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Making the Most of Your Data with Population Health Management

With health care shifting from volume-based to value-based care, there is heightened focus on patient outcomes and providing quality patient care. Since the HITECH Act passed in 2009, there has been an increase in incentives for providers to participate in quality programs, such as Meaningful Use. These incentives, and penalties, show no sign of slowing down anytime soon. One initiative we’ve been hearing a lot more of lately is PHM, or Population Health Management. Like most buzzwords in health care, there’s a lot of excitement around the possibility of implementing a successful PHM program, but what does that look like in practice? First, it’s important to understand what PHM is, the challenges around PHM, and some steps we can take to move us in the right direction.

So what is Population Health Management? PHM seeks to improve the clinical and financial outcomes of a group, or population, by using patient data from multiple health care resources and analyzing that data into a single patient record. In short, PHM seeks to help chronically ill patients get better, while also decreasing the amount of money spent on patient care. In order to successfully implement a PHM program, it’s important to define your population. Typically, population health focuses on identifying the sickest patients and usually those with chronic conditions. Sadly, these sick patients shouldn’t be hard to find: as of 2012, 117 million people, about half of all adults, had one or more chronic health conditions. 25% of adults had two or more chronic health conditions.

While there are certainly enough chronically ill patients for health care organizations to target through a health management program, PHM does not come without challenges. For one, interoperability in health IT has its limitations. Many EHR systems do not communicate with one another, so if a patient is admitted to a hospital that uses one EHR system, and then that patient sees their primary care physician who uses another system, that patient record becomes fragmented. In other words, we rarely see the same intelligence tools (EHRs, PMs, etc.) used across multiple organizations. And when data across different systems is collected, how can we transform these inputs into one streamlined output? Additionally, while we certainly have a large pool of patients to select for PHM programs, patient compliance is often outside of the control of a provider or health care organization.

Even with the above challenges, PHM is not futile and are things we can do to steer us in the right direction. Care coordination, a huge focus here at pMD, allows physicians to coordinate care across multiple organizations, leading to improved transparency into that patient’s health care journey. A great example of this is the AIM program in Anchorage, Alaska. In addition to connecting care communities, interoperability must become a reality if PHM is to succeed. Interoperability refers to the ability for different health systems (EMRs, practice management systems etc) to exchange and share information. Lastly, getting patient involvement and buy-in is tremendously important when we talk about improving outcomes in PHM. Medication compliance, engaging in online patient portals and patient education are all ways medical professionals can encourage their patients to become involved in their health outcomes.

The shift from fee-for-service to value-based care is certainly a refreshing change, and one in which pMD is prepared to help. pMD encourages communities of physicians to communicate through our secure messaging platform to ensure continuity of care from hospital to PCP. Improving outcomes for patients has obvious benefits for all health care stakeholders. As a matter of fact, improving prevention and disease management for chronic illnesses, such as diabetes and heart disease, could save the US over $1 trillion by 2023! While value-based care is still a work in progress, programs like PHM are moving us in the right direction.
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