Report Highlights Role of Health IT in Managing Patient Population Health

Family physicians in the throes of creating patient-centered medical home (PCMH) practices, learning about medical neighborhoods, and gaining full functionality of their electronic health records (EHRs) may appreciate a new report that illustrates how those three activities work together to benefit patients.

The report, "Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood,(" was released by the Patient-Centered Primary Care Collaborative (PCPCC) at its annual meeting in October.

Report co-author Michelle Shaljian, M.P.A., the PCPCC's director of public affairs, sums up the report's value to busy family physicians this way: "We're seeing the evolution of the patient-centered medical home from a practice-level philosophy to a community-level philosophy, so we really wanted to give physicians, clinicians and community stakeholders a perspective on how this could be done at a much broader level."

The goal, says Shaljian, was to avoid overwhelming physicians and to help them understand that this is work that can be done incrementally. "I think there is a lot of 'initiative fatigue,' and this is really to give everyone a primer on what can be done now, what can be done in the future and what they can build toward," says Shaljian. "There are pieces they can pick up at any time," she adds.

Key Points

Report authors note that a population health approach -- where stakeholders calculate the health outcomes of a group of individuals -- requires collaboration among patients, physicians, insurance companies, the government, the private sector and local communities.

"While our current system is designed to respond to the acute needs of individual patients, it must transition to one that anticipates and shapes patterns of care for populations and addresses the environmental and social determinants of health," says the report.

According to the report, the PCMH sits at the center of the model and is surrounded by the larger and more inclusive medical neighborhood. It is the neighborhood that connects physician practices to hospitals, home health agencies, mental health agencies, and community organizations that encourage healthy lifestyles and safe environments. But health information technology (IT) is the foundation of it all.

"We believe a critical tool in this effort will be the widespread adoption of health information technology," says the report. Health IT offers a structure to help primary care practices within and throughout the medical neighborhood provide better access to care, communicate more effectively and work together as teams.

"Implemented effectively, it also has tremendous potential to identify health trends in local communities, exchange information across organizations, coordinate care as patients transition between providers, and enables secure communications between providers and their patients and families."

The report recommends 10 specific health IT tools and strategies that can help achieve population health management in the medical neighborhood. The essentials and their functions are

  • electronic health records to perform documentation tasks, populate patient registries and create structured data;
  • patient registries to act as the central database for patient monitoring and care management;
  • health information exchange to enable coordination of care;
  • risk stratification to classify patients by their health status and health risk;
  • automated outreach to generate messaging to patients who need preventive or chronic disease care;
  • referral tracking to ensure receipt of test results from outside consultations;
  • patient portals to engage patients in health care self-management;
  • telemedicine to engage patients between face-to-face visits and to help reduce those in-person encounters;
  • remote patient monitoring to allow for quick physician intervention and enable patient control of chronic conditions; and
  • advanced population analytics that allow evaluation of patient population segments and assessment of organizational performance.

Working Models

The report includes three case studies in population management. "I want to emphasize the diversity and range that we have included in the case studies," says Shaljian. The case studies focus on a group of pediatric practices in Winston-Salem, N.C.; a community health center in New York City; and a multispecialty group practice in Richmond, Va.

"These are very different practices, and they all are dealing with very different populations and different needs of their communities," says Shaljian. "But they all seem to make it work with this ideology in place."

For example, the case study focusing on Bon Secours Virginia Medical Group in Richmond examines how the organization -- with 140 locations and 25,000 patients -- manages patient risk in an accountable care organization model.

Bon Secours implemented a care team model as part of an advanced medical home pilot project in June 2010. The practice took a number of steps, including

embedding care managers in the form of nurse navigators into the primary care team,
implementing health IT that empowered the care team to efficiently manage the health of patient populations,
building a registry to identify high-risk and high-use patients,
implementing an automatic outreach program to prevent 30-day hospital readmissions, and
engaging patients via personal health records and email communication with caregivers.

"For the first few years of the project, Bon Secours shouldered the expense," says the report. "The organization is now poised to reap the rewards of its investment."

In the first six months of its value-based contract with CIGNA, the group practice achieved a 27 percent reduction in readmissions and is $1.8 million below its projected spending. The group has hit many care-quality metrics and soon will qualify for "gain sharing (with CIGNA), a development that will bring a projected annual savings of $4 million," says the report.

Looking Ahead

According to the report's authors, the United States is long overdue for payment reform that encourages a population-based approach to better health.

"PHM (population health management) strategies will not be possible until new financial incentives in health care evolve and become prevalent," say the authors. The current fee-for-service payment system "discourages providers from caring for patients outside of face-to-face encounters or proactively seeking out patients with gaps in their preventive or chronic disease care."

Improvements in health IT, including "out-of-the-box" features to simplify tasks, also are in order, say the authors, as is enhanced workforce education and training to educate physicians and other clinical staff members on how to effectively use EHRs and PHM tools.

"It will also be critical to incorporate the PHM and meaningful use model into medical school curricula and accreditation exams," say the authors.

Lastly, patients should be encouraged to manage their own health or disease status. "Accounting for population health requires a lot of things, but most importantly, it's the relationship between the patients and their providers, the providers and their colleagues, and those practices and the rest of the community," says Shaljian.

"It's an all-in kind of approach to population health, and it's not just health IT; it's about what people are doing with that health IT to make all of these improvements and innovations."

Shaljian says family physicians have always been extremely aware of the needs of patients and their families, so incorporating a population health philosophy would build a bridge "between the patients they've been taking care of for so long and the rest of the community."

Physicians can begin to address questions about which of their patients are most at risk and how to proactively reach out to them, says Shaljian. And, practices can identify where costs are coming from, which, in turn, will allow them to manage the business end of the practice more effectively.

"This is about bringing all the pieces together," says Shaljian. "It's a very forward-looking approach to family medicine."

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