Why is Population Health Management Important?

Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

The way we see healthcare today is very different from what it was a couple of decades ago. Back then, we did not have the technology to capture the best practices. But, today we have the capability to use medical data as a source of innovation and create impact at scale. But the question is are we capitalizing on it? Have we made the lives easier for both patients and care teams? Are we close to the goals we started chasing ten years ago?

When we talk about innovation in healthcare, we stumble across intuition. The intuition of care teams enhanced by data-driven approaches. It is not just limited providing connectivity to healthcare organizations; it is also about providing advanced analytics and reducing the cumbersome, tedious work! Like deep diving for hours on Excel or making quality tracking and reporting easier.

The concept of population health management is a new one. It has evolved from an idea to become a clinical discipline that works on developing and continually refining measures to improve the health status of populations. A successful population health management program thrives on the vision to deliver robust and coordinated care through a well-managed partnership network. This said, there is no one definition of Population Health Management, fifty different CIOs in an interview gave different definitions to this term. It is a broad concept and covers a lot under its umbrella.

What does an ordinary health IT setup lack?

True, the healthcare systems are working on building the skills to interact and develop well-planned health intervention strategies to move away from the traditional fee-for-service model to value-based reimbursements and incorporating value, but they are falling short in many areas:

Limited EHR capability: EHRs played a pivotal role in digitizing health care, but with EHR technology many restrictions came along. Today, only a few are equipped to support the necessary interoperable standards. To deliver better clinical outcomes, it is of paramount importance that we have the data and right analytics to ensure improvements; something healthcare organizations lack even today.

Integrating data sources: A patient who is being relocated to a new state and will have a new PCP and Care Coordinator. Can we say with confidence that the patient’s information will be available to the new PCP? In a large healthcare network, there is labs, pharmacy, clinical, claims, and operational data, but the capability to integrate it into a single source of truth is still a challenge for many! This has limited the potential of care teams and made them communicate in a disconnected ecosystem.

Risk Stratification: 50 percent of expenditure in healthcare is on 5 percent patient population. Wouldn’t it be great if we could find these patients and cure them before any acute episode? Back in 2012, about 117 million Americans had one or more chronic conditions, and account for 86 percent of the entire healthcare spending. The road to population health management will require care teams to recognize at-risk population timely to reduce cost and improve outcomes!

Creating and monitoring care plans: Curing a patient is a long process; post-acute care is equally important as much inpatient care is. Registered nurses, physicians, and care coordinators have many patients to take care, and this is when technology can help them the best. The available resources can be increased many folds with health IT. Care plans can be generated automatically which can be monitored by caretakers on a regular basis as scheduled initially.

Engagement: Easy as it may seem, engagement is still a dream yet to come true on the road to population health management. Engagement is critical on two fronts: the provider network and the patient. Healthcare organizations still have to ramp up their efforts on bringing everyone in the loop, and developing effective patient engagement endeavors and promote their outreach.

Population Health Management with Datashop operating system

The transition to value-based care in healthcare industry calls for population health management. One which can help the healthcare organizations in integrating data, performing analytics, performance tracking, quality reporting, reducing network leakage and accelerating developments in the right areas.

With all this in mind, Datashop thrives on delivering a comprehensive population health management solution that gives real-time insights to caregivers and allows them to identify and mend the care gaps within the defined population. Datashop works on some major fronts:

Seamless data integration: Datashop comes with pre-built connectors to more than 50 widely-used EHR systems and can ingest structured, as well as unstructured clinical, claims, labs, pharmacy, and operational data and present it in a clean and standardized form. Every single patient’s data is mapped out on the network and EMPI is assigned to him for future references.

Risk stratification: According to various risk models, Datashop’s risk Navigator assigns risk scores to the patients and stratifies population based on their vital medical signs. Furthermore, providers and payers can create patient and disease registries for a better understanding of the population.

Identifying and Addressing care gaps: Once the data is aggregated, it is presented as a holistic, Patient 360 record where providers can look at every patient profile. Once the healthcare networks have the view of all the patient sorted according to various parameters, such as disease type, risk scores, etc. they can easily identify the at-risk population and engage them timely.

Monitor Outcomes: It’s extremely important that healthcare systems track their growth and take corrective measures to sustain it. Datashop equips providers with drilled-down analysis which they can use to evaluate their clinical outcomes, the cost of care and patient satisfaction levels. Combined with predictive analytics, healthcare organizations can determine probable outcomes and take some measures to correct their course of action.

Care management: Datashop provides the care teams with advanced care coordination. Providers can easily track the patients who are in need of chronic care. Additionally, Datashop’s artificially intelligent care coordination streamlines the process. A health coach can view all the recently discharged or at-risk patients in a timeline fashion. Push alerts about such population make it really easy for them keep up with the population trend.

Moreover, Datashop provides intuitive and visually adaptive dashboards which remove the hard work required while dealing with excel sheets, saving a lot of time for the care teams. Datashop also provides the capability to create custom measures and dashboard for a better understanding of population and one’s network’s performance.

Into the Future: A Value-based Care World

Most healthcare organizations understand the potential and value of an effective population health management solution, but only a few have been able to achieve the goals. The need of the hour is the right platform that combines technology with analytics and approaches the ultimate goal of population health management with a methodical approach. Datashop provides data integration on its bi-directionally interoperable platform that helps healthcare organizations overcome the barriers to realizing their benchmarks and extend their commitment to their patients at lowered costs, achieving true value-based outcomes.

One needs to be future-ready to be able to deal with the challenges which might come later. Next generation technology which not only streamlines the healthcare delivery process but brings the golden memories of healthcare back.

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