The ABCs of Population Health: It’s a Team Sport | #NHITweek

This blog post was crafted in celebration of National Health IT Week, which takes place Sept. 26-30. Get involved!

Relevant Hashtags: #NHITweek | #PopHealthIT | #UnicornJess

Population health is the topic du jour for the health care industry, and I’m glad to see us all focusing on this important issue. But there is a lot of confusion as to what, exactly, constitutes population health. Or more correctly, an effective population health system.

A good population health program consists of four major components:

  1. Identification and stratification of risk within a discrete population
  2. Dissemination of information to physicians, care coordinators or others designated to contact patients and arrange follow up.
  3. Appropriate follow up to further understand the risks for individual patients, identify gaps in care and design a care plan to help the patient improve his/her health status.
  4. Ongoing care individualized to each patient’s need. That might be coaching, medication reminders, telehealth visits, remote monitoring or other strategies customized to each person’s condition and socio-economic environment.

The key to making a population health program effective is ensuring that all four components are in place and working well. If there is a break anywhere in the chain, you lose the opportunity to improve patients’ health. The best analytics in the world are useless if the results do not quickly and easily pass into the hands of the people who can take action. And very good follow up and care planning can be ineffective if the ongoing support is lacking.

One of the biggest barriers to effective population health improvement is friction in the flow of information between health plans, hospitals/health systems and physicians. This has been a constant source of difficulty for the entire healthcare ecosystem for years, but with the new focus on population health and improving outcomes, it has reached a new level of urgency.

In traditional African societies coronary artery disease is virtually nonexistent, but in the migrant population to Western societies the rates are similar to those of the local population indicating that the primary determinants of these diseases are lifestyle and diet and not genetic. These indicators are a key asset in changing our healthcare system and addressing the current 75% of our healthcare spending that is focused on patients with chronic conditions which have their roots in lifestyle choices and behaviors. To address these challenges we need a way to better target our limited healthcare resources more cost effectively for maximum effect and identification and targeting with a robust population health system is no longer a nice to have – it’s a must.

To help patients improve their health, not just react to a situation that has already developed, requires information and insights. But in a survey of primary care physicians by The Commonwealth Fund, only 31% of U.S. physicians said they are notified when a patient is discharged from the hospital or seen in an emergency department. This is important information for primary care physicians, and is not that difficult to fix. All you need is standard protocol in place and a mechanism for notification. It could be a standard action that happens at every discharge. It could even be automated. If the retail industry can automatically send an email to confirm an order, hospitals and health systems should be able to send an automatic email to a physician with discharge information. But hospitals and health system executives haven’t made it a priority, so it doesn’t get fixed.

Get to Know your Teammates

This is just one example of the inward-looking approach that still permeates much of healthcare. Hospitals, nursing homes, skilled nursing facilities and other care providers pay attention to what happens within their organizations, but they neglect to look beyond. Organizations act as though the care they give is the only care patients receive. They forget that there are a multitude of other professionals who are also responsible for care and need to know what’s going on. We don’t just have data silos in healthcare, we have attitudinal silos that make data transfer and exchange an afterthought at best.

It’s like each care provider is a golfer alone on the course and the patient is the ball. As long as that lone golfer moves the ball forward, it’s all good.

The reality is that healthcare is a team sport, more like football (or soccer as it is called in the US) than golf. If you can’t make an accurate, effective pass to your team mates, you lose the ball.

But patients aren’t balls, they’re human beings. When one member of the healthcare team fails to inform the rest of the team, a human being gets lost in the confusion with poor outcomes and frustrated patients.

In population health improvement, you have to play on a team, because it takes a wide variety of skills to make this all happen. And you have to be aware of all the other players on the team. The successful population programs include everyone who is part of the community – not just the healthcare system and resources but all aspects of the community. Dell Medical School held an inaugural event to crowd-source their population health strategy, coming up with areas of focus and metrics for success that included input from a wide range of stake holders. This is the kind of team based approach to population health that will help the whole community win – getting people healthy and staying healthy.

It Starts with Leadership

Most healthcare organizations are at least partly aware of the problem and are making efforts to solve it. But it is a complex problem, involving, as I noted above, attitudes as well as technology. To make data flow freely to those who need it, you have to have effective technology to integrate, manage and analyze the multitude of data streams in healthcare, and you also need leadership who prioritize data sharing over the competitive interests of conflicting health delivery systems. With free flowing information routed to all the interested parties including the oft forgotten but all important patient, in understandable and actionable form that includes the insights and management options we can successfully identify those at risk and develop appropriate interventions. By including the patient and personal care team that typically includes multiple family members we capitalize on underutilized resources that are both essential and highly effective at improving the trajectory for the patient’s outcome.

Custom Communication and Targeting

Traditional systems and methods have targeted the existing clinical systems and communications which, while suited to some, fail to adapt to the changing world of technology and the fact that people no longer go online – they live online. This doesn’t just apply to patients and their families; it’s increasingly true for clinicians. It can be as simple as a text based reminder for medication, timed to coincide with the patients personal schedule and preferences or as complex as an automated avatar with augmented intelligence that engages with the patient to assess their status and determine the need for additional intervention or personal follow up by the care team.

Each year National Health IT week raises awareness of technology in healthcare, bringing together innovators and key healthcare leaders who are diligently working together to make the best use of information technology to improve the healthcare systems and ultimately our each and everyone’s individual health. This past year we lost one of the titans whose personal journey of uncoordinated care she shared in her attempt to correct the system – Jess Jacobs (#UnicornJess). It might be too late for Jess but let this be the year we move past the individual approach in healthcare driven by underlying economics and focus on the team sport of population health and democratize access to the best possible care and outcomes to the widest swathe of people…worldwide.

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