How technology can assist with population health

In the years since the Obama administration passed legislation requiring hospitals and physician offices to adopt electronic health records (EHRs) that digitize patient data, technology has been the driving force behind initiatives like population health management.  

In fact, technology is critical to physicians’ ability to scale population health initiatives as providers eek out nuggets of information that track large numbers of patients often suffering from chronic illnesses. By analyzing patterns, trends and associations among a larger group of patients, providers can gain insights that reveal which group of patients are improving and why and which patients’ condition is worsening. Based on this information, physicians can make better decisions to improve outcomes among a larger group of patients.

As providers embark on population health initiatives the technology they use can assist them in three fundamental ways, said Cynthia Burghard, research director at IDC Health Insights, a division of Framingham, Mass.-based IT research firm IDC Research Inc.

1.  Analytics. Physicians can rely on EHRs and claims data to perform many tasks such as identifying the best patients for intervention. Another benefit of technology is that population health programs are tied to a series of metrics that reveal gaps in care as well as provide certain quality metrics. By evaluating the data, physicians can better understand how their practice is performing and make changes to improve their care treatment plans. Software that tracks social determinants of health, behavioral health and other non-clinical drivers of health and diseases are also being introduced to gain a fuller picture of a patient’s well-being.

2. Technology that supports care paths. Increasingly, software tools are being used to manage patients’ adherence to everything from taking medications to remembering their appointments. For example, a diabetic patient that forgets to take their medication on time will receive a text message every morning instructing them to take their pills. These reminders could be set by the patient or at the physician’s office where the use of an automated system can send alerts to multiple patients.

3. Patient engagement. Technology can support communications through multiple channels to connect with patients and improve patient behavior. Through the use of tools such as a secure message on a patient portal, a secure text message to a mobile device or wearable devices, doctors can receive patient data and monitor their patient anywhere and in real time.

Other technologies such as telehealth systems used to treat patients over long distances, mobile devices to input and access patient data and cloud computing, which is a cost effective way to help providers store, managing and organize patients’ health records, are all supporting technologies for population health management.

Next: Structuring a population health plan

Structuring your population health plan

As small practice physicians sort through the population of patients whose data they want to capture, and focus on what technology they’ll use and which organizations they want to partner with to leverage technology and resources, Burghard said physicians must decide how they’ll structure their population health plan.

“Small group practices have to ask themselves, ‘Where can we make a dent? Who are the best group of patients to take on certain improvements? Are we really good at managing diabetics or are we better at managing hypertension? Do we have relationships with cardiologists for managing hypertension and can we have a group effort?’” Burghard said.

Small physician practices have an advantage because they know the patients that have multiple comorbidities and the patients who don't comply with preventative screenings. That information can be analyzed from an EHR, Burghard said, but if small practices want to scale their population health management plans, it's good to evaluate whether they have the capability or can get the capability to be successful.

“A lot of the failures around population health are around risk-based contracting,” Burghard said. “Providers don’t understand the resources that are required versus the resources that they have available to them.”

She also said group practices of any size that have taken on population health in a very tactical way may have some technology, and they may hire a nurse care manager but they don’t go further. In essence they don’t develop strategic plans that can advance their ability to improve outcomes and reduce costs which are some of the benefits population health has to offer.

“To be successful and scale population health, healthcare organizations need to be more strategic and establish new processes such as reminding patients about the need for screenings when they are in the physician’s office, coordinate care after hospital discharge to avoid readmission, and establish urgent care of other services to divert patients from the emergency room,” Burghard said.

As technology continues to drive innovation into the practice of managing large numbers of patients, population health’s success will increasingly rely on strategic thinking, performance measurements and technology that can generate scalability on large data projects.   

“My advice to small practices is take a good hard look in the mirror, find large enough data sets to analyze and then start looking for partners,” Burghard said.