As the healthcare industry places more emphasis on population health management (PHM)--the approach to health that looks beyond the individual and identifies groups that need specific types of care—providers need to make a lot of fundamental changes. They need to rework their technology infrastructure, capture and manage more patient-related data, and improve clinical workflow automation. So says a new study from the Institute for Health Technology Transformation.

Population Health Management, A Roadmap for Provider-Based Automation in a New Era of Healthcare suggests that PHM is the key to succeeding in patient-centered medical homes and Accountable Care Organizations. Both types of organizations link reimbursements to quality metrics and reductions in the cost of care for an assigned group of patients.

The report cites a variety of technology tools needed to keep populations healthy and minimize the need for expensive interventions such as emergency department visits and hospitalizations. Those tools include electronic health records (EHRs), telehealth platforms, electronic registries, data management software, and analytics systems. Providers can use EHRs and automation tools in particular to identify and stratify patients, identify care gaps, measure outcomes, and encourage patients to assume more responsibility for their health, said the report.

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Unfortunately, the tools organizations currently use aren't up to the task, the report concludes. Current tools don't have the ability to store, manage, and distribute comprehensive, timely and relevant information to the degree needed for PHM. For example, EHRs often don't contain the wealth of information available about the care that patients have received outside an organization, and they aren't designed for interoperability. Likewise, EHRs usually lack the ability to provide real-time alerts for preventive and chronic care, and do not generate quality and population reporting. Therefore, today's EHRs are not designed to effectively advance PHM, say the report's authors. Providers also must develop electronic registries with population-wide databases that aren't limited to patients with specific diseases.

The report, which was prepared in consultation with a broad range of industry experts, notes that as patient data populates IT systems, managing the data poses another set of difficulties. "Data management for PHM purposes is also challenging because each provider and health plan has a different system for patient identification and provider attribution," it states. "Community HIEs should use master identification numbers for patients and providers. EHRs and other healthcare applications should include fields for linking data across data sets and matching patients to their primary care providers."

The report's findings underscore the reality that most organizations are not yet ready for population health management, Waco Hoover, CEO of the Institute for Health Technology Transformation, said in an interview with InformationWeek Healthcare. "When you talk about population health management you're talking about interventions, you're talking about stratifying a patient population and targeting those patients who are at most risk today but also next year, and then you're talking about having a system in place to take preventative action."

Hoover said health organizations need to close the information gap so that physicians can use technology to positively affect patient outcomes. He also said PHM will require patients to do a better job of monitoring their own health.

"Given potential healthcare reform and efforts to increase quality and efficiency of care in the setting of persistent fiscal limitations, the importance of leveraging information technology and focusing on population health management has become a top priority for many health care institutions," Andy Steele, director of Medical Informatics at Denver Health, and a coauthor of the report, said in a statement.

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