NOUS. Health Management. Importance of Population. White Paper INFOSYSTEMS LEVERAGING INTELLECT

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1 NOUS INFOSYSTEMS LEVERAGING INTELLECT White Paper Importance of Population Health

2 Abstract The revised healthcare regulations in US markets like the Affordable Care Act (ACA) law, the demands of providing Physician Quality Reporting System (PQRS) details for incentive and regulatory programs or engaging the patient to achieve the outcome based incentives, are not easy accomplishment unless right systems are in place. The Population Health (PHM) serves a great deal in all these activities for both individual healthcare settings like physicians' offices, outpatient clinics, nursing homes, skilled nursing facilities or any care facilities and for the network managements. Ever heard of the eradicated diseases like Smallpox, Rinderpest? Know how the diseases like polio, malaria are tackled by different countries in a combined effort? Heard how regional diseases like Hookworm, measles are eradicated? The Health authorities and policy makers, with the concern over citizens devise different health programs, which could otherwise not just cost the individual patient, but the society in whole. Think about the modern day concerns like Obesity and Smoking. The ill-effects may not only limit to the individual, but others in the circle of influence. How will the government work over such items, though they are all lifestyle-based and individualistic? In this white-paper, we explore the different elements involved in population health management which have major implications for public policy decisions, Care continuum, Healthcare Economics and Total Health Care outcome. We explain Population Health in short and how can it can add value alongside other systems that are already in place throughout the care lifecycle. Population Health can be explained in simple terms as the categorizing Patients into different population categories based on risk levels. It also, analyses the reasons for the diseases and engages the patients with programs that could result in improving care quality and reducing overall healthcare costs. Introduction Similarly, how should the stakeholders in the Care Continuum like Payers, Providers engage in achieving the generalized goals? The answer is Population Health. This white papers tries to explain different activities involved and then the means to achieve those goals of PHM, in a modern day technology-driven lifestyle. 2

3 Are the incentives only reason for implementing Population Health (PHM)? Population Health is the managing and improving of the care quality and outcomes of a defined population as a whole. The targets set for the defined population can be achieved by targeting interventions to sub-groups, thus helping to improve individual outcomes which in-turn improve outcomes measures of the whole group or population for the given health goals. This can be used to manage the resources for right areas and achieve better ROI and quality of care. This betters the outcomes of the high-risk patients, by reducing common incidents and high-cost complications in additions to ensuring incentives or incomes through Pay-for-Performance (P4P) programs. Meaningful Use Stage 2 and stage 3 require meeting targets for clinical measures and care providers must submit all the defined care given information into Patient Quality Reporting System (PQRS). Having a PHM system helps in knowing population requiring interventions thus improving outcomes without having to list for each categories through systems that are not designed for this activity. Payer organization processing the claim settlements come across such data from the clinical and claim information, about the likelihood of the patient's condition in the near future and resulting clinical and financial consequence due to it. If a seamless system to manage these are built to alert the care managers to know them, the overall cost of the care is reduced for all involved. Over the years, the payers and providers have gained lots of insights about the trends and patterns about the patient or consumer behavior, but very little is done with it, as they did not form the core to the area they were working. 3

4 Let us consider an example of Obesity as a case for Population Health, without delving much into the exact activities and detailed considerations, but as a mere example to understand. For to consider someone as obese, there needs to be definition of what condition qualifies. In this case, it can be measure of BMI. BMI measurement alone can be a consideration and will require waist measurement. But both have limitations. However, they form the ground for classification. Major activities of Population Health Now, how serious is the condition of the patient? And how to control the ill-effects? Does the patient require a Bariatric surgery? What are the predicted risks of having a surgery or not having a surgery? How should the care giver engage the patient before or after the surgery? What are the behavioral or Lifestyle changes required by the patient? And how to engage the patient to observe those recommendations? How are the outcomes of the engagement measured and controlled? These are some of the activities that will go into the population management. It includes, whole Program design, communication, incentives, physical activity programs, nutritional programs, devising innovative interventions, etc. 4

5 The PHM implementation mainly involves following activities. 1 Defining population Categorize patients into key population groups: Using the data collected through different systems bucket them to different population groups based on the target criteria. Challenge is to collate what is structured and what is random data and convert it into useful data. Data from every possible system source should be considered. The classification can be based whatever the system is generally considered. Popularly they are classified into four categories High-cost Patients; Rising-risk Patients; At-risk Patients; and Healthy Patients. The percentage categorization is again part of the design criteria. This stage calls for well managed Data Mining and Analysis of different data like Demographic Data, Clinical Data, and Pharmaceutical Data. There could chances of missing information or collating issues. With the help of insights gained, Health managers need to device strategies and justification for classification of population. Using various mathematical models and available data, the categories could be classified, for example like - High-Cost Patients 5%, Rising-Risk Patients 20%, At-Risk Patients 40%, Healthy Patients 35%; or so. These would be used in working further on cost effect, care gaps, analysis, etc. Based on the need for granularity, this categorization can still be sub-divided into smaller groups and narrow down on the interesting cases and conditions. 5

6 2 Identify care gaps and stratify the risks - Analyzing to locate risk causing sources: Giving due consideration for broader set of risks, and with the knowledge and insights gained over the years, determine the risk causing factors and finding out which care interventions will give most desired outcomes. Based on the trend and pattern formation, use different data analysis techniques, to gain a better understanding of which interventions will actually make a difference. Population health managers should consider a broader set of risks, like social risk, geographical risk, and behavioral risk. In addition, the degree of patient engagement through different channels, this can make a big difference in which interventions are most appropriate and most effective. 6

7 3 Engaging patients, Managing care and Measuring the Outcome - Intervention and patient engagement of the focused population group: As there needs to be different kind intervention requirements for each population group of patients, a properly categorized population group allows the population health manager to engage available limited resources on groups where they will do the most good. Each population segment has an intervention strategy appropriate for its level of risk. Close interaction between Care Managers, who have insights of different care conditions and population group. Based on the need of the category, High-Cost Patients engaged through Health Coach Assignment; Rising-Risk Patients through Behavioral Health Consultant; At-Risk Patients through Peer Group Connections and Healthy Patients with Preventive Care Outreach activities. Though engagement is done based on need, efforts should also be spent to understand the actual outcome of this set of engagement. Flexibility should be maintained to accommodate any changes to the co-ordination based on the outcome. Enough consideration should be given for improving the clinical and financial outcomes, through disease management, case management and demand management. Constant deployment of analysis over Clinical measures and health outcomes to reduce the care costs and effectiveness of care quality. 7

8 An EHR has been built to store patient s data, support documentation needed for billing and for creating a care plan but when it comes to retrieving meaningful data to identify patients with critical risk, it requires someone to make use of disparate systems and manual reconciling is needed. The challenge here is, it is multi-step, cumbersome and complex. It is almost impossible for any EHR to create a meaningful data itself, or to get this data into a PHM system. Payer organization processing the claims settlements come across such data from the clinical and claim information, about the likelihood of the patient's condition in the near future and resulting clinical and financial consequence due to it. If a seamless system to manage these are built to alert the care managers to know them, then overall cost of the care is reduced for all involved. Opportunities to engage the patient for appropriate care management program or suitable intervention be explored all the time. The system should be flexible enough to accommodate any changes required on the criteria being considered. Other activities of Population Health Current established systems like EHR or PMS can only provide capabilities specific to their job function and little can be leveraged in terms of predictiveness of the patient conditions and thus risk levels. Suitable employment of the PHM not only helps in identifying the patients, but also streamlining the process with the evidence. Well-built predictive models not only eases the function but provides options to measure and control the activities. All options to automate any activity involved should be considered. Surveillance systems in claims processing and such will lead to less intervention by Care Managers on daily basis, except only for over-seeing the functioning of the system and make modifications based on the need. Data processing will not be limited to finding the critical patients or the prospective benefits, but also in the controlling the costs of a plan and predict the financial state and readiness to meet any adverse events. The responsibility of the care giver and payers are not limited to per incident, but also on the outcome of the treatment. This requires engaging the patients or the consumers constantly and understanding the risk levels of managing the member. 8

9 With the popularity of the smart phones and social media, the engagement and communication is quicker and less expensive. Think about a case, where an alert had to be communicated to a member or a group of members. The traditional means of contacting would not have yielded good results and would not have put the member in the comfort. With the automated feedback systems with integration to Social media and smart devices. Use of multi-channels like Mobile, Portals, Devices, Kiosks, apps, etc., have led to diversity and boundless opportunity for communication. Automated systems can take care of raising the alerts, sending communication to the members. What happens when a drug is recalled by a drug company, how the existing patients prescribed with those medicines are notified about it. How to re-issue the prescriptions for the same and engage the patient in such cases? All this could be managed easily should there be a PHM solution in place, which helps with Push notifications or group alerts or personalized alerts. The core objective of PHM is also to build a seamless communication, delivery of service and engagement of the patient/consumer irrespective of the patient s location. To meet these goals, it definitely requires the usage of mobile health and telehealth technologies. Few other areas that help to attain this phase of PHM is mobile application, interactive web-based application, customized education programs and Personal health records. 9

10 Stages and Components of Population Health in Care Continuum EHR Define Population Data Analytics Data Werehouse Population Monitoring / Identification Population Analytics Identify Care Gaps Clinical Databoards Health Assessment Patient cost and Utilization Stratify Risks Predictive Modeling to Stratify Population Risk Stratification Care Continuum Engage Patient No or Low Risk PHR Moderate Risk Health Promotions, Wellness Health Risk Organizational Interventions (Culture/Environment) High Risk Care Co-ordination/ Advocacy Disease/Case Patient Portals Telehealth Device Integration Tailored Inventions Person Community Resources Care Manage Care Wellness Programs Operational Messures Messure Outcomes Programe Outcomes Psycho-social Outcomes Behavior Change Clinical and Health Status Productivity, Satisfaction, OOL Revenue Cycle Financial Outcomes Provider Network

11 Population Health not necessarily targets individuals, but tries to manage the outcome of the whole population to the desired target goals and thus bringing down the overall cost of all. Any opportunity to implement population health management in any healthcare settings should be readily adopted and overall goal of reducing cost and meeting quality care standards should achieved. How are these data generated being analysed to understand if there are any trends formation or changes required into the algorithm applied or strategy employed, collecting metrics and visualization of the trends, patterns to meaningful insights should be employed. Employing either metric-based dashboards or KPI based dashboards to monitor the progress should form an integral part. Conclusion Authored By: Ravi Prakash H S, Business Analyst, Nous Infosystems Nous Infosystems is a CMMi Level 5 SVC + SSD v1.3, ISO 9001:2008, and ISO/IEC 27001:2013 certified global Information Technology firm providing software solutions across a broad spectrum of industries. Major offerings include Digital Transformation, Application Development & Maintenance, Enterprise Application Integration, Product Engineering, Business Intelligence, Independent Testing and Infrastructure Services. 6 For more informtion, Please visit - or mail us at info@nousinfo.com Copyright Nous Infosystems. All rights reserved.