The term Population Health has replaced patient engagement as the latest buzzwords in healthcare. There are a few reasons for this. It is a necessary evolutionary strategy born out of the worsening epidemic of chronic diseases (obesity, diabetes, hypertension, and others). It is also the foundation of a new payment model. Population health is best defined in an article in the American Journal of Public Health by Kindig and Stoddart as “…the health outcomes of a group of individuals, including the distribution of such outcomes within the group…The field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.” Of related importance is addressing disparities in healthcare as contributors to outcomes. As patient outcomes become a metric for value based healthcare payment models, the focus of providers is shifting to preventive medicine, less testing and procedures, and helping people manage their own lifestyles as much as their chronic condition care. Addressing epidemic levels of chronic diseases as a matter of public health (as was done in past centuries in efforts to address infectious diseases) may seem appropriate on the surface, but presents problems concerning civil rights and other regulatory bodies.
- It is about people. An interesting overview of the potential roles of the Center for Medicaid and Medicare Services (CMS) in population health management (PHM) is given in an article in the New England Journal of Medicine. It describes the importance of healthcare between visits to providers, issues around provider scope of practice, necessary partnerships with private industry, and other issues. The article conveys a realistic assessment of the magnitude of the challenges involved in such an undertaking. It will not be something addressed with a single program, entity, or technology. A population is composed of individuals. Many will share common chronic diseases for which treatment guidelines are in place. Others will be at high risk of developing these chronic diseases. Within these groups lie factors which cannot be approached in a cookie cutter fashion.
- It creates a new and questionable way of paying for healthcare services. While population health outcomes are a laudable goal of payment models, there are limitations to what an individual healthcare provider can accomplish. One cannot force a patient’s change lifestyles or medical regimen adherence. Tools which improve adherence and lifestyle can be ‘prescribed’ but many need to be proven and adoption will take years before a (potentially) positive financial impact is felt, for which payment models should take a huge back seat to patient outcomes as a focus of PHM. What does not need to be proven are benefits of changes in lifestyle (which can be facilitated with motivational messages, coaching, and financial incentives). As with all policy changes, the devil is always in the details. Will a physician in a solo or small private practice who is exempt from having electronic health records be held to the same metric standards of PHM as a large physician ACO? Will physicians in geographical areas of high and low rates of obesity or significantly diverse ethnicities be held to the same outcomes metrics? Questions remain as to whether PHM will actually change the delivery of care itself by physicians. According to a report by The Rand Corporation the implementation of other newer health care payment models have resulted in huge increases in non-clinical administrative burdens without a significant change in face to face care changes. I would submit that better access to relevant data (via excellent analytical tools) reviewed and managed by informaticists (recently approved as an internal medicine subspecialty) with technology providing accurate and filtered actionable data is a better way to effect change in care. The implementation of deep and customizable (according to clinical profiles, geography, genetics) patient population registries with analytics and EHR interoperability seems to be an appropriate first step.
- It is a potential equalizer for providers and patients. EHRs were touted to decrease divides among populations by providing data which can result in the delivery of more equitable care. This hasn’t happened because of the inability of EHRs to collect data from multiple disparate sources, facilitate data searches, provide good analytics and to proscribe strategies for PHM. EHRs have the potential to improve patient care if improvements in the user experience of providers via easy to use interfaces and customizable data collection and analysis take place. Patients on the other hand desire, deserve and are not offered portals with good visuals, are mobile, and provide information which they feel will be useful to their clinicians. Patient use of portals presently has been sadly predominantly limited to encounters of minimal quality meeting Meaningful Use criteria which enable providers to receive incentive payments.
- It provides a new focus for innovation and investment. As with all new initiatives in healthcare, PMH presents opportunities for innovation and thus investment in products and services designed to provide the necessary infrastructure and tools to support it. Adoption of tools which provide a perspective (via good registry and analytics) on what is ‘going on out there’ (outside of the enterprise) as well as others connecting the public as consumers and patients to providers is the minimum goal we need to first achieve. According to the 2015 HIMSS Leadership Survey, 38% of respondents said they had PHM tools in place and 51% said their organization improved population health based on IT tools. Two-thirds stated that their organization was increasing its IT budget this year. However, according to a KPMG poll, 38% of respondents described their PHM capabilities as in their “infancy.” Investment by enterprises in analytics is critical in these efforts. The technology is here. Putting the pieces together (see below) and adopting them involve shifting cultural, economic, and internal political forces.
- It requires a multidiscipline team and portfolio of technologies. There is no single organizational department, process or technology which can address PHM. The varied needs of the spectrum of individuals in a population and requirements of different enterprises necessitate diverse strategies, goals, and utilization of human and material resources. As stated previously on this site, technology is not a solution but only becomes such when incorporated into processes and human workflows which accommodate it. Predictive analytics, proscriptive analytics, excellent remote patient monitoring tools, customized and EHR-integrated connected clinical business intelligence,* and intuitive user interfaces* all provide elements necessary for successful PHM. Partnerships among technology vendors, public and private healthcare stakeholder sectors, and between patient advocacy and provider groups need to occur for success. It will take investment and creative strategies to design the most economical,efficient and effective PHM initiatives.
The culture of healthcare on the part of patients and providers must change. Transformation needs to occur more quickly than regulators expect from changing payment models. There is a stellar quality of leaders already in this field. They must be given the political clout and technology tools to achieve those goals because clinicians and patients will not tolerate the status quo of the 15 minute encounter for much longer. The goals of population health management, if focused on the people and not regulations, commercial successes of vendors, or payer subscriber levels, can be met in some significant degree.