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Population Health Paves the Way for Improved Patient Outcomes

Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

The health of a population is dependent on a number of variables within the environment, economy and individual genetics. For example, education, access to healthful food, income, availability of healthcare services and individual family history are among the contributors to the health of a population. Healthcare providers have a significant (but partial) role to play, and that has become magnified in the drive toward improved outcomes and performance.

With a focus on ensuring healthy populations, healthcare providers have been implementing software and programs that support the delivery of care designed to

• keep the patient out of the hospital,

• reduce acute events in patients with chronic diseases such as diabetes and hypertension, and

• ultimately improve outcomes for population groups that they serve.

As reported in Forbes, “getting the providers to achieve the goals of population health also means doctors and hospitals need the tools to get their patients the right care, in the right place and at the right time. That helps providers and insurers focus on the 10% to 20% of the population responsible for most costs in the healthcare system.”

Geisinger Health has focused on the health of their population and is successfully using their electronic health record (EHR) and analytics to improve, pneumococcal vaccination rates and depression screening for adults, among various other outcomes. Using analytics, they identify patients not seen by their primary care provider (PCP) in the last 12 months, do not have a future appointment and have an open gap in their care.

Improved Outcomes from Population Health Focus

The HIMSS Health IT Value Collection reports on other providers who have also focused on population health. Some of the areas of focus and their improved outcomes are:

Colon cancer screening:

o Grove Medical Associates, Jersey City, N.J., increased the percentage of colon cancer screenings from approximately 12% to 75% of their patients who are eligible for the screening over a nine-year period.

o DotHouse Health, a federally qualified health center in Dorchester, Mass., found that after assessing their data and revising their workflow for colorectal cancer screenings they boosted screenings from 49% to 64%.

o P.A.S.E. Healthcare in Milburn, N.J., improved their colon cancer screening rate by over 80%.

o Jacqueline Delmont, MD in Franklin Square, N.Y., achieved a 25% increase in colon cancer screening with the help of her EHR.

o Lone Star Circle of Care, in Georgetown, Texas, increased colorectal cancer screening by 71% after implementing their EHR.

Tobacco Cessation:

o Coastal Medical, an accountable care organization (ACO) in Providence, R.I., increased tobacco cessation among their patients from 64% to 83%.

o HealthNet in Indianapolis, Ind., used their EHR network to facilitate increased adult tobacco assessment and cessation counseling rates to 100% in the region.

o Yale-New Haven Hospital of New Haven, Conn., facilitated increased adult tobacco assessment and cessation counseling rates to 100% through the utilization of their EHR.

Many of these process improvements are achieved through the partnering efforts of professionals and organizations in each community. The National Academy of Medicine (formerly Institute of Medicine) called for this partnering in its report, The Future of the Public’s Health in the 21st Century, where it addressed the need for significant movement in “building a new generation of partnerships that draw on the perspectives and resources of diverse communities and actively engage them in health action.” (Institute of Medicine, 2002)

Improving the health of populations is important for everyone concerned: patients, providers, payers, policy makers and the public. While it calls for some fundamental changes in healthcare delivery, it is vital for a vibrant and productive society.

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