The Right Population Health Analytics to Transform the Patient Experience

By Abhinav Shashank, co-founder and president, Innovaccer.

Abhinav Shashank
Abhinav Shashank

Consider a situation where healthcare is not just an industry term — a situation where EHRs are not an integral part of physicians schedule but just a support to providing care. All considered, imagine a situation where patient-centric care actually involves the patient, and patient engagement is not just a buzzword but a reality. Unfortunately, all these imaginations were supposed to be a reality, but still, healthcare managers and organizations are struggling with the problems such as the lack of patients’ adherence to medication, varying trends in the population health, and a lot more. Patient population, nowadays, expect the same on-demand delivery convenience from the healthcare organizations as they get from the other companies, like Netflix.

Why is Patient Engagement the Core of Providing Patient-centric Care?

To understand the value of the patient in the entire care continuum, let us take an example. Consider a patient, Marcus, who works at an IT firm and is affiliated to a Commercial ACO in his county. Marcus is a 65-year-old male suffering from comorbidities like Type 1 Diabetes, and diabetic retinopathy. He is at constant risk of sporadic elevated blood pressure.

In the year 2016, Marcus visited the ED approximately five times. Considering the situation, his primary care physician referred him to a specialist and prepared a schedule comprising at least two monthly visits.

The year 2017 started with a lot of workload for him at his firm, and he was unable to keep up with the prescribed schedule. Because of improper communication between his PCP and him, his physician was not able to keep track of Marcus’s health. As a result, the ED utilization rate for Marcus increased from five times to nine times. Because of enhanced stress and improper quality of care, the sporadic episodes of elevated blood pressure turned into a constant problem of hypertension. Also, the overall cost of care for Marcus increased drastically.

Challenges in Achieving True Patient Engagement

Patient engagement, in itself, is not as simple as ABC. It is not just bringing patients in the cycle of care continuum but enhancing the patient’s skills, ability, knowledge, and most importantly, willingness to participate in the task of managing his own care. The concept of providing care with “engaged patients” sounds great theoretically, but it is not that smooth sailing. According to a survey, nearly 87 percent of the patient population believes that communication with their doctor apart from their scheduled appointments is really important.

The major flaw is the lack of awareness among the patients regarding their care procedures. Many patients are ignorant of the clinical processes which a physician follows, and they might miss out on major health details. With no actual knowledge of the disease symptoms, patients might not report to their physicians which might lead to reduced patient engagement, not to mention the increased risk of developing a chronic disease.

Care teams play a vital role in engaging the patients through regular follow-ups. Irregular and fragmented workflows of care managers and lack of personalization might lead to the generation of ineffective care plans for the patients. Reduction in patient engagement could also be the result of under utilization of technologies to analyze the massive amount of patient data that care managers have at their disposal. Through building more personalized care plans, patients can be engaged at a more grass-roots level.

Driving Effective Engagements through Value-based Care

Predictive population health analytics is the answer to nearly every problem linked with patient engagement. Advanced predictive analytics tools will help in dealing with the problems of disparate data systems and can pinpoint the exact area on which healthcare organizations can focus. Leveraging the insights obtained by data analytics, care teams can prepare the statistical models to prioritize each patient and can take necessary measures to engage patients in the process of decision-making. Understanding the patients’ habits by the care teams increases the chances of preparing personalized care plans for them and enhancing the level of patient satisfaction.

With enhanced technologies, advanced tools, and constant patient engagement, individual care management can pave the path for systematic population-level solutions. Whether it may be population-level or individual-level intervention, it is essential to identify the root cause of the problem. With interactive analytics, the physicians can identify the episodic outcomes variations. Systematic analysis of patient population can not only help in stratifying population based on factors such as risk-scores but can also lead the way for holistic diagnosis and personalized care being delivered based on key health trends.

When it comes to realizing smart healthcare choices, we always eliminate a major factor- social and behavioral determinants of health. This data helps in identifying individual struggle with daily routine activities and can turn out to be a strong tool in eliminating the barriers which are outside the limits of healthcare. Care organizations can classify the area’s population based on various parameters like language, accessibility to vehicles, and others to manage their outreach programs.

Including social determinants of health data for advancing patient engagement can be highly beneficial for healthcare. For instance, if the physician knows her patient to be someone who follows an unhealthy lifestyle, she can take preemptive steps to avoid the occurrence of any illness that the patient might have become prone to. Moreover, the patients can be made aware beforehand about any health risk they might be contracting because of their lifestyle, environment, neighborhood, eating habits, etc.

Advanced Approach to Bridge the Physician-Patient Gap

Healthcare organizations are constantly trying to improve the patient experience of care and deliver quality at every step. And the immense amount of healthcare can serve as a significant avenue for innovation to enhance patient engagement. A patient can receive care from multiple facilities- even within a network. A comprehensive, accurate picture can be obtained only when the patient health data is obtained from all these facilities and brought together on a unified healthcare data platform.

Such a healthcare data platform can integrate disparate sources into longitudinal records that detail every patient’s risk scores, medical history, admissions and discharge events. These records can be further analyzed to understand the gaps in care, learn about the impacts of ongoing care programs, and plan timely interventions for the patients. With a close monitoring of care programs impact the patients, the care teams can address the specific blind spots, and even link community resources to assist patients with their varying needs. One such organization, with the use of an integrated, data-driven approach, was able to reduce SNF visits in their network by 12 percent and cut down their 30-day readmission rate by 7.14 percent.

The Road Ahead

In the present healthcare scenario, patient engagement is like the medicine which is to be prescribed to every patient as well as provider. Changing the entire nation’s healthcare ideology to a single patient-centric approach is tough, but this transition is vital. It is nearly impossible to realize engaged patients without a strategic approach covering the overall domain of the healthcare. Being an integral part of healthcare, patients serve as one of the major drivers in the improvement of the overall picture. Properly engaging them not just to improve their individual health but for improving the entire population health is a must and cannot be neglected in the long run.

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