After data analytics: Using IT to bolster care coordination in population health management

Payment reform in healthcare and the shift to value-based care are prompting hospitals and healthcare providers to more intently manage the health of overall populations or segments of populations. As a relatively new focus area for the healthcare industry, hospitals are finding different ways to delve into population health and health management initiatives that are both practical and effective.

Data is integral to managing population health, as hospitals and health systems need to have metrics outlining the characteristics of their population in order to make necessary changes or develop initiatives to improve the cohort's health. Health IT tools are becoming central in population health management and care, as hospitals seek analytic tools to help them make sense of the data and create actionable plans.

Chicago-based Cadence Health, now part of Northwestern Medicine, uses Epic's Healthy Planet and Cogito platforms to manage its value-based care relationships . The Cogito module is a data warehouse that also offers analytic and reporting functions. Healthy Planet is an aggregate suite of population health tools that allow providers to manage populations, which Dan Kinsella, CIO of the West Region of Chicago-based Northwestern Medicine, says are broken down into three objectives to reach population health goals: "You collect data, you analyze data and you engage with the patient," he says.

However, analysis of data only goes so far, and to achieve a truly successful population health program, Mr. Kinsella says hospitals should focus on what comes after the data. "When you do [data] analysis, they tell you two things: who your sickest patients are and how your providers are performing against success metrics. When you talk about the chain of value-based care, the secret sauce is not in the analytics — it's in the care coordination."

But care coordination is dependent on analytics, Mr. Kinsella continues. "There are finite resources available to engage with the cohort, and you have to figure out where you can be most effective. That's where analytics comes in," he says.

The same theory applies in the population health program at Bridgeport, Conn.-based St. Vincent's Health Partners, a physician-hospital organization that has been incorporated for nearly three years. Its population health management program is focused on helping its physician members identify the needs of their cohorts so the physicians can make necessary changes to care plans. St. Vincent's Health Partners uses McKesson's population health manager, risk manager and care manager platforms.

As a physician-hospital organization, St. Vincent's Health Partners has to address each of its member's populations and mine down data pertinent to all of its members' cohorts. For its purposes, St. Vincent's Health Partners is not focused on connecting EMRs with a population management perspective; rather, it collects data from the EMR and presents it back to physician members in a way that is actionable. "For our organization, we have over 12 different EMRs, so what we've tried not to do is view this at the point-of-care interaction. We've tried to use data to empower each of our members with timely data that allows them to get insight into that population and define that population in a way that meets the needs of the organization as a whole as well as the individual member," says Michael Hunt, DO, CMO and CMIO of St. Vincent's.

Like Mr. Kinsella, Dr. Hunt says care coordination is instrumental to population health management. St. Vincent's Health Partners seeks to move that coordination from the enterprise level to the individual provider level.

"From an enterprise level, historically, influence from a care coordinator or case manager to a patient isn't that successful," Dr. Hunt says. "We've tried to leverage the relationship of a patient with a direct provider. The chance of that patient being more successful with their care if their provider is creating most of that care is almost 90 percent."

To do so, St. Vincent's Health Partners uses McKesson's platforms to take the enterprise-level data and mines it down to information specific to each provider in as close to real-time as possible each month to allow providers to make operational changes "as locally as possible," Dr. Hunt says.

Population health, though, takes into consideration more than just patients receiving care in the hospital — healthy people and even employees are part of that cohort, says Mr. Kinsella, and they may not yet have had a traditional episode of care that establish a record in the EMR. "They may be in a state of wellness and could never have been seen [by a provider]," Mr. Kinsella says. "One of the key Healthy Planet features addresses the ability to ingest a list of 'members' for whom we have assumed a level of accountability, and create a record in Epic prior to them even being seen by a provider."

Key takeaways
Population health is an emerging priority for hospitals and health systems as the industry moves toward value-based care. In navigating these new waters, Mr. Kinsella suggests organizations move cautiously in developing population health infrastructure and keep things simple.

"There are a lot of complex analytics products out there. Don't over-buy. If your business needs are emerging and modest, measure your investment in your population health solution accordingly," he says.

And, in approaching strategies, Dr. Hunt suggests breaking down the care responsibilities.

"If you look at the national models, they center on how you manage a population and then how do you manage an individual patient," he says. "What we try to do in our operational model is to say the enterprise takes care of the population, and the provider takes care of the patient. They really have to occur simultaneously. Neither strategy can be independent of the other."

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