Population Health Management: How Data Management Will Revolutionize the Way You Provide Care

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1 October 2014 : How Data Will Revolutionize the Way You Provide Care BlenderTM: The Next Wave 8 the Right Patient Data Usability of Tools 15 share:

2 The fee-for-service reimbursement model, once the standard mode of producing revenue, determined that each provider would be paid primarily on the number of patients seen and treated or volume-based care, rather than the outcome of those visits or the patient s overall health, referred to as value-based care. There was no incentive to change that because preventive care and collaboration, the foundation of value-based care, did not directly produce revenue. The fee-for-service payment model facilitated rising healthcare costs because the more diagnostic tests that were run or the more interventional procedures performed, the more patients were charged and the more providers would profit. Sky-rocketing healthcare costs alarmed elected officials, healthcare policymakers, insurance companies and consumers, and prompted passage of two recent laws that spawned a fundamental change in how healthcare is delivered and paid for in the United States. These laws, the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act, incentivized health care providers to implement electronic health records and facilitated accountable care organizations and better collaboration among health providers through a mixture of incentives and penalties. Together, these laws formed a foundation for change in the healthcare system by making it imperative that the overall health of patients be managed by incentivizing disease management and penalizing rehospitalizations. The result has been an emphasis on value-based care, a care management strategy focused on costs, quality and outcomes. These new policies are creating the most drastic changes the healthcare industry has seen in the last 20 years, says Lisa Rawlins, senior vice president for SRG Technology, based in Ft. Lauderdale, Florida. Health Tools // October 2014

3 As a result, private health insurance payers, in increasing numbers, have created their own incentive and quality metrics programs to keep patients healthy and out of the hospital, demonstrating the movement towards valuebased care that is replacing the former fee-for service model. The biggest keys to success for healthcare providers under these new payment models are proactively managing the health of their entire patient population through increased communication and encouragement to seek preventive care, coupled with tracking key health metrics through an operational model known as population health management. Population health management, or PHM, combines team-focused, collaborative care, the right software tools for data management and the healthcare provider s existing infrastructure of patient information (EHRs) and practice management systems to improve clinical decision-making, patient engagement and, ultimately, outcomes. n Health Tools >> // October 2014

4 The legislative, regulatory and payer initiatives success around value-based care all rely on driving fundamental changes to the delivery of healthcare services from a reactive, visit-based approach to a proactive, patientcentric approach based on cost-effective clinical interventions. That s where population health management comes in, because PHM drives the delivery of higher quality, cost effective care by shifting from a volume-based to a valuebased model of care delivery. This creates a dramatic change to clinical workflow and the way providers and patients interact, Rawlins points out. In a volume-based system, clinical workflows are reactive. The patient shows up sick and the clinician steps in, Rawlins says. In a population health management model, patient outreach, education and intervention are done prior to the patient presenting at the physician s office, flipping the whole clinical workflow on its head in the way in which a physician and the corresponding health team interacts with the patient. Centers for Medicare & Medicaid Services (CMS) and private payers continue to look to payment models rooted in population health management to control healthcare costs. As long as costs rise, expect the demand for population health management to continue, says Adrian Zai, M.D., Ph.D, MPH, clinical director of population informatics at Massachusetts General Hospital in Boston. In a population health management model, patient outreach, education and intervention are done prior to the patient presenting at the physician s office, flipping the whole clinical workflow on its head in the way in which a physician and the corresponding health team interacts with the patient. LISA RAWLINS, SENIOR VICE PRESIDENT FOR SRG TECHNOLOGY Population health management is the best way to contain costs. It s about quality over cost. It s going to keep happening as long as the cost of care is an issue, Zai says, adding that attempting to deliver value-based care without population health management drives up costs and is not beneficial for physicians. Health Tools // October 2014

5 The ACO payment model requires a physician practice to lower its growth in healthcare costs while both meeting performance standards on quality of care and putting patients first. One pioneer ACO reported a cost saving of $14 million, with $7 million paid to the provider organization. Rawlins explained. Other payment models gave practices incentives to better manage a group of patients by allowing them to increase revenue through the financial savings derived from proactive, high-quality care. Zai offered the hypothetical example of a practice that is historically paid $225,000 a year to manage 500 diabetic patients, but by better managing the care at a reduced rate, the practice can keep any leftover funds if the physicians manage the care of those patients well. The great thing about a PHM initiative is that it truly allows for team-based care. The physician is the integral part of an entire care team. The appropriate information gets pushed to the person on the care team that is trained to take the necessary action. ADRIAN ZAI, M.D., PH.D, MPH, CLINICAL DIRECTOR OF POPULATION INFORMATICS AT MASSACHUSETTS GENERAL HOSPITAL The provider would need a population health management solution to manage those diabetic patients best, Zai believes, because there wouldn t be enough hours to schedule a visit with every patient. Even if there were, care of the whole population wouldn t be optimal because a lot of those visits would be spent with healthy patients. If the provider has 1,200 total visits to use for this specific population for the year, this means one to two visits per patient at most, making it critical for the provider to optimize the care by monitoring the patient population as a whole on a continuous basis to see who is at high risk and who isn t and determine the appropriate intervention, Zai points out. The success of a population health management system is ultimately driven by several factors. The first is having a system that facilitates patient attribution to the correct provider. The second is identifying the needs of patient populations. The third is the ability to effectively manage data to facilitate the right patient interventions to achieve healthcare goals. Once the provider addresses these areas, the final piece of the puzzle involves the use of team-based care to create the strong collaboration necessary to successfully tie it all together. Going back to Zai s example above, every patient in the diabetic patient population wouldn t always need a direct physician intervention. Some patients would need just a nurse phone call or a nurse visit, Zai says. Others might need an automated referral to an insulin management program because they re not managing blood sugars well. Health Tools >> // October 2014

6 The great thing about a PHM initiative is that it truly allows for team-based care. The physician is the integral part of an entire care team, Zai says. The appropriate information gets pushed to the person on the care team that is trained to take the necessary action. This allows for practitioners on the care team to practice fully within their scope of practice, eliminating the need for physicians to spend time on administrative duties and allows for more one-on-one time with their patients. Use of a robust population health management system helps the healthcare provider make better use of scarce resources, says Tanya Zucconi, senior project manager, clinical performance reporting at Brigham and Women s Physician s Organization in Boston and user of a population health management system. With population health management, you re talking about a large number of patients, that s part of the whole issue, Zucconi says. A population health management system allows you to be more effective with your limited clinical and financial resources and that s tremendously important and that s where a lot of the impact has been seen. Population health management tools help with both patient accountability and engagement of the care team, Rawlins believes. PHM gives you the ability to collect data points throughout the monitoring and managing of care instead of episodic care data points, Rawlins says, which then allows translation of the data into action plans for either the patient and/or for the physician/care team. n Health Tools >> // October 2014

7 Sponsored Content SRG Technology, a software solutions company, claims its population health management (PHM) system, Blender TM, can get healthcare providers ducks in a row. A catchy phrase, but is there any truth to the claim? An effective PHM system will integrate disparate data sources into a cohesive analytic source allowing providers to proactively manage care, promote wellness, and reduce costs. Convincingly, Blender TM does just that and more! It begins with the data. Traditionally, healthcare data is securely stored in information silos such as lab information, primary doctor EHR, specialist EHR, claims, etc. But rarely does the healthcare data intersect in a meaningful way. That makes it very difficult for healthcare providers to see the whole picture and make decisions based on all of the data. TopCare brings it all together: sorts, filters, analyzes and reports through easy-to-use, nice-to-look-at, role-based dashboards and patient registries, taking healthcare organizations data under its wing to ensure improved outcomes. The true TopCare differentiator is the additional level of support it provides by using customerdefined metrics to generate recommendations for improving inefficiencies, closing gaps in care, reducing readmissions and encouraging patient engagement and education. Recommendations can be configured to address any situation a provider may want to look at more closely. TopCare was developed with the newest technology, allowing it to easily adjust to change and growth including the realignment of recommendation parameters. People like to use TopCare. The friendly, intuitive user experience within TopCare is often undervalued. The fact is, if people don t like using a technology system they won t use it. The unique TopCare workspaces provide a platform for patients and providers to communicate effectively and efficiently. Patients can actively engage in their own health and wellness plan. Entire care teams can easily communicate, collaborate and share best practices. Workspaces are individually relevant. TopCare shares information based on customer-defined roles. The right people receive the right information. Workspaces and dashboards can be configured by individual users with simple click-anddrags to create the desired screen design for the most comfortable and efficient use. Ease-of-use increases active engagement which leads to a healthier, happier population. TopCare is a collaboration between Massachusetts General Hospital s Laboratory of Computer Science (MGH LCS) and SRG Technology. The contribution of MGH LCS years of population health research and expertise gives TopCare a tremendous, unique value. SRG Technology brings the cutting-edge software solution but also education industry expertise. TopCare contains several traditional education tools to promote patient engagement and professional development setting it apart from all other population health management systems on the market. Healthcare administrators are inundated with change right now and many fear that implementing a PHM system will be too difficult, too costly or both. But TopCare adds value and keeps it simple. By drawing data from disparate sources; aligning an organization s needs with recommended actions; reducing gaps in care and workflow inefficiencies, TopCare ensures providers are focused on patient care without sacrificing the bottom line like water off a duck s back. n // October 2014

8 When it comes to population health management, the right data is the information that helps the individual healthcare entity achieve its objectives. These can be internal goals of the practice, goals set by a payer for its population or a combination of both. I think the regulatory and contractual obligations are critically important because they allow us to pursue our clinical interest, which is to provide the right care to the right patient at the right time, Zucconi says. I think that works much better in concert with the payers, rather than people just deciding it is time to be efficient or offer quality care. A common misconception many in the healthcare industry have is that investment in an EHR system, or even a practice management system, is sufficient to collect the data elements needed to successfully manage a patient population. While EHR systems try to expand toward population health management type functionality, they are designed to present data one patient at a time. Electronic health records systems are designed for visitbased medicine. When you log in, the first thing you do is type in the medical record number of the patient and look at the record, Zai points out. But if I want to know at any given time which diabetic patients are not controlled, or their blood sugar is out of whack and requires insulin titration, I don t know which medical record numbers to type into the EHR to get a full picture of my diabetic patient population. That is a problem. With a robust population health management tool, you sign on as a caregiver, a care team member or care team lead, and you are going to see a list of activities to act on, within the next week, and within the next month, in order to better manage that entire patient population. LISA RAWLINS, SENIOR VICE PRESIDENT FOR SRG TECHNOLOGY In order to effectively manage all of the data being generated by the health provider, e.g. claims data, lab data, and operational data, the provider needs a robust management tool, a function that an EHR is not equipped to perform, according to Rawlins. A robust population health management tool is not like a current EHR system where you are going to log on as Health Tools // October 2014

9 a doctor or nurse and sort through those entire files to find the one patient you are looking to manage, Rawlins says. That s historically how all health IT systems have been designed. With a robust population health management tool, you sign on as a caregiver, a care team member or care team lead, and you are going to see a list of activities to act on, within the next week, and within the next month, in order to better manage that entire patient population. In fact, one of the principal reasons a healthcare provider can t rely on the EHR to be a population health management tool is that all of the data needed to truly manage your population effectively isn t all in your EHR, Zai points out. For example, a population health management tool will draw on data from different areas of your EHR, such as results of procedures and lab tests; clinical notes; or admit, discharge, transfer systems; but also other sources such as claims data, he adds. Your population health management system should, for example, tell you if a patient has a track record of canceling appointments or being a no-show. In some cases, the no-show rate can run as high as 20 percent, Zai points out. With that information, it would be customary for the PHM tool to prompt you to contact that patient directly. The advantage of using the population health management tool is that not only will it tap into your data, but it can give you predictive analysis on patient behavior and give you specific guidance on patient management. It identifies the gaps of care and is prescriptive in what needs to happen to better manage that patient population, says Rawlins. While structured data such as specific lab results or identified gaps in patient care are pivotal tools to help manage a patient population, a large amount of the information a healthcare provider has about a patient is the provider s narrative documentation about the patient. An effective population health management tool can actually search that data, known as unstructured data, based on clinical keywords and analytics, and use it to support the structured data that the population health management tool already has, Rawlins points out. The data assets you manage also have to be current in order to ensure the interventions and care decisions are accurate, Zai says. When the data leads to an intervention, the data reflects the intervention. When patients are able to use engagement tools to enter their own data, a population health management tool also has to facilitate an intervention the patient finds meaningful. n Health Tools >> // October 2014

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11 It s clear that a population health management tool is one of the most powerful ways to ensure an entire patient population receives high-quality care in the most cost effective manner. The healthcare provider ultimately determines how to best mine the data to achieve necessary objectives, whether driven by the payer or internally. Previously, physicians had to pull all of that data themselves, without knowing which components were actionable. In a role-based population health management system, if the eye exam is out of date, the secretary will be prompted to call the patient to schedule it; or the nurse will be assigned to call for the lab tests. ADRIAN ZAI, M.D., PH.D, MPH, CLINICAL DIRECTOR OF POPULATION INFORMATICS AT MASSACHUSETTS GENERAL HOSPITAL A good population health management tool helps by identifying patient populations based on the intensity of the intervention needed, which influences the type of intervention and the member of the care team best suited to do the intervention. The result is that the care team is able to operate most efficiently and better manage the time of the healthcare provider s most valuable resource, the physician. If I m counseling a patient with diabetes, there are certain things I need to know, such as urine test results; whether the patient has had an eye exam or a recent foot exam; if the patient needs a nutritional consult; and the patient s most recent lab tests and blood pressure, Zai explains. Those are a set of things I need in order to make certain decisions as a physician. Previously, physicians had to pull all of that data themselves, without knowing which components were actionable. In a role-based population health management system, if the eye exam is out of date, the secretary will be prompted to call the patient to schedule it; or the nurse will be assigned to call for the lab tests. The physician will be notified of potential adjustments to the medication dosage if the patient has high cholesterol, Zai says. By monitoring that lab value the care team is notified when to take an intervention, Rawlins says. If a care team is not having those lab values done on a regular basis then the provider doesn t know if a patient Health Tools // October 2014

12 population is improving or getting worse. Having that information instructs care. Building metrics tailored to the administrators of the healthcare practice or to the appropriate staff frees the physician to treat patients without having to think about the patient s insurance status or the patient s ability to pay, Zucconi says. We want providers to take the very best care of all of their patients, Zucconi notes. On the administrative side, we try to keep an eye on some of these other issues in case there are decisions to be made about how these resources are to be allocated or how new projects are to be created. We are better able to focus on how might we want to direct funds and projects and include our clinical colleagues in the decision-making process. When administrators are asked where their numbers are coming from or asked for the details about how choices are being made, a good population health management system will enable healthcare administrators to show where the data is coming from, and how your performance measures against other metrics, Zucconi says. n Health Tools >> // October 2014

13 Usability of Tools There are many stories in the healthcare industry about technology purchases that turned out to be money wasted because care teams found they couldn t use the tools without an excess of frustration or a drain on productivity. When it comes to population health management (PHM) tools, the keys to successful usability are giving people role-driven tasks, determined by the individual s role or function within the larger framework of the organization and team, that enable the entire care team to be as successful as possible, and for the tool to be able to quickly adapt as the practice s goals and patient metrics change. The tool needs to be quickly configurable for new population health management initiatives, Zai says. What makes a PHM robust is how effectively it can help healthcare organizations overcome the difficulties of transitioning into this new model of care. A robust PHM system will help you easily break down your populations into different risk buckets, clearly showing you which patients need what, or pushing segments of your patient population to the right user or the team member who will provide that intervention. This prevents everything falling back on the physician, If providers are only looking at the EHR, or claims or pharmacy data, they don t have the full picture to make a decision. PHM tools offer the best opportunity for the clinician to intervene positively in the patient s care. TANYA ZUCCONI, SENIOR PROJECT MANAGER, CLINICAL PERFORMANCE REPORTING AT BRIGHAM AND WOMEN S PHYSICIAN S ORGANIZATION, AND USER OF A POPULATION HEALTH MANAGEMENT SYSTEM Zai points out. The right PHM system focuses on creating collaborative, team-based care. The physician isn t alone holding all of the responsibility: he or she is a member of an entire care team. With PHM, the appropriate information is pushed to the right person on the care team so that the right action is taken. That push of information goes both to individuals and to specific job functions based on the needed intervention. For each member of the care team, the population health management system delivers specific tasks and job functions most relevant to driving successful outcomes. Health Tools // October 2014

14 The best population health management tools are so efficient at gathering data that they vastly increase the productivity and job satisfaction of members of the care team. One recent study showed just how much TopCare powered by Blender TM, a popular system, was able to free up clinician time. It took two nurses working an hour and a half each week, more than 30 work days, to manually identify all of the patients in a certain patient population. It took TopCare 15 minutes to manage that population, Rawlins says. Imagine how much time it freed up for those nurses to see additional patients and better manage the current population. Using a PHM system like TopCare improves clinical outcomes while improving the efficiency and time management of clinical staff. In another example, the PHM tool saves the physician time by directing other members of the care team to educate patients about screenings, for instance, of diabetes. Because of this, most patients had diabetes screenings done before having clinic time with the provider. Because the PHM system addressed the need to educate patients about being proactive in the detection of any potential health issues, Zai adds, the patients and providers time were used more efficiently. The physician time saved was also a huge asset because it enabled the team to focus more on the direct care of the patient. Population health tools give you confidence in the information you are looking at. The population health management system is improving on and automating processes by incorporating EHR, claims, billing and imaging data to give the most robust picture so that when providers are trying to intervene, all of the data is in one place, Zucconi says. If providers are only looking at the EHR, or claims or pharmacy data, they don t have the full picture to make a decision. PHM tools offer the best opportunity for the clinician to intervene positively in the patient s care. n Health Tools >> Usability of Tools // October 2014

15 After years of wrangling for ways to control healthcare costs, government and healthcare payers have finally made a clear push toward value-based care, paying for good outcomes instead of volume-based, fee-for-service practices that left healthcare providers overwhelmed and consumers needs unmet. While value-based payment models are still in their infancy, more and more healthcare providers see many of their plans and payers explore the population health management, or PHM, model of proactive, preventive care. Achieving success in this new world requires the right tools to proactively manage patient populations, which means a complete picture of each patient s real-time data. Healthcare providers can no longer afford to let patients with chronic conditions slip through the cracks, only to provide costly interventions later. By using the right PHM system, providers receive the necessary tools so that care teams are fully informed of their patient population s overall health. A successful PHM system also has to be nimble enough to grow as a provider s population management needs change, yet be easy to understand and use so that healthcare providers across a care team will put it to work quickly and effectively. Healthcare providers need a robust population health management tool like TopCare powered by Blender TM, one that is comprehensive enough to tap all of the healthcare provider s data sources. PHM systems like Blender TM successfully weave all of the necessary elements to create a unique, effective population health management system, allowing providers to achieve the best in proactive, cost-effective patient care. Healthcare organizations across the country recognize that population health management systems are the future of healthcare. Embracing the right tool now helps healthcare organizations make the inevitable transition to PHM easy. n Health Tools // October 2014