Population health management (PHM) means different things to different people. It is a term which is in vogue now because of its injection into healthcare provider payment models and describes a strategy in which individual and patient subgroups are cared for outside of the traditional office and hospital sites. In a previous post I discussed why population health management matters. Such a strategy necessitates technology which interacts with patients and their caregivers in a bidirectional way with clinicians and ancillary staff. These interactions should involve both objective data and subjective insights from patients. In this piece I’d like to give my thoughts on what constitutes ideal patient management technology irrespective of one’s definition or the long-term survival of ‘population health management’ in payment models.
- Patient-facing portal. I was taken aback in discussions with some PHM technology vendors whose product had no patient-facing aspect. Such an approach defeats the mission of PHM which by definition incorporates patient self-management and behavior modification. The aim of PHM is to extend care outside of the brick and mortar of traditional venues, transforming points of living into points of care. If most chronic diseases are preventable in large part with lifestyle changes, then PHM must extend to the patient/consumer and the places where these choices are made.
- Mobile platform. Any technology which addresses direct patient care today needs to be on a mobile platform. It is unfortunate that mobile versions of most electronic health records are woefully inadequate today. The mobility of a PHM platform should be a given, since it is something both providers and patients expect today. Due to the critical nature of patient/consumer involvement required for self-management, mobile is a prerequisite component for success because most patients and caregivers expect this from any digital technology.
- Connected care tools. PHM is all about collecting data and at the same time transforming it into relevant Objective information via patient-generated data sets is a critical component of PHM. The types of data sets collected would hopefully depend upon the patient or disease state population in question. The data must be filtered to be relevant to both clinicians and patients. Patient-derived data tools (relevant to vital signs usable for heart or lung disease, diabetes, activity tracking, medication adherence, behavioral health) may be provided as third party technologies or proprietary to the PHM platform vendor. Patient-derived data also comes in the form of subjective data. Objective data must be supported with patient reported outcomes which provide necessary real world evidence. Together, the objective and subjective data complete a picture that benefits the individual patient (who can ideally view personal data relative to others in the population examined) a targeted patient population, the clinician, payer, and other stakeholders in HIPAA compliant ways.
- Real-time analytics. There is no arguing that Big Data is critical in healthcare today. What is underappreciated is the value of real-time analytics to enterprise operations, patient safety, and better clinical outcomes. Yet analytics are woefully underutilized by healthcare enterprises. In a Deloitte Center for Health Solutions 2015 US Hospital and Health System Analytics Survey of CIOs, CMIOs, and senior IT leaders, less than 50% had a clear integrated analytics strategy. As correctly pointed out in the survey, value-based care will necessitate such a strategy in order “…to blend financial, operational, clinical, and other data to achieve their goals of improving quality, providing access, controlling cost, and managing provider networks…” A platform which curates such data in real-time with customizable analytics by each stakeholder (including patients themselves) is what makes the data relevant. Big Data collected by payers (including Medicare), regulatory agencies and others is often up to 12 months old. Process and patient outcome improvement as well as patient satisfaction cannot be dependent upon such outdated information. In addition, the data is raw, unfiltered, and not user-specific. Enterprises need to pivot quickly to provide the best services in the most economical way. The ability to have current accessible relevant data is expected and available in all business settings. It is imperative and even more important in a sector of the economy which utilizes almost 18% of the USA’s GDP.
- Social interaction. As stated above, active patient participation in a PHM is critical. This relates primarily to the importance of human behavior as a driver of health, wellness, shared decision making and treatment. The importance of social media in healthcare cannot be underestimated. Social media in healthcare involves both patients and clinicians exemplified by such online sites as Mayo Clinic Direct. Such interaction promotes communication which improves treatment adherence as well as serving as a source of patient reported outcomes (PRO) data (see above). The value of online patient communities has been appreciated for a while now and supports a comprehensive PHM strategy.
As one can see, PHM is a concept which is not standardized and developing both in terms of strategy as well as the role of digital technology in it. I am eager to observe how the challenges of digital divides, patient behavior, and the culture of traditional healthcare affect the extent and rate of adoption of PHM strategies. I look forward to and am optimistic about the future in this regard.