Optimizing Technology to
Achieve Population Health
Shannon Nielson, MHSA, PCMH-CCE
Centerprise, Inc
May 5th, 2015
Indiana PCA Annual Conference
www.centerpriseinc.com
Population Health MANAGEMENT
Improved Pt. Experience
Whole
Person Access
Interdiscipli
nary
Population
Data
Community
Population
Stratification
Measurement
Payment
Care
Coordina
tion
PI
QI
Population Health Data
Primary
Care
Access
Team
Based
Care
Populati
on
Health
Manage
ment
Outreach
Care
Manage
ment
Information Technology/EMR
Patient
The Buzz Words
• Population Health:
Outcomes of a group of individuals, including
the distribution of such outcomes within the
group
• Population Health MANAGEMENT:
Set of interventions designed to maintain and
improve people’s health across the full
continuum of care-from low-risk, healthy
individuals to high-risk individuals with one or
more chronic conditions
Visit Data
EMR
PHM
X
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Population Data
X
Coordinated Care
X
Tracking
X
X
Data
X
X
Information
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X
Analytics
X
Pre visit summaries
X
X
Clinical summaries
X
X
Data Validation
X
Risk Stratification
X
Patient Engagement
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X
Clinical vs. Claims Data
Separate
Collaborative
Technology makes PHM Sustainable
Institute for Health Technology
Transformation- A Roadmap for
Provider Based Automation in a
New Era of Healthcare
www.centerpriseinc.com
10 Technology PHM Tools
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EHR
Patient Registries
Health Information Exchange
Risk Stratification
Automated Outreach
Referral Tracking
Patient Portals
Telehealth/telemedicine
Remote Patient Monitoring
Advanced Population Analytics
www.centerpriseinc.com
Patient Registries
• What? List of visits or patients at a given time
and continuously
• Who? Identification and grouping of
patients by information
• Why? Population to perform an action
• How? Practice specific evidence based
guidelines
• When? At execution or immediate and ongoing
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Risk Stratification
• Who? Patients at risk
• What? Patients in need of care management to
avoid a negative financial, clinical or satisfaction
experience
• When? At the time of visit , pre-visit and post visit
• Why? Visit alerts for missed opportunities and
visit needs and Proactive care management
to improve clinical outcomes between visits and
promote patient engagement
• How? Visit alerts and chart prep
Evidence based decision support on an
entire population using clinical and financial data
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Automated Outreach
• Who? Patients defined by practice
• What? List of patients requiring communication
from practice
• When? At time of execution or as scheduled for
automatic generation
• Why? Identified need at time of execution
or patient falls into eligibility criteria
• How? User defined report to identify all current
patients automatic report triggered by definition
and schedule
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Advanced Population Analytics
• Who? Patients as defined and encounter based
or population data– as a percentage of
additionally defined population-today and now
• What? Numerator and denominator for utilization
in information based decision making and PI
• When? On demand or real time
• How? Report building with static criteria
or variation in definition
• Why? A number Or information to analyze pt.
population and use for decision making, PI and
planning
Influence: Data
HIGH
Patie
nt
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Visit data
Structured data
Reporting
Outreach
Referral Tracking
Point of Service
Electronic Encounter Alerts
Minimal paper
Patient engagement
documentation
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Unstructured data
Referral Tracking
Data Validation
High paper use
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Referral Tracking
Care Management
Automated Outreach
Data Validation
Reporting
ANALYTICS
Benchmarking
Risk stratification
External population measurement
Customization of structured data
Patient Engagement tools and information
Population data
Visit data
Proactive population alerts
• Risk Stratification
• Care Management
• External Population
Measurement
• Benchmarking
• Population alerts
LOW
LOW
Population
HIGH
The (HIGH) Performance Equation
Goals
Goals
Execution
Execution
Performance
Influence
Level of
Performance
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How do we get there?
• Defined goals and objectives
– Organizational Strategy
– Organizational Structure
• Tools of Influence
• Execution
– Skilled Staff
– Involved Staff
– Engaged Patients
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PHM as Influence
PHM as Influence
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PHM as Influence
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PHM as Influence
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The Triple Aim Equation
EMR
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Encounter
Based
One Pt. at a
Time
Rule Based
Provider Led
Pay for
Encounter
PHM
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Patient
Based
Multiple
Populations
Outcome
Based
Data led
Pay for Value
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PHM in our Reality
• Clinical
Huddle
• Pre-visit
identification
of visit needs
• • Pt.
Pt.checks
checksininupdate
update
information
• Pt. reviews
• Pt.
waits for
medication
• intake
Pt. reviews
health history
• Pt. waits for
intake
• Pt.
when sick or in
• Calls
Pt. receives
need
communication
• Pt. isidentifying
scheduledneedas capacity
allows
Outreach. is scheduled
as capacity is defined
by patient dataincludes same day
• Pt. schedules
electronically
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•
Outreach
Track referrals etc…
F/U on care plans
Missed opportunities
Care Coordinator
contact
• AnalyticsINFORMATION
• Pt• is Pt.
roomed
is roomed
• Vitals
taken
• Reconcile
• Reason
forand
meds
visit health history
documented
• Vitals
documented
• Self
management
goals
reviewed
• Barriers
addressed
• Needed
interventions
addressed
• Pt. leaves with clinical
• Pt. leaves with
summary and self
CLINICAL summary
management plan
• Pt. returns to normal
• Pt. works toward goal
activity
• Pt. navigated to
• Pt. goes to referrals?
external needs
• Pt. identifies need for
(referrals, community,
visit
lab)
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••
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Review
of
RFV
reviewed
RFV
Identified
Dx
interventions
Referrals
addressed
Clinical goals
Treatment
treatment
set
Rx Engagement
Pt.
Clinical plan
Treatment
summary
Barriers
addressed
“what matters to
the patient”
Your PHM Solution-Day to Day
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Patient care opportunities
Access analysis
Utilization monitoring
Clinical performance
Data validation
Care coordination
Patient engagement
www.centerpriseinc.com
Your PHM Solution-Strategy
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Information based strategy
Information based decision making
Influence
Scope of Services
Growth
Needs Assessment
Access
Quality Plan
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Organizational Population Health
Assessment
• What is our population health goal/strategy?
• What information do we want?
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What information do we have?
Where is the gap?
Can we get this information?
What is needed in order to get this information?
Who has this information?
Who has access to this information
• What do we do with this information?
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Where in the workflow is information important?
Who is accountable AND responsible for the execution?
Do we have access to this information in workflow?
Will the information help us to execute on the overall strategy?
What does this information mean to the patient?
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Pop Health IT Assessment
• Clinical
• Operational
• Financial
• Patient Centered
• Sustainable
• What is the process
• Who is executing
• What is the outcome
• How does outcome align with goal
• ANALYTICS
• What do we have
• What is the current state
• What does this impact
• What do we need
• Why do we need it
• What are you we going to do with it
Strategy
Information
Execute
Influence
• Interpret the information
• Implement in workflow
• Visualize the information
• Communicate the information
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Successful Pop Health IT IS High
Performance
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