The Quest For Population Health Management - InformationWeek
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David F Carr
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The Quest For Population Health Management

Vendors large and small seek to prove they have the right tools for proactively managing patient health, coordinating care across providers, and supporting accountable-care models.

continuity of care. "I think of this as HIE 2.0," Agrawal said, with the focus the addition of a portal "for clinicians to see all the data they need to do their job."

The UPMC Windows 8 tablet app I wrote about the other day takes advantage of similar healthcare data integration and population health technology platform from Caradigm, a joint venture of GE Healthcare and Microsoft.

The technology firms pursuing population health management are not all big systems integrators, nor are they all taking the same approach.

InformationWeek contributor Mark Braunstein, who leads the informatics program at Georgia Tech, mentioned ClarityHealth as one of the startups doing impressive work that he encountered during his tour of the show floor.

In addition to sharing data recorded in software at hospitals and doctors' offices, many of these systems aim to promote evidence-based medical decision-making by providing easy access to research on what treatments are most effective for any given disorder. That factual information can also be combined with clinical data and analytics to make projections. MEDai, which is part of LexisNexis, takes this approach.

Every population health management venture claims to provide actionable information, but often it's more backward than forward-looking, said Peter Edelstein, chief medical officer for MEDai. "Once my diabetics have lost their kidneys, they're not really actionable anymore," he said. "What really you want to do is identify these groups of people while there's time to make a significant impact on the quality of care, which in turn reduces the price."

MEDai's approach combines access to troves of reference data with proprietary predictive analytics, he said. One future approach the company is likely to pursue tapping all the public information indexed by LexisNexis. For example, one way to compile a better predictive score of how likely an individual is to adhere to a doctor's orders for medication, rest, or exercise might be to look at how disciplined they are in other areas of their lives -- like whether they are current on their mortgage, Edelstein said.

Athenahealth took advantage of HIMSS to introduce AthenaCoordinator Enterprise, a version of its cloud software aimed at hospitals and large healthcare networks for care coordination across multiple providers and EHR systems. That may not be a complete population health offering, but "anyone who says they have a complete solution is not thinking about the problem clearly," said Athenahealth COO Todd Park.

Park, the original developer of the AthenaNet cloud software platform, was at HIMSS to give a presentation (mirrored in an essay for re/code) on "What Healthcare Can Learn from" He sees the transition from fee-for-service to value-based reimbursement as "massively overhyped," in the sense that new reimbursement models are catching on slowly overall, with big regional differences in the rate of adoption. The consumerization of software is an even bigger trend, he said, and care coordination will have to get better for that reason alone.

"Care coordination, in some ways, is customer service," Park said.

Download Healthcare IT in the Obamacare Era, the InformationWeek Healthcare digital issue on the impact of new laws and regulations. Modern technology created the opportunity to restructure the healthcare industry around accountable care organizations, but IT priorities are also being driven by the shift.

David F. Carr oversees InformationWeek's coverage of government and healthcare IT. He previously led coverage of social business and education technologies and continues to contribute in those areas. He is the editor of Social Collaboration for Dummies (Wiley, Oct. 2013) and ... View Full Bio

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User Rank: Apprentice
3/10/2015 | 2:52:31 PM
Population Health Management
I have consulted and developed patient engagement/population health technology for for over 10 years, and David Carr is spot on with this article. 


I  Back office Infrastructure:

EHR- Analytics

Risk Stratification

Define populations


II  Front End Outreach/Measurement:

Engage and Monitor Patients

Manage Care of Populations

Measure Outcomes & Satisfaction

Close Gaps & Improve Care

Phase I does not improve health without Phase II, and there are 3 technology options to remotely engage, monitor, and measure the outcomes of a specific population (I am speaking of chronic populations, the target of healthcare reform, not every individual in geographical region)

1 Voice -automated, interactive

2 Data- Email/Text

3 Video

We chose a hybrid 'voice' technology on the front end, data on the back(provider) end, because both the size, and characteristics of most 'at risk' populations (elderly) necessitates quick and easy to use, anywhere, for scalability. We determined video, while a good technology, was too intrusive for most, and the special hardware, software, and WiFi was needed, limit it's use to much smaller populations.  

Mark Craig

BON HealthWatch



User Rank: Apprentice
3/12/2014 | 6:15:05 PM
Re: Have you found good tools for population health management?
I am sorry, you are wrong David. 

Your are confusing a type of chronic care management with population health.  The best definition of "population health management" is the one from Prof. D. Kindig and it is quoted widely in the book on "Population Health" edited by David Nash et al. 

Also, except in a few places like Joslyn, most chronic patients are treated singly and NOT in groups.   
David F. Carr
David F. Carr,
User Rank: Author
3/12/2014 | 5:46:55 PM
Re: Have you found good tools for population health management?
Conversations about population health management often start with talking about "groups of people" like diabetics -- by far, the most commonly used example -- who are subject to similar ills and need to be tracked and coached in similar ways to keep their conditions from deteriorating. Yes, I agree that part of the point is to go beyond what medications they're taking (or failing to take) and look at lifestyle choices that are as or more important in whether they stay relatively healthy.

Diabetes is a focused, practical example, but the longer range vision is of managing the health of entire populations -- maybe not everybody in the community but everyone included in an accountable care organization or other structure where the incentives are oriented to keeping everyone healthier. At this point, that may just be a dream -- really active care management programs are still too expensive to apply to everyone, and the chronic disease sufferers make sense to focus on first.
User Rank: Apprentice
3/11/2014 | 4:17:56 PM
Re: Have you found good tools for population health management?
Let's make sure we understand what "population health" means. It is not managing the health of populations.  The term was used because many of the factors that affect the health of chronic patients lay beyond the scope of health care and they are known as "social determinants."  Access to care, availability of open spaces to exercise are some of the examples of social determinants and these factors to gether with the health care factors of treatments etc. are collectively referred to as "population health".

As Dr. Dave Kindig of the University of Wisconsin has pointed out in one of his blogs, managing these elements of "population health (he even has an oft quoted diagram describing this) is not easy at all. How do you rate availability of "nutritious food", or value of bicycle paths in a quantitative manner.  Yet, that is what is needed for population health management.

I think the author is really referring to managing the health of "groups of people" with similar health issues.  Even with this restricted definition there is a serious problem.  What is a metric for determining health of populations?  Without such a metric you cannot even say whether the health of a group of people is improving or not. Even if you had lab data available how do you compare populations with thousands of individuals when there are two or more items in the data set for each person?

I have had to develop a completely new and patented method to accomplish this. It wasn't easy and it took over 6 years for a team of programmers to complete the work.  We are currently analyzing the Medicaid population in a state to understand disease burdens and their trends. 

User Rank: Apprentice
3/11/2014 | 2:42:52 AM
Re: Have you found good tools for population health management?
A well-researched article highlighting the need for technology in the healthcare industry. Treading on these lines Summit Planners Technology of Singapore offers the medical & clinic software which has a proven track record of considerably improving the overall patient care in a clinic or hospital. Its host of cloud-based modules have simplified the operations & administrative functions of a medical office as well.
User Rank: Apprentice
3/4/2014 | 4:13:21 PM
predictive technology
Great article regarding the need for more proactive technology.  SILVERSPHERE has this same focus in helping caregivers take a more proactive approach.  Babyboomers are more savvy and aware than the generations before them.  We need to provide them and the people that take care of them with the tools to maintain or improve their quality of life safely in whatever setting they call home.
David F. Carr
David F. Carr,
User Rank: Author
3/4/2014 | 3:27:33 PM
Have you found good tools for population health management?
What software or cloud tools have you found useful for managing the health of patients and specific categories of the population, such as diabetics and heart patients?
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