Population Health Management eBook

Population Health Management

Value of Up-to-date, Comprehensive And Aggregated Data

In our last chapter, we described how population health management (PHM) was changing clinical roles in both large and smaller healthcare organizations, namely due to the advanced technology that is helping providers deliver optimal care. The data analytic capabilities of a PHM platform, however, are only beneficial to these providers if the data is as current, comprehensive and aggregated as possible.

With up-to-date, even real-time, data, clinicians can identify potential adverse health events sooner across large populations of patients to prevent an unnecessary emergency department (ED) visit or hospital admission. Patients can also receive chronic condition management, recovery support and education during ideal, teachable moments. These factors are crucial for succeeding under the value-based care models described in chapter 1. It may sound time-consuming and complex to access and analyze these huge amounts of timely data, but with the right processes and technology, healthcare organizations can save significant time and effort that they are currently expending on PHM.

Real-time Data Shifts Focus To Preventive

The importance of timely data for PHM interventions cannot be overstated. Avoidable readmissions not only contribute to overall costs, but healthcare organizations can also be penalized as much as 3 percent of their Medicare payments for these events under the Centers for Medicare and Medicaid Services' Hospital Readmission Reduction Program (HRRP). Under the program, the hospital bears the penalty if patients with certain conditions are readmitted within 30 days and the cause of readmission was determined to be avoidable.

“…Under the (HRRP)… the hospital bears the penalty if patients with certain conditions are readmitted within 30 days and the cause of readmission was determined to be avoidable.”

Keeping HRRP-patients, or any high-risk population, out of the hospital requires integrated access to data aggregated from multiple outpatient facilities where the patient would receive post-discharge care and appointments. Also included would be pharmacy data to ensure prescriptions are being filled and documentation from home-health providers to track a patient's recovery and/or chronic condition management.

Capturing, aggregating and analyzing all of this comprehensive data can seem like a massive, time-consuming effort. However, sophisticated and integrated PHM technology is available that automatically aggregates, analyzes and presents data from different providers and organizations as it is captured. The platform also alerts care managers and other clinicians to follow up with recently discharged patients and gathers information through automated, mobile-based surveys. Systems can also inquire why appointments were missed through text messages, portal messages, interactive voice response phone calls, or whichever method the patient or provider prefers.

These timely interventions can be delivered in a fraction of the time of manual data searching, phone calls and waiting for responses. Most importantly, patients receive the support, education and care they need to stay adherent to care plans instead of returning to the hospital.

Comprehensive, Aggregated Data Enables Effective Interventions

Timely data is essential, but the information also needs to be comprehensive and captured from throughout the care continuum to identify care gaps and non-adherence to a treatment regimen. An aggregated and holistic view of the patient includes, as mentioned above, data from outpatient facilities, pharmacies and other providers, as well as non-clinical, social and environmental data that influences patients' actions just as much if not more than the care delivered at hospitals or practices.

Such social determinants of health data sets can include:


Physical Environment

Air and water quality, housing type, transportation, parks or walking access, proximity to grocery stores, distance to primary care provider.


Health Behavior

Diet and exercise, smoking, healthy activity, care-plan adherence behavior, healthy attitude, behavior modifiability.


Social Data

Education, literacy, employment and financial history, family and social support.

These data sets, and many others that are available, are run through sophisticated algorithms to offer an actionable view of patients that enable more relevant and effective interventions. A better understanding of a high-risk patient's social determinants of health also helps care managers understand, communicate and overcome obstacles that may be affecting more than just one patient.

Such interventions can then be more broadly applied across larger groups, improving efficiency while optimizing care.

Timely interventions, however, are just as important as up-to-date data. In the next chapter, we'll explore the importance of analysis married with proper actions to help healthcare organizations achieve their value-based care goals.

InteliChart Chapter 2

How PHM is changing clinical roles to produce better outcomes.

Chapter 4 InteliChart

How insights from PHM can lead to prompt patient interventions.