Health systems are not the only stakeholder to place heightened emphasis on population health management to lower costs and improve outcomes amid the shift to value-based care. Technology suppliers, even patients, are amongst several others with a vested interest.
To achieve success in population health management initiatives, clinicians must view patients as a valued member of the care team, capable of taking on more responsibility for their health choices. Health systems must also implement the right technology to effectively track and manage their patient populations.
North Kansas City, Mo.-based Cerner rolled out its cloud-based, big data platform, HealtheIntentSM, in 2013. The platform can receive data from any EHR, health IT system or disparate data source, enabling organizations to collect, organize and analyze data in near real-time across the care continuum. This access to data enables organizations to create a longitudinal record that serves as a single source of truth for individual patients, identify specific risk factors for each patient and match patients to the right care programs.
"Creating a longitudinal record is paramount," said James Kanary, senior director of population health management for Cerner. He believes the health care industry is moving from documenting care to planning care. A longitudinal record that flexes in near real-time based on a patient's individual health and care journey can help with this transition, he says.
Mr. Kanary and his colleague Justin Kimbrell, a population health management senior strategist for Cerner, met with Becker's Hospital Review during the Institute for Healthcare Improvement's National Forum in Orlando Dec. 12 to discuss the role of data in population health management and what Cerner is doing in this area.
Editor's note: Responses have been lightly edited for length and clarity.
Question: How do health care and the care team need to be redefined to better support population health management?
James Kanary: I think a theme in the industry today is that it is all about the patient. We're now using words like "consumer" to describe patients. We need to change the narrative and center the model around the person, who should play a more active role and be a key member of the care team. I think the movement toward consumer-owned and directed health records is a big part of that change. What if the patient moves or changes jobs? Does all their information go with them? Unfortunately, the way the models work today, a lot is governed by where you live. Our health information needs to travel with us, just like our Facebook profiles do.
Justin Kimbrell: The care team needs to be more coordinated, and that's where the industry is going. That comes from a longitudinal record and care plan. Being able to see what other clinicians and specialists are doing with your patients is very important and will reshape health care.
Q: What is the role of intelligence in effectively managing populations? What is Cerner doing in this area?
J. Kanary: The role of intelligence is to expose insights to a patient, provider, health plan or employer that they would not have known otherwise. It involves taking the data, making it meaningful and then implementing insights into the workflow. We feel pushing insights into the workflow is vital to facilitate impactful actions in a timely manner.
We don't expect intelligence to operate solely within the EHR. It needs to happen at the cloud level, so we can then push insights into the right workflow, and that includes systems that aren't Cerner. HealtheIntent offers algorithms that help alert clinicians on certain conditions, like sepsis or venous thromboembolism, and this knowledge can be pushed into non-Cerner systems. We built application programming interfaces for the platform to push the right workflow into other EHRs, such as Meditech or eClinicalWorks.
This intelligence is inherent in both our longitudinal record and plan. We also can't ignore the importance of social determinants of health, such as income, access, education and environment/housing. We are very focused on incorporating those relevant data sources and updating the record and plan accordingly. For example, if environmental data being ingested indicated the pollen level was high in a specific ZIP code, intelligence can send out a high pollen alert through the care plan to asthmatic patients living in that area.
J. Kimbrell: The workflows James mentioned can be completed by a physician, care manager, nurse or patient through a portal, phone, etc. We especially need to make processes easier for patients. We all live on our phones, and that's just the way it is. If we can't make it so that patients can do what they need to on their phones, we're missing the boat. We're working on pushing intelligence to mobile devices, like the phone, through algorithms from our HealtheIntent cloud.
Q: How can hospital leaders feel confident in their organization's data, especially in relation to population health management?
J. Kanary: A lack of trust comes into play when clinicians see disparities in data between different systems. It becomes a fog of data to them. Data overload is the enemy here. We're inundated with it every day — how do you make sense of it? Cerner works to make sense of disparate data and make it more digestible.
You need to aggregate the data in intelligent ways, which is something we've learned over the last five years with HealtheIntent. We're now contracted with more than 144 organizations and more than 600 data sources, including more than 30 EHRs. As we've pulled this data over the years, we've become more cognizant of sharing data in a way that's intelligent and easy to comprehend.
A clinician doesn't need to know the 10 to 15 times someone has been diagnosed with diabetes. They only need to know that person is living with diabetes, unless they want to see the details.
J. Kimbrell: Our platform also contains 65,000 clinical concepts, which are standardized concepts in the health industry, like ICD10 or SNOMED. When you map to industry standards, it adds a level of trust for clinicians.
Q: What is the role of nontraditional stakeholders, like payers or employers, in population health management?
J. Kanary: It's all about the shift in risk. Who is taking on the risk of paying for the health and care of the population? Employers are responsible for roughly half of the lives in the U.S. in terms of Americans covered by some sort of employer-sponsored health plan. We're seeing more interest from employers taking on more responsibility for cost, quality and health outcomes. Some of the growth areas we see are in on-site health clinics and analytics for employer populations. It's not just claims anymore. Employers want to see real-time clinical data from EHRs to close gaps in care, and they want employees to take a more active role in their health.
On the other side, providers and payers want access to claims and other clinical data, so they know what's going on with a patient when they're out of network. We can — and do — broker that type of interoperability and data exchange between the two parties.
Anytime you can align payers, providers and employers, facilitating them being on the same page so they know who they're taking care of, how to engage them in meaningful way and how to empower them to create better outcomes — that's the holy grail.