How Do We Automate Population Health Management?

Executive Briefing | by | December 14, 2017

Monica E. Oss
Monica E. Oss

“Pop health is still a pretty manual process. Having a dedicated solution, let alone a dedicated analytics platform, to address pop health is not as widespread as one might think.”- Brendan FitzGerald, Research Director at HIMSS Analytics

When I first read this quote in a recent article in Healthcare IT News, Population Health Is A Manual Process Now, But Just Wait Until The Tech Matures, I was surprised but not shocked. And the operational realities and potential of automating population health management became more apparent in the session that I moderated at The 2017 OPEN MINDS Technology & Informatics Institute last month, Future State: Evolving Care Models For Improving Population Health, featuring Scott Green, Senior Vice President, CareGuidance, Netsmart and Rachelle Glavin, Director of Clinical Operations, Missouri Coalition for Community Behavioral Health.

Scott Green, Senior Vice President, CareGuidance, Netsmart and Rachelle Glavin, Director of Clinical Operations, Missouri Coalition for Community Behavioral Health

What caught my attention was Ms. Glavin’s statement that a report, based in a primary care setting, found care managers in a “non-automated” system spend 40% of their time searching for patient-level data. That “current state” really explains a lot about what I see as a continuing point of contention between health plans and provider organizations about the rates paid for care coordination. (For more on medical home, and health home rates, check out Health Home Performance & Payments – The High & The Low Remain Miles Apart, Does The Medicaid Health Home Model Work? The Payer Perspective On The Future Of Specialty Care Coordination Programs, and U.S. Medicaid Health Home Market: The 2016 OPEN MINDS Update).

She spoke to the system that they are just putting in place—a platform where teams from 35 mental health and substance use treatment providers could access data from internal and external sources in real time to provide insights for proactive consumer care management. (For more information about the Missouri CMHC Healthcare Home Program, and outcomes produced from that program, check out Missouri CMHC Healthcare Home Program.)

The main message on the day: population health management tools need to integrate consumer data in a structured way and deliver actionable information to the team tasked with coordinating care in real time. Mr. Green spoke to the difference between “data” and “information.” Data is a “big pool” of information, almost useless in an unstructured state. Managers won’t know what the data says without organizing the data elements and setting standards for how they relate to one another. Ms. Glavin expanded on that premise: “This is about getting the data into one central place, instead of asking care managers or those responsible for redirecting care, to log into multiple systems as many pop health efforts require. From a day-to-day standpoint, leveraging that aggregate data to create dashboard views, alerts, and actions that are important to my role on the care team is what matters. Seeing who needs an intervention, and who is at risk, at both the population and the individual consumer level is what makes the data actionable.”

My big takeaway from the day is that for provider organizations to succeed in value-based reimbursement arrangements, their managers need information systems that aggregate consumer data from disparate sources and provide insights into how to “act” on that data to improve consumer health and reduce use of unnecessary and/or inappropriate resources. We’re a long way from that—but the organizations that get there first will have a distinct competitive advantage.

For some interesting reading on the future of care coordination, check out these resources in the OPEN MINDS Industry Library:

For more on the health home initiative of the Missouri Coalition for Community Behavioral Health, check out our coverage in:

For even more on the state-of-the art in health homes and specialty medical homes, join us on June 6 in New Orleans for The 2017 OPEN MINDS Strategy & Innovation Institute, where Athena Mandros will present “The Return On Investment Of Health Homes & Medical Homes.”



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