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Why moving beyond the EHR is needed for population health

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- EHRs — and the data they hold — are critical to succeed in population health, but they’re not enough.

This message is surely a tough one for many US providers who have spent years and tens of millions of dollars (if not a lot more) to implement an organization-wide EHR system. According to industry analysts, many of these organizations are reluctant to consider other solutions for population health management or accountable care, choosing instead to wait for their EHR to evolve to address the new demands associated with taking on and managing risk.

It could be a long wait because what’s needed to succeed in population health — analysts largely agree — spans a wide range of functionality going far beyond what EHRs were built to do. This is an unwelcome reality owing largely to the fact that 99 percent of patient activity happens outside of the hospital or clinic, beyond the scope of the EHR.


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Providers need to embrace EHRs for the purpose they serve: The digitization of clinical data inside the health system is critical to improving care and outcomes in much the same way electronic data has been key to transforming banking, travel, retail and other industries. At the same time, however, it’s important to support approaches that turn data across the health system — both inside and outside of EHRs — into a strategic asset to improve the quality of care, the patient experience, and the outcomes for patients and populations.

We have the approach and tools to make it happen today.

Data aggregation and control

Aggregating and gaining control of data is the essential first step to transforming care and one of the most overlooked by healthcare organizations. Providers need access to data from systems across the community, including multiple EHRs, billing systems, payers, pharmacy systems, labs and health information exchanges (HIEs). Healthcare organizations need to bring the data together, transform it into a consistent and usable format, store it, and use it to deliver the right information at the right time to caregivers.

In more technical terms, health systems need to aggregate and normalize clinical, operational, and financial data from across the care continuum and apply terminology mapping to make that data accessible and usable through a variety of applications. By using a data aggregation platform to combine clinical and claims data into a data asset, healthcare organizations can gain a comprehensive, longitudinal view of each patient that enables the best decision making possible regarding care for the individual.  But this is just the beginning.

Healthcare analytics

The rich data asset opens up a new world of analytics that is critical to achieving desired clinical outcomes and financial results in a complex environment defined by healthcare challenges too vast, patients too numerous, and resources too few to sustain high-touch care management processes.

Analytics drives a new approach to patient care by enabling organizations to understand the clinical and financial risk of populations for which they’re accountable and to initiate the actions needed to manage that risk. Performing analytics using clinical and claims data, organizations can gain deep insight into patients, populations, and performance; predict outcomes; and rapidly identify the actions needed for improvement.

This insight can be gained through a wide range of analytics solutions that deliver retrospective views of activity, ongoing surveillance of current activity, predictive modeling of future activity, as well as root-cause analysis.

For example, organizations can use retrospective analytics for performance and activity reporting, including patient attribution utilization, variation in care, and total cost of care. Near real-time reporting can support care management, identify gaps in care, and alert physicians and patients for care planning from a population view. With risk stratification and predictive modeling, organizations can classify patients by health risk to deliver cost-effective interventions and predict and prevent readmissions.

Care coordination and management

The next step toward realizing the goals of population health is translating knowledge and insight into action. With an understanding of their clinical and financial risk, providers can take the steps to manage that risk using new solutions for improved care coordination, utilization of resources, and care management — and, ultimately, higher patient satisfaction and lower cost of care.

Experience in accountable care has identified best practices for care management and coordination within the population to drive improved outcomes, processes, reimbursement and patient satisfaction.

• Extract patient information

• Analyze data and identify population at risk

• Provide information and intervention at the point of care

• Share data across the care team

• Share and manage the care plan

• Personalize patient care, monitor, and intervene

Effective care management solutions can leverage aggregated clinical, administrative, and financial data to identify candidates for program enrollment, address gaps in care for managed patients, streamline population management, and enable efficient use of evidence-based medicine. Effective care coordination tools use near real-time data and built-in workflows to prompt providers regarding additional health conditions, giving them the opportunity to improve patient health and facilitate better utilization of resources.

Patient engagement and wellness

When you consider that 99 percent of patient activity happens outside of the health system, patient engagement is pivotal to managing the health and wellness of populations and achieving desired outcomes. It’s paramount for providers to take advantage of the opportunities at hand to engage patients for better results:

• Patients within an episode of care: Making patients part of the care team, engaging with them early in the episode and in the hospital, preventing readmissions, and providing them with tools for self-care.

• Patients with chronic conditions: Addressing the segments of the population that generate the highest cost, yet are motivated and open to patient engagement, by providing for ongoing care management in the home.

• Healthy patients: Engaging them in wellness and health maintenance and promoting fitness and positive behaviors to prevent health episodes and cost.

Organizations can use technology in many ways to support patient engagement for each of these opportunities, for example, they can:

• Establish collaborative care plans to enable patient self-management and track progress to goals

• Enable electronic communication between care team and patient

• Provide patients with online access to their personal health record

• Incorporate patient-reported biometric data into care management

• Deliver educational resources to help patients prepare for visits or improve compliance

• Send patient alerts to improve preventive care, identify gaps in care, or detect disease

• Offer online health risk assessments to identify at-risk patients

• Offer motivation tools to encourage healthier behavior

From data to desired outcomes

The EHR is an essential piece to healthcare transformation, but as a solution purpose-built to gather single-patient data, it’s just one piece of a much larger puzzle. The key to achieving our goals is looking beyond the EHR and making strategic use of the clinical, financial and operational data available across the entire health system. Let’s start talking more broadly about a new era of solutions that can get us to better population health: data aggregation, analytics, and applications for care coordination, care management and patient engagement.

As vice president of population health for Caradigm, Brian Drozdowicz is responsible for defining and delivering the company’s healthcare analytics and population health management solutions for providers and payers. Brian holds a BS in business administration focused on management information systems and finance from Rensselaer Polytechnic Institute and an executive MBA from Northeastern University.

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