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    Population Health Management: Systems and Success

    What is Population Health Management?

    Although the term Population Health Management (PHM) has become something of a buzz-word over the past few years, the concept is often unclearly defined and even less well understood. Population Health Management has to do with the organization and management of the healthcare delivery system in a manner that makes it more clinically effective, more cost effective and safer. PHM means the proactive application of strategies and interventions to defined groups of individuals across the continuum of care in an effort to improve the health of the individuals within the group at the lowest necessary cost. The advent of shared accountability financial arrangements between delivery systems and purchasers has created significant financial incentives to focus on PHM and measuring and reporting its outcomes.

    Review of Population Health Management Companies

    Population Health Management Challenges

    Plenty of things make tackling population health management difficult. The proper collection and use of data is central to those issues. The emerging “pay for value” reform era has left healthcare organizations struggling to compile and structure the immense quantities of data required for success. While electronic health records (EHRs) provide the raw clinical data for many large hospitals and physician practices, making that data accessible and usable – and reporting on the outcomes – remains a puzzle for most.

    Three Critical Systems Needed for Effective Population Health Management

    Based on many years of various forms of population health improvement experience in a variety of health systems, we see three consistent systems that need to be put in place and managed in order to achieve consistent, systemic population health improvement.

    ACO Population Health Management Solutions Stage 1

    1. A Data Warehouse and Analytics Measurement System

    Enterprise Data Warehouse

    You need data across the entire continuum of care in order to manage patient populations.  This requires an enterprise data warehouse (EDW) platform.  An EDW is the central platform upon which you can build a scalable analytics approach to systematically integrate and make sense of the data.

    Health Catalyst deploys a unique Late-Binding™ Data Warehouse that enables healthcare organizations to automate extraction, aggregation and integration of clinical, financial, administrative, patient experience and other relevant data and apply advanced analytics to organize and measure clinical, patient safety, cost and patient satisfaction processes and outcomes.

    Foundational Dashboard and Reporting Applications

    Today, most of your analytic resources are tied up doing manual reporting.  New requests often take weeks or even months to clear the queue.  You need to free up these analytic resources to focus on identifying and solving real problems instead of producing reports.

    Health Catalyst provides a series of Foundational Applications which significantly accelerate the manual reporting work of many analysts into near real-time executive and department reports and dashboards.  Population Explorer, one of our most popular apps can produce the equivalent of 1000 dashboards with over 100 metrics.

    Discovery Applications

    Making sense of your volumes of population health data can be overwhelming.  You need a systematic way to understand and evaluate the important opportunities and allocate resources to work on those key processes.

    Health Catalyst provides a series of Discovery Applications that will help you prioritize the opportunities within your system and help you focus on the areas of greatest opportunities in terms of quality of care improvement, cost reduction, revenue enhancement or patient injury prevention.

    Advanced Clinical, Workflow, Operational, and Patient Safety Applications

    Most important, you need a systematic way to improve care across the continuum:

    1. Identify how the care continuum functions and flows throughout the system.
    2. Understand the correct use of evidence-based guidelines, which are the most critical items to measure in determining optimal care delivery.
    3. Collect and analyze the data in order to measure baselines, set improvement goals, implement changes, and measure results that improve quality, satisfaction or costs.

    Health Catalyst provides an ever growing number of Advanced Applications which have been optimized to support the data and analytic needs of some of the highest priority population health improvement and cost opportunities.  Advanced Applications provide deep insights into evidence-based metrics that support multi-disciplinary teams in driving for care improvements that result in measurable improvement in quality, outcomes, patient safety, and waste reduction.

    These modules span the continuum of clinical management of populations and clinical workflows (e.g. HF, Diabetes, AMI), patient injury prevention (e.g. HAI, ADE), and department operations (e.g. ER, OR, Radiology).

    2. A Systematic, Evidence-Based Content System

    In order to improve care and reduce costs, any population health initiative needs to understand what evidence and expert consensus exist about care best practices and waste reduction opportunities. Quality improvement and waste reduction opportunities abound. Recent estimates have calculated as much as $750B in total US healthcare waste.

    Unfortunately most studies show that it can take years to systematically integrate new knowledge and best practices into a standard process of care. You need a standardized way of integrating evidence into care delivery that takes weeks, not years. Health Catalyst has identified three important areas of waste reduction opportunities that we build into our applications:

    • Ordering waste
    • Workflow and operational waste
    • Patient injury waste

    As population health initiatives focus on these three waste reduction or cost improvement areas, they simultaneously improve the quality of care and help reach the needed value-based cost objectives.

    Health Catalyst Advanced Applications have built in advanced content starter sets.  These starter sets include evidence-based clinical cohort definitions, draft AIM statements, and starter visualizations (including clinical or operations dashboards, balanced scorecards, etc.) that include core clinical and operational metrics for measurement and improvement.

    Other starter set resources may include project charter templates, project plan templates, draft electronic value stream maps (eVSM), order sets, etc. These starter sets are then localized and fingerprinted to match individual customer needs during the Health Catalyst consultative implementation process from direct input by client clinicians, clinical operations leaders, and analysts to produce optimized solutions for the client’s unique healthcare organization.

    Once implemented, the flexible Health Catalyst Late-Binding™ Data Warehouse platform makes it easy to expand, modify, and create new content.

    3. An Organizational Deployment System

    Population Health Management is not a series of one-time projects.  It requires systemic and sustained efforts across a system to win and maintain hard-fought gains.

    Once a population health initiative is able to effectively collect and use prioritized data to guide improvement, satisfaction, and cost reduction efforts, leaders must organize permanent teams which span facilities, traditional departments, and acute/ambulatory boundaries, and integrate technical and clinical personnel across the care continuum in order to sustain their gains. These teams need to be permanent teams that set up continual and iterative improvement process cycles.

    Health Catalyst has years of experience in leading, coaching, and advising many stages of this organizational development.  We offer different types of Health Catalyst Services and even have developed Health Catalyst University where we train in many data-driven organizational improvement processes.

    Why All Three Systems Are Critical

    All of these three systems are critical for effective, systematic, and sustained Population Health Management success.  If any one of the systems is missing or weak, you end up with sub-optimal results.

    Click the titles below to see the optimal and suboptimal results of the three critical systems

    Research Centric
    This approach focuses on academic ideas and published papers, but is deficient on practical applications.
    IT Centric
    These often become focused on reducing the information request queue instead of a clinical/IT collaborative approach to solving problems.
    Organization Centric
    Evidence-based  and accurate measurements are generally missing from these projects.  Clinicians usually stop making requests out of frustration.
    LEAN Centric
    This leads to improvements which are generally unsustainable.  It becomes difficult to manually measure after the first 2-3 projects.
    Automation Centric
    In this approach, the process is automated but often not improved.  This path is common in many EMR implementations where much work is accomplished but the results don’t meet expectations.
    Science Project Centric
    This approach results in pockets of excellence throughout the system.  However, there is usually a limited ability to roll these improvements through the system due to a lack of a systematic approach that scales.

    Population Health initiatives can only successfully thrive and scale when all three systems are functioning well.

    Population Health Management Strategies Webinar

    Read More About Population Health 

    A Landmark, 12-Point Review of Population Health Management Companies
    Dale Sanders, Senior Vice President, Strategy

    Population Health Management: Implementing a Strategy for Success (white paper)
    David A Burton, MD (Former Chairman and CEO)

    How Community Care Physicians Deliver Effective Population Health Management with Analytics
    A health system case study

    Using Advanced Analytics to Manage Population Health in Primary Care Clinics
    A health system case study

    View Product Demos

    Population Explorer (6-minute product demo)
    A multi-purpose tool to literally discover hundreds of population cohorts in minutes.  I

    Community Care (6-minute product demo)
    A multi-application demo showing regulatory metrics, provider/clinic compliance, filtering, and drill down to support a community care initiative