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Population health management: Enabling technology strategies


The following article discusses the two enablers, technology and strategy, to consider when health care provider organizations embark on a path to effectively manage the health and care of a patient population. These tools and technologies should enable the strategy which is governed by organizational business objectives and frameworks for successful population health management.

Tools and technologies

Identifying the tools that enable a successful population health management strategy from an information technology (IT) perspective is an important step. There are various tools available in the market from some of the larger electronic health record (EHR) vendors as well as various niche technology vendors. The following is an approach to understanding key capabilities when evaluating technology solutions and building a toolkit that effectively supports a population health management strategy.

Tools and resources include:

  • Risk stratification tool – This tool provides a method to analyze and understand a patient population by a multi-factorial risk calculation based on past medical history, demographics, socio-economic indicators and more. At a minimum the data sources driving this risk stratification include the core EHR data along with the claims data for this patient population. Further insights can be derived from integrating data from additional sources, such as health information exchanges (HIEs), laboratory information systems (LIS), third-party EHRs, pharmacy benefit managers (PBMs) and public health departments.
  • Care coordination tool – This is an essential tool that is also called a care management or customer relationship management (CRM) tool that is primarily used by the care coordinators or care managers responsible for managing the overall care of a patient whether inside or outside the hospital. This tool provides a mechanism to add tasks and goals that are assigned to each patient. It also has a tracking mechanism to document compliance, status and notes as well as the ability for the care coordinator or care manager to communicate with patients in the form of secure messages.
  • Longitudinal health record – A longitudinal health record provides an ability to create a single patient-centered view of all relevant patient health information. It helps create a complete picture of the patient’s health across all venues of care and episodes. This longitudinal record will also enable predictive analytics based on prior trends and provides decision support for the clinicians at the point of care based on past history and standards-based care models. An essential component to enabling a longitudinal record is the ability for the various IT systems and solutions to share data via integration and interoperability.
  • Health care data analytics and data warehouse – A data warehouse with robust data analytics capabilities is an important tool for population health management. The data will need to be normalized to integrate data elements from disparate data sources through architecture and governance. This will create a data set that is a single source of truth, and also enable the use of scheduled and ad hoc reports as well as defined dashboards to measure organizational performance on critical operational, clinical or financial metrics.
  • Patient engagement portal – Patient engagement is another key element of a population health management platform that enables a variety of communications with patients and providers as well as a forum for patients to access their health data. An engaged patient population makes the task of managing care much easier for the providers and the care managers. The patients may utilize this portal to download and transfer applicable health information or review available patient education content on-demand. The more advanced portals also provide a mechanism for patients to sync data from their remote monitoring devices and fitness tracking devices, or manually upload other forms of patient-generated health data (PGHD) like past medical history, allergies and home medications. A key to the shifting paradigm where the providers benefit from engaging their patients as opposed to waiting for the patients to engage them is enabled by a successful patient engagement portal.
  • Telemedicine platform – A growing trend in health care today is the ability to utilize a telemedicine or telehealth platform which would allow for virtual visits between the providers and the patients. This would be beneficial at times of specialty referrals, remote monitoring for follow-ups or for patient education purposes. The ability to take care of patients where they are rather than where the clinicians are represents a paradigm shift from traditional practice. This can also serve a need when the patients are unable to meet with the providers in person due to health or proximity reasons. Advantages of this approach include better patient satisfaction and improved patient engagement and compliance in the care management process.

A strategic approach to population health management

Below are some of the key objectives that constitute the tools and processes which support development of a population health management strategy.

1.     Identify the care delivery capabilities of your organization and care network along with the stipulations of your payer contracts and reimbursements.

  • Evaluate the current capabilities of the organization for access to care
  • Create a process map of the care continuum for the target patient population within the network as well as the venues of care (e.g., clinic, emergency room (ER), urgent care, acute, post-acute) to determine the most cost-effective processes for care delivery
  • Perform a gap analysis to identify areas of patient leakage when the care needs to be provided outside the hospital network (e.g., specialty clinics, ER)
  • Make a financial risk calculation pertaining to payers and reimbursements based on gaps of care

2.     Develop the tools and processes to understand your patient population from the perspective of risk, costs and care demands.

  • Identify the patient population
  • Create a registry of patients based on condition and disease
  • Risk stratify this patient population based on known information and predictive insights

3.     Create a unified longitudinal health record across the care continuum.

  • Create a comprehensive patient-centered view of health data that includes information from disparate sources
  • Build a process to normalize the data from different sources to get a complete picture of a patient’s health across different episodes of care
  • Consider benefits of leveraging HIEs and other interoperability frameworks to contribute to and consume external patient data

4.     Create or enhance the tools and processes for effective care team collaboration in an integrated care delivery model.

  • Standardize care processes
  • Document consistent patient information through transitions across the venues of care
  • Leverage technology enablement for care coordinators so they can engage and manage patients
  • Ensure close collaboration between physicians and care coordinators to maximize care

5.     Promote patient engagement by providing consumer-friendly tools; incorporate patients in the care management process.

  • Consolidate the patient engagement platform to a single point of entry which enables patients to be engaged in their health care process
  • Provide access to health data, diagnostic test results and patient education content in a timely fashion
  • Allow for two-way communication tools between providers and patients through messages, document exchange or telehealth that improve patient satisfaction
  • Enable PGHD to become a part of patient health records
  • Engage with patients through leveraging telehealth technology such that care can be provided where patients are without needing them to come into the clinic or hospital

6.     Establish a solid data foundation layer enabling trending, measurement and analysis.

  • Utilize this data foundation, or warehouse, as a single source of truth for all reporting and analytics needs
  • Build an extendable data model to incorporate the necessary data feeds
  • Develop a presentation layer that allows for data to be rendered in a meaningful way
  • Establish a data governance process for access, use and harmonizing of the data within this foundation

The right tools and a focused strategy work hand in hand when executing an optimal population health management initiative. Learn more about common challenges related to population health management and the importance of mobility and interoperability in Population health management: Technology interoperability is key.


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