Healthcare provider organizations across the country have been spending more time focusing on population health management. It is of utmost importance to take care of individual patients, but focusing on the health of populations, especially those with chronic conditions, can enhance care quality and cost efficiency.

Information technology plays a huge role in population health. There’s no way to manually deal with the huge amounts of data generated by a pop health program, and advanced analytics are needed to glean the insights necessary to improve care delivery for populations.

It’s one thing to have the technology in place to facilitate a population health management program. It’s quite another to ensure that technology is operating at peak performance-levels and tailored to the needs of individual healthcare provider organizations.

Here, three population health IT experts – from Enli Health Intelligence, Epic Systems and Optum – offer some perspective and best practices for optimizing technology to help meet their pop health goals.

The impact of digital technology

In the past, healthcare CIOs were limited to operating back-office applications. Now, they’re tasked with operating 24/7, mission-critical systems.

Being a good technology operator is not enough anymore. The CIO must understand the impact of digital technology in every aspect of their organization – because it impacts reputation, financial performance, and the ability to effectively and efficiently deliver care, said John Kontor, senior vice president, Optum Advisory Services, a part of population health, health IT and analytics vendor Optum.

"CIOs are key architects and innovators when it comes to certain strategic capabilities for provider organizations."

John Kontor, Optum Advisory Services

“CIOs must position themselves as innovative stakeholders – and position IT innovation as imperative to growth,” he said. “In addition to being a good technology operator, CIOs are key architects and innovators when it comes to certain strategic capabilities for provider organizations. This includes working alongside clinical stakeholders and C-suite colleagues to drive a population health strategy.”

A clear opportunity is for CIOs to optimize technology that already is within every healthcare-provider organization – the electronic health record, he explained. This has to include EHR optimization to align clinical and technical workflows, he said.

“In the context of the current COVID-19 pandemic, for example, EHRs can be used to enhance some of the basics – like [identifying] high-risk individual patients to target outreach and education, or automatically [enrolling] COVID-19 test-positive patients into registries to guide monitoring and follow-up,” he said.

“We have even seen advanced organizations rapidly integrate care and coding – risk adjustment – gap tools directly into their EHR-enabled telehealth workflows to scale efficiency and [the] impact of tele-visits that otherwise might have been focused on a single problem or question.”

Automating decision support

An important best practice when optimizing pop health IT is the automation of provider decision-support to improve comprehensive quality and reduce variation in healthcare, said Dr. Joseph Siemienczuk, Chief Medical Officer at Enli Health Intelligence, a population health IT vendor.

“The application of evidence and best practices to patient care is vital in population health,” he explained. “From peer-reviewed publications to evidence-based guidelines, there are rich resources available for providers in support of high-quality, individualized care. But they are not useful in the rapid-fire setting of patient encounters. There is too much information, too many sources, and it is not presented in the context of an individual patient.”

"The application of evidence and best practices to patient care is vital in population health."

Dr. Joseph Siemienczuk, Enli Health Intelligence

Care recommendations must be made with due consideration of the demographics, comorbidities, and the individual’s personal and healthcare history, he advised.

“This requires perusal of rich clinical and often claims data of each individual in order to assure personalization,” he added. “Vaccinations are a useful example. There are published vaccine schedules but the patient’s age, gender and medical history must be considered. And then, that patient’s own vaccination history must be applied. The time providers have with each patient is too limited for this to be practical.”

The Centers for Disease Control and Prevention has published algorithms that can automatically incorporate all needed information and apply up-to-date vaccine schedules, he suggested. The content is open source, and when properly applied can provide virtually instant decision support for providers in the exam room, he added.

“So a comprehensive and accurate recommendation for vaccines can appear on screen to support the care of every patient, in every encounter,” he said.

“But the algorithms must be codified and appropriately connect to the data source, generally the electronic health record. And CDC updates are frequent; it is not acceptable to rely on out-of-date recommendations. Fortunately there are technology solutions available today that provide just such functionality. Comprehensive and context-sensitive instant decision support is the first pillar of population health.”

Transforming care delivery

On another pop health front, success in population health requires not only optimizing technology, but also examining and redesigning the approach to care delivery, said Ryan Bohochik, director of value-based care at Epic Systems, an EHR and population health IT vendor.

“Take primary care, for example – are we focused only on the immediate need, or are we using information available to drive prevention?” he said. “Everyone on the team plays a role in shifting from fee-for-service to value-based care. From providers addressing care gaps in the office, to care managers reaching out to patients in the home, to front desk staff ensuring patients are up to date with their annual screenings, everyone has a role to play – and those roles continue to evolve.”

"Technology can support connections that reduce administrative complexity by automating the sharing of clinical information from providers to payers, helping providers close care gaps."

Ryan Bohochik, Epic Systems

If used well, technology can play an integral role in this transformation, he advised. A comprehensive health record can analyze complex factors across a population to identify patients who may be at risk – whether it’s that they don’t have access to healthy food, or that they’re having trouble managing a chronic illness, or that they’re lonely, he said.

“In some cases, it’s all of the above,” he added. “When that patient comes in, providers know to complete a foot and eye exam, but they may not know that she is struggling at home. The same system that helps identify the patient’s needs can also set her up with connected devices to manage her diabetes, connect her with community-based organizations to address food insecurity and mental health, and monitor progress along the way.”

Continuous care coordination

One best practice for optimizing pop health IT is ensuring platforms and applications support continuous care coordination, said Siemienczuk of Enli Health Intelligence.

“Value-based care and reimbursement has made healthcare organizations responsible for the health outcomes and cost of care for patients, but encounter-room technology was designed for transactional care,” he explained. “Even high-acuity patients spend precious little time in healthcare encounters. In order to effectively manage chronic conditions, I must have continuous oversight and connectivity with my patients.”

Human nature leads to procrastination and neglect of things that are not immediately triggering symptoms, he said.

“So as soon as I can detect that a patient is overdue for a service, I should be proactive and make contact,” he said. “This can be accomplished by liberating the care plan from the electronic record. The care plan, now mobilized, is still part clinical but largely about communication. And it can be delivered in now preferred modalities like text, smartphones and tablets.”

There is no timelier example than the COVID-19 pandemic, he continued.

“While much of our attention is focused on the sickest patients in hospitals, the majority of patients will be managed at home, in self-isolation,” he said. “We don’t want to make them come to the office if they don’t need hands-on care, as it exposes the community and the healthcare workforce to risk. But we also can’t just leave them on their own.”

Their test results must be tracked, capability and resources for safe self-isolation assessed, and patients must be educated on safe practices, he said.

“And then regular two-way communication must be prompted and tracked,” he added. “Again, there is care coordination software that is purpose-built to track, manage and support these patients through the course of their illness, and ultimately return them safely to the community. Software development is so nimble that COVID-19 care coordination platforms have already been developed, tested and deployed.”

AI and NLP

Kontor of Optum Advisory Services offered another best practice: CIOs should consider forward-thinking technology that has the potential to massively impact the organization’s ability to manage population health. For example, technologies like artificial intelligence and natural language processing in connection with pre-authorization, risk adjustment, chronic condition management, telehealth and modeling/analytics.

“When it comes to COVID-19 response, resource modeling can help project COVID-19 prevalence at a localized level, enabling projection of infection, resource needs, and demands such as hospital bed availability, discharge options, mortality and more,” he advised. “As we look toward economies and care settings opening back up, using AI-powered tools to predict and early-identify future flares will be critical also.”

CIOs and other technology executives are in a position to elevate the role of IT to enable new models of care. Thoughtful IT, Kontor said, should help healthcare provider organizations take better care of patients. By aligning IT strategy against organizational goals, CIOs can help ensure that technology investments drive better outcomes, patient and physician engagement, and efficient care delivery, he said.

Collaboration with health plans

Another key to success with pop health IT is working collaboratively with health plans, said Bohochik of Epic Systems.

“As groups pursue shared-risk arrangements, it’s important that both participants are taking advantage of the same information,” he advised. “Technology can support connections that reduce administrative complexity by automating the sharing of clinical information from providers to payers, streamlining the prior authorization process, helping providers close care gaps within workflow, and providing patients and providers with suggestions for lower-cost medication alternatives.”

The common theme across both of these factors is that technology should provide those working in the healthcare system with the tools they need for success in population health as a core part of everyday processes, he said. With better sharing of information and coordination between partners, health systems can achieve better outcomes and help to improve the health of their patients, he concluded.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
Healthcare IT News is a HIMSS Media publication.