How Population Health Management is Changing CFO Perspectives

Post by Matt Wood

Chief Financial Officer, Caradigm

As healthcare moves from fee-for-service to pay-for-performance, population health management is changing how Chief Financial Officers (CFOs) of health systems approach their roles. Population health aligns quality with revenue, which then aligns the goals of CFOs with Chief Medical Officers (CMO) and Chief Quality Officers (CQO) more closely than ever before. Mark Bogen, CFO and senior vice president of finance of South Nassau Communities Hospital in Oceanside, N.Y. describes the shift for CFOs in this recent Becker’s Hospital Review article:

“I think the biggest thing is CFOs…they’re going to have to continue to get out of their comfort zone with the traditional financial indicators that predict revenue, that predict cash flow, and be more aware of where we’re headed, how many lives are we covering and the utilization and the outcomes attached to the clinical pathways that we’re allowing access to,” he says. “I know that’s a tough thing to get used to, but quality and outcomes are where it’s at, so you’ve got to be in that loop.”  

Population health presents an opportunity for CFOs to increase margins through lower costs, shared savings and bundled payment programs, and increase revenue through the addition of other risk-based agreements. To realize those benefits, CFOs should understand the key requirements of population health solutions as much as the CMO and CQO and participate in the evaluation process as a key stakeholder. For population health to successfully increase margins and revenue, providers need solutions that can:

1) Aggregate and normalize all data (e.g, clinical, claims, financial) across all systems.

2) Apply analytics to that data to stratify populations down to an actionable number of patients with the highest ROI.

3) Surface data and analytics at the point-of care in near real-time to guide decisions and improve productivity.

Without these capabilities, investments in population health solutions run the risk of underperforming on quality improvement and therefore, not delivering ROI. As the internal subject matter expert on ROI and the owner of financial performance, CFOs should play an important role in population health as it can help pave a stronger financial path for their organizations. I believe that having more stakeholders aligned around quality is the first step to drive better patient outcomes, so I look forward to having more conversations with CFOs about population health.

What is Population Health Management Really About?

Post by Neal Singh

Chief Technology Officer, Caradigm

Population health management is still such a new concept that I often get asked the question, “what is pop health really about?” It’s a question that I enjoy having discussions about because it helps put into perspective where healthcare is today and why it needs to take a different path in the future.

Healthcare has historically been transactional. A sick patient visits a physician when they need care, receives that care and the physician gets paid for the transaction. Physicians get paid every time they see patients, whether patients get healthier or not. Electronic Medical Record systems (EMRs) also emerged to facilitate this type of episodic care. However, the downside of transactional healthcare is that it’s reactive and not coordinated, which leads to lower quality of care and higher costs. The passing of the Affordable Care Act in 2010 and the shift in reimbursement models to value-based care have challenged the transactional model.  

Hospital networks are now incentivized to make a population of patients healthier under risk-bearing financial arrangements. By aligning the economic incentives for care delivery and utilization among the patient, provider and payer, population health seeks to improve quality and reduce costs through proactive and coordinated care. New healthcare information technology has emerged to enable population health, and that’s what Caradigm delivers in four key capabilities: 1) Data Control 2) Healthcare Analytics 3) Care Coordination and Management 4) Wellness and Patient Engagement.

Here’s an example of the power of population health. Imagine a large provider with a total population of 1.6 million patients, 77,000 of whom are diabetics. Whereas many population health solutions can predict which 55,000 of those 77,000 diabetics are going to incur the highest costs next year, Caradigm® Risk Management powered by LexisNexis with MEDai Science can identify which patients should be prioritized because of their cost savings potential based on a number of factors including clinical risk, inpatient and emergency room visit risk, forecasted costs, patient motivation, and movers risk (i.e. the risk of transitioning to high risk over the next 12 months). In the case of this particular population, there are 900 patients who will be highly impacted by intervention and management and yield a significant cost savings.  That’s meaningful intelligence that helps large providers with constrained resources know where to take action today.

As exciting as that intelligence is, it’s just one part of the population health story. The story continues in better managing the care of those 900 patients and empowering them to take greater responsibility for their own care, but we’ll save those discussions for another time.

I am passionate about population health because it’s next-generation healthcare that benefits everyone – patients, clinicians, providers and payers. Leading healthcare organizations are already executing on it today, which will help them be the healthcare leaders of tomorrow. To learn more, please check out the resources page on our website at



Why Care Managers Should Be Excited About Population Health Management

Post by Vicki Harter

Clinical Product Manager, Caradigm

Patient care is part science (i.e. tests, treatment) and part art (i.e. communication, motivation, prioritization). Today, effective population health solutions can link the science and the art in a game-changing way that will help care managers deliver better care, more efficiently.

Care managers are asked to do a lot. The typical care manager at a large hospital network has a full case load, which limits the ability to deliver quality care across a population. The reality is that we’re not going to have enough care managers to care for the growing number of patients, so we have to become more efficient. We also need to empower motivated patients to manage their own care.

Caradigm® Care Management was developed in partnership with Geisinger Health Plan based on extensive observations of their care management team. Together, we came to the conclusion that what care managers needed most was to 1) have complete data and analytics in a single workspace and embedded into workflows and 2) automate routine processes. Here are just a few examples of how a care manager’s life can be made easier:

  • Task lists and interventions are automatically generated from assessment responses that list the top interventions needed to get the highest risk patients to a better place and assure consistent work practice.
  • Complete medication histories can be brought into single patient views that display order history and fill history for easy review.
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).
  • With a full 360 degree view of patients, care managers can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient centered care by incorporating patient personalized goals into care plans.
  • Patient workloads or specific tasks can be reallocated to other care managers or support staff, assuring “top of license” activity.
  • Best practices of care managers can be identified and then shared across the team.

This is exciting, transformational change. Care managers today are hunting down information from many systems and storing that information all over the place on sticky notes, notebooks, applications, and then must synthesize that into a care plan. Multiply that by 50, by 100, by 200 patients, and it’s challenging to do it efficiently. Caradigm’s population health management solutions are transforming care management, and I am thrilled to be part of the journey.

The Growing Complexity of Identity and Access Management

Post by Azam Husain

Senior Product Manager, Caradigm

Identity and access management (IAM) is getting harder. It used to be a single physician would view one record for one patient during one visit at one location, but now everything is multiplied. Healthcare providers are rapidly expanding their scope of influence by adding independent physicians, hospitals and other providers to their network. IAM is now a broader business challenge that not only affects security and compliance, but also patient safety, clinician satisfaction as well as IT resource utilization.

If anyone knows about the challenge of IAM, it’s Bobby Stokes, AVP Identity Management and Development Services of Hospital Corporation of America (HCA). HCA, recognized for security excellence, must share patient information securely and efficiently across 160+ hospitals, 1000 hospital affiliates, and 100,000+ users. Five percent of all U.S. inpatient admissions take place in a HCA facility. As Stokes said on last week’s webinar, “That’s an interesting mix of concerns.”   

Today, IAM is a balancing act. First, healthcare organizations have a responsibility to ensure the privacy of protected health information from internal and external threats. Inappropriate access to data has resulted in multiple data privacy violations recently (see here and here), and is an area that providers need to take greater control of. Second, data has to be easily available for clinicians to consume and comprehend. Clinician workflows can be streamlined by reducing the number of system log-ins and by providing patient context across those systems. Lastly, from a provisioning perspective, IT needs tools to manage the sheer volume of requests they are faced with. Without solutions that can automate provisioning processes, IT is forced to spend excessive amounts of time on user provisioning, which can also cause delays in clinician access.

If you missed last week’s webinar where Bobby Stokes talked about how HCA approaches identity and access management, then you can catch the recording here.

The Rise of Clinically Integrated Networks and Population Health Management

Post by Scott McLeod

Director of Product Marketing, Caradigm

A notable healthcare trend is the rapid rise of Clinically Integrated Networks (CINs) in accountable care. Children’s Health System of Texas just announced its new system structure as a clinically integrated pediatric health system. Ascension Health and CHE Trinity Health recently announced a clinical integration partnership that has the potential to reach three-quarters of patients in Michigan. EvergreenHealth also launched the first CIN in the Puget Sound region earlier this year.

The growth in CINs is being driven by the shift to value-based reimbursement. Payers and employers favor providers that can deliver high-quality care in an efficient manner, and clinical integration enables collaboration among independent providers to meet that requirement. These independent physicians, hospitals and other providers now share responsibility for the care of patients across the community, and must share patient information to fulfill that responsibility.

Enter population health management as a new solution to help with the coordination, collaboration, and measurement of quality among a community’s providers. Although CINs have typically invested in an electronic medical records system (EMRs), they are still unable to manage the health of populations because EMRs are usually designed for only single-patient interactions. Accountable care and value-based reimbursement demand systems that manage health across populations outside of episodic care in clinical settings. Organizations need comprehensive health histories and need information at the point-of-care to help make better clinical decisions.

As CINs mature and evolve, their story ultimately leads to population health management. To learn more about this topic, sign up for our whitepaper entitled ‘Clinically Integrated Networks and Population Health: Taking the Next Step’.

Quality Improvement: Going Beyond Retrospective Reporting With Population Health Management

Post by Kendra Lindly

Senior Product Manager, Caradigm

Often, quality efforts in healthcare are focused too much on retrospective reporting of measures, and not on improvement of those measures. It’s important to understand the past, but that alone does not drive improved patient outcomes. To drive measureable improvement, you need to identify the root cause of care gaps and apply the intelligence within clinician workflows to close those gaps. 

As a result of the rise in population health management, solutions have emerged to help healthcare organizations take this next step.  For example, a clinical analyst can quickly drill down in a specific ACO 33 measure to determine the root cause of non-compliance, then guide actions of clinicians to remedy that gap. Advanced population health solutions can track gaps and surface areas of non-compliance within the workflow of the EMR while the physician is still in the presence of a patient.  This enables a physician to address gaps before the patient leaves. Care managers can have a task list automatically generated for them that prioritizes their daily activities. These are just a few of the many practical ways that new solutions are innovating quality improvement efforts.

 Check out this infographic to learn more about the impact of poor quality on patients, healthcare providers and the economy—and how it can be remedied. You can also download our whitepaper entitled ‘Quality Improvement in the Advent of Population Health Management’ by completing this form.

Webinar Tuesday: Identity and Access Management at HCA – Taking Control in the Era of Population Health

Post by Christine Boyle

Senior Vice President of Marketing, Caradigm

When you have the operational scale of Healthcare Corporation of America (HCA), identity and access management (IAM) is a massive undertaking. Recognized as a security innovator by CSO Magazine, HCA is continuing to set the bar high by improving security and access to protected health information across 160+ hospitals, 1000 hospital affiliates, and 100,000+ users. While the primary goals of IAM are security and compliance, it is an area with broader business value. IAM enables security leaders to partner with clinical leaders to drive efficiencies in how clinicians consume patient data, which impacts patient safety and the overall quality of care.

If you’d like to hear how HCA approaches IAM, it’s not too late to register for our webinar today at 1 PM ET. The always entertaining Bobby Stokes, AVP Enterprise Systems at HCA, will be discussing how HCA is taking control of its data to manage security and compliance risk while improving clinician access. You can register here.

Innovations in Population Health Management – a discussion at iHT2

Post by Michael Simpson

Chief Executive Officer, Caradigm

I had the pleasure of participating on a population health panel at an IHT2 conference held recently in Seattle.

As you’d expect, moderator Mark Hagland, Editor-in-Chief of Healthcare Informatics, drew on a variety of perspectives – primary care, public health, IT – from a variety of healthcare providers and vendors – to discuss what’s happening in population health management today and where we’re headed.

Some of the key Population Health points covered were:

  • Moving from episodic, single-patient care to managing the health of populations represents a seismic shift that will require many years and tremendous patience to achieve, despite widespread industry commitment and focus. It’s going to take many years, for example, for physicians to change their way of thinking from operating as individual problem solvers to serving as members of a broader care team. They’ll need evidence that team-based care works.
  • The ongoing debate about the pros and cons of electronic medical records underscores the need to significantly streamline clinician workflows and deliver IT solutions that work in a practical way. While a paper-based system might not measure up in terms of data quality, it’s a highly efficient way of capturing information. We need to find a way to maintain that level of efficiency with technology while improving data capture and quality.
  • Success in population health requires looking holistically at the lives of patients and populations – factoring in their social, economic and physical environments, not just clinical data. Time spent between a patient and a doctor in a clinic or hospital is extremely limited. The vast majority of what impacts a patient’s health happens elsewhere. We need to put the patient at the center, engage the patient in his/her care through creative approaches and incentives like games or competitions, and establish a comprehensive community health record, not just a personal health record or EMR. We need to make that community health record easily accessible by the entire care team, including the pharmacist, the behavioral health specialist, the care manager, the primary care provider, and equally important, the patient.
  • To make progress in population health management, healthcare organizations need to start small, focus on making an impact in a discrete area, and expand on that success. For example, a provider in Canada began their population health efforts by focusing on HIV-positive individuals. They set up one central resource to identify all treatment associated with HIV patients, connected databases, and proactively tracked when patients were diagnosed, how quickly they were linked to care, when they were put on Antiretroviral Drugs, etc., and helped them with housing needs.  Their approach can serve as an effective blueprint for managing the health of other populations.
  • Success in population health begins with collecting the right data and performing analytics to identify not just those patients that are costing your organization the most time and money today but those patients of highest risk of costing your organization the most next year. Once that risk has been identified, the extended care team can work together to address those patients’ needs proactively and keep them out of the high risk, high-cost category. Those analytics capabilities exist today.
  • Last but not least, while we’re all concerned about identifying and addressing gaps in care to achieve the highest level of quality possible, we also need to focus on revenue. If an organization can identify revenue opportunities, it can invest more in care optimization going forward. “Without income there are no outcomes.”

iHT2 Michael Simpson on Panel

New Automated Tool Builds IAM Application Connectors

Post by Jim Campbell

Vice President of Identity and Access Management, Caradigm

It’s always nice when a product can align with industry trends. But our latest offering for customers and partners is actually the product of the confluence of two ongoing healthcare trends, which are inherently at odds:

On one hand, to succeed in population health, large integrated delivery networks, academic medical centers, government facilities and community hospitals need control of their data, including the ability to minimize the risk of unauthorized access to patient data.

On the other, the ability to share data across the healthcare community is fundamental to the success of integrated, accountable care and improving population health. In this environment, health systems and hospitals need to quickly provide access to applications while ensuring compliance with data privacy and security requirements.

But until recently, building connectors into clinical applications often meant having thinly stretched IT staff write code or investing in expensive technical resources.

That’s the significance I see in Caradigm® Bridge Studio, which squarely addresses both requirements, providing a level of agility in identity management that healthcare organizations haven’t enjoyed before.

The availability of Bridge Studio marks the industry’s only point-and-click wizard for building identity management connectors into clinical and business applications. Part of our Identity and Access Management (IAM) suite of products, Bridge Studio works in conjunction with Caradigm Provisioning software, allowing our customers to build identity management connectors into their clinical and business applications without the need to write code or invest in technical resources. With this new capability, healthcare organizations can rapidly expand automated provisioning to a wider set of clinical and business applications – helping them meet the challenging objective of making the right patient data available at the right time to the right people.

To ensure that Bridge Studio meets real-world needs, it was developed based on input and technical previews by our IAM customers, including Saint Luke’s Health System of Kansas City.

2014 Caradigm Customer Summit Day 3: Demonstrating Progress with Population Health Management

Post by Christine Boyle

Senior Vice President of Marketing, Caradigm

On the final day of the 2014 Caradigm Customer Summit (see Day 1 and Day 2 recaps), we heard  customer speakers say that it’s critical to show progress quickly on your way to the strategic goal of population health management. First, Virtua Healthcare shared how they used Identity and Access Management to improve clinician access to data. In one specific workflow, they reduced the number of clicks needed from 60 to 13, which will have enormous impact given how many times every day that workflow is repeated. Provisioning of new users that used to take days can now be done in hours. These measureable results have driven higher clinician satisfaction scores and built momentum for additional projects that will continue to improve security, HIPAA compliance and patient safety.

We also had a great panel of providers share thoughts and recommendations from their experiences with population health. Everyone agreed that prioritization is challenging, but essential because no one has unlimited resources. You need to show quick wins to your leadership team as you progress to an overall vision. Data consolidation is often a logical starting point and viewed as a major win by leadership because of the known complexity around that. After that, the data can start to have an impact and you can choose between specific initiatives that fit your needs such as streamlining CMS quality improvement reporting, automating care management workflows, risk stratifying your patients, lowering readmissions, etc.

The transformation to population health management is not easy, but the promise of rewards is great. The good news is that you will be able to celebrate many smaller successes on the iterative journey to population health. Dr. Edelstein, CMO of Elsevier Clinical Solutions said on the first day of CCS that he entered healthcare to deliver quality. That’s what population health management and our industry is ultimately about, which is a vision worth striving for together.

It’s been a gratifying three days at CCS 2014. I thank our customers, guest speakers, and partners who traveled great distances to collaborate around population health here in Seattle. I look forward to celebrating the new success stories and learnings at the Caradigm Customer Summit one year from now.


“Innovations in Population Health Management” Panelists