation of care delivery costs. ACOs andotherorganizationsthatareatfinancial

riskmusthavethesefiguresinordertostay within a budget and determine which providers are most cost effective.21

If an organization does not have access to paid claims data, it may use billing data fromitsfinancialsystemasasubstitute.Inan ACO or a clinically integrated network, this“pre-adjudicatedclaimsdata”maybe drawn from the billing systems of all participants. When coupled with lab values, prescriptionfillinformationandotherclinical elements, the combined data set can be used to populate registries, even without EHR data or with data only from the dominant EHRs in the network.

Risk Stratification

With 5% of the population accounting for nearly half of all health costs,22 it’s critically important for healthcare organizations that aretakingfinancialrisktoknowwhothosepatients are. In addition, only 30% of the patients in the high-risk category were that sick a year earlier.23 So organizations need a method to stratify their population by health risk and provide the appropriate interventions to prevent people who are moderately sick from becoming severely ill. They must also identifyspecificcaregapsintheirpopulationto ensure that patients receive the preventive and chronic care they need to maintain their health and control their conditions.

Riskstratificationreferstotheperiodicandsystematic assessment of each patient’s health risk status, using criteria from multiple sources to develop a personalized care plan. Apatient’shealthstatusmaybereflectedbyascoreorplacementinaspecificcategory,based on the most current information

5% of the population accounts for nearly half of all health costs, but only 30% of the patients in the high-risk category were high cost a year prior.


available.24Theidentificationofapatient’shealthriskcategoryisthefirststeptowardsplanning, developing and implementing a personalized patient care plan by the care team, in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other providers, intensive care management, or collaboration with community resources. The care team’s observations also play a vital role. The more variables included in determining the risk category, the more reliable and accurate the prediction of future health risks and costs can be.

Severity of medical condition has historically beentheprimaryfactorforstratification.Itisthemostreadilyidentifiableandperhapsthe most useful in and of itself. However, meshingseveritydatawithpatientspecificcharacteristics related to co-occurring medical and behavioral health disorders, patientconfidence,andpsychosocialriskfactors such as living alone or low income, allowsforamuchmorerefinedapproachtostratificationandinformedpatient-centriccaremanagement strategies and interventions.

Stratificationprofilescanalsoidentifypatients at high risk for poor compliance or untoward outcomes that do not necessarily meet“high”severitycriteria;conversely,patients with an illness or symptoms classifiedashighseveritymaybeassignedto a relatively low risk level if the patient has other characteristics which suggest thatthissingleriskfactorisnotsufficientto substantiate assignment to a high risk category. For example, a patient with a history of elevated HbA1c who has well controlled blood pressure and lipid levels

and takes medications as prescribed would not be regarded as high risk.

Multifactorialstratificationcanalsobeused to determine the resources required to address risk reduction across the organization and the most appropriate allocation of those resources. For instance, nurse care management might make more sense than an increase in PCP visit frequency, depending on the patient’s particularprofile.Thus,riskstratificationcanguide the timeliness of responses required byspecificsubgroupsratherthanapplyingone standard to all patients.

Organizations can use multiple means to risk-stratify a population. Patients or employeescanbeaskedtofilloutahealthrisk assessment that may be online. If an organization has a registry, it can apply analytics to that database to identify patients whose health indicators suggest that they are high risk. The best approach is to do both and to pull in any other available data that will help the organization get an accurate picture of a person’s total health situation. Some patients who may not yet be high risk could easily move into that category because of psychosocial factors such as living alone or having a low income or poor access to care.

Inaddition,theriskstratificationcanhelpcare managers determine the priority they assign to their patients and the types of interventions that are appropriate for each one. For example, high-risk patients may need more personalized attention, whereas those in the medium-risk category may only require automated messaging and online

To evaluate its performance, an organization that engages in PHM can leverage a data warehouse or population analytic tools needed to convert its data into useful intelligence.


education. Low-risk patients may simply be prompted to maintain their health and get appropriate preventive care.

To identify care gaps, clinical analytic tools automatically and continuously apply decision support rules to the structured data in a registry or data warehouse. These analytics can generate exception reports, which identify patients who do not meet specificcriteriaforbestpractices.Examplesinclude patients with persistent asthma who have not been prescribed an inhaled corticosteroid, patients over 50 who have not had a colonoscopy in the past 10 years and elderly individuals with multiple chronic conditions and recent hospitalizations or emergency room visits.

In addition, the system should be able to generate panel reports, which show providers and care teams key indicators about all of the patients they are responsible for. These brief summaries facilitate treatment review and care planning ahead of patient encounters.

Advanced Population Analytics

To manage population health, a provider organization or an ACO must measure itsclinicalandfinancialoutcomes.Theorganization must track the health status of its patient population—and particularly its high-risk patients—to reduce the per capita costs of care and improve the health of populations. It can also use historical data to predict what costs will be going forward.

To evaluate its performance, an organization that engages in PHM can leverage a data warehouse or population analytic tools

needed to convert its data into useful intelligence. Besides the patient-level reports described above, these reports must be able to give providers, care managers, and organizational management views of how well the population is being managed at a variety of levels.

At the top level, for example, managers should be able to see the prevalence of common chronic diseases in the organization’s population. They should be able to risk-stratify that population by condition and see how the portion of high-risk diabetic or hypertensive patients is changing over time. Managers should also be able to look at which segments of the population are generating the highest costs and how that changes, so they can shift resources as needed. And their analytic tools must enable them to evaluate the performance of individual providers and practicesonbothqualityandefficiency.43

A physician should be able to access reports on his or her own population of patients with a particular chronic condition and see how those patients are doing over time. These reports can help identify patients who are outliers in terms of health status and those who have not received appropriate care. Providers should also be able to compare their own performance on quality measures with national benchmarks and with the average for their practice or organization.

To assess population health at a particular point in time, organizations can use measures that describe care processes, such as how many patients with diabetes received an annual eye exam, intermediate outcomes such as blood pressure or

HbA1c, and long-term outcomes. The latter measures include both clinical data and patient-reported data, such as functional status and self-perceived health. Organizations must also continuously measure patient satisfaction. By tracking progress on all of these metrics over time, they can see whether they are improving the health of their population.

Furthermore, organizations that are taking financialriskneedtohavetheabilitytounderstand how the quality of care impacts the cost of care and how that is likely to affect future costs. To do this, they must risk stratify the population as described above, but must also focus on which individual patients and population segments are likely to generate future costs. Then interventions should be designed to provide patient-centered care and shared decision making with those patients to curb risk factors and control chronic conditions.

In addition, organizations must determine which providers utilize the most resources for particular types of care, risk-adjusting that data for the relative illness and compliance of their patients. With this information, they can construct reliable cost andqualityprofilesandsteerpatientstothemostefficient,high-qualityproviders.

Byusingriskstratification,predictivemodeling and provider utilization data, organizations can obtain a perspective on their current and future costs. But to truly managethatfinancialrisk,theymustlearnhow to manage population health effectively. And to do that, they must fundamentally change the process of care delivery, using the appropriate automation and analytic tools.

To truly manage financial risk, organizations must learn how to manage population health effectively. And to do that, they must fundamentally change the process of care delivery, using the appropriate automation and analytic tools.


Patient Level HIT ApplicationsIndividual Engagement A population health management approach requires an organization to reach out to and engage patients who

have care gaps to alert them that they need to make appointments with their providers or take other action to

close these gaps. Automation is crucial to systematizing this approach. Manual methods are too expensive

and time consuming to ensure periodic outreach to an entire patient population, including people who have not

sought care but need it.

An electronic registry populated with EHR and administrative data can be the basis of this kind of outreach. When combined with evidence-based clinical protocols and analytic software, the registry can supply the information that tells the automated messaging system when to call patients who are due for particular services. Automated communications can also be used in a variety of patient education and engagement activities.

A study of automated phone messaging to patients with diabetes and other patients with hypertension showed that it was effective in encouraging many of them to seek appropriate care for their conditions, includingofficevisitsandtests.33 Similarly, the use of automated messaging to promote adherence to statin medications was shown to be effective in a large scale, randomized trial at Kaiser Permanente.34

The same kind of automation tool that triggers appropriate and timely messaging to patients can also be used to alert physicians and care managers that particular patients need particular services or urgent interventions. An EHR can provide some of these alerts, but only when it’s accessed, which would normally be during a patient visit. These kinds of reminders—limited to a narrow range of healthmaintenance,decisionsupport,andchroniccarealerts—areinsufficientforpopulationhealthmanagement.


Care ManagementOne of the hallmarks of an organization prepared to manage population health is the use of care managers to coordinate care and ensure that all patients receive appropriate interventions. As they do in traditional disease management programs, these care managers work closely with high-risk patients to reduce exacerbations of their conditions that can lead to ER visits or hospitalizations. But to optimize population health, they must also maintain contact with other patients who fall into the low-risk and medium-risk categories. It is impossible for them to manage the care of so many patients without the use of automation tools.

A few years ago, researchers calculated that it would take 18 hours a day for a primary care physician to provide all evidence-based preventive and chronic care to a typical panel of 2,300 patients.25 Just to deliver all recommended care to a panel of 2,500 patients for the 10 most common chronic diseases would take more than 10 hours per day, another study found.26

While there is no comparable published research on the amount of time it takes care teams to do that work, unpublished data from a large Midwestern group indicates that care management requires an average of 138 minutes of staff time per patient. When thatfigureiscomparedtotheprevalenceof complex chronic conditions in a typical primary care primary care practice, it can be inferred that a single PCP with a panel of 2,500 patients would require 1.35 FTE care managers, and a 10-doctor practice would need 13 care managers.27

Most physician practices cannot afford so many care managers. Moreover, many care management tasks are routine and do not require the involvement of clinicians. Automation can perform these routine jobs, freeing nurses and doctors to care promptly for the patients who need their attention.

Automated patient outreach and the automatic alerting of care teams to patient care gaps are examples of such an approach. In addition, health risk assessments can be offered online; assessments, customized learning materials, and self-care recommendations can be sent to patients via web portals or secure e-mail; and campaigns can be designed to improve the care of all relevant subpopulations.

When applied to patients with chronic diseases, these campaigns can be tailored for people in hundreds of different subcategories. For example, a diabetes populationcanbeclassifiedintopatientswith type 1 diabetes, type 2 diabetes, type 2 diabetes and hypertension, poorly controlled type 2 diabetes, and so forth. Different educational materials and self-care recommendations would be sent to patient populations in each cohort, using one or more automated modes of communication, including text, phone and email, as preferred by the patient.

Virtual and Remote MonitoringOnce an organization has reorganized its care processes within the context of the medical neighborhood, a subsequent step in its journey to population health management is to use technologies designed to provide care and patient education remotely.

These applications fall roughly into three categories: telehealth, which automates the process of keeping track of changes in patient health status; telemedicine, which permits patients to consult with physicians or nurses through audio and video conferencing; and web portals, which can be used to share information and interact with patients online.

Telehealth can include home monitoring, mobile monitoring or a combination of the two. Home monitoring is used most frequently with high-risk patients such as those with congestive heart failure or people recovering from operations; but it has also been used successfully to help people control other chronic conditions such as diabetes and hypertension. Monitoring data can help inform care plans and can form the basis for automated or live feedback to patients on their health management.

A number of mobile apps designed for smartphones and tablets also enable consumers to monitor their own conditions. The value of most of these apps has been limited so far, because few physicians are viewing the monitoring data.28 That’s expected to change, however, as provider organizationsincreasinglytakefinancialriskfor care delivery.

Telehealth provides continuous data on a patient’s condition and increases patient engagement in their own care. Studies show that this can improve patient outcomes and that it is cost effective.29 But for healthcare organizations to make good use of this data in care management, they must activate automated protocols so that care managers and physicians are alerted only

Once an organization has reorganized its care processes within the context of the medical neighborhood, a subsequent step in its journey to population health management is to use technologies designed to provide care and patient education remotely.


to exceptions that require their attention and disposition. Moreover, as Partners Healthcare in Boston has shown, doctors are more likely to pay attention to the data if it’s integrated with their electronic health records.30

Telemedicine, which has been around far longer than telehealth, started off by helping patients in rural areas connect with specialists in metropolitan regions. But in recent years, health insurers have begun using telemedicine to enable their members to consult with doctors hired by the plans or by an outside service to diagnose and treat minor complaints remotely. A number of states also require health plans to cover telemedicine services. And new technology, such as smartphones equipped with digital cameras and video chat features, makes telemedicine cheaper and more accessible than it once was.

From the perspective of population health management, telemedicine can reduce costs and improve care by keeping patients away from ERs and costly specialists when their problem is treatable outside of a face-to-face encounter. But practices and hospitalsmustfigureouthowthese“virtualvisits”fitintoclinicalworkflows.

The use of patient portals with EHRs was uncommon until recently, when the Meaningful Use Stage 2 regulations put providers on notice that they might need portals to meet the patient record sharing criteria.31 These portals also provide a method to automate communications with patients and provide them with educational materials. With 20-25% of providers already usingportalsandfinancialincentivestoadopt portals, they must be considered an

increasingly important accessory of PHM.32

A study of Kaiser Permanente’s patient portal showed that a large portion of plan members accepted and used it. Between 2004 and 2007, v isits to the portal tripled to an annual total of 33 million. The portal’s most popular functions were viewing lab results,requestingprescriptionrefills,ande-mailing with doctors.33

Team-Based Care CollaborationNothing hampers care coordination in the medical neighborhood like a lack of communication among providers. But it’s still the exception for primary care doctors to be informed when their patients are admitted to or discharged from the hospital—although they may receive a discharge summary days or weeks later. Lack of follow-up care after discharge can result in complications and a worsening of patients’ conditions.34

Referrals from primary care physicians to specialists also represent an opportunity for improved communications. Only 62% of primary care physicians report getting consult results from specialists, although 81% of specialists say they send the information back to the referring doctors. Conversely, 69% of PCPs report sending a patient’s history and the reason for consultation to specialists always or most of the time, while only 35% of specialists say they get that information most of the time.35

Changes in payment models and the structure of healthcare delivery are expected to alleviate many communication problems. But information sharing mechanisms must be improved to provide the kind of consistency that population health management demands.

Changes in payment models and the structure of healthcare delivery are expected to alleviate many communication problems. But information sharing mechanisms must be improved to provide the kind of consistency that population health management demands.


One lever for improving these communications is the Meaningful Use stage 2 regulations. These require providers to exchange care summaries at transitions of care, such as hospital discharges and specialty referrals. But that exchange must take place electronically in only 10% of such transitions, and just once with a receiving provider who uses a different kind of EHR than the sender.36

Health information exchanges can facilitate the sharing of information between unrelated provider organizations. But a recent study found that only 30% of hospitals and 10% of ambulatory practices participate in suchHIEs,whichmostoftentrafficlabresults, clinical summaries, and discharge summaries.37 Private HIEs enable providers within a particular healthcare enterprise to exchangedata,butthatmaybeinsufficientwhen managing population health.

Secure messaging using the Direct Project protocol is also being increasingly utilized to send and receive clinical messages. But many providers still lack access to Direct messaging. Even those who have it cannot use Direct to query the EHRs of other providers for relevant patient data.38

There are other solutions that provider organizationscanusetofillsomeofthesegaps. For example, there are referral management applications that can be used to make and track referrals. Northwest Physicians Group, a Seattle-area IPA, uses a web-based referral service that allows specialists to let primary care practices know what information they will need for a referral. Patientreferralsarenolonger“lost,”becausethey can be electronically audited, and the systemenablesa“closedloop”ofcarethat

supportsnotificationofthespecialistvisitback to the referring physician. It also gives providerstheabilityto“chat”aboutthepatient via secure messaging.39

The Wright Center for Primary Care in Archbald, Pa., also does electronic referral tracking to improve care coordination. The practiceusesitsEHRtocreatean“openreferrals” tracking sheet that a staff member is responsible for monitoring. When a referral issent,itisclassifiedasemergent,priorityor routine on the tracking sheet, and referral resourcesintheofficekeeptrackofwhichof these appointments have been kept and whether a report came back. If a specialist recommends a test, the referral is kept open until the results have returned.40

Organizations can also use an application that connects with patients shortly after hospital discharge. This type of solution can be used to ask patients if they have questions about their discharge instructions or medications, automatically transfer patients to a care team member or trigger outbound calls from their physician or primary care practice. And it can help to ensure a doctor visit has been scheduled to improve the transition of care experience and patient satisfaction.41

Studies show how important such IT tools can be in improving coordination in the medical neighborhood. Just 17%-20% of primary care physicians report that they’re routinelynotifiedofdischarges;20%-40%say they receive discharge summaries two weeks or more after their patient leaves the hospital.Sixty-fivepercentofdischargesummaries lack information on pending tests; 21% omit data about discharge medications; and 14% don’t mention follow-up plans.42


ConclusionTo support the objectives of PHM, the care team can use technology to ensure that proactive

processes are in place to manage the health care needs of all patients—even those who have

not scheduled visits, paying special attention to subpopulations of patients with chronic diseases,

complex conditions, and behavioral health issues.

These population management activities can require the sophisticated use of electronic health records and other population health management tools to identify and track cohorts of patients by risk level, adherence to care plans, appropriate medication use, and achievement of therapeutic targets.


1. David Kindig and Greg Stoddart, “What Is Population Health?” Am J Public Health. 2003:93:380-383.

2. Reference ii.

3. Donald M. Berwick, Thomas W. Nolan and John Whittington, “The Triple Aim: Care, Health and Cost,” Health Affairs, May/June 2008, 759-769.

4. AHRQ, “Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care,” July 2010, accessed at http://pcmh.ahrq.gov/portal/server.pt/gateway/ PTARGS_0_11787_945869_0_0_18/.

5. Care Continuum Alliance, “Advancing the Population Health Improvement Model,” accessed at http://www.carecontinuumalliance.org/phi_definition.asp.

6. PCPCCwebsite,“DefiningtheMedicalHome,”accessedathttp://www.pcpcc.net/about/medical-home.

7. David M. Lawrence, From Chaos to Care: The Promise of Team-Based Medicine. Cambridge, Mass.: Da Capo Press, 2003.

8. Agency for Healthcare Research and Quality, “Coordinating Care In The Medical Neighborhood: Critical Components and Available Mechanisms,” white paper, June 2011, accessed at http://www.pcpcc.net/sites/default/files/resources/Coordinating%20Care%20in%20the%20 Medical%20Neighborhood%20%283%29.pdf.

9. Premier Healthcare Alliance, presentation, “Clinically Integrated Networks: a Population Health Building Block,” 2013.

10. Ken Terry, “Caradigm Expands Health Information Exchange Capabilities,” Feb. 28, 2013, accessed at http://www.informationweek.com/healthcare/electronic-medical-records/caradigm-expands-health- information-exch/240149713.

11. AT&T press release, “Baylor Healthcare System Deploys AT&T Healthcare Community Online,” Oct. 26, 2011, accessed at http://www.att.com/gen/press-room?pid=21839&cdvn=news&newsarticle id=33178.

12. AHRQ, “Coordinating Care In The Medical Neighborhood.”

13. Paul A. Nutting, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange, Elizabeth Stewart and Carlos Jaen, “Transforming Physician Practices to Patient-Centered Medical Homes: Lessons From the National Demonstration Project.” Health Affairs, 30, no. 3 (2011): 439-445, accessed at http://content.healthaffairs.org/content/30/3/439.abstract.

14. Institute of Medicine, Crossing The Quality Chasm: A New Health System for the 21st Century, 3. Washington, D.C.: National Academy Press, 2001.

15. AHRQ, “Coordinating Care in The Medical Neighborhood.”

16. Institute for Health Technology Transformation, “Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare,” accessed at http://ihealthtran.com/pdf/PHM Report.pdf.

Notes


17. Suzanne Felt-Lisk and Tricia Higgins, “Exploring the Promise of Population Health Management Programs to Improve Health,” Mathematica Issue Brief, August 2011.

18. Institute for Health Technology Transformation, “Population Health Management.”

19. AHRQ, “Coordinating Care in The Medical Neighborhood.”

20. Ken Terry, “Why Are Insurers Buying Physician Groups?” Hospitals & Health Networks, Jan. 1, 2012, accessed at http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/ Article/data/01JAN2012/0112HHN_FEA_trendwatching&domain=HHNMAG.

21. Institute for Health Technology Transformation: “Healthcare Analytics: The Information Backbone of Risk-Bearing Organizations,” accessed at http://ihealthtran.com/healthcare_anayltics.html.

22. AHRQ, “The High Concentration of U.S. Healthcare Expenditures,” Research in Action, Issue 19, accessedathttp://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html.

23. Ian Duncan, Healthcare Risk Adjustment and Predictive Modeling. Winsted, CT: ACTEX Publications, 2011.

24. Reference iv

25. AHRQ, “Practice-Based Population Health,”17.

26. TedWymyslo,“TheRoleofaRegistryinAchievingHealthCare’sNewFocus:PopulationHealth,” Focus, American College of Medical Quality.


28. Ken Terry, “Strategy: How Mobility, Apps and BYOD Will Transform Healthcare,” InformationWeek Healthcare, July 10, 2012, accessed at http://reports.informationweek.com/abstract/105/8914/ Healthcare/strategy-how-mobility-apps-and-byod-will-transform-healthcare.html?cid=SBX_iwk_fture_ Analytics_Healthcare_healthcare&itc=SBX_iwk_fture_Analytics_Healthcare_healthcare.

29. Jared Rhoads and Clive Flashman, “Teleservices for Better Health: Expanding the Horizons for Patient Engagement,” CSC white paper, accessed at http://assets1.csc.com/health_services/downloads/CSC_TeleServices_for_Better_Health_Expanding_the_Horizon_of_Patient_Engagement.pdf.

30. Terry, “Partners Integrates Home Monitoring Data With EHRs,” InformationWeek Healthcare, June 28, 2013, accessed at http://www.informationweek.com/healthcare/electronic-medical-records/ partners-integrates-home-monitoring-data/240157431.

31. Pamela Lewis Dolan, “Will meaningful use spur growth of patient portals?” American Medical News, Sept. 17, 2012, accessed at http://www.amednews.com/article/20120917/business/309179967/6/.

32. Terry, “Patient Portal Explosion Has Major Healthcare Implications,” iHealthBeat, Feb. 12, 2013, http://www.ihealthbeat.org/insight/2013/patient-portal-explosion-has-major-health-care-implications.

33. Ann-Lisa Silvestre, Valerie M. Sue, and Jill Y. Allen, “If You Build It, Will They Come? The Kaiser Permanente Model of Online Health Care.” Health Affairs, 28, No. 2 (2009):334-344.

34. AHRQ, “Coordinating Care in the Medical Neighborhood.”

35. Ibid.


36. CMS, “Stage 1 vs. Stage 2 Comparison Table for Eligible Professionals,” August 2012, accessed at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ Stage1vsStage2CompTablesforEP.pdf.

37. Julia Adler-Milstein, David W. Bates and Ashish K. Jha, “Operational Health Information Exchanges Show Substantial Growth, But Long-Term Funding Remains a Concern,” Health Affairs, July 2013, 10.1377/hlthaff.2013.0124.

38. Terry, “Direct Clinical Messaging Surges in Multiple Contexts,” iHealth Beat, Aug. 20, 2012, accessed at http://www.ihealthbeat.org/insight/2012/direct-clinical-messaging-surges-in-multiple-contexts.

39. Puget Sound Health Alliance, “Spotlight on Improvement: Effective Referral Management,” May 2012, accessed at http://www.clarityhealth.com/resources/PSHA-Spotlight-Improvement-Effective-Referral- Management.pdf.

40. Qualis Health, the Commonwealth Fund, GroupHealth, “Closing the Loop with Referral Management,” seminar slides.

41. Phytel website, “Phytel Transition: Hospital Post-Discharge Management Tools,” accessed at http:// www3.phytel.com/solutions/population-health-management-systems/discharge-readmission-solution.aspx.

42. Kripilani, et al. JAMA 2007. Bell, et al. JGIM 2008, cited in “Closing the Loop with Referral Management.”


shifting to value population health management...

Documents