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June 4, 2015 News No Comments

Laying the Foundation of Healthcare’s Next Generation of Care
By Dana Alexander, RN


Population Health—it’s something we all talk about, and have for years. It’s the Holy Grail we’re all after, and just recently there’s been a glimmer of hope in the eyes of healthcare leaders everywhere that maybe managing the health of our communities is closer than we thought. As incentive programs and federal regulations push us towards a value-based service and payment reform, the motivation is stronger for more collaborative, integrated health management. Now more than ever is the time to start the discussion, which is what prompted my recent white paper, Population Health: Laying the Foundation of Healthcare’s Next Generation of Care.

A fair disclaimer for readers: This is not a rose-colored vision of providers across the country holding hands and solving all the health challenges patient populations face. Population health management (PHM) is not a system you can implement, or a program you can put in place overnight — it’s a lot of hard work, including technology challenges and culture shifts across providers, payers, and patients. But with all good things, the hard work pays off, resulting in better, safer, higher-quality, and more affordable care for our communities.

We all have different visions of PHM — for me, it comes down to four separate, but intertwined pillars: data management; population management and risk stratification; care management; and patient engagement. A lot has happened in a decade to make these four aspects come together, and we’re finally using data, technology, and legislation to lean a bit closer to the Triple Aim of better quality, lower costs, and improved health.

Data Management. The phrase “You’re only as good as your weakest link” couldn’t be truer than with healthcare data. In the era of Big Data, data analytics, and business intelligence, the data we use to make more informed decisions, better understand our populations, and predict health occurrences has to be rich, reliable, and, most importantly, standardized. Healthcare data comes in all different forms and fashions, EHRs only being one source (granted, a very important one). Standardization of data isn’t just important for using it, but also for sharing it. The secure exchange of population health data via HIEs is a critical and up-and-coming milestone for PHM.

Population Management and Risk Stratification. Provider registries, EHRs, etc. are already collecting data on our populations, and providers use this in smart ways to understand which patients need what treatment and at what levels of care. That being said, and going back to data management and sharing, this view of a patient population is limited, sometimes even within hospitals in the same health system. Disparate systems and siloed data leave providers to make encounter-based decisions versus patient-based decisions, holding back the potential of true management and risk stratification. The big picture of risk stratification takes health and demographic data and turns it into a large-scale view of a population’s health, plus provides the ability to drill down to at-risk subpopulations for targeted …. you guessed it:

Care Management. Targeted, proactive care management models, utilizing data sharing and risk stratification, offer patient populations care management programs that 1) address the health challenge 2) treat it 3) prevent it, and 4) communicate with and provide tools to specific groups that improve health moving forward. Telehealth strategies are quickly becoming the “go-to” care model, especially as our patient populations become more tech savvy. Care models that make sense for the patient (both for their health and their lifestyle) are the success stories. Engaging patients in their health … OH, wait ….

Patient Engagement. Like I was saying, engaging patients in their health in ways that touch their day-to-day lives not only opens up the lines of communication outside of a doctor’s office, but makes patients more engaged, and therefore accountable for, their own health. Patient engagement is the lynchpin of a successful care management model, but it starts with the organization understanding the patient, which comes from population management and risk stratification, which comes from standardized data management, which all comes together and succeeds with open, secure information sharing.

As you can see, each of these aspects intertwine with one another — each can be more successful with the advancement and fine tuning of the other. For a lot more on this topic, take a look at the complete white paper.

Dana Alexander, RN is vice president of clinical transformation at Divurgent.


JenniferMr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan

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