The heart of population health management is having a surveillance capability that recognizes patterns in patient data and care management characteristics and exposes impending high-risk clinical events, gaps in care coordination or non-compliance in patient situations.
By Femi Ladega, CTO, Healthcare and Life Sciences, CSC
To manage population health effectively, an organization must be able to track and monitor the health of individual patients. It must also stratify its population into subgroups that require particular services at specified intervals. From a care management viewpoint, patients should be stratified by their risk of getting sick or sicker.
Grouping patients into categories by condition has been the traditional approach of disease management programs. In contrast, care management stratification focuses on whether patients are ill enough to require ongoing support from a care manager, have less serious chronic conditions that warrant interventions to prevent them from worsening, or are fairly healthy and just need preventive care and education.1
Risk stratification must be dynamic in nature. Payers use predictive modeling algorithms that can help forecast which patients are likely to have significant health costs. Electronic health records (EHRs) can generate alerts for preventive and chronic care, but typically prompt providers only when a patient’s record is opened, usually during a visit. Real-time prompting is needed to assist providers and support patient empowerment. Electronic registries fed by EHRs, administrative data, social status data and other federated data sources are a superior source of actionable data and risk stratification reports. When such registries are coupled with evidence-based clinical protocols based on national standards, specific messages can be generated, reminding patients to make appointments for needed chronic and preventive care.2
The transition to a system of population health management promises to improve access to important resources when they are most needed, like doctors and facilities; to free up public funds for new systemic investments; and to bring better health and well being to a much broader segment of society.
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Read more in this paper, Digital Revolution Enables Population Health Management.
This paper is part of the Journey to the Digital Enterprise paper series.
1) Agency for Healthcare Research & Quality, “Practice-Based Population Health,” pp. 21-22.
2) Suzanna Felt-Lisk and Tricia Higgins, “Exploring the Promise of Population Health Management Programs to Improve Health,” Mathematica Policy Research Issue Brief, August 2011, accessed at http://www.mathematica-mpr.com/publications/pdfs/health/PHM_brief.pdf
Femi Ladega is Chief Technology Officer for CSC’s Healthcare and Life Sciences global industry group. Femi has undertaken major healthcare transformation engagements in Europe, America, Middle East and Australia and is working with the UK government to develop and implement flagship healthcare solutions as part of the National Programme for IT (NPfIT), the largest civil IT transformation program in the world.