This paper examines the critical role of technology in population health management (PHM), a system that rewards healthcare organizations based on quality outcomes across entire patient populations rather than individual encounters. The analysis focuses on four essential PHM functions enhanced by information technology: data collection, storage, and management; population stratification and monitoring; patient engagement; and outcome measurement. Through examples including immunization registries and mHealth applications, the paper demonstrates how automation, electronic health records, predictive modeling, and PHM dashboards enable healthcare providers to deliver value-based care more efficiently while reducing costs and improving patient compliance and health literacy.
Population health management (PHM) has gained prominence in mainstream healthcare organizations in recent years for the simple reason that healthcare is changing, and physician groups and healthcare systems are being forced to adapt to a new system in which they are rewarded based on how well they meet the quality objectives of the entire patient group rather than individual patients. The twenty-first century healthcare platform places more emphasis on value as opposed to volume, and organizations that can devise proper mechanisms for delivering quality, patient-centered healthcare across entire populations are deemed to have an edge over their competitors.
It is for this reason that public health professionals and physician groups have continually engaged information science and technology in their public health activities—all in an attempt to make full use of their potential and consequently increase their level of effectiveness. Technology has increasingly become an integral part of public health activities, and most essential PHM functions have been automated. This essay examines how technology has improved the flow of population health activities within four essential PHM functions: data collection, storage, and management; population monitoring; patient engagement; and measuring outcomes.
Before embarking on the main discussion, it is prudent to first define a number of key terms used throughout this text.
The Institute for Health Information Technology defines population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (Institute for Health Technology Transformation, 2012, p. 5). Medical care is just one of the key factors influencing these outcomes; others include social support, employment, educational level, and income level.
Population health management refers to the act of formulating and implementing health strategies to ensure that healthcare is delivered effectively, patient populations are managed efficiently, overall costs of healthcare delivery are minimized, and care is provided on the basis of value as opposed to volume (Hodach, 2014; Nash, et al., 2010). PHM is about devising ways through which the chronic and preventive care needs of the entire patient population can be effectively addressed. Its primary objective is to ensure that the health interventions employed at any particular point in time are relevant to the health risks facing the population at that particular point (Public Health Informatics Institute, 2011).
The overriding goal of PHM is to minimize the cost of health interventions and procedures and to keep the population as healthy as humanly possible. The procedures and tasks involved in PHM are often repetitive in nature and could cost an entity huge losses in terms of lost employee time, redundant work, and unnecessary financial expenditure. Automation has gone a long way in smoothing out the activities, tasks, and functions of PHM, saving both time and money and making the whole idea of PHM more economically feasible.
Through automation and information technology, health organizations are better placed to assess the needs of their patient populations and to stratify them more effectively based on health risks, health status, geography, and demographics (Institute for Health Technology Transformation, 2012).
How patient data is collected and managed determines, to a large extent, how effective the processes of administration of care will be. Electronic health records (EHR) aid organizations in executing this function by allowing for the sharing of crucial patient data across multiple healthcare organizations. These records have provided sufficient starting points for the development of population-wide databases and community health information exchanges that aid in the tracking and monitoring of population health (Institute for Health Technology Transformation, 2012).
Through these information exchange platforms, physicians are able to share information about patients' health problems, procedures, lab results, and medications regardless of where they are located. Furthermore, such registries make it relatively easy for population health managers to identify disease-related trends and commonalities in certain population groups. This way, they are able to single out the risk factors and risk elements that predispose the patient population to specific diseases and to subsequently develop suitable health interventions for addressing them (Yasnoff, et al., 2000).
A perfect example demonstrating how community health information exchanges have aided in PHM is the central immunization registry in Arizona, which was used to store immunization information from both public and private providers in the state. This system made it possible for state healthcare providers to identify geographical areas where children ran a higher risk of disease owing to under-immunization (Yasnoff, et al., 2000).
Similarly, in California, the existence of a central computerized immunization registry allowed state officials to effectively identify, recall, and revaccinate four children who had received vaccine from a sub-potent group, thereby saving the state the trouble of having to revaccinate the whole lot of 15,000 children within the same neighborhood (Yasnoff, et al., 2000).
In order for an organization to manage the health of its patient population effectively, it must specify the population into different subgroups based on the seriousness of their specific conditions or on whether they are fairly healthy and only in need of education and preventive care (Institute for Health Technology Transformation, 2012). Further, patients can be classified based on demographics or the financial and behavioral risk they pose to the organization. Classifying patients correctly is the first step toward providing accountable and effective care.
Wrong classifications often have serious consequences and could prove quite costly to an organization. For instance, a patient's condition could worsen if they fail to receive the ongoing support of a care manager because they have been wrongly classified under the "fairly healthy" category.
Technology comes in handy in helping organizations place patients in the appropriate patient categories. Predictive modeling algorithms have, for instance, been widely used to classify patients based on their risk of suffering relapses or further health complications in the coming months (Institute for Health Technology Transformation, 2012).
Further, there are a number of health IT tools and computer applications that facilitate the classification and monitoring of patient populations by narrowing down subgroups (essentially helping providers target particular groups), making patient data actionable (by prompting providers about patients' care needs), and making data actionable by prompting and alerting patients to make appointments with their care providers (Institute for Health Technology Transformation, 2012).
Patient engagement is a crucial factor in the delivery of care, be it at the individual level or the population level. It includes, among other things, involving patients in their own health and collaborating with them to help them understand their care plans and the reasons why they need to comply with the recommended health guidelines (Institute for Health Technology Transformation, 2012).
Through technology, organizations are able to operate instant messaging services in which they send regular prompts to all their discharged patients, reminding them of the need to call the hospital in case of any health concerns, the need to fill their prescriptions, techniques for maintaining a healthy lifestyle, and so on (Institute for Health Technology Transformation, 2012). This way, the organization is able to stay in touch with its entire patient base and not just those actively seeking healthcare or the frequent callers at the call center.
Moreover, physicians have been able to carry out online risk assessments, through which they can easily identify patients with the most urgent healthcare needs or those who require a lot of assistance and education in managing their health (Institute for Health Technology Transformation, 2012). This way, they are able to effectively organize their case loads on the basis of urgency and to serve a higher number of patients than they initially could.
Care providers are able to interact with their patient populations through tailored educational programs and web-based applications such as mHealth, in which case they are able to, among other things, recommend screening tests, prescribe online educational programs, and increase patients' awareness of health-related issues (Institute for Health Technology Transformation, 2012).
Studies have found such programs to be effective in increasing the levels of awareness and compliance among patients. In fact, according to a report by the Veterans Health Administration group, they have cut hospital bed days and admissions by 25% and 19% respectively (Institute for Health Technology Transformation, 2012).
Organizations need to evaluate their health outcomes in order to determine how effective they have been in meeting their intended objectives. PHM dashboards have facilitated this process of evaluation by allowing physicians to carry out data analysis and generate standardized reports that make it possible for health officials to analyze data over multiple periods, identify trends, spot gaps, and formulate effective correctional mechanisms (Institute for Health Technology Transformation, 2012).
The use of IT by public health and healthcare professionals in PHM has greatly improved the delivery of care at both the individual and population levels. By strategically combining technology and health communication processes, public health professionals have been able to build knowledge and healthy skills among the patient population, facilitate consumer and clinical decision-making, support care at the home and community levels, increase the effectiveness of public health and healthcare service delivery, and improve healthcare safety and quality among the patient population.
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