Getting patients healthy and keeping them that way — optimizing wellness and managing chronic conditions in a way that controls costs — is no easy task. But it's one made possible by emerging technologies as Meridian Health and other IT savvy providers are showing.

The six-hospital health system in Neptune, New Jersey started a full-fledged, IT-supported population health management program early in 2015 with the three aims of improving the health of its 1.1 million patients, improving the quality of their care and reducing healthcare costs.

This story is part of a reporting package on the rise of population in health in healthcare IT management. Stories include our analysis of health system strategies, an overview of the work done by Essentia Health and a look at how mobile apps are supporting initiatives.

It integrated healthcare data from 15 different sources into a data warehouse with a disease registry system using Cerner’s HealtheIntent tool. The number of data sources will increase to 20 by the end of March and include systems for hospitals, clinics, long-term care facilities, home health, labs, payers with which Meridian has accountable care organization agreements and Jersey Health Connection, the local health information exchange.

"A core focus for Meridian has been creating a platform that allows us to gather clinical, claims and other data, and aggregate the data into one database, upon which we can do sophisticated analytics, allowing us to create a comprehensive view of everything going on with the consumer," said Meridian vice president of IT Steve Sakovits.

A Meridian caregiver does not have to be a data scientist to understand what they're looking at in the data warehouse, added CIO Rebecca Weber.

"We have the system set up with easy-to-use dashboards so caregivers can see, for example, that this patient is overdue for a test or that there may be an issue they did not see," Weber said. "It all makes sense to the end user."

More than 250,000 disease registries in the system stratify those 1.1 million patients into various disease states, making it easy for clinicians to see gaps in care with patients and identify which gaps are most pressing, enabling clinicians to more simply schedule visits for screenings, blood work or other tests, all in real time, Sakovits said.

In less than a year, Meridian Health has seen solid results from its population health management program.

"We average more than 3,000 unique patient views in the registry system per month by care managers and clinicians," Sakovits said. "Our latest data from the Centers for Medicare and Medicaid Services shows a marked decrease in emergency department visits and hospital admissions for high-risk Medicare Shared Savings Program patients. We have experienced significant improvement in our ability to meet quality metrics for our value-based contracts for our owned ambulatory practices, because our care managers now have visibility to care that has occurred across the Meridian continuum, when in the past they only saw what was documented in the ambulatory EMR."

Further, Meridian has been able to develop what it calls LACE reports — based on length of stay, acuity of admission, comorbidities and emergency room visits — that predict readmission or death within 30 days of discharge, Sakovits explained.

"We now can ensure we have appropriate follow-up post-discharge based on these predictive analytics," he said.

Sweeping the industry

Population health management is an increasingly important strategy that more healthcare providers and other industry players are adopting. And as they embrace this practice, they're depending to information technology to make population health work. Health systems are using electronic health records, telemedicine programs, mobile tools, data warehouses, analytics and more to manage population health. And they're seeing a bright future for population health and the IT that powers it.

Today, 67 percent of healthcare organizations have population health management programs in place, according to a 2015 study by HIMSS Analytics, which polled 200 healthcare executives to track the use of population health IT and consultants for an idea of what their projects will look like in five years.

Most organizations have focused their population health efforts on chronic disease management (83 percent of respondents with initiatives in place) and wellness/preventive health (82 percent), HIMSS Analytics found. Providers are using existing systems such as EHRs and analytics to power their efforts. As for vendor solutions marketed specifically as "population health systems," only 25 percent of organizations with population health initiatives in place currently use a vendor-provided population health solution.

That said, there remains some squishiness when it comes to precisely defining the term. But many health system executives and clinicians agree that the so-called Triple Aim is the best way to understand what the goal is.

Leading population health chronic disease management initiatives

Source: HIMSS Anayltics, 2015

As defined by the Institute for Healthcare Improvement, the Triple Aim seeks to optimize health system performance by improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of healthcare.

Cynthia Burghard, research director, IDC Health Insights, says it's important to also take technology capabilities into account: "The ability to analyze data and identify a population. The ability to create and monitor care paths and the ability to communicate with patients and populations around health issues."

John Moore, founder and managing partner at Chilmark Research, a healthcare IT research and consulting firm, meanwhile, defines pop health thusly: "It's the business of care, the proactive management of the health of a given population by a defined network of providers in partnership with community stakeholders. It's a move from passive care to proactive care."

Tech trends

A wide variety of healthcare information technologies are being used to bring population health management efforts to life. Some are foundational and widely used; others are still up-and-coming.

"Electronic health records are table stakes," said Joseph Siemienczuk, MD, chief medical officer at Enli Health Intelligence, a population health IT vendor. Enli was recently identified by KLAS as the top-performing population health vendor.

"I don't think you can likely execute effectively on population health management in the absence of EHRs," said Siemienczuk. “Fortunately, EHRs have become gratifyingly prevalent, so it is not a limitation today."

Moore identified three types of technology as pivotal to population health management.

"First, a system of records, a place where you can create and manage a longitudinal patient record that includes not just clinical data but patient-generated health data and claims data so caregivers can understand patients within a network of providers," he said.

"Second, analytics, where you understand the cost of care delivery, who is most efficient at delivering care, compliance of patients, which patients can be influenced and understanding transitions in care."

Third is what Moore called systems of engagement: "How you structure all of this information, beyond the traditional health information exchange, which just moves information around, but something that provides insights to those on a given care team," Moore said. "Then that leads to guidelines, clinical pathways and more."

On top of the conventional clinical and claims data that technologies collect, providers have to start thinking about how other types of medical data can be collected and aggregated by IT.

"We are starting to look at biomolecular, imaging, pharmacological and biosensor data," said Sakovits. "How do we get information from things like smart-clothing and social apps and invest this data with advanced analytics, serving up wisdom to physicians and consumers? Then we can aggregate data from all sources and reach out via a consumer app and advise patients of things they need to be aware of. We can centrally avert a catastrophic event."

Reality check: Population health vendors

Trending up among healthcare information technologies that support population health management efforts are systems specifically designed for and named after these efforts.

Population health systems are finding favor among some provider organizations. Population health management vendors represent an emerging market, said Burghard.

"There are vendors coming into this market from just about everywhere in the industry," Burghard said.

Those include traditional EHR makers such as Allscripts and Cerner as well as upstarts such as CareSync, CircleLink Health, Enli, MD Revolution, SmartLink and others.

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“There are a number of analytics vendors improving their capabilities, there are boutique consulting companies offering technology,” Burghard added. “We'll see consolidation in the market in the next 12 to 18 months."

Some experts, however, do not believe these population health solutions are yet up to the task.

"To date, nothing has been able to address the whole spectrum of population health management, going from systems of record to analytics to systems of engagement," said Moore. "However, vendors have done a hell of a lot of work recently to close some of these gaps. Some population health management vendors are about 80 percent there."

What to watch for

As 2016 unfolds and technologies and techniques evolve, hospital executives should keep their eyes out for new developments that can help advance population health management efforts.

"CIOs should be paying attention to what is happening with the Fast Health Information Resources, or FHIR, application programming interface standard of HL7, understand it and question their primary vendors as to the vendors' development stances regarding FHIR and how soon CIOs will see solutions based on FHIR," said Moore.

The FHIR specification can facilitate data sharing among all healthcare IT systems in ways that will improve caregiver access to clinical data sources and ultimately help health systems better achieve population health goals.

Another developing technology CIOs should be watching is cognitive computing, said IDC’s Burghard.

"We're just scratching the surface of the power of cognitive computing in healthcare," Burghard said. "It's a set of technologies and tools that allows organizations to do things like pattern analysis and natural language processing that will help clinicians."

Meridian CIO Weber said that hospital leaders, clinicians, data scientists and others must truly understand where the population health movement itself is headed.

"CIOs need to think bigger. They really need to store all the data they think they will need in the future, and embrace the users of data because the users are the ones who will need it. Population health management has to be a joint effort,” Weber explained. “CIOs need to be part of an interdisciplinary, cross-functional team of clinicians and administrative representatives that defines requirements, sets priorities and marches down the same path together."

Twitter: @SiwickiHealthIT