Provider-Based Population Health

Automation tools for population health management will become more important than ever in 2012 as a growing number of healthcare providers begin 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).

Patient-Centered Medical Home Improves Care Coordination

The PCMH is already generating tremendous enthusiasm among providers and payers. In 2012, it will join the mainstream of healthcare delivery as organizations recognize that it is the best vehicle for attaining the objectives of accountable care.

Without the ability to leverage digitized clinical data, it is impossible to achieve the medical home’s primary goal of improving care coordination in a scalable way. Fortunately, the federal government’s HITECH incentive program is driving the rapidly increasing adoption and meaningful use of EHRs. As structured electronic data becomes the norm, many more providers will be able to tap clinical databases for real-time identification of care gaps, automated outreach to patients who need preventive and chronic care, care coordination, predictive modeling and risk stratification of the population. These tools will help providers build successful medical homes and ACOs.

Automation Technology Supports Patient Engagement

Meanwhile, efforts to promote patients’ engagement in their own care will benefit from the accelerating use of automation technology to replace outmoded, inefficient manual processes. In addition to automated patient outreach methods, online educational tools and health-risk assessments will become commonplace. Mobile health applications will proliferate. Most important, physicians and care teams will have the tools they need to maintain continuous contact with patients between office visits or episodes of care.

Population Health Management and Automation

Finally, care management will benefit from the new automation approaches. Healthcare systems are placing care coordinators within physician practices, and those professionals are beginning to leverage digitized health data to help them manage patient populations. We will see much more of this kind of activity in 2012.

A crucial component of healthcare reform is to transform our care delivery system to improve quality and control costs. To do that, the government is working with the private sector to test and promote new structures such as the patient-centered medical home (PCMH) and the accountable care organization (ACO). Both of these innovations, which will gain momentum in 2011, require providers to make sure that everyone in their patient population is receiving appropriate preventive and chronic-disease care.

Today, many physician practices and hospitals still operate in the traditional fee-for-service model.  To build a successful medical home or ACO, however, providers will have to coordinate care and work with patients to improve their health between as well as during office visits. They will also have to track and monitor their patients’ health status, and reach out to those patients who are noncompliant or have fallen out of touch with their physicians.  In essence, they will be required to adopt a population health management approach and strategy.   And more importantly, they will need automated capabilities in order to support these initiatives.

Even with financial support from payers, physician practices cannot do this type of population health management without the aid of health information technology. Beyond electronic health records, they will need registries, multi-channel patient messaging technologies, and web-based tools for health risk assessments and patient self-management education.  Using registry-generated data to identify care gaps, physicians will be better able to deliver necessary services to patients when they visit, matching care team skill sets to patient-specific needs.  Similarly, care managers will use advanced population-based reporting and stratification to identify patients who need personalized interventions, and deliver automated methods to empower patients to become active participants in their own health.

In the next year, we’ll see the spread of these automation and care coordination tools as alternative care delivery models take root and grow. While experts say it will take some time before population health management becomes the norm, many healthcare leaders are already jumping on the bandwagon to take advantage of the incentives that Medicare and private insurers are offering.

Steve Schelhammer is CEO at Phytel.