Pop health yielding results, but efforts face rising complexity

Implementing appropriate IT is only part of the challenge in stratifying and effectively treating patients.

To a degree, population health management doesn’t have the wow factor possessed by many of the hot technologies grabbing the attention of information executives.

Let’s face it—things like blockchain technology, precision medicine, artificial intelligence and machine learning—get a lot of attention. Over time, these approaches—and the IT to support them—hold significant promise to improve healthcare delivery.

But even without the big headlines, population health is quietly yielding positive results for providers. Health systems are becoming increasingly adept at using population health initiatives to segment patients into groups and then define care processes tailored to each group. They also are also coordinating care across healthcare settings, teaching patients how to manage their health effectively, and helping chronically ill patients avoid high-cost ER visits and hospital stays.

For example, Borgess Health, a three-hospital system based in Kalamazoo, Mich., decreased the number of adult patients with uncontrolled diabetes from 29 percent in March of 2015 to 15 percent in June of 2016. To define this population, Borgess included adult patients with a hemoglobin A1c greater than nine as well as adult patients with diabetes whose A1c had not been checked in more than a year. Armed with information about patients with uncontrolled diabetes, clinicians and administrators developed an action plan focused getting patients who hadn’t had their A1c level checked in more than a year back into the healthcare system.

But advancing expertise in population health requires a heavy dose of IT. To segment patients into groups, health systems aggregate and then analyze data from EHRs, financial systems and other sources. After developing action strategies based on their analysis, they also use analytics to track improvements in costs and clinical outcomes by provider, clinic and institution.

Improving care delivery through population health management will become more crucial as healthcare organizations take on more financial risk. In fact, a total of 68 percent of respondents to a recent Health Data Management survey say population health management is either extremely important (26 percent) or very important (42 percent) to their organizations.

The study was conducted by Health Data Management and SourceMedia Research, the research arm of HDM’s parent company. A total of 160 responses, primarily from provider organizations, were received in late 2018.

In addition, another 23 percent of respondents said they expect population health management will be somewhat important to their organizations.

However, respondents generally say their organizations lag in the effectiveness with which they manage population health. Only 8 percent of respondents say their organizations are extremely effective in managing population health, while another 30 percent said their organizations are very effective.

In addition, another 43 percent of respondents to the survey say they are only somewhat effective in managing population health.

The differential between importance and effectiveness in managing population health underscores the complexity of improving initiatives that take care of patients more effectively. Doing so involves more than just technology—it impacts analytics, clinical workflows and approaches, and more, within healthcare organizations.

In addition, from an IT perspective, no single vendor in the current healthcare IT market meets all the requirements of population health management that providers are looking for, says Dale Sanders, who spent 22 years as a healthcare chief information officer and now serves as senior vice president at Health Catalyst, an analytics vendor.

The HDM survey asked respondents to identify their biggest challenges in managing population health, and coordinating care across the continuum was identified as the most difficult obstacle to effectiveness—some 57 percent of respondents named managing transitions in care as the most vexing problem for their organizations.

Close behind in respondents’ eyes is the ability to track care quality and outcomes, mentioned by 53 percent.

Other significant challenges include bolstering patient engagement and developing new workflows, both mentioned by 38 percent of respondents; communicating best practices, identified by 31 percent; and stratifying patients by risk and type of health condition, mentioned by 30 percent.

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