Population Health Management: We'll Get There

Joseph C. Kvedar, MD

I have to agree with Paul Cerrato's musings that population health management will require a great deal of work and more robust and sophisticated electronic health records and clinical analytics tools to make it a reality in our healthcare system. However, as a member of the Care Continuum Alliance board of directors, I am more bullish than he that it will be the next revolution in healthcare delivery.

The Care Continuum Alliance promotes a proactive, accountable, patient-centric population health improvement model. It features a physician-guided healthcare delivery system designed to develop and engage informed and activated patients over time to address both their immediate illness and their long-term health. The companies and organizations that are members of the Care Continuum Alliance believe that managing health requires the active, integrated involvement of all healthcare professionals, coordinated with patients and their caregivers and families.

Population health improvement focuses on three components: the delivery of care by a primary care physician in a leadership role; an activated, involved patient who accepts personal responsibility; and the expansion of care coordination provided through wellness, disease, and chronic care management programs.

As we move into a world of accountable care and capitation, there are greater opportunities--and a greater need--for us to use connected health programs to extend ourselves across a larger patient population and take care of them effectively outside of the office setting. We're talking about innovative programs that get us into the care coordination world as opposed to the office visit world.

At the Center for Connected Health, for which I am director, we are fortunate to be part of the Partners HealthCare system, one of the pioneer accountable care organizations (ACOs). For the past several years, Partners has been developing the necessary infrastructure to tie in patient information gathered from the remote monitoring devices that patients are using at home via our connected health programs to facilitate population health management.

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But herein lies the challenge that Cerrato's commentary rightly pointed out. Most providers do not have the ability to collect, store, and report the patient data needed to widely implement population health management programs. This is just not a part of today's standard of care at most provider organizations.

Electronic medical records (EMRs) have become widely adopted and are a very important technology to help providers improve quality care. But, EMRs do not, for example, collect patient data from outside a medical setting, nor do they provide real-time alerts for preventative and chronic care.

The accountable care model is very disruptive and is causing large provider organizations to create new systems and infrastructures to extend across larger populations of patients, while better utilizing our precious healthcare resources, to deliver quality care to more patients. It's just going to take some time for us to build the infrastructure, tools, and organization needed for this model of care.

To address this critical need in our own provider network at Partners HealthCare, we plan to fully integrate our Center's latest generation technology platform with Partners' primary EMR system, which will allow our programs to handle large patient populations. It also will enable us to incorporate new data from a variety of consumer devices, an important factor as personal health devices are becoming more widely used to collect vital signs and other patient data. Data collected via sensors in a patient's home, such as blood pressure and blood glucose, will eventually be displayed via Partners' secure patient and provider website portal. This will allow providers to automatically access our connected health data directly from their patient charts, and view population-based results.

This type of fully integrated technology infrastructure can facilitate real-time population health management. But the healthcare industry has a ways to go to widely implement such a robust technology platform. As we quickly move in that direction, however, we are creating systems that can predict which patients will be at risk for expensive care, and how we will use connected health tools to extend our providers across larger patient populations. We'll use brick and mortar buildings more strategically and better utilize our human resources to deliver quality care to large populations.

We, as healthcare providers, cannot dismiss the power of population health management and must embrace the opportunities to use technology to better connect with and manage our patients' health and wellness, whenever and wherever the patient needs us.

Joseph C. Kvedar, MD, is a member of Care Continuum Alliance board of directors, director of the Center for Connected Health, and an associate professor at Harvard Medical School.