Many organizations are finding the rush to implement EHRs years ago may have been short-sighted or premature, discovering their electronic data is siloed and largely inaccessible for any meaningful population health management (PHM) analysis.
As such, organizations are working to optimize or replace EHRs, which is proving to be just as expensive, if not more so.
However, a new or optimized EHR is not necessary for organizations to achieve their PHM and value-based care goals. What is required is that they strategically implement technology and workflows to automate data capture, analysis and even patient outreach to help control the staggering expenditures of chronic disease.
Ever expanding value-based payment
Now that nearly all hospitals and health systems have electronic health records (EHRs), organizations are attempting to leverage this data to improve outcomes and reimbursement under value-based care payment models. But, value-based care goals are uniquely based on an organization’s patient characteristics, but nearly all providers’ PHM and value-based care goals are squarely focused on chronic disease. This is not surprising considering chronic disease consumes more than $3 out of every $4 spent on healthcare.
That is why marrying PHM and value-based care goals will not only guide how organizations implement technology and workflows to manage chronic-condition populations, but it will also save physicians, care managers and other providers time in the long-run.
Three elements of effective, automated PHM
The three elements of an effective PHM strategy are focused on helping care managers and physicians minimize their search for data as well as manual data entry. However, organizations need to first set these automated processes in motion. Establishing patient outreach parameters beforehand based on the organization’s value-based care goals is required.
The three PHM strategy elements are:
1. Integrated information systems through a PHM hub
To make PHM processes more efficient, organizations need to first align PHM and value-based care quality goals. MACRA’s Quality Payment Program is just the tip of the iceberg when it comes to value-based care as both the federal and government and commercial payers are continually pursing new programs. A new enterprise-wide EHR system is not a requirement for effective PHM, but data from the EHR as well as from patient registries or HL7 feeds needs to be comprehensive and timely for meaningful analysis and reporting. That’s why organizations need to seek out a platform that is truly vendor agnostic and easy to integrate. Expensive customizations or a flat-out refusal to link systems with other vendors should immediately disqualify any platform going forward.
2. Intervention rules based on Value-Based Care goals
Once systems are integrated with a PHM platform, the organization will need to establish rules that will trigger an automated intervention notification to at-risk patients. This could be based on clinical and behavioral data, such as test results, care-plan adherence patterns, or missed appointments. Sophisticated PHM platforms, however, incorporate in the analysis clinical data with rich social information, such as data on education, employment, income, debt, family and social support, neighborhood, and other metrics.
Based on these factors, an organization can establish rules to automatically contact patients within a designated population using their preferred communication method. These notifications could prompt the patient to take an action, offer education or to remind them about upcoming care and offer help. Multiple rules can be combined for an even more granular automated analysis and outreach. Regardless, the care manager would only have to create the rules one time and the platform will automatically search the databases for at-risk patients.
3. Pre-established workflows
With the rules in place, the physician and care manager will need to create a workflow for responding to patients in the targeted population, or to receive notifications from the PHM platform if an automated outreach is not feasible or appropriate. Many times, an in-office appointment is not always necessary. A phone call with a clinical support staff member, automated prescription renewal, help with transportation, or overcoming an appointment scheduling obstacle is enough to get the patient back on track with treatment adherence. The key with these workflows is to respond as quickly as possible to help the patient re-engage in their treatment plan.
By following these three elements, organizations can begin to take on the enormous costs of chronic conditions while improving the efficiency of high-risk patient outreach and communication. The resulting increased adherence and engagement will continue to pay dividends as the industry deepens its commitment to value-based care.
About the author:
Gary Hamilton is CEO of InteliChart