Insights on population health

Population health remains at the forefront of innovative patient care, as health systems and medical practices expand and extend their focus on patient groups defined by geographic area, with a specific chronic disease, covered by a specific payor or other distinctive factors.

One in two adults in the U.S. has a chronic disease, and one in four has two or more (National Center for Chronic Disease Prevention and Health Promotion). Across the globe, a 57% increase in the prevalence of chronic diseases is expected by 2020 (World Health Organization). These patients require proactive management to limit morbidity and help control long-term costs.

Defining Population Health
These staggering statistics point to the challenges health systems and medical practices face when defining and managing patient populations. Most healthcare organizations define populations for measurement and specific quality improvement projects based on the patients they serve. There is no single definition.

For example, physicians and other clinicians review and analyze patient populations using multiple criteria, which include chronic disease, geographic region, gender, payor or other relevant factors.

Health information technology – that is electronic health records along with population health and analytic tools – enables access to valuable patient data. Healthcare providers can then analyze that data to identify members of patient populations and develop programs to aid in the treatment at the bedside and strategies to reach out to those patients who aren’t presenting on their own.

Managing population health challenges
Population health management requires new models of care that enable clinicians to stay in contact with their patients – and their health – even when not seeing their caregivers. Patients don’t visit their doctor for a variety of reasons, most likely because they feel fine – but lack of time and budget constraints are also factors.

Engaged in the day-to-day of patient care visits, clinicians and health systems can now support their patients using timely electronic reminders to help maintain patients’ health. Clinicians can access EHR and claims data to ensure the entire population is current on vaccines, or monitor blood sugar levels of patients with diabetes, and confirm they receive annual foot and eye exams.

With this population health management approach, the healthcare team can address the challenge of staying in contact with patients by using available technology to reach out to those who need specific care.

Solving population health challenges in the future
Moving healthcare forward means embracing value-based care and changing reimbursement models. As value-based care payment models evolve, no one is sure exactly what to expect; however, the payment model will likely drive many decisions about healthcare delivery overall. Development of these payment models continues, as healthcare looks to ensure that patients receive both cost-effective and quality treatment when and where they need it.

Healthcare providers will continue to rely on data to help define and care for the patient populations they serve. Data accessed through the EHR plus other IT tools and resources provides critical information. Advanced data analytic capability to improve population health will move quality patient care to the next level.

Telehealth and other remote visits now offer – and will continue to provide – much-needed access options to patients, especially those in rural areas with limited access to healthcare providers close to home.
How will healthcare providers care for patient populations, improve people’s health, implement systems that work, and control costs over time? These are important questions at hand. 

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