The ultimate goal of population health management is to improve the health of populations. This goal can be achieved by providing preventive services, managing chronic diseases and engaging patients in their care. Patients need to be engaged in decision-making because wellness efforts depend on patients making healthy choices over the long term. Technology is a powerful tool hospitals can use to engage patients and reach their goal of population health.
Engaging patients through technology
"Probably the most exciting innovation in development across the country is consumer engagement through the use of personal information devices, [or] smart phones," says Richard Afable, MD, president and CEO of the affiliation of Orange, Calif.-based St. Joseph Health and Newport Beach, Calif.-based Hoag. Companies are creating apps to help patients find medical information, manage chronic conditions and access healthcare providers.
HHS and other federal organizations have latched onto this trend, launching app challenges to encourage developers to create consumer-friendly, health-related applications for smart phones and other devices. For example, in May HHS named Lyfechannel the winner of the healthfinder.gov Mobile App Challenge for creating an app that helps consumers use the website for prevention care planning.
Hospitals and health systems can also engage patients by creating patient portals, which allow patients to schedule appointments, email physicians and access their medical records. Enabling electronic communication between patients and providers improves patients' access to healthcare services in today's consumer-driven marketplace. Sharing information with patients electronically also helps hospitals coordinate patients' care. "[Technology] becomes a coordination element of integrated care conducted by integrated systems like Hoag and St. Joseph as we move forward," Dr. Afable says.
In fact, technology may be the lynchpin of integrated care, according to Dr. Afable. "Twenty years ago, we never really had integrated care because we didn't have the tools necessary. The tools are now becoming available," he says.
Managing population health in the digital age
Health IT can also help hospitals manage patients' health over time and from a distance through remote patient monitoring. Population health managers aim to keep patients healthy, meaning out of the hospital and in the home. Remote patient monitors allow patients to stay at home while data about their medical condition is transmitted and assessed by healthcare providers.
For example, patients' daily weight is one of the most important parameters to manage congestive heart failure, according to Dr. Afable. Patients can use scales that transmit their weight wirelessly to a site where care coordinators use software to alert them to weights that indicate a patients' deteriorating health. The same way a credit card company may alert a customer to unusual activity on his or her card, care coordinators can contact patients when their weight fluctuates unexpectedly, Dr. Afable says.
By talking with patients about the reason for the weight change, they can decide the appropriate action, such as scheduling a home health nurse visit, reminding patients to take their medication or sending an ambulance, if necessary. "We're moving toward a business model in which we're rewarded for creating technology and systems so that we are providing what [the patient] really needs," Dr. Afable says.
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Why Every Hospital Can't Manage Population Health, and Why That's OK