Provider-Based Population Health

Online health risk assessments (HRAs) can be used to help make patients aware of their health problems and to help care managers stratify their patient populations by health risk. This approach complements the primary risk stratification strategy, which relies on registry reports to classify patients based on clinical data. ... Read more

On April 12, 2012, Joslin Diabetes (the world’s largest diabetes research and clinical care organization) and Phytel announced a collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies in diabetes care. ... Read more

Companies in the healthcare industry should regularly ask themselves the question, “Should we spend time and resources improving existing products and services or innovating new ones?” The answer to that question depends on several factors. Traditional quality programs, such as Lean and Six Sigma, focus efforts on improving existing products and services. ... Read more

The goal of population health management (PHM) is to keep a population as healthy as possible. It is well known that about 5 percent of patients’ use 50 percent of healthcare resources and 10 percent use 70 percent of those resources. So, while PHM’s goal is to take good care of every person, organizations must pay special attention to these high-risk patients in order to lower population health costs to the maximum extent possible. Many organizations that are beginning to manage population health are focusing on the top 5-10% as a beginning strategy. ... Read more

Recently, Physicians Practice published an article, “Top 4 ACO Considerations for Physicians.” It posed this question to readers: “Confused about how ‘accountable care’ will affect your practice? We’re here to help.”

Overall, this was a great article with comprehensive points detailing the challenges that physicians and practice administrators need to consider for an ACO model. However, I had some concerns over the prominence the article gave to using an EHR to mine population data. ... Read more

Automation tools for population health management will become more important than ever in 2012 as a growing number of healthcare providers begins to take responsibility for the cost and quality of care. Some organizations will further integrate their information systems and automate their care-coordination processes to prepare for the assumption of financial risk. And more and more providers will focus on the patient-centered medical home (PCMH), which can produce short-term financial and clinical benefits while paving the way for the formation of accountable care organizations (ACOs). ... Read more

As a veteran of the disease management industry, and most recently, spending several years assisting provider organizations to manage their patient populations, I fully appreciate the problems inherent in traditional employer-based and health plan-sponsored disease management programs. However, like Al Lewis, I also disagree with the statement that disease management is dead. Although some models have failed in the past, disease management models continue to evolve and are being transformed and incorporated into new physician-led population health models such as the Patient-Centered Medical Home. Further, as health systems assume more financial risk and move towards Accountable Care Organizations, they will take on responsibility for managing entire populations and will be using population health tools and services that evolved from the original disease management principles and fundamentals. ... Read more

A Value Stream is an end-to-end process that flows horizontally through an organization in order to provide value to a client, patient or customer. Many organizations map processes vertically rather than horizontally focusing on a department over the entity that flows through the entire organization. In a horizontal process design, however, because the entity is what is mapped and not a facility or department, handoffs can be visualized and downstream affects identified. ... Read more