Proactive Care based on PHI and Patient Demographics
Population Health Management software enables care teams to share PHI (patient demographics, medical history, conditions, medication list, etc.) and to gain insight and manage health proactively. It is THE next critical step in Healthcare IT advances, and there’s no clear market leader yet. With this being the case, I decided it was time to write on the current state of Population Health Management software.
American healthcare insurance companies (i.e. the payers) and hospitals, clinics, etc. (i.e. the providers) need to share data and collaborate in order to successfully transition to the new value-based accountable care model (Obamacare), where the payers and the providers share the risk (see Payer News and Moves at HIMSS14 and 8 Reasons Payer Data Sharing is Essential in ACOs).
The key to a successful ACO is effective Population Health Management (see So what Exactly Is Population Health Management?). PHM requires proactive strategies and interventions to defined groups of individuals. For example, a particular General Practitioner’s (GP’s) patients, in an effort to improve the health of the individuals within the group at the lowest necessary cost.
PHM requires a provider to do a lot of things proactively such as automatically identifying patients that have care gaps and finding ways of getting those patients to come in for their annual physical.
The following roadmap helps healthcare organizations navigate the path toward implementing effective population health management:
- Establish precise patient registries
- Determine patient-provider attribution
- Define precise numerators in the patient registries
- Monitor and measure clinical and cost metrics
- Adhere to basic clinical practice guidelines
- Engage in risk-management outreach
- Acquire external data
- Communicate with patients
- Educate patients and engage with them
- Establish and adhere to complex clinical practice guidelines
- Coordinate effectively between care team and patient
- Track specific outcomes
So, who is going to do all of this work I just identified? Certainly not the doctor or the nurse, who are already swamped. Enter the evolution of 3 key roles:
- The Care Coordinator
- The Case Manager
- The Utilization Manager
Understanding these personas and their workflow, what will be useful to them, when to surface data, etc., are all key questions that software vendors need to consider.
Analysts are forecasting that the Population Health Management Market will be worth $40.6B by 2018.
No single vendor in the current market meets all the requirements of population health management. And it’s no wonder! There is no clear buyer or clear user/workflow pattern that has emerged yet.
A vendor that enters this market is effectively throwing software ideas against the wall and seeing if something sticks. They will need to be prepared to continually iterate software to keep up with the evolving processes.
Check out this article on the Evolving Role of the Care Coordinator. This was written two years ago and yes, this is still a major trend, but how much more do we know about the care coordinator today?
How do different vendors stack up right now for population health software?
Traditional HIT and EMR companies – Providers are beginning to discover the limitations of the EMR for managing at the enterprise-level all of the information necessary for effective risk-sharing (see here). EMRs are mostly focused on meaningful use and episodic sharing of information for patients that come into the office.
- Little capability to find and engage the patients that need to be seen, but are not yet engaged (i.e. not proactive).
- There is no standard way to exchange gaps or other actionable information via a “closed loop” process between actionable recommendations and actions taken.
- EMRs generally don’t manage state or discrete data.
Traditional HIT and EMR companies that are looking to enter the market are largely focused on the creation of new software from scratch. MEDecision and MEDHOST appear to be examples of software vendors who have successfully transitioned from more traditional healthcare IT offerings, to specialized population health management software.
HIEs – Health Information Exchanges are good at aggregating data from different sources, but are not designed to store or analyze the data with the level of sophistication required for supporting a risk-sharing model.
PHM-specialized software vendors – including Phytel, Caradigm, Health Catalyst, etc. have various shortcomings (see one competitive firm’s analysis here).
Payers – Some employees of insurance companies have the experience to deal with risk management, population management and actuarial risk balancing. For example, network officials can review clinical data and make phone calls to primary care doctors if they haven’t been seeing patients who have high acute-care utilization. The data is also useful in ensuring that discharged patients receive necessary follow-up care, and in helping the executives quantify the results of their efforts in metrics, such as reduced readmission rates.
Cigna, a global health insurance service company, would like to provide their data at the point of care (e.g. lab results, gaps in care), but they face a number of technical and usability challenges:Clinical workflow – how
- Clinical workflow – how does data and timing align with practice workflow?
- Evaluate information conflicts – where do claims/insights from health plan data align or conflict with EMR information?
- Lack of automated and efficient two-way communication. “Closing the loop;” how does information flowing to practice, result in data response to health plans and actionable insights for the payer?
- Lack of suitable interoperability standards, HL7, and CCD are especially poor for PHMThey’re not integrating with an EMR product; they’re integrating with a single EMR deployment at a participating provider site. Each site deployment is a whole new project with little in common with the others.
- They’re not integrating with an EMR product; they’re integrating with a single EMR deployment at a participating provider site. Each site deployment is a whole new project with little in common with the others.
While cooperation with other parties is part of the strategy, payers aren’t resting on their laurels. Some have taken the initiative and offered their own PHM software, notably Aetna’s Healthagen portfolio for PHM and UnitedHealth’s PHM software via their Optum business.
Payer success in this market will take time, because:
- They are relatively new to creating engaging software (see the recent Payer Apps: An Epic Fail).
- Their PHM portfolios (at least Healthagen and Optum) are made up of product acquisitions, making interoperability, and user experience consistency across products a challenge.
- Payer motives are typically distrusted in regards to gathering patient data.
In my view, whether you are a traditional Healthcare IT or EMR vendor, a niche PHM vendor, a payer giant, or a startup, the keys to Population Health Management software in 2016 will be:
- A deep understanding of the target users that the software is serving; their goals, motivations, workflow, and the overall journey (developing a user experience persona and journey map for the Care Coordinator role would be a good start).
- Access to accurate population data – which implies interoperability – will encourage cooperation between all of the above entities.
- An emphasis on engaging the patient (through self-care software, communications technology, alerts, and interventions, etc.).