Disclosure Statement: The content and/or presentation of the information will promote quality or improvements in healthcare and will not promote commercial interests
UTILIZING POPULATION HEALTH DATA John Studebaker, MD, MS
OBJECTIVES Describe the concept of population health management and why its all the rage. Describe the technology of population health management. Identify approaches for implementing population health management.
SET THE STAGE
EVOLUTION Current growth rate in health care spending is not sustainable. Current system rewards treating illness much more so than preventing it. Payers (including CMS) are motivated to try different approaches.
TRANSFORMATION How health care is paid for Shared Risk Models - ACO Value-Based Care How health care is delivered Patient Centered Medical Homes Integrated Delivery Networks Medical Neighborhoods
POPULATION HEALTH: Front and Center Focus Shift from one patient at a time to all patients at a time How to manage a group of patients Clinical Goals Financial Goals How to know what is working (and what is not) Measurement Rapid Improvement Cycles
WHAT IS POPULATION HEALTH? The health outcomes of a group of individuals, including the distribution of such outcomes within the group. --Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, 366-369
INDIVIDUAL HEALTH
PANEL
CLINIC OR SYSTEM
PUBLIC HEALTH
THE SPACE BETWEEN INDIVIDUAL HEALTH and PUBLIC HEALTH Responsibility for a group of patients. NOT restricted by a disease, nor by a demographic, nor by geography.
POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions,
POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions, implemented for populations defined by a healthcare need or condition,
POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions, implemented for populations defined by a healthcare need or condition, that help patients and caregivers optimize care, prevent future complications and maximize opportunities for wellness.
POPULATION HEALTH POPULARITY
TECHNOLOGY OF POPULATION HEALTH MANAGEMENT
Data Sources
Data Sources EHR / EMR Practice Management
Data Sources EHR / EMR HIE Practice Management Registry Outside Clinics
Data Sources EHR / EMR HIE Legacy Systems Practice Management Registry Lab Outside Clinics Pharmacy
Data Sources EHR / EMR HIE Legacy Systems Claims Practice Management Registry Lab Outside Clinics Pharmacy
Data Sources EHR / EMR HIE Legacy Systems Claims Practice Management Registry Lab Home Monitoring Outside Clinics Pharmacy Personal Devices
Health System Perspective EHR / EMR Practice Management
Health System Perspective EHR / EMR Practice Management Data Warehouse
Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab
Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab Registry
Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab EHR / EMR Registry
Person Perspective
Person Perspective My Cardiologist My Dermatologist My Doctor
Person Perspective My Chiropractor My Cardiologist My Dentist My Dermatologist My Doctor My Care Coordinator My Kids Pediatrician
Person Perspective Urgent Care My Pharmacy My Chiropractor My Cardiologist My Dentist My Dermatologist My Doctor My Care Coordinator My Kids Pediatrician
Person Perspective Lab from Urgent Care Urgent Care My Pharmacy My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My Care Coordinator My Kids Pediatrician
Person Perspective Lab from Urgent Care Urgent Care My Insurance Plan My Employer My Pharmacy My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My FitBit My Care Coordinator My Kids Pediatrician
Person Perspective Lab from Urgent Care Urgent Care My Insurance Plan My Employer My Pharmacy??? My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My FitBit My Care Coordinator My Kids Pediatrician
Regional Perspective
Regional Perspective Health Systems Hospitals
Regional Perspective Health Systems Hospitals Primary Care Clinics Specialty Clinics Urgent Care
Regional Perspective Health Systems Hospitals Primary Care Clinics Specialty Clinics Urgent Care Safety Net Health Department Dental Clinics
Regional Perspective Health Systems Hospitals Primary Care Clinics Ancillary Care Specialty Clinics Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers
Regional Perspective Health Systems Hospitals Payors Primary Care Clinics Ancillary Care Specialty Clinics Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers
Regional Perspective Health Systems Patients Hospitals Payors Primary Care Clinics Specialty Clinics HIE Ancillary Care Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers
Regional Perspective Health Systems Patients Hospitals Payors Primary Care Clinics Specialty Clinics HIE Ancillary Care Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers
Data Aggregation
Data Aggregation EDW
Data Aggregation EDW Interfaces Mapping
Data Aggregation EDW Interfaces empi Mapping
John Smith Who is Who? - empi
Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht
Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht 01/23/58 Jan 23 rd 1958 January 23, 58 1-23-1958
Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht 01/23/58 Jan 23 rd 1958 January 23, 58 1-23-1958 222-33-4444 123 Main Street
Lasix What is What? Mapping
What is What? Mapping Lasix Furosemide
What is What? Mapping Lasix Furosemide IV Tablet
What is What? Mapping Lasix Furosemide IV Tablet 20mg 40mg 80mg
What is What? Mapping Lasix Furosemide IV Tablet Coding Systems: RxNorm NDC GPI 20mg 40mg 80mg
What is What? Mapping Past Medical History Physical Exam BP Allergies
Analytics
Analytics Queries Filtering / Sorting
Analytics Queries Rules Engine Filtering / Sorting Standards
Analytics Queries Rules Engine Clinical Risk Filtering / Sorting Standards Financial Risk
Analytics Queries Rules Engine Clinical Risk Predictive Modeling Filtering / Sorting Standards Financial Risk Contract Modeling
PHM Tools and Applications
PHM Tools and Applications Care Management Addressing Care Gaps Patient-Centered Care
Patient Engagement PHM Tools and Applications Patient Self Management Care Management Addressing Care Gaps Patient-Centered Care
Patient Engagement PHM Tools and Applications Patient Self Management Care Management Addressing Care Gaps Patient-Centered Care Quality Improvement
Patient Engagement PHM Tools and Applications Patient Self Management Care Management Reporting Benchmarking Addressing Care Gaps Quality Metrics Patient-Centered Care Quality Improvement
Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Care Management Addressing Care Gaps Benchmarking Quality Metrics Resource Allocation Workflow Optimization Patient-Centered Care Quality Improvement
Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Risk Management Care Management Benchmarking Resource Allocation Addressing Care Gaps Quality Metrics Workflow Optimization Patient-Centered Care Quality Improvement
Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Risk Management Care Management Benchmarking Resource Allocation Network Leakage Addressing Care Gaps Quality Metrics Workflow Optimization Contract Performance Patient-Centered Care Quality Improvement
COMMON MISCONCEPTION: I have an EHR, therefore I have all the PHM tools I need. AKA: I bought an EHR, it does this stuff right out of the box.
EMR / EHR EHRs are tools for data entry and workflow support. They are powerful transaction machines built to create a billable document. They are an important part of the equation, but not the only piece.
EHR AS THE ANSWER Data Sources Data Aggregation Analytics PHM Tools and Applications
SO WHAT IS THE ANSWER!? Understand what you re trying to accomplish. What tools will you need to meet your goals? Which pieces do you already have, and which will you need to find?
QUESTIONS?
CONTACT INFORMATION John Studebaker, MD, MS 608.729.7530 john.studebaker@forwardhealthgroup.com www.forwardhealthgroup.com