Shifting to Value: Population Health Management Technologies for Accountable Care
A new whitepaper, “Shifting to Value: Population Health Management Technologies for Accountable Care,” explores that as population health management takes center stage in healthcare transformation, it’s becoming clear that the medical neighborhood must be better organized to improve care coordination and ensure that all patients receive the right care at the right time. The hub of the medical neighborhood—which includes primary care physicians, specialists, hospitals, post-acute care providers, ancillary services, social service agencies, and public health departments—is the patient-centered medical home, which guides patients through the system. Health IT is the glue that connects the providers in the medical neighborhood to each other and to their patients.
Care teams perform the work, not only of managing care for individual patients, but also of population health management. Besides the clinicians within a practice who provide patient care, the care team should be expanded to include all of the providers who deliver care to a particular patient. When electronically connected, this extended care team can continuously send and receive updates and can easily exchange views on a patient’s condition and treatment.
Whether the medical neighborhood is organized by clinically integrated networks, health information organizations, or accountable care organizations, it requires interoperable EHRs and advanced data aggregation, analytic and automation tools to manage population health effectively. The ten most effective health IT tools for population health management are as follows:
- Electronic health records
- Patient registries
- Health information exchange
- Risk stratification
- Automated outreach
- Referral tracking
- Patient portals
- Remote patient monitoring
- Advanced population analytics
These applications can be categorized as population-level solutions or patient-level applications. The core of both categories is the patient-centric registry, a frequently updated collection of patient data that drives both population-level analysis and care management. Patient registries are the central database for population health management in the medical neighborhood. Populated by clinical and administrative data, they’re used for patient monitoring, patient outreach, point of care reminders, care management and other purposes. They can also be used for health risk stratification, care gap identification, quality reporting, and performance evaluation.
At the patient level, population health management requires an organization to reach out to and engage all patients who have care gaps, whether or not they visit their providers. Physicians and care managers must also be alerted about those care gaps, and they must have a mechanism for intervening with patients who need routine care, as well as high-risk patients who require immediate attention. Traditional manual methods are too labor-intensive and time-consuming to do all of this consistently and comprehensively. So healthcare organizations must deploy automation tools and integrate them with registries and other data sources to make sure that patients receive appropriate services.
Among the automation solutions that have been shown to be most effective in population health management are automated messaging systems for patient outreach; automated systems for alerting care teams about patient needs; and online health risk assessments, customized educational materials, and self-care recommendations. Telehealth and telemonitoring can help monitor the health status of high risk patients and can give all patients remote access to their care teams when they need it.
Learn More: A New Resource
Phytel has released a new whitepaper titled, “Shifting to Value: Population Health Management Technologies for Accountable Care.”
Anyone that is involved in healthcare transformation—including healthcare system and insurance executives and frontline providers—should read this paper to get an in-depth view of where healthcare is heading and how it will get there. The more that healthcare professionals understand about the medical neighborhood and population health management, the faster they can move the ball forward.
Download the free whitepaper, here.