The 2014 iHT² Health IT Summit in Atlanta was a great opportunity to share / learn about the current state of population health management experiences from a number of amazing health systems and their leaders in the southeast US.  Below are a few of my observations and take-aways:

Focused on delivering the Triple Aim, the participating organizations are managing risk in different ways (ranging from pay for performance, bundled payments, shared savings, ACO arrangements and capitated risk). Represented at the meeting were Integrated Delivery Networks, post-acute care organizations, telehealth service providers, the CDC, CMMS, and vendors providing various software, infrastructure, and consulting services supporting population health. Dr. Kevin Fickenscher’s keynote set the tone of the meeting, declaring ‘Profession-Centric’ (the ‘guild’) healthcare delivery is being replaced by a systems-centric approach to healthcare delivery. Clearly, a new era of multi-disciplinary teams managing the care and wellness of populations (‘Team-Based Care Continuum’) is emerging as a replacement.

Some key observations presented during the panels, talks, and group discussions reflect the increasing experience of healthcare organizations as they deliver on the objectives of the Triple Aim:

1. Analytics are necessary (gaps in care, prospective, predictive, risk, etc.), come from many different sources (several are external to the EMR), and need to be easily accessible. Some analytics are based on claims, others are purely based on clinical EMR data, and a few are emerging from combined data sets. Unfortunately, with all of these different sources, there is not a single analytical view of a patient. Furthermore, to access these analytics, providers and care managers have to examine multiple ‘lists’ from multiple different analytic and reporting tools. Health system leaders from Carilion, BayCare and Carolinas, all expressed a requirement that gaps in care, risk, and cost data need to be easily accessible by clinicians. Dr. Kristyn Greifer, VP of Population Health Management for WellStar, also observed that access to real time analytics are a necessary part of care delivery.

2. Patient Centered Medical Homes have been deployed to ensure the best care is being delivered to patients with single or multiple chronic diseases. However, there is an experience that the use of registry tools in conjunction with the EMR can lead to increased utilization without major changes in clinical outcomes. To achieve the necessary outcomes, health systems need to identify patients who need/can benefit from comprehensive plans of care coordinated by care managers. Carilion Clinic has invested extensively in EMR infrastructure, registries, an EDW, and multiple analytic tools. Dr. Stephen Morgan, Sr. Vice President and CMIO, shared their approach of investing in more care managers and the arduous task of crafting care plans within the EMR. An interesting discussion with the audience explored that pursuing population health activities can have a definite impact on hospital volumes and profitability. Clear challenges exist in the transition from fee for service to fee for value, but one thing is clear, Carilion Clinic is working to deliver on their Triple Aim oriented Vision 2017 of “We are committed to a Common Purpose of Better Patient Care, Better Community Health and Lower Cost.”

3. Traditional patient portals are good, but there is a need for deeper engagement. Groups of patients are wanting to understand their plan of care, message their providers, and participate in programs to monitor their chronic conditions. The adoption of “Blue Button” is increasing and there is a need for shared decision-making tools, patient reported outcomes, and access to specific types of analytics. These types of tools could help to increase patient engagement. Another key issue identified was ‘portal sprawl’ or ‘portal fatigue.’ Some health systems are now just saying ‘no’ to the portals that health plans wish to deploy as part of an ACO arrangement and prefer to stick with a single portal experience for their patients.

4. Health Information Exchanges are evolving. Some of the organizations are now in their second and third rounds of participating in health information exchanges. Baptist Pensacola is participating in a truly unique exchange with a local competitor, the military, the VA (opt-in), and a local Skilled Nursing Facility. The Baptist CIO, Steve Sorros, shared that the exchange is helping ambulatory clinics deliver more informed care to our uniformed personnel and veterans. Future business drivers to create sustainability for local exchanges will leverage the ‘last mile connectivity’ created as a result of this exchange (results delivery, sharing care plans within a clinically integrated network, payer participation for sharing data, alerts, etc.).

5. Telehealth – One provider of remote care services, the Global Partnership for Tele-health, provided more than 140,000 remote encounters last year (focused in Georgia and Alabama) and is anticipating that number to exceed 200,000 this year. That’s starting to approach the number of in-person ambulatory encounters seen by smaller health systems. Cleveland Clinic has integrated home monitoring devices with traditional care programs, and is considering further expansion using Microsoft HealthVault-connected devices. In a note of caution during his presentation on ‘big data,’ Dr. Ryan Uitti, Deputy Director of the Mayo Clinic Kern Center for the Science of Health Care Delivery, shared findings from a 2012 study of 205 elderly patients with multiple co-morbidities which showed “no difference in combined hospitalizations and ED visits between patients receiving tele-monitoring vs. usual care.”¹ He also shared information on a new application Mayo has developed called “AWARE” to support active surveillance and situational awareness of critical care patients. The initial evaluation of the application indicates a decrease in cognitive overload for clinicians, a decrease in errors, and a decrease in the amount of time spent looking for data or performing tasks. These varied experiences indicate that additional technologies (and services) need to be applied to the right populations, at the right time, and with the right supporting clinical programs.

6. Retooling your People – West Georgia Health’s CIO, Sonya Christian, their CFO, Paul Perrotti, and Director of Nursing, Tracy Gynther, made one thing very clear: Their people (employees, nurses, and doctors) are their most important asset as they improve and evolve their services. Despite providing 85% of the care in their market, the health system is investing in re-tooling their staff, increasing staff participation, promoting new efficiencies through the application of lean production methods, a system-wide focus on patient safety and multi-disciplinary teams.  Five years without a single Ventilator Acquired Pneumonia episode required a relentless multi-disciplinary collaboration between physicians, nurses, and respiratory therapists. As health systems prepare to embark on increasing population health activities, the engagement (and collaborative ownership) of all staff across multiple settings of care is required for success.

What has your organization done in these areas? Are you integrating external analytics into your EMR? What types of tools are you using for performing care coordination and care management? In future blog posts, we’ll explore each of these areas in more detail.

(1) Takahashi, Paul; Pecina, Jennifer; et al, “A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits.” Arch Intern Med. 2012;172(10):773-779.