HIT Think

How technology can help providers improve pop health efforts

Healthcare providers agree that focusing on prevention can help reduce care costs and drive better outcomes and patient experiences. In turn, those things lead to reimbursements. Providers also know that a key part of prevention involves proactively managing the care of both groups and individuals – something that carries significant challenges for healthcare teams.

A recent survey by West Corp. revealed that accessing essential data from disparate systems, staffing limitations and lack of consistent strategy are common obstacles providers experience related to population health management. For healthcare teams, technology plays a major role in overcoming these challenges.

When hospital and health system providers, physicians and other medical professionals were asked to identify obstacles surrounding population health management, about a third of respondents pointed to data, staffing shortages, and difficulty developing a consistent strategy as each being substantial issues.


According to survey responses, 44 percent of providers feel that obtaining sufficient staffing to run an effective population health program is difficult. Also, 38 percent of providers agree that without established best practices, achieving the best outcomes for an entire population is challenging. Finally, 35 percent of all respondents indicated that they did not have adequate access to clinical data from disparate systems.

The very basis of population health is data. Providers can only manage population health if they have data to use as a guide. Therefore, it is vital for teams to be able to leverage data from their electronic health records systems so they can better understand the makeup and needs of their overall patient populations. The good news is that two-thirds of the medical professionals surveyed said they currently utilize EMR data to help predict health issues for patients. That is an important first step to identifying strategies that will help keep patient populations healthy.

From an IT perspective, one way to ensure population health success is to make sure reliable data is easily accessible. Clinicians typically need help retrieving and analyzing data. By putting valuable data and key insights into the hands of clinicians, healthcare IT professionals can lay a foundation for successful population health management.

Staffing is considered to be another primary challenge related to population health management. After all, providers that are not accustomed to using data to stratify health risks, assessing patients’ needs between appointments, contacting patients to encourage participation in routine preventive services or monitoring conditions for signs that additional support is required, can be overwhelmed by having to find staff to perform these tasks. However, while taking on these population health responsibilities does require some staffing adjustments, healthcare teams need to realize that through automation, managing population health is achievable.

In a recent interview, Bill Spooner, retired CIO from Sharp HealthCare and now an independent healthcare IT consultant, noted that provider organizations must have seven key information system components to effectively manage population health initiatives. The components, taken together, give healthcare organizations a solid foundation in taking in patient data, storing it, organizing it and acting upon it.
June 17

Staffing challenges can be solved by automating outreach efforts. While it may be impossible to manually reach out to 500 patients to see whether they are, for example, taking their prescribed blood pressure medication, automated technology can make this type of outreach possible. And automated outreach requires minimal staff to execute.

By using EMR data to stratify patient risks, healthcare teams can develop and send communications on a one-to-many basis to help groups of patients manage their health. Once risks are stratified and patients are organized into subgroups, providers can use automated technology to deliver communications that engage and activate patients. This automation reduces the pressure on clinical staff and allows providers to contact entire groups of patients effortlessly.

For example, a clinic’s diabetic patients can be put into a diabetes management program where they will regularly receive automated communications tailored to their needs. This might include text messages that alert them when they are due for foot or eye exams, voice messages that prompt patients to schedule appointments for A1c draws, or seasonal emails with information about flu shots. The point is, the repetitive outreach that benefits groups of patients with similar health conditions and needs can be performed automatically – so the strain on clinical staff is limited. Staffing becomes much less of a problem when teams rely on automated technology-enabled communications.

Hospitals and health system providers know that engagement communications can drive patients to take actions to become healthier. A large majority (80 percent) of hospital and health system providers believe their patients are receptive to receiving text messages about their care. They also believe sending text messages to patients can strongly influence patients to take specific actions, like schedule a follow-up appointment.

Sending automated messages is only effective if there is a good strategy behind the communications. Healthcare teams need to think through the messaging and timing of communications. Also, to manage the health of an entire population, providers need to be able to do more than just send messages to patients, they need to be able to receive information and respond appropriately. Every population health strategy should include two-way communication. IT staff can help ensure technology is set up to allow for two-way communication.

Effectively managing population health aids provider organizations in achieving their financial goals. Preventing health issues before they begin reduces healthcare costs and makes life better for patients. Demonstrating a pattern of results that includes reduced care costs and positive patient experiences can help healthcare organizations earn reimbursements. For example, hospitals and health systems may be able to reduce readmissions and avoid negative payment adjustments by implementing population health strategies.

Despite its challenges, population health management offers many opportunities for patients and providers. Health IT professionals can support the population health mission with efforts that ensure technology is used to deliver valuable data, automate processes and make strategic connections with patients.

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