The Promise of Population Health

Rohan Dsouza
5 min readMar 9, 2015

There is a lot of talk about the next big way to revolutionize how healthcare is delivered in the United States. Population Health, the buzzword surrounding all of us, is loosely defined as “the management of health outcomes with the implicit goal of improving the outcomes”. While it has not reached superstar status like Meaningful Use, or bastardized as much as ‘Big Data’, Population Health is gaining in popularity, and when used with the acronyms we all know and love, like ACA, PCMH, ACO, MSSP, and HEDIS, PHA can be a real conversation starter (or stopper, depending on who you’re talking to).

Among the many things that we as a nation are proud of, healthcare spending, and snowballing healthcare budget deficits isn’t one of them. But, I truly believe we are making progress in fixing this broken system. Early results from pilot population health management programs have yielded good, and sometimes stellar outcomes. Think reduction in readmission’s, cost savings, and happier patients.

As a data geek, most of the decisions I make in my life are influenced by data; prospective decisions are based on retrospective data points . Early in my EHR career, I looked forward to the day when well-formed electronic patient records with thousands of unique clinical data points would be available for making data-driven decisions. While I can’t say we are completely there yet, we are now able to leverage clinical data points along with vast amounts of structured claims-based data. This provides our clinical care teams with statistically relevant data offering insight into their patient populations. I believe this is the true promise of population health analytics.

Population health is a complex solution to an even more complex problem. When added to the day-to-day pressures to use EMR, comply with Meaningful Use, and prepare for the momentous ICD-10 transition, compiling data, and understanding how to use the data can seem overwhelming to our clients. Knowing that there is no “one size fits all” solution, practices who are interested in implementing a population health protocol should try to align their priorities with the Institute for Health Improvement’s (IHI) Triple Aim campaign:

Improving the patient experience of care

Improving the health of populations

Reducing the per capita cost of patients

Understanding the role the three “Ps” (Provider, Patient, Payer) play when it comes to developing a successful population health management program is paramount to providing the all-encompassing solution to succeeding in this nascent environment. Population Health Analytics is more than just delicious pie charts and fancy web-based technology. It is the ability to bring a complex combination of variables together in a way that aligns the entire patient population picture into focus, when before it was just a series of unrelated data points.

While much of the news surrounding population health All-Stars comes from large, high-profile organizations, it is, in fact, the smaller, well-managed, primary care-focused Accountable Care Organizations (ACO) that are really hitting the ball out of the park. Success in these many pop health programs can be achieved by practices of all sizes, so don't be afraid to jump on the pop health bandwagon. If you are not sure where to start, I have highlighted three areas that are pivotal in researching before you jump in headfirst.

Understand your options: The world of population health can sometimes feel like a Las Vegas casino. With so many options to bet on, it is alright to take a cautious approach — start with the slot machine before diving into the high risk, high reward tables. Today almost all payers offer some type of value-based purchasing incentive (reimbursement based on what you do vs. how much you do). These are also known as shared savings plan, and can take several forms — Patient-Centered Medical Home (PCMH), Accountable Care Organization (ACO), or other pay-for-performance programs that developed by individual payers. Practices can earn significant reimbursements by making small workflow changes, and ensuring that there is coordinated care for every patient. Medicare Advantage is another model that is gaining traction. By understanding the Hierarchical Condition Categories (HCC) used to code visits, practices all over the country are reporting significantly higher reimbursements. We don’t recommend jumping into the deep end of the pool, but by researching their options, practices will see that it is easy to keep their head above water!

Signal vs Noise: Data and analytics play a pivotal role in the success of every population health program. In the quest to achieve the triple aim, practices need to invest in an analytics solution that provides insight into the various cohorts that make up the population. With an analytics solution implementation, it is important to understand the difference between a “signal” that triggers an action vs. “noise” that is not actionable and can be ignored. Recognizing that there is a fine line between capitalizing and capsizing, every individual in the care team should work in synchrony while identifying the organization's key performance indicators (KPI). Now that critical data is liberated from the information silos of EMR and claims databases, it is easy to get carried away with the sheer volume of data that is available. The investment of time to identify the KPIs that will benefit your group’s understanding of their performance will ensure you capitalize on your investment in analytics rather than letting the data capsize your initiative.

The Primary Care Provider (PCP) is the QuarterBack!: The PCP in every population health initiative plays an important role of quarterbacking the care team. PCPs and their respective care teams often become the triage point of the patient panel to organize the coordination of care between specialists, providers of ancillary services like labs and imaging, and in-patient settings. ACOs and PCMHs must invest many hours and resources in providing their PCPs with the right training, adequate support staff in the form of care managers, care coordinators, and software tools that will not disrupt their existing workflows. If there was a silver bullet that would solve the problem of disruptive adoption of new technology in care settings, it would be the ability to provide population health-centered metrics directly to the PCP at the point of care, embedded in the provider’s existing workflow. I believe that the EMR of today is the gateway to effective population health solutions of tomorrow.

It is too soon to tell whether Population Health programs such as ACOs, PCMH, and others will bend the cost and quality curve But one thing is certain; population health is here to stay. Early signs point to an improvement in the way services are delivered that will revolutionize the way we look at healthcare in America. It makes for changing, albeit challenging times, for all of us who work in the healthcare industry.

I hope you are as excited as I am to be part of the generation that turns these current challenges into opportunities for future generations. Here’s to making a positive and sustainable impact on our society.

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Rohan Dsouza
Rohan Dsouza

Written by Rohan Dsouza

Building the Internet of Healthcare. When not geeking out on healthcare data, Im experimenting in the kitchen or out exploring the great PNW