Slideshow 6 Lessons from the Population Health Management Front

  • February 22 2015, 7:10pm EST
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6 Lessons from the Population Health Management Front

The February cover story of Health Data Management, Population Health: Promise Becoming Reality, examines the technical underpinnings for managing populations that finally seem to be coming into place, and how providers leverage the IT to identify which cohorts of patients are most in need of ongoing care management.

“While these efforts are still in the very early stages, the documented care improvement and cost savings results thus far are pretty clear--finding patients with conditions that need care management is possible now, and will become absolutely necessary before long,” writes reporter Greg Goth. (Photo: Fotolia)

A new day

New in-house or commercial population management tools are being used as adjuncts to electronic health records. “One of the things I see that is very exciting is, we can begin to look at managing populations of patients far more effectively than we did in the 1990s, when we failed at doing capitated healthcare because we didn’t really have data to do it correctly,” says Jeffrey Galles, D.O., chief medical officer at Tulsa, Okla.-based Utica Park Clinic. “We didn’t have the tools to create the automated outreach and we didn’t have the ability to engage patients because we didn’t have the resources in place. We lost lots of money and created ill will with patients and providers.” (Photo: Fotolia)

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Be picky

However, Galles cautions that predictive tools that may not be ready for prime time should be given time to mature. There is no need now for overreach in identifying patients with “pre-” conditions such as “pre-diabetes” or “pre-hypertension.” Finding and engaging patients with clearly defined conditions is already possible and cost-effective. “We don’t need to make up disease states; we already have enough disease states that are not managed,” he adds. “Down the road we may want to look at predictive tools, but right now we don’t have to. We have plenty of disease to manage in our own practice already.” (Photo: Fotolia)


Some similarities between providers pioneering coordinated management are becoming apparent. There is a common need for better IT-enabled communication between providers and outside entities such as social services, and it’s likely the next step in identifying which services, such as transportation or mental health, should be prioritized for chronic patients. Also, a common realization has been that EHR systems are not up to the task of assisting the new workflows and information needs of coordinated care by themselves. Providers are buying third-party population management tools or building them in-house. (Photo: Fotolia)

Matching patients with care team

Some providers are learning that the identification capability most needed isn’t basic notification that a patient has a specific high risk, but the ancillary capabilities of matching those patients with care coordinators, nurse navigators and the right care environment, and enabling a steady stream of communication with the patient, supported with tools to quickly identity care gaps and reconcile medication received in the hospital with outpatient prescriptions. (Photo: Fotolia)

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Saving Money

A 60-provider pilot of a new population health management platform at Utica Park Clinic resulted in $840,000 in new billable revenue while closing care gaps. Further, supporting R.N. care coordinators with automated care reminders showed measurable health improvements. (Photo: Fotolia)

Own it

At Geisinger Health System, rheumatologists created a value-based course of treatment for rheumatoid arthritis (RA) supported with IT tools, and took ownership of RA treatment across the delivery system. They streamlined contradictory data elements that may over-identify patients through inaccurate diagnoses or multiple codes, and created a more accurate registry of RA patients. Eric Newman, M.D., director of rheumatology, says rheumatologists are very accurate in making a RA diagnosis, but primary care doctors are less so, maybe up to half the time. “In ICD-9, there are essentially three codes for rheumatic disease,” Newman says. “There’s really only one, it’s 714.0. The other two are used less than 1 percent of the time.” (Photo: Fotolia)

Learn More

The February cover story on population health management is available here . (Photo: Fotolia)