Population health management is quickly becoming a critical competency for healthcare organizations large and small.
From the primary care offices responsible for preventive services to inpatient hospitals on the hook for penalties around 30-day readmissions, understanding patterns of risk and acting proactively to avoid expensive health events are crucial for success in a value-based world.
In order to get ahead of rising risks and close gaps in care, healthcare organizations are investing billions of dollars in data analytics tools that deliver predictive alerts, clinical decision support, patient relationship management capabilities, and other functionalities to support the Triple Aim.
The stakes are high for organizations participating in pay-for-performance models or accountable care arrangements, and providers simply cannot afford to make a substantial investment in a population health solution that ends up falling short of their needs.
Choosing a population health management company that can become a true partner in success requires a careful assessment of the market and detailed knowledge of the organization’s own resources, objectives, strengths, and weaknesses.
Create a goal-oriented roadmap
Population health management is a wide-ranging, culture-driven outlook on healthcare that should, ideally, become deeply integrated into every part of an organization.
“Transitioning your practice mindset and approach from providing episodic care at appointments to a more proactive approach to managing your patients' health can seem daunting,” acknowledges the American Medical Association in its Steps Forward educational modules.
“One ‘best’ way to approach [population health] management does not exist; different practices and organizations have succeeded with various approaches to both in‑reach and out‑reach. Assess your practice and your resources, and create a model that will work best for you and your patients.”
Identifying an overarching goal – and the series of smaller tasks that build upon one another to achieve that larger objective – can help organizations understand exactly what technology they will need to support ongoing progress.
For example, a primary care provider may wish to work towards a long-term goal of reducing the number of emergency department visits for its diabetic population by 20 percent over the next 12 months.
In order to achieve this goal, the PCP will need to achieve a number of contributing objectives, including:
- Developing a patient registry to flag all patients with a diabetes diagnosis
- Ensuring that every patient who meets the clinical criteria for diabetes has a coded diagnosis in their current medical record
- Creating a health maintenance template within the electronic health record (EHR) to illuminate gaps in care and prompt action from providers
- Implementing a care management program designed to help diabetic patients manage their own health
- Hiring or training a care manager or patient navigator to engage individuals in chronic disease management, ensure collaboration between providers, and prevent lapses in blood sugar control
- Tracking and reporting upon results, including any changes in emergency department utilization that may be attributed to the initiative
Organizations that already have a robust patient registry or currently utilize an EHR with effective health maintenance templates will likely find themselves in need of slightly different additions to their population health toolkit than a provider that is starting from scratch.
While it may seem like a Catch-22 to ask providers to select detailed population health goals before they have the technical capability to examine their patient data, providers have a number of resources at their disposal to help define strategic objectives.
“One ‘best’ way to approach [population health] management does not exist.”
Payers with access to longitudinal claims data may be able to assist with flagging high-cost conditions or noticeable gaps in screenings or follow-ups.
Payers also hold much of the responsibility for architecting value-based care arrangements and the quality measures that indicate success. Provider organizations have a financial incentive to focus on those quality measures, and may find that some or all of the roadmap for success with those metrics is already available to them.
Providers can also turn to community organizations and public health departments for inspiration, especially around the social determinants of health and their impact on community outcomes.
CMS also provides county-level chronic disease data, spending data, and care disparity information at the county level to help providers determine what interventions may be most necessary to target.
Map population health goals to specific health IT capabilities
Meaningful, measurable, and well-defined goals are directly correlated to making smart technology purchases.
Without clearly defining goals and the associated tasks that lead to their completion, organizations run the risk of purchasing redundant tools or overinvesting in options that may not be completely necessary for their chosen objectives.
To ensure that organizations are exploring the right options to support their current and future efforts, providers should understand exactly what technology tools are required to check off each item on their roadmap.
Most incremental goals, such as segmenting a population into low, medium, and high risk for a certain condition, can be mapped to a specific component of typical population health management health IT offerings.
Population health management platforms, whether they are stand-alone systems or features integrated into an electronic health record, must enable one or more of the following capabilities:
Population health management requires synthesizing data from multiple sources to develop comprehensive portraits of individuals and the sum total of healthcare services they receive.
Aggregating claims, lab data, pharmacy records, imaging tests, specialist notes, inpatient records, and socioeconomic data can give providers actionable insights into rising risks, missed opportunities for interventions, or behavioral patterns that might lead to poor outcomes.
Data aggregation is closely tied to data warehousing – organizations must have somewhere to store their combined data sets. Both require a reliance on industry standards to ensure that data is clean, complete, correctly reconciled, usable, and interoperable once it has been collected and is ready to deploy for analytics.
“A strong PHM solution is flexible in aggregating data and enabling provider organizations to make sense of it,” said KLAS Research in a 2018 report. “It must be reliable in maintaining data feeds and accomplishing the Herculean task of cleaning the data so that the functionalities of the second vertical—data analysis—can be successful.”
With many healthcare organizations utilizing a patchwork of infrastructure, and pipelines between different EHRs and other data generation systems still posing some problems, a population health platform that can reliably aggregate data from across the care continuum is a foundational necessity for success.
Once data is aggregated, it can be analyzed. Healthcare organizations are increasingly relying on analytics to stratify patients by risk using collected longitudinal data, which is a key first step for developing personalized disease management programs and coordinating care.
Risk scoring can also be used to feed predictive analytics algorithms, including machine learning and artificial intelligence models, to alert providers to impending events such as an emergency room visit or hospitalization.
“A strong PHM solution is flexible in aggregating data and enabling provider organizations to make sense of it.”
Automated analytics capabilities are particularly important for keeping track of large populations over long periods of time due to the sheer complexity and volume of the data involved.
Vendors should offer analytics capabilities that allow providers to attribute patients to particular clinicians, measure and report upon performance and quality metrics, and track internal goals and benchmarks, according to KLAS.
“The vendors who drive the highest satisfaction tend to do well with prepping data before it reaches the analytics tools,” the report notes, highlighting the importance of data aggregation as the first step for actionable analytics.
The report also recommends choosing a vendor that is willing to collaborate closely with the organization and its unique needs. Even organizations that are fortunate enough to have experienced in-house data analytics teams will require some degree of input, advice, and action from a solutions provider.
“When collaboration isn’t happening on a close level, there can be lack of understanding about the functionality and a decreased ability to get the necessary information,” KLAS cautions.
Reporting and visualization
Data that gets to the right person at the right time also has to be in the right format for easy, intuitive consumption.
Visualizations can help to highlight key concepts and ensure that important information is seen and utilized appropriately.
In the healthcare environment, “getting through so much raw data is extremely difficult, especially for someone who isn’t trained to see the patterns,” says Steve Davis, Health Research and Policy Writer at Deloitte.
“Cleaning the data and presenting it in a visually meaningful manner makes it a lot easier to sift through large volumes of information.”
Visualizations, dashboards, and graphs that represent data accurately and consistently are necessary to help end-users correctly interpret the patient stories behind the data.
“In healthcare, we see a lot of things that look like trends but that might just be correlations without provable causation,” said Davis. “For developers, the trick is how to represent those visually without implying something that you don’t mean to convey.”
Population health management companies should offer dashboards, charts, and interactive visualizations that follow commonly accepted conventions, including consistent use of units, chart types, and colors, clear labeling of axes and data elements, and the ability to drill down into the data sources contributing to the chart or report.
“Cleaning the data and presenting it in a visually meaningful manner makes it a lot easier to sift through large volumes of information.”
Since the ability to take action on information depends on how well that information is presented and how easy it is to consume, organizations looking to flag certain aspects of patient care for their clinicians are encouraged to choose population health tools that are visually pleasing and easy to understand during hectic days and short appointments.
Care management and care coordination
Once gaps in care are identified, they must be resolved quickly and efficiently to forestall preventable acute events. Care management and care coordination strategies are integral components of a successful population health management program.
“For high-risk and/or high-cost populations, personalized care plans play a critical role in coordinating care among various providers,” explains the Agency for Healthcare Research and Quality (AHRQ).
“Other services, such as coordination of specialty referrals, assistance with ancillary services, and referrals to and coordination with community services, also support high-risk and/or high-cost populations.”
Care management and care coordination tools support providers as they create and deploy comprehensive care plans for individuals with chronic diseases and other complex needs.
These tools must be able to identify modifiable risk factors, foster communication between care providers, and equip care managers with patient outreach capabilities.
Care management software should prioritize collaboration and communication between disparate provider organizations, according to a 2017 report by Chilmark Research.
Every member of the patient’s care team, from PCPs to specialists to hospitalists, should be able to view and appropriately edit a patient’s shared, longitudinal record. This capability allows the entire team to work together without duplicating effort or missing critical steps in the process.
“It is well understood that poorly executed transitions of care between different locations (e.g., from hospital to primary care) are associated with increased risks of adverse medication events, hospital readmissions, and higher health care costs,” observed AHRQ.
“Determining which transitions present the greatest risks and targeting CM services to patients undergoing those transitions should conserve resources and lead to better cost and quality outcomes.”
The health IT system should be able to deliver meaningful event alerts, such as admission, discharge, and transfer (ADT) notifications, without overwhelming users with low-value messaging.
Care management tools may also provide information on existing interventions, including structured chronic disease management programs or alert providers to new programs for which the patient may be eligible based on available clinical criteria.
“Many organizations are pushing to have all of this housed within their EMR,” points out KLAS. “Thus, there is a need for strong interfacing or integration with the EMR to facilitate the flow of information care managers need.”
Care management and patient engagement are closely aligned, and many of the technologies and strategies overlap. However, while care management is largely a provider-to-provider issue, patient engagement focuses on building relationships between the providers and the recipients of healthcare services.
Patient portal adoption is on the rise thanks to the EHR Incentive Programs’ successful campaign to integrate the technology into provider offices and hospitals. As of 2017, more than half of individuals have been offered access to their personal health data, and about half of those patients (28 percent of all patients) have viewed their information online.
But effective patient engagement transcends the patient portal. Providers are increasingly exploring proactive outreach tools, such as text messages and automated phone calls, to keep individuals on track with their chronic disease management programs and other health needs.
Vendors are now offering patient engagement technology platforms that deliver tailored educational materials, track completed and missed interactions with patients, and collect patient satisfaction data to further optimize engagement efforts, KLAS says.
“Currently, many organizations’ patient engagement strategies are fairly broad and don’t yet go beyond basic patient satisfaction,” the report added.
“Patient engagement is currently the vertical with the least adoption. Many provider organizations have not deployed patient engagement functionality because they are still building out their patient engagement strategies.”
Patient engagement technologies are also evolving rapidly, especially as artificial intelligence matures to support chatbots, ambient computing, and virtual personal assistants.
“Many provider organizations have not deployed patient engagement functionality because they are still building out their patient engagement strategies.”
Low adoption rates and a constant stream of new options can complicate the process of choosing a health IT toolkit that will deliver value immediately while still remaining future-proof.
Numerous niche vendors are taking advantage of the fluid market by offering smaller, targeted, bolt-on tools that are intended to supplement existing patient engagement strategies, KLAS notes.
The plethora of options and the quickly maturing environment reinforces the notion that organizations should establish clear, concrete, and well-defined goals before investing in a particular technology approach.
Identify vendor-customer partnership values
In the world of enterprise technology, a relationship with a vendor is typically an ongoing affair. Health IT vendors are increasingly selling platforms, not just individual tools, that align a customer with an entire ecosystem of related technologies.
Platforms have their merits, especially as organizations continue to struggle with interoperability woes and outdated legacy systems. But adopting a “health IT operating system” also comes with challenges – and those challenges can be compounded if a vendor and a customer are not on the same page.
Just as every organization has its own population health management goals, every provider prioritizes different aspects of the vendor-customer relationship.
To ensure that an organization’s expectations are fulfilled, leaders should assess exactly what they desire from each step of the sales, implementation, and support process.
Sales and contracting
Just like any relationship, a hard sell at the beginning can be very convincing but not entirely representative of what comes next. Organizations should go into a negotiation with a clear idea of what they are looking to purchase, how much they are able to spend, and what contracting provisions they are willing to accept.
Several high-profile incidents earlier in the decade led the Office of the National Coordinator to release a detailed guide on how to contract successfully with health IT vendors, including strategies for identifying hidden fees and potentially problematic data ownership clauses.
Before signing on the dotted line with any health IT vendor, organizations should have legal experts review the contract. If the vendor balks at having to answer questions, especially around critical issues such as HIPAA compliance, providers may wish to look elsewhere for their technology needs.
Implementation and training
Implementing a new technology can be a time-consuming, costly, and frustrating affair, especially if the vendor is part of the problem and not part of the solution.
The ONC suggests that all contracts should include a warranty from the service provider that all vendor-associated personnel will be adequately trained to implement the technology, that the vendor will not cause harm to the organization or its data assets, and that all implementation and maintenance services will be conducted in a timely manner.
Vendors should explain exactly what they offer in terms of implementation support, staff training, and troubleshooting. Some vendors are extremely involved in the process, while others encourage customers to take matters into their own hands.
If the available support has been clearly explained but is not sufficient for the organization’s needs, leaders should consider contracting with a consultant or hiring an implementation expert to guide the organization through the early days of adoption.
Alternatively, providers may consider cloud-based or as-a-service models that typically require less up-front investment in the implementation process.
Upgrades and optimization
All software becomes outdated at some point, and upgrades are an inevitable part of the health IT adoption equation. Upgrades can be problematic, however, especially if there are unexpected fees involved or systems must be taken offline during the process.
On-premise solutions typically require more extensive effort to upgrade, while many cloud-based systems tout their ability to roll out changes quickly and seamlessly across the entire customer base at once.
No matter what the process, organizations should understand what is involved in moving to a different version or tweaking a functionality to better suit their needs. Vendors should be able to explain the process and identify potential pain points that may impact daily operations.
Vendors should also be upfront about costs to implement new versions, migrate data between versions, or provide on-site support staff during an upgrade.
Customer service and support
Customer service during day-to-day operations is equally important for ensuring that an investment in a population health management tool is worthwhile.
Help desk personnel should be responsive, knowledgeable, and transparent with callers when an issue will take extra effort to resolve.
“Those who call into the help desk want to be more than a ticket,” says Dan O'Connor, RN, from Stoltenberg Consulting.
“They want to be acknowledged as individuals with critical needs that should be addressed quickly and professionally. If end-users are not satisfied with help desk issue resolution and knowledge transfer, the same mistakes will repeatedly occur, causing operational redundancy and patient care inefficiency.”
“Those who call into the help desk want to be more than a ticket.”
Vendors that do not supply effective and efficient customer services are likely to quickly lose the loyalty of their end-users – and organizations may find that their clinicians start grumbling about having to work under less-than-optimal conditions.
Even the warmest vendor-provider relationship can hit unexpected snags when a tool malfunctions or a misunderstanding occurs.
While no organization wants to enter a contract with negative expectations, providers should be frank and open with their vendors about what should happen when the two entities don’t see eye-to-eye.
Customers should be shown a clear pathway for escalating complaints or questions, and vendors should be highly responsive when such a situation arises. Informal discussion or formal mediation may offer a solution before litigation is required, the ONC says.
No matter what strategies are included, dispute resolution plans are among the most important parts of negotiating a strong, equitable contract.
“A well-drafted dispute resolution provision can help ensure that problems are satisfactorily resolved in a manner that is beneficial to you,” says the guide. “Additionally, a dispute resolution clause can help to preserve the parties’ relationship during challenging periods.”
Ask for peer recommendations
Organizations that have defined their population health priorities, matched those goals to specific technology capabilities, and decided how to best craft a positive vendor-customer relationship may still be missing one key component of making a good decision: input from their peers.
While organizations should strongly consider having candid conversations with colleagues at similarly-sized providers, market reports that collect in-depth insights from existing customers can also be a significant part of choosing a population health management company that will produce ROI with minimal friction.
Many of the well-known EHR vendors also top the list of best-in-class population health management solutions.
Epic Systems, Allscripts, athenahealth, and Cerner Corporation consistently receive high marks in customer satisfaction, functionality, and usability from industry observers including KLAS, Black Book, and Chilmark Research.
But dedicated population health management and data analytics vendors are also exceedingly viable options.
In its most recent population health report, KLAS cited Enli as its “Best in KLAS” population health winner. The Oregon-based solutions provider received much higher-than-average marks for sales and contracting as well as service and support.
Forward Health Group and HealthEC also garnered positive reviews from customers, especially the accountable care organizations (ACOs) and smaller hospitals they serve.
The KLAS report observed that EHR-based population health management products tend to be broadly but shallowly adopted with only average consumer satisfaction, whereas more niche solutions are able to provide high levels of clinician engagement and deliver targeted insights.
A Black Book Market Research brief from early 2017 concurred with the notion that best-of-breed population health management and analytics solutions provide more satisfactory experiences than their EHR-driven competitors.
IBM Watson Health, The Advisory Board, Optum, and Wellcentive Philips were among the top ranked companies in that report, despite the fact that participants in the research tended to prefer comprehensive platforms that combine EHRs with population health over a module-based infrastructure.
The variation in consumer satisfaction may once again highlight the importance of creating a comprehensive wish list and communicating clearly with vendors before implementing population health management tools.
As functionalities continue to evolve and data analytics become more and more central to success with value-based payments and other innovative delivery strategies, providers should careful examine both their own objectives and the existing options on the market.
Planning carefully before committing to a population health management company, and collecting information from peers and other industry sources, can help to ensure strong alignment between a provider’s goals and the technologies that will support them as they work to reduce costs and improve the delivery of quality care.