by Wendy Bartlett / September 4, 2018

Population Health Management: A Conversation with Diane Conroy

Our conversation with Diane Conroy centers on how healthcare organizations can benefit from implementing a Population Health Management (PHM) initiative. We explore the power of automating workflows and how results inform the structure of intervention campaigns that lead to improved outcomes.

Diane serves as the Vice President of Consulting and Professional Services for INTELICHART. She has over 18 years of experience in senior roles associated with the successful deployment of healthcare information systems. Diane has successfully orchestrated the electronic health record (EHR) utilization for thousands of physicians in both acute and ambulatory environments. Her vast experience crosses the spectrum from business development to project and department management.

What are the features of population health management technology?
Advanced population health management technology enables care teams to confront the health of their population head-on with a simple approach that aggregates patient data, selects metrics to impact,
creates automated campaigns, and delivers outreach and trend outcomes.

In past decades, managing complex patient populations with chronic conditions and challenging social determinants of health was labor-intensive, if not impossible, due to lack of available data, staff, and automation tools. Newly available PHM technology helps organizations manage interventions outside the patient visit. Identifying non-compliant patients and patients with chronic conditions in need of services and gaps in care are just the tip of the iceberg when interpreting patient populations. Another equally important strength of the technology is identifying patients that can be intercepted before the onset of disease and prevent them from getting sick in the first place.

By using predictive analytics, patients that are (for example) on a course for developing diabetes, hypertension or cardiovascular disease can be brought into a wellness program and stall or eliminate the disease rather that treat it after the fact. Take a young man who is getting close to a BMI of 25 and has a strong family history of diabetes and cardiovascular disease. All indicators point to the likelihood that he is at risk for chronic conditions associated with obesity. Using early interventions to encourage a focus on wellness could reduce, and potentially prevent, that risk.

What is the process for implementing a PHM initiative?
The old saying “you can’t manage what you don’t measure” is highly applicable to effective PHM. That is why before establishing your PHM campaign strategy, it’s crucial to determine your organization’s most urgent or significant goals. It’s tempting when starting out with PHM campaigns to create as many as possible and determine which one is most effective. A better strategy is to create a manageable number of quality initiatives and then refine and improve them until the response rate and other results reach the desired objectives. The healthcare organization will then need to set associated benchmarks in the PHM technology platform for continuous monitoring, analysis, and reporting.

Here are the steps for implementation:

1. Define Populations
Extensive query capabilities enable users to define patient populations and perform risk stratification with unlimited criteria, including social determinants of health. Since the technology seamlessly integrates with the organization’s electronic health record (EHR) and other information systems, selecting patients across broad criteria is simple. Here are just a few possible criteria:

• Gender
• Occupation
• Residence location
• Emergency department utilization
• Positive or negative response to automated interventions
• Recent test results
• Any clinical identifier, such as lab value, medication, diagnosis
• Payer or value-based care payment program
• Any combination of above

I recommend that users start with four measures – two that are more complex in nature and two that are less complex. More complex criteria may be HbA1c between 5.7% and 6.4% and number of encounters they’ve had in the last six months. Less complex ones may be if the patient is registered in the portal.

2. Automate Delivery
Rules-based campaigns allow users to define the events of an intervention. (Phone call, letter, postcard, email, text or survey)

3. Customize Surveys
Drag and drop design tools make designing any survey type easy. An array of tools and widgets meet design needs and the ability exists to define weighting and scorecards.

4. Reports and Benchmarking
Robust reporting, tracking, trending and benchmarking allows data analysis at the patient, provider and organizational levels.

Can you explain more fully the role surveys play in the overall initiative?
Surveys quantify patient satisfaction and capture patient reported outcomes (PROs). As the industry pushes towards value-based care, a greater emphasis has been placed on listening to patients, particularly regarding how they view their own health status and quality of life. These patient-reported outcomes are essential for helping identify obstacles to effectively manage patient health. Patient-reported outcomes are also increasingly important to payers under value-based care payment models.

Surveys not only help an organization capture valuable patient-reported data, they also nurture engagement outside the visit. PHM technology can deliver surveys to patients’ mobile device or portal. Questions can inquire about any aspect of the patient’s health condition management, post-discharge recovery, care delivery experience and quality-of-life questions concerning physical function, mental health, sleep or the ability to participate in daily activities. Based on patients’ responses, intervention can be automated by response or escalated to a live care manager for a more in-depth interview.

Although automated methods are most efficient, a live phone call with a clinician is essential for certain conditions, situations, and risk factors. PHM technology assists in these cases by automatically reminding the care manager to conduct the interview and offering to create the electronic questionnaire form to be completed. Based on responses from any of the PRO outreach methods, the care team can then decide to adjust the prescribed treatment.

A benefit of using a mobile device or a computer to capture PROs is that patients can report their perspective at a moment when they have time to reflect away from the distractions of a busy practice, hospital, or workplace.

Surveys are especially useful when patients visit specialists or other healthcare facilities that are unaffiliated with your healthcare organization. In these instances, an organization may not discover the out-of-network patient care was delivered until after the patient’s health plan has reimbursed the claim, which could be 90 days later. By setting rules based on responses, critical information is quickly gleaned from the PRO. Effective PHM relies on up-to-date data so interventions are timely and effective. Capturing data from patients through automated surveys eliminates crucial lag time.

You mentioned patient engagement. Can you elaborate on that?
Automated communication and intervention enable stronger patient engagement even if patients are not interacting with a live care manager because it demonstrates the healthcare organization is vested in the patient’s health and quality of life year-round. While it is a valuable management support tool and can help patients stay adherent to their care plans, it is not a replacement for clinician experience and judgment. PHM automation simply eliminates some of the time-consuming, non-essential activity so care managers can focus their clinical and interpersonal skills on helping more complex and challenging patients achieve optimal outcomes.

What do you want people to know about INTELICHART and its HealthyOUTCOMES Platform?
INTELICHART has a unique suite of solutions called HealthyOUTCOMES that integrates with 25 leading EHRs and currently enhances the patient experience for more than 2,500 healthcare organizations. This powerful platform incorporates PatientPORTAL, a portal that enables patients to actively manage their healthcare data in a single view, PatientSURVEY, an automated solution for collecting patient surveys and outcomes, PatientNOTIFY, an automated solution for patient notifications, and PopulationHEALTH, a tool that manages populations with automated patient interventions to create healthy outcomes.

Our solutions use the same integration, which makes it easy for customers to use one, or all, of the solutions from the platform. With HealthyOUTCOMES, your organization works in harmony with one vendor for all your solutions, as opposed to the inconvenience of working with numerous vendors and disjointed applications that don’t mesh.

We pride ourselves on our agile software development as we continuously improve our product and add enhancements based on requests from our customers. Listening to our customers and meeting their needs is very important to us. We have four releases every year and we have a testing environment that we make available to our customers so they can see what new features we’re working on and give us their feedback before going live.

Most EHRs can pull data, and INTELICHART’s Boolean access to data is exceptionally robust. It’s what our HealthyOUTCOMES solutions do with that data that makes us unique. We’re on a mission to transform the patient experience in and out of the office by innovating a combination of software and services that guide the patient on a journey to a lifetime of healthy outcomes.