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4 questions to ask when operationalizing population health management

As the industry continues its steady march toward value-based care, success will depend on how well we operationalize population health management. Four key questions include:

1) Who is my patient population?

The first step in effectively managing the health of a patient population is to define the population. Possibilities include dividing patients into groups by payer, geographic area or, perhaps, people with a specific condition. A single organization will likely define and use multiple populations depending on the work being done.

No matter how providers define their populations, electronic health records (EHRs) and population health tools must be able to help them identify members of the population and turn the available data into information clinicians can use to direct care while continuing to refine the data over time.

2) What’s best for patients?

Population health is a team effort, with patients always at the center. As we move toward value-based care, providers will become responsible for an entire population’s clinical outcomes. We must do what’s best for them – when they come into the office, and when they don’t.

Every office visit is an opportunity to deliver more complete care for patients. However, when primary care physicians are going from patient to patient, seeing them for an unrelated condition, it’s easy to miss those chances to ensure that patients are current with all their preventative care, such as vaccines, mammography, or colonoscopy.

Providers and health systems need to use both EHR and claims data to help identify those patients who never come in, and then need a mechanism to reach out to them. In this way, for example, providers can make sure the entire population is up to date on vaccines, or the diabetic population is regularly reporting blood sugar levels and receiving annual foot and eye exams.

3) How do I get paid for these services?

The patient always comes first, but to remain viable, practices must consider how these services will be reimbursed. As value-based care payment models continue to evolve, no one is sure exactly what to expect other than that the way we receive payment will drive many of the decisions about what, when and how care is delivered.

Most physician practices contract with multiple private payers along with Medicare and Medicaid.  Historically, each of those payors requested different quality measures and offered a variety of pay for performance programs. So, one patient has Payer A, who measures success one way, but another has Payer B, who will measure it another way. Clinicians must approach each patient thinking about doing their best for that person, and not about the differences in how insurers measure quality.

4) What technology will best help me manage these populations?

Technology must help providers manage patients across the entire continuum of care. Today, telehealth and email visits are emerging methods by which providers are managing patients remotely, and their use is continuing to grow.

Population health management is a team sport. Patient information and care plans must be securely accessible to all team members to promote coordination throughout our fragmented system, as helping maintain a healthy population is not limited to any individual care setting.

Advanced analytics are making it increasingly possible to slice and dice the data, providing a variety of views of patient populations. The importance of this capability will continue to increase as the shift to value-based care continues.

These tools must make insights available within the clinician’s workflow, or they will not be successful. Data needs to be available from the EHR even if it resides elsewhere. Various data sources need to be aggregated and normalized into information which is presented in a manner that enables the clinician to act upon it.


Editor’s Note: To read more from Dr. Blackman, see 7 Questions with Michael Blackman, MD, MBA, Medical Director for Allscripts in Becker’s Hospital Review.

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