by Nandini Rangaswamy
Executive Vice President and Chief Strategy Officer, ZeOmega
Healthcare organizations are increasingly turning to population health management (PHM) to help them adopt the value-based care models to which the industry is shifting.
Unfortunately, there is little consensus on how to define exactly what PHM is. Based on 14 years of experience and success in a competitive health IT market, ZeOmega has concluded that truly effective and impactful PHM is comprised of five distinct components, or pillars, which are essential for healthcare entities to prosper in the changing market.
Introduction
Healthcare's evolution has reached a pivotal juncture. At no point in history have we seen an array of external factors simultaneously converge to create such a perfect storm of change and transition.
Consider this...
According to the World Health Organization, healthcare currently accounts for almost 18 percent of the gross domestic product -- a figure that continues to rise -- and consumer out-of-pocket costs are at about 21 percent.
The Affordable Care Act is bringing millions of previously uninsured individuals into the system.
Over the next 15 years, some 76 million Americans will reach retirement age.
Almost half of us are afflicted with chronic conditions, for which we take at least one form of medication.
"Population health management requires more collaborative and inclusive methodologies driven by technology that enables organizations to meet current needs while equipping them for tomorrow's challenges."
Regulatory changes are focusing more attention on things like behavioral health coverage, medical loss ratio, Meaningful Use, Medicaid expansion, and HIPAA. Sociopolitical forces are driving health insurance exchanges and healthcare retail markets. Cloud computing and the use of personal mobile devices with clinical and consumer data has skyrocketed.
Genomic medicine continues to trend upward...
The list is as exhausting as it is exhaustive. And, collectively, it is causing healthcare organizations to dramatically re-think their roles as the lines that distinguish them increasingly blur. They are being tasked with figuring out a way to make sense of all this change while controlling costs and improving care. As a result, they are shifting from traditional care management models to population health management (PHM). This requires more collaborative and inclusive methodologies driven by technology that enables organizations to meet current needs while equipping them for tomorrow's challenges.
If you ask 10 health IT professionals to define PHM, you are likely to get 10 different responses; from simple ID and risk stratification, to patient engagement tools. At ZeOmega, we believe it is much broader and based on Triple Aim thinking around lowering the per capita cost of care, increasing the quality of that care, and improving the overall experience.
For us, it is built on five primary pillars that are essential to achieving these goals:
Program Design and Governance
Data Integration and Aggregation
Actionable Intelligence
Holistic, Patient-centered Care Management
Consumer Engagement
In PHM, information technology plays a critical role as the great enabler in achieving Triple Aim initiatives. It is our shared view at ZeOmega that healthcare organizations transitioning to truly effective PHM initiatives require tightly integrated, end-to-end, scalable solutions across these five pillars to help them succeed. This paper offers a close examination of each pillar and explains how it is essential for healthcare organizations to adopt them if they hope to succeed in the industry's burgeoning value-based environment.
Pillar One: Program Design and Governance
Deploying a successful PHM program is more than just implementing technology. It is a complete transformational undertaking that impacts an organization's people, change management processes, and current and future business models. Since these initiatives are so complex and dynamic, adequate planning and clarity around desired goals becomes paramount to their success. A failure to plan is a plan for failure – especially in the case of PHM. As a result, Program Design and Governance is the first pillar of a successful PHM program.
An organization converting to value-based care must first clarify its short- and long-term goals. These could be fairly narrow, such as complying with a particular regulation, achieving a STAR rating, reducing readmission costs, improving outcomes quality, or increasing patient satisfaction. Goals could also be fairly broad such as –"Moving to value-based care arrangements for over x% of the business in the next five years." It is important to determine how each goal will/should be measured. Clarity around specific metrics and their definitions will eliminate any future ambiguity on whether or not a goal was actually met.
A good program design should also consider organizational assets and limitations. In fact, an objective analysis of the organization's strengths and weaknesses can provide the basis for a solid PHM deployment plan. Early achievements are crucial to the success of any transformational initiative. Leveraging existing strengths to reach some short-term milestones can build momentum as organizations take on the more difficult challenges of closing gaps in infrastructure, staffing, and processes.
For example, a health system seeking to transition from a fee-for-service model to value-based care should first obtain accurate, real-time snapshots of readmissions data by facility, provider, and care team. A second logical step may be to deploy best practice care transitions capabilities that can demonstrate reductions in readmissions as measured by step one. Once these two steps are in place, the health system may be able to leverage medical appropriateness and/or clinical decision support capabilities to take on additional risk, such as bundled payment or carve-outs for episodes of care.
An effective PHM deployment plan also incorporates proper alignment of stakeholder incentives. For example, it would be unreasonable to expect a patient centered medical home model to succeed if the primary care physician is still solely compensated on the number of patient visits.
CMS and private payers, including some of ZeOmega's clients, recognize the importance of this alignment and are beginning to reimburse/sponsor PHM-type activities by physicians. While payer reimbursement is currently at the activity level in the short term, we believe the incentive will become increasingly aligned with clinical quality and outcomes as providers become adept at delivering value-based care.
A robust PHM solution should not only effectively deploy the PHM program's governance processes, it should also be able to measure the actual performance in real-time.
It needs to use that intelligence in a virtual feedback loop to drive continuous improvement across the healthcare organization. Any solution that requires the healthcare organization to expend extensive effort to create this automated loop cannot be a strategic solution. It is more of a stop-gap.
Implementing a PHM program involves selecting technologies that fit current needs and can easily and cost effectively change and adapt as the organization evolves. It is crucial for a healthcare organization to align with a vendor who approaches the PHM initiative as a strategic partner – not merely an IT provider. That is, a vendor who backs up its technical platform with consultation on best practices and strategic alternatives. This, along with a firm leadership commitment and solid change management strategy, is the foundation for a PHM program that will not only address short-term needs, but serve as a long-term solution as requirements evolve over time.
"It is crucial for a healthcare organization to align with a vendor who approaches the PHM initiative as a strategic partner - not merely and IT provider...a vendor who backs up its technical platform with consultation on best practices and strategic alternatives."
Pillar Two: Data Aggregation and Integration
The emergence of the three-party healthcare system – patient, payer, and provider – several decades ago caused health information to become increasingly siloed. Today, stakeholders are recognizing the importance of eliminating these barriers to glean intelligence from data throughout the healthcare ecosystem in order to effectively drive-value based care.
In recent years, payers and providers have begun to realize the need to share data with each other, which presents interesting implications for disparate, often proprietary clinical and non-clinical systems trying to exchange data.
Technology advancements such as the Internet, cloud computing, data mining capabilities, health information exchanges, and the explosion of personal devices and mobile apps, among other things, have created a treasure trove of information. And thanks to technology, it is now feasible to economically extract intelligence from it. If aggregated properly, these increasingly diverse and more robust data can lead healthcare organizations to a new level of personalized medicine that helps them achieve the Triple Aim.
How can organizations effectively aggregate this data? More importantly, what constitutes a robust data integration and aggregation strategy that can help an organization to ascend the evolutionary curve of PHM? It all begins with understanding the different dimensions of data.
First, data existing in various systems can be either structured or unstructured. Any organization that has implemented an interface has already worked with some type of structured data – claims, CCD, lab and pharmacy information, etc. – since this is what most integrations involve. However, some of the most relevant information for driving effective PHM is often the unstructured data existing in these same systems: EHR notes that capture the physician's differential diagnoses for a particular condition, history and physical information, discharge summaries, diagnostic reports, progress notes, and so on. A good PHM solution should be able to aggregate both data types.
Second, there is a general consensus that valuebased care must take into consideration both the individual's clinical and psychosocial health determinants. This means organizations seeking to deploy effective PHM programs should be able and willing to aggregate a more diverse set of data – clinical, demographic, environmental, behavioral, etc, – for every individual they serve. The immediate opportunities in PHM to improve quality and reduce cost are comparatively rudimentary. However, as organizations mature, a PHM solution that cannot handle data diversity will be at a distinct disadvantage in several respects.
Third, data exchange can happen in real time or in batch mode. Organizations have historically deployed batch integrations to aggregate data, and this approach will remain relevant in many scenarios. However, as the notion of delivering the right care to the right person at the right time becomes a key factor of effective PHM, there will be greater emphasis on real-time integration.
An effective PHM solution will also consider as part of its data aggregation strategy the ability to resolve which individual the data belongs to (the Jon Doe who visited the clinic is the same as John Doe who went to the ER), who the provider is (Dr. Johnson practicing at this clinic is the same as the visiting physician Dr. Johnson at the other facility), and various stakeholders.
A good data aggregation solution should also be able to track data sources and authenticity. This becomes especially important as the number of data exchange points increase exponentially. The ability to discern whether to rely on self-reported information versus a lab feed becomes crucial in making the right decision.
"Organizations seeking to deploy effective PHM programs should be able and willing to aggregate a more diverse set of data -- clinical, demographic, environmental, behavioral, etc, -- for every individual they serve."
Pillar Three: Actionable Intelligence
Healthcare organizations utilizing analytics to predict future costs is not a new concept. They have been mining claims data for years to ascertain individuals' risk profiles for actuarial purposes, and to predict the likelihood of costly services consumption. Analytics solutions have continued to expand the types of data they use in order to increase the accuracy of their predictions or, in other words, improve the insight they gather. While this approach has proven beneficial and adequate over the years, the shift to value-based care has generated a need for a new brand of analytics; one that provides timely and actionable intelligence so organizations can act accordingly to ensure better outcomes and/or lower costs.
Actionable intelligence, like most buzzwords, is often overused and misused. So what really is it? I believe the following example clarifies the difference between insight, or intelligence, and actionable intelligence.
If a person is diagnosed with diabetes, but has not had a foot exam in the last 12 months, that is insight/intelligence.
But this is not always useful information because it doesn't recommend the best course of action to take for that particular patient. Knowing that the patient is a Medicaid member and a single mother with a sick child at home helps determine the next best thing to do. In this situation, instead of bombarding the individual with alerts about a missed foot exam, the next best course of action may be scheduling a home health nurse to perform the foot exam at the patient's residence, or providing temporary transportation and child care support so she can visit the physician's office. This is the key difference between a solution that provides actionable intelligence and one that is merely predictive in nature.
Being able to make recommendations based on predictive insights increases the solution's effectiveness. In the example above, the ability to anticipate that a foot exam gap is likely to occur even before it does and assigning the home visit is extremely powerful functionality for an organization seeking to deploy an effective PHM program.
It has become readily accepted today that a patient's impediments to action or change are often due to behavioral, psychosocial, and environmental factors. In order to be truly meaningful, actionable intelligence must include these dynamics in addition to traditional clinical health determinants. Any analytics capability that does not is missing valuable contextual information and will not be able to provide optimal intelligence.
"PHM platforms that do not seamlessly integrate actionable analytics and workflow in real time are missing a valuable opportunity to positively impact patient health in the most efficient way."
Additionally, PHM platforms that do not seamlessly integrate actionable analytics and workflow in real time are missing a valuable opportunity to positively impact patient health in the most efficient way. As the industry pushes to increase the efficiency and efficacy of care, PHM programs that use limited resources most wisely are better positioned to succeed. For an organization with limited resources the next best thing to do for an unmotivated at-risk individual may be to do nothing at all. But taking this same approach to improving the actionability of PHM analytics is not an option. Not for organizations seeking success in value-based care.
A PHM platform with robust actionable intelligence capabilities is crucial to the fourth pillar of population health management: holistic, patient-centered care management.
Pillar Four: Holistic, Patient-Centered Care Management
One could make a very strong argument that the many moving parts and different variables associated with healthcare's rapid evolution to value-based models and PHM all boil down to one thing: the consumer. If these new approaches are going to succeed, it is essential for the individual to be at the center of the healthcare ecosystem.
Truly impactful, value-based care is only as good as the PHM technology it relies upon, and that technology must facilitate holistic, patient-centered care management.
Imagine what even the London Symphony Orchestra would sound like if each member was reading from a different sheet of music. In a sense, healthcare is largely seeking to overcome this very problem today. Interdisciplinary care teams – physicians, case managers, pharmacists, payers, and even patients and their care takers – have information, but it is not always the same information. Sometimes, it is as if they are all looking at different sheets of music.
This is where a progressive PHM technology can make an enormous difference by delivering complete – and consistent – patient data and evidence-based content to each team member where and when they need it, and through whatever channel best suits them. This is care coordination that is truly coordinated; from the simplest ongoing maintenance touch-points and reminders, to the most complex conditions and cases. The key is putting the patient at the center of the engagement, where they are far are more likely to engage for better outcomes, which helps healthcare organizations steadily maintain high levels of care quality.
But patient-centered, holistic care management does not end there. It is also about personalizing care to the individual and their needs. For example, a clinician educating an Asian patient who is at high risk for diabetes about controlling their rice intake is more relevant than simply suggesting they reduce carbs. Ascertaining the individual's life circumstances, their "context," so to speak, becomes essential for care team members so they can devise and implement an appropriate, personalized care plan.
"Fully coordinated, personalized care is the key to increasing efficiencies, reducing waste, lowering costs, and, most importantly, helping people live healthier lives."
With the technical resources we have at our disposal today, healthcare does not have to be – nor should it be – one-size-fits-all. For value-based models to truly flourish and reach their maximum potential, they must rely on technology that not only puts the patient at the center of the care universe, but understands that each individual is different and, accordingly, helps manage care on a case-by-case or, better yet, person-by-person basis. This type of fully coordinated, personalized care is the key to increasing efficiencies, reducing waste, lowering costs, and, most importantly, helping people live healthier lives.
Pillar Five: Consumer Engagement
In today's technology-driven society, mentioning the term "consumer engagement" in the context of healthcare brings to mind young-ish, otherwise healthy people jogging in the park with Fitbits® or Jawbones®. For those of us in PHM, however, consumer engagement has a much deeper meaning. It is about empowering the individual to become more actively involved in their healthcare, regardless of age or where they find themselves in the care continuum: young and fit, chronically ill, or nearing end-of-life.
PHM programs that downplay the importance of consumer engagement will not be as successful as those with effective consumer engagement strategies. So then, how do you effectively engage with consumers who, we must remember, are unique individuals? Consumer engagement strategies that account for drivers of human behavior will be able to empower the individual to make the right decisions about their healthcare. A comprehensive consumer engagement strategy typically encompasses three phases – educate, engage, empower.
First, consumer engagement approaches should seek the best way to reach an individual and educate them about their present health situation. Take, for example, an individual identified as pre-diabetic. Is the person even aware that they are pre-diabetic and do they know the factors that contribute to their condition? Do we know that individual's readiness to change and the likely barriers to change? If the individual was unaware that he is a pre-diabetic, but is now interested in learning more, then being able to put together an education program that reflects his communication preferences drives greater effectiveness. However, knowing that the individual is currently going through depression due to a death in the family instead suggests that the best way to address the situation is to help them through their situation and then engage on the diabetes risk discussion when the patient is in a better frame of mind. Measuring the effectiveness of the educational initiatives also becomes key. For example, do we know if the patient actually sat through the online diabetes educational program? If not, would a gentle reminder help? A robust PHM platform should be able to facilitate such personalized educational activities based on the individual's behavioral and psychosocial context. Educating a consumer is much easier than taking them to the next level, i.e., getting them engaged in their care.
Revisiting the pre-diabetic, in most cases, it is likely that these individuals do in fact know what the key drivers of their condition are – poor diet, lack of exercise, unhealthy lifestyle choices, and so on. Yet few are compelled to make necessary changes. Most of us know that good diet, exercise, and lowering stress are keys to promoting overall health, yet how many of us actually do, or plan to do, something about it? Identifying the right motivating factors can help drive more effective engagement strategies. For example, a woman may be more motivated to begin a weight loss program because she wants to look her best for her daughter's wedding than for the apparent health benefits. Here, helping her track her weight loss goals to the "Big Day" and the things she needs to do to wear "that dress" will definitely yield better results than a program that simply emphasizes how losing weight positively impacts her health.
"Consumer engagement strategies that account for drivers of human behavior will be able to empower the individual to make the right decisions about their healthcare."
Engaging people is one thing; keeping them engaged is another. How many of us sign up for health related alerts, but soon tune them out due to alert fatigue? A good PHM platform should enable organizations to track actual patient engagement and constantly tweak their strategies to maximize engagement. We may be able to convince a person with a past history of cardiac failure to upload their blood pressure and weight every day through a wearable biometric device or a scale that transmits data to the PHM platform, but they may soon tire of doing so. Feedback that gives helpful pointers about what went well and what didn't may keep them more engaged. If the heart disease patient knows that a sudden change in biometrics (weight) is not only tracked but will result in care team action – such as a call to determine if a visit to the doctor is necessary – then he may be more willing to stay engaged.
The third phase of consumer engagement is getting to the empowered consumer. An individual who is educated and engaged in their healthcare, when provided with the information and decision support tools necessary to make a healthcare decision, is likely to make the best healthcare choices for them. And, as in other industries, an empowered healthcare consumer is likely to make decisions based on quality, cost, and convenience. That might mean receiving immunizations at the local pharmacy because it is inexpensive and convenient, or going to the oncology specialist two towns away even though they are a little more expensive, because that specialist has been handling the patient's case for the last two years.
As PHM gains momentum, healthcare organizations are rethinking their roles and reassessing how to better engage with individuals. Those who successfully implement PHM's five pillars will be best positioned to thrive in a value-based care environment. This is the true convergence of the entities healthcare has traditionally delineated as "payer" or "provider." As healthcare continues its rapid evolution, successful organizations will no longer fit into these categories. They will become true health and wellness companies focused on the individuals they serve.
About the Author
Nandini Rangaswamy, MBA
Executive Vice President and Chief Strategy Officer, ZeOmega Chairman of the Board
Nandini Rangaswamy has a background in management consulting with work experience that spans several industries including Healthcare, Pharmaceuticals, Travel and Telecom.
Prior to joining ZeOmega, she worked at Accenture in the Corporate Strategy, Mergers & Acquisitions Group. Her work included advising clients on M&A;, strategy, identifying potential acquisition candidates, valuing candidates, analyzing deals and conducting due diligence. Her work also included prioritizing performance improvement initiatives for clients through assessment of economic impact of operational and financial value drivers. Before transitioning into management consulting, Ms. Rangaswamy worked at The Sabre Group and Abbot Laboratories, leading IT projects at both companies.
Ms. Rangaswamy holds an MBA from The Wharton School at the University of Pennsylvania, Philadelphia, and a Bachelor's Degree in Electronics Engineering from Bangalore University.