Nowadays, sitting comfortably on the outer edge of population health management is not a progressive enough approach for medical providers whose reimbursements are tied to the health outcomes of patients. Payment models are evolving, and that means the choices patients make and how they take care of themselves can actually impact physicians financially. As a result, physicians need to dive in and get serious about using population health strategies to assess health risks, so they can create sub-populations and match individuals into efficient care programs that meet their health needs.
The American Academy of Family Physicians suggests that practices that implement population health programs can more easily:
- identify patients who need evidence-based chronic or preventive care.
- provide planned care and outreach based on patient diseases or conditions.
- provide patient self-management support.
- monitor patient progress and recommend changes to care plans.
- monitor practice performance by tracking patient data and comparing it with national guidelines or internal benchmarks
The key to achieving these population health benefits is data. Doctors (and even most patients) know that there are many things that influence health outcomes. Access to quality clinical care, social and economic circumstances, physical environment, and of course lifestyle behaviors are some of the factors that affect health. By leveraging data, healthcare teams can better understand those factors impacting their patients, and then work to create proactive care programs for different patient groups – for example, healthy patients, at-risk persons, and those with chronic conditions.
Electronic health records (EHR) hold valuable information about individual patients. Piece together insights from individual patient data and you have a larger picture of the makeup of a population. When EHR systems are optimized, each patient’s electronic record contains a comprehensive health history that can be used to signal next steps in individual patient care, and also population health management.
A basic strategy for using data to support population health management includes these steps:
- Learn how to use your EHR system to collect patient data.
- Use data to thoroughly assess your overall patient population.
- Apply multiple filters and segment patients into groups based on clinical, claims, and demographic data.
- Match groups of people to care management programs that meet their clinical needs and are operationally efficient.
Understanding the health risks of all the patients within a practice is nearly impossible without reliable data. Obtaining that data can be challenging for practices that do not have the experience or resources they need to collect it. If organizations are not able to effectively leverage data, there will be a whole variety of problems as they try to manage the health of their greater patient population. It is advisable that healthcare teams find a consultant if they are not well-equipped to handle data collection and analysis on their own.
The point is, doctors can no longer afford to treat population health as an abstract concept. Therefore, learning to work with data and adopting proactive population management strategies are must-do actions under value-based payment models.