HIT Perspectives: Making The Leap

HIT Perspectives – February 2014

Making the Leap: Going from Managing Episodes of Care to Populations

By Michael Solomon, ECare Management Practice Lead
The move from volume- to value-based payment is accelerating as public and private payers change the rules to shift more financial risk to health care providers and consumers. Winners in this seismic transferal of how care is paid for are already in the midst of redesigning their organizations to proactively manage acute episodes of care as well as the health of defined populations. This entails changes to every aspect of care management, including patient outreach, clinical integration across the continuum of care, quality improvement and financial performance. Underlying all these reengineered functions is a robust, patient-centric information technology infrastructure to support care across the continuum — from the physician’s office to the patient’s home and every point of the continuum in between.

What is causing the growing momentum toward population health management in response to value-based payment? Working with our clients, we see the same set of drivers as 12 to 24 months ago. However, they are looming larger, with rapid advances in health information technology (health IT) acting as the catalyst for change.

Drivers. Pressures are mounting to proactively manage populations rather than episodes of care. Driving change more than ever are:

  • Growth in Accountable Care Organizations (ACOs) and their nucleus of Patient-Centered Medical Homes (PMCHs). At the core of improving quality and reducing costs is the ability to proactively identify patients needing care and then effective coordination across the continuum of care. ACOs — which numbered about 500 in 2013 — will be focusing on improving the health of attributed populations to improve outcomes, manage risk and cut costs. Many of them will be elderly and chronically ill, so successfully managing the care of these high-cost populations will be integral to ACOs’ meeting cost and quality targets.
  • Payment policy levers. Reimbursement is one of the most powerful means available to effect change. Medicare and Medicaid payment and delivery policies (including ACOs, PCMHs, and bundled payments) promote prevention and wellness, which are cornerstones of population health. They also incentivize providers to take responsibility for population health outcomes. The same is true for many private payers. In addition, both public and private payers require that providers meet population health-based quality measures and report on them using health IT.
  • Statutory requirements. Proactively identifying patients needing preventive and follow-up care — a key function of population health management — is part of meaningful use (MU) stage 2 and expanded requirements are expected in MU stage 3. Several provisions of the Affordable Care Act are related to an expanded focus on population health. For example, most hospitals must conduct a Community Health Needs Assessment once every three years that includes a prioritization of health needs in their community along with measures and resource strategies to address them.
  • Federal stimulus. Improving population health through the use of health IT is a goal of the strategic plan of the Office of the National Coordinator for Health Information Technology (ONC). This ensures that resources and requirements will be brought to bear in this area. The federal government also will continue to intensify its numerous population health-based programs for managing chronic diseases, aging, mental health and substance abuse — the latter of which is becoming a growing problem among the elderly. These will be above and beyond the population health-based programs conducted by the Centers for Disease Control and Prevention.
  • New ONC leadership. Dr. Karen DeSalvo recently was named head of the ONC. To be sure, Dr. DeSalvo brings much relevant health IT experience to the table. But you also view the world from where you sit. Dr. DeSalvo also holds a master’s degree in public health from Tulane University and a master’s degree in clinical epidemiology from the Harvard School of Public Health, both of which taught her to look at many health care issues through the lens of population health. This intensive training, plus her clinical work with disadvantaged populations, suggests that Dr. DeSalvo is likely to bring more attention on how population health issues can be addressed by health IT. In fact, she has publicly stated that ONC’s “next phase” will include emphasizing how health IT may be harnessed to improve population health.

Moving forward through health IT. The accelerated migration toward population health will be enabled by a range of health IT tools, including electronic health records (EHRs), health information exchange (HIE), data analytics, patient engagement and care management processes. For example:

  • Health data analytics. Innovations in data aggregation and online analytics are bringing powerful tools to the market that can be used by managers and clinicians at organizations large and small. The challenge will be to determine which particular types of analyses on what data will be most beneficial to an organization that must manage risk for a defined population. Identifying the 20% of patients driving 80% of a cohort’s health care costs is a good place to start. From these data, patients who are most likely to experience a high-cost intervention can be identified with predictive analytics and targeted proactively with appropriate care interventions.
  • Proactive care management. Population health management innovators recognize that the only way to move the needle on patient outcomes is to put the results of data analytics into the hands of clinicians at the point of care. A technology platform that integrates an EHR with a patient registry — both connected to an HIE with access to other EHRs and claims data —– will provide the basis for new work flows. These will facilitate coordination of care and “pull” the patient into the system before conditions worsen or become even more costly, or before potentially adverse events occur, such as an emergency room visit or hospital readmission. Innovative communications will be employed, based on identification of high-risk patients, to interact with the care team, patients and caregivers. Innovations in health IT will also enable care coordination in community practice settings, where the integrated care management platform is very important to assist the care coordinator with essential activities.
  • eMedication Management. A major aspect of care management is the management of a patient’s medications across the continuum. Because of the substantial role of medication therapy in caring for patients with chronic conditions, this is a fault line for financial viability and quality of care. Health IT will enable the electronic management of medications (eMedication management) to reduce costs and improve quality, safety and adherence. eMedication management, for example, relies on EHRs to electronically prescribe medications, which is informed by clinical decision support, and share the information among the care team and other stakeholders, such as prescription benefit managers and payers. This allows the care team — physicians, patients, pharmacists, nurses and care managers — to collaboratively develop and effectively manage medication therapy for the patient regardless of his or her health status and location on the continuum of care. Health IT is central to medication reconciliation. Point-of-Care Partners (POCP) has developed a new model describing the need for and use of eMedication management. Click here to learn more.
  • Patient engagement. Patient engagement is a key part of population health management. Health IT tools to integrate patients into care team activities and help a patient self-manage his or her health are critical to the “last mile” of population health management — working with individual patients who are at the greatest risk of adverse outcomes. As patients move through the continuum of care, health IT tools will be essential for enabling them and caregivers to access health information and share in decisions about the patient’s care plan; assessing patient adherence and satisfaction; and managing care transitions across multiple provider organizations. This will involve use of applications (apps) for smartphones and tablets, mobile technologies, and “wearable” devices for patient self-monitoring. Remote patient visits and monitoring will improve care for the elderly and chronically ill, as well as allow them to stay within the community instead of being institutionalized.
  • Infrastructure. According to the American Medical Association, the current health care infrastructure was designed to treat acute episodes and must evolve to also more effectively promote preventive care and treat chronic conditions. That transformation is happening today through an increasingly robust health IT infrastructure. For example, disease prevention, early detection, and condition management for various populations are being enabled through the exchange of clinical and administrative data within and across sites of care. Population managers are using health IT to exchange data across the entire continuum of care. HIEs are on the rise and are the nexus for exchanging population health data among stakeholders and permitting large-scale data analytic efforts.

POCP is advising several clients on strategies and programs to position their organization and its customers to manage populations in the new era of value-based care. Our consultants are recognized throughout the industry for their expertise in eMedication management, data analytics, and patient engagement. Let us put our knowledge and experience to use for your organization in the management of this transformational shift in health care.