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The Challenges and Promise of Population Health Management

May 17, 2016

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As US health organizations continue to amass unprecedented pools of patient data, many providers are getting a sustained view into population-wide patient trends for the first time, and it’s is changing the way providers understand and influence healthcare outcomes.

The population health management (PHM) care model seeks to improve patient satisfaction and clinical and financial outcomes by using patient data analysis to identify and address health trends among at-risk patient populations.

PHM emphasizes the aggregation of patient data from a variety of sources, like claims data, outcome data, and social health determinant data, which the CDC suggests accounts for 75% of population health.

Ushered in by evolving value-based care reimbursement models, PHM reflects a pivot away from responsive, episodic care towards coordinated care aimed at stemming the tides of poor patient outcomes, particularly as it relates to chronic care.

No Small Feat

The bevy of health IT components that factor into population health management strategy include, but are not limited to health analytics, data storage and access, security, interoperability, patient engagement and workflow management.

According to HIMSS Analytics’ Essentials Brief: 2015 Population Health Survey, “sixty-seven percent of surveyed organizations claim to have population health programs in place,” though they largely appear to be going it alone, with only a quarter of those surveyed reporting using a vendor solution to address their population health needs.

Beyond core platform functionality, data is the leading sore spot for providers pursing population health management solutions. Specifically, interoperability and data access issues still pose big challenges to providers. Findings in Premier’s Spring 2015 Economic Outlook Survey reveal that “more than two-thirds (68 percent) of respondents said their health systems are successfully accessing data from the ambulatory EHRs of their employed physicians, [yet] barely one-third (38 percent) said that they're successfully accessing data from affiliated or non-employed physician networks.”

Limited access to data savvy personnel resources like security experts and health data analysts represents another PHM hurdle for providers. Employee crossover from payer to provider markets is one way organizations are filling new population health roles.

Pop Health Potential

While population health management programs will likely eventually be the normal order of business in healthcare, priorities will vary between health organizations and over time. Here are just a few of the ways providers are putting PHM into action:

Community Engagement - Many providers tackle patient education programs as one of their initial population health initiatives, fostering relationship building with patients beyond the traditional walls of institutionalized care and increased patient ownership of health.

Predictive Analytics - With the right data and machine learning in place, providers can tap into like-patient population commonalities, map the collective health trajectory of at-risk patient populations and use that patient persona data to address anticipated health threats. Advancements in the areas of data visualization and IoT device integration stand to bring new levels of insight to the market.

Intervention Campaigns - Through routine outreach to at-risk patient populations, providers are proactively influencing or intervening in patient outcomes. Mobile and telehealth solutions promise to streamline the art of digital patient engagement – a market that seems ripe for CRM-like tech adoption.

We are on the brink of a realm of immense new potential in healthcare.

Population health management represents the first collective step towards preemptive health monitoring, which stands to revolutionize US healthcare delivery. Using a collective view of care to help drive positive individual outcomes echoes the American sentiment of “e pluribus Unum” (“of many, one”).

Data advancements driven by PHM initiatives are poised to take healthcare research, predictive analytics and personalized care initiatives to new heights. While the effort will take a lot of work on behalf of many people, the broader understanding of the variables influencing health outcomes could contribute significantly to addressing health disparity issues in the US.