Population health management is a core competency of an accountable care organization or a clinically integrated network that aims to succeed under value-based reimbursement. To manage population health effectively, an ACO or a CIN must have a holistic view of patient data.

Data from a single EHR does not offer this comprehensive view. The ACO or CIN must build an infrastructure that can automate the collection and normalization of clinical data from multiple EHRs and other sources, as well as claims data from payers. This infrastructure includes an electronic data warehouse (EDW) where data can be analyzed, and a health information exchange (HIE) that can be used to share key data and insights among members of the network.

This information must be injected directly into clinicians’ EHR workflows. Physicians will not leave their EHRs and go to a website to obtain outside information on their patients.

A holistic view of patients can help physicians avoid redundant orders and procedures. Care teams can also use this kind of data to prevent hospital admissions and emergency department visits. Both of these outcomes can reduce cost and utilization of resources, helping ACOs and CINs to stay within their budgets.

Here are some ways that a holistic view of patient data can support population health management:

  • Risk stratification. ACOs and CINs must be able to stratify their populations by health risk and identify who needs what kind of care. The combination of claims data, which is broad but is often out of date, with narrower, timely clinical data from multiple sources can be very powerful in determining health risks. Social determinants of health, captured from the EHR, patient-generated health data or both, can be used to further refine risk stratification for personalized care plans.
  • Actionable data. After constructing a holistic view of the aggregated data in an EDW, ACOs and CINs must push the clinically important data and associated insights to the EHRs of member practices and hospitals. An HIE that has two-interfaces to these EHRs can be used both to collect data and send back information that can be used in patient care, including care gap summaries, medication updates and admission-discharge-transfer (ADT) alerts.
  • Patient outreach. Holistic patient data can be used with automated patient outreach applications to increase compliance with care plans. This information flows into electronic registries that show which preventive and chronic care services patients have received and when they’re due for care. Triggered by nationally recognized protocols, automated messaging urges patients to see their providers. Depending on patient preferences, these messages can be delivered by email, text or interactive voice response. ACOs and CINs can also use simple questionnaires to create psychographic profiles of patients to fine-tune messaging and increase its effectiveness.
  • Closed-loop referral management. With an HIE that connects primary care physicians to specialists, an ACO or CIN can do closed-loop referral management. When the PCP chooses a specialist, the referral management software can generate a CCD clinical summary based on the holistic patient data, imbed it in the EHR, and transmit it to the specialist through the HIE. The consultant’s report flows back into the PCP’s EHR the same way. If the patient doesn’t see the specialist, the PCP is informed. A similar strategy is used to tell the doctor whether the patient filled a prescription or got a lab test that he’d ordered.

A holistic view of patients is essential to population health management. Without it, a provider has no way of knowing whether patients received particular services outside of his or her practice or network. That lack of knowledge leads to redundant care and makes it difficult for the clinician to make optimal medical decisions. In addition, a comprehensive view of patients’ tests, treatments and health status can help care teams identify and intervene with patients who are at high risk of being hospitalized.

ACOs and CINs need a sophisticated infrastructure to create holistic views of patient data. But once the requisite components have been put in place, the organization is in a much better position to succeed under value-based reimbursement.

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