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PROVIDER-LED

POPULATION HEALTH MANAGEMENT

Key Strategies for Healthcare in the Cognitive Era

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PROVIDER-LED POPULATION HEALTH

COMPANION GUIDE

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What you will learn

Population Health Management

Why population health management addresses the care of populations and the engagement of patients across care settings and over time.

Accountable Care Organizations

How ACOs have strong incentives to improve population health to meet quality goals and reduce costs.

Patient-Centered Medical Homes

How the PCMH model is essentially holistic primary care, in which physician-led care teams coordinate and manage care, and how they can achieve their full potential by integrating with the medical neighborhood and automate care management.

Predictive Modeling

Where predictive modeling can be used for risk stratification of a population or risk adjustment, and how it is used to classify the population into high-, medium-, and low-risk categories so care teams can deliver appropriate interventions to each group.

Clinically Integrated Networks

Why clinical integration of providers must come before ACOs and population health management.

Lean Care Management

How automation tools for risk stratification, patient outreach, and care management can leverage the capabilities of care managers and enable physicians and all care-team members to work at the top of their licenses.

Data Infrastructure

Why a healthcare organization’s data infrastructure is critical to its success in population health management, and how infrastructures must be comprehensive, scalable, and flexible for years to come.

Social and Behavioral Determinants of Health

How social and behavioral factors play a giant role in health, to an even greater extent than health care proper, and explain the variances in individual health over time.

Cognitive Computing

How cognitive computing can become a dependable and essential assistant to physicians and to organizations engaged in population health management.

Patient Engagement

Why patient engagement is vital to quality improvement, better patient outcomes, and population health management, even being called the “holy grail” of population health management.

Samples from the Book

 

Foreword

Health care in the U.S. does not function as an effective system for a variety of well-documented reasons, as I pointed out in my introduction to the textbook Population Health: Creating a Culture of Wellness. With a strong push from the federal government, as well as private payers, the U.S. health care industry is slowly pivoting toward value-based reimbursement. This transition to “income for outcome” will incentivize health care providers to pay more attention to non-visit care and will induce health care organizations to start managing the health of their patient populations, not just their health care. Only by doing so can they hope to reduce costs and improve quality enough to succeed financially under the new payment models. Moreover, to manage care properly, disparate health care providers and institutions will have to cooperate with each other to build a real health care system.

The premise of this book, contained in its title, is that population health management (PHM) cannot succeed unless physicians, their care teams, extended care networks, and community resources align with each other. It makes a whole lot of sense for doctors to play a leading role in population health management. Outside of friends and family, consumers trust physicians more than any other health care constituency, and certainly more than insurance or drug companies. The doctor-patient relationship is the key to patient engagement, which can lead to improved medication adherence, evidence-based guideline compliance, and lasting, sustainable health behavior change.

Written by the experienced team at IBM Watson Health, the book focuses sharply on the practical mechanics of how healthcare organizations can transition to population health management. While generous dollops of theory are also provided, the most germane parts of the book describe the practice of this new model (to most practitioners) of health care delivery.

For example, consider the chapters about consumer engagement and the social determinants of health. Individual engagement is a prerequisite of population health management; without it, people are less likely to make the lifestyle changes required to prevent or reduce the impact of chronic illnesses. But to get individuals engaged and support them in self-care management, health care providers must also be aware of the social determinants of each person’s health. As noted in Chapter 13, clinical health care accounts for only 10%-25% of the variations in individual health over time. Health care’s influence on the length of quality life would be markedly augmented, however, if it were combined with efforts to improve the social, economic, emotional, and physical environmental factors that contribute to health.

Research supports the need for population health management to extend beyond health care.  Collaboration among providers on care coordination will ultimately need to incorporate social services, behavioral health, job placement and advancement, housing, and possibly spiritual and other community resources.

During my tenure in many population health leadership roles, including being the Global Medical Leader of GE and Corporate Medical Director for Truven Health Analytics, I learned the importance of paying attention to all health determinants, especially in engaging non-compliant individuals.  Often their resistance can be overcome by enlisting other domains for assistance.   Many people are more inclined to manage their own care, for example, after establishing a home to live in and finding a steady job.

Another theme that runs through the book is the need to build a health IT infrastructure that can support population health management. Initially, many health care delivery systems assumed that they could simply rely on their EHR vendor to give them everything they needed. But experience has demonstrated that the EHR is only a starting point. It requires additional advanced data sources, cognitive analytics, secure, cloud-based platforms and mobile capabilities to establish a robust population health solution.

Moreover, PHM requires the ability to aggregate, normalize and analyze data from many different sources. Individuals receive their care across multiple care settings; many different care providers function inside a variety of delivery systems; and members of accountable care organizations (ACOs) utilize many different EHRs and patient portals. To connect these providers and health records requires the pursuit of interoperability, which is still largely lacking in health IT systems. These systems also lack the kind of clinical decision support and automation tools needed to facilitate care management and to make it efficient and effective. Longitudinal care coordination will ultimately require a personal health record that includes data from all care settings in which the patient has been treated.

The book’s final chapter takes an in-depth look at the exciting developments in cognitive computing, which has the potential to take health care and PHM to a whole new level. A next-generation big data approach, cognitive computing can help health care organizations understand their populations better by providing insights into factors such as demographics, geographical location, behavioral health, transportation, lifestyle choices, consumer purchases, and socioeconomic status.

Cognitive computing can also search the medical literature in seconds, can use natural language processing to convert unstructured data into structured data, can improve predictive modeling, and can provide the analytic power to help physicians understand the genomic information about the people on their panel. This is what doctors will need in 21st century medicine. On their own, they will never be able to absorb more than a tiny fraction of the 1 million new published articles that come out each year. And with the emergence of genomics, proteomics, and microbiomics data, analytics will be an essential part of everyday medicine. Doctors will require significant learning  – indeed, cognitive – computing resources to determine the relevance of all this data so they can provide highly personalized care, precision medicine, and the most appropriate care pathway for each person.

The most valuable lesson you will gain from this book, however, is that health care providers can impact the health status of the communities they serve. By doing so, they can improve the health of individuals and can also contribute to their performance as workers and as family and community members. The potential impact is enormous.  This can lead not only to a higher quality of life for individuals, but also to enhanced productivity for employers and greater prosperity for communities.

Ray Fabius, MD
Co-founder, HealthNext
Former Chief Medical Officer, Truven Health Analytics, and GE Global Medical Leader

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Chapter Overviews

Chapter 14

The future of population health management (PHM) will be tied to the rise of cognitive computing, which uses massively parallel processing and artificial intelligence to convert unstructured data into structured data, search the medical literature, and find connections among myriad types of data. Clinicians can collaborate with cognitive computing systems, which learn from experience, to improve health care

Chapter 13

Including social and economic factors as well as physical environmental factors, SDH accounts for much more of the variations in individual health than health care does.

Chapter 12

Readmissions, which affect nearly a fifth of Medicare patients discharged from the hospital, are more numerous than they should be because of the fragmentation of our healthcare system. Multiple government programs have been established to address this problem.

Chapter 11

Patient engagement is essential to improving health outcomes and is therefore an integral part of population health
management. Visits to physicians alone are not enough to sustain patient engagement, but the physician‐patient relationship is critical to success in this area.

Chapter 1

Healthcare reform hasn’t solved the major problems of our system with cost, quality and access. To do that, we’ll need to achieve the Triple Aim, including finding a way to manage population health efficiently.

Chapter 2

In 2010, the Affordable Care Act authorized a Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will continue to advance ACO models. Private payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.

Chapter 3

The patient‐centered medical home (PCMH) movement is growing rapidly, with support from both private insurers and the government. While medical homes can’t achieve their full potential until they integrate with the medical neighborhood and start automating care management, new financial incentives will support PCMH evolution.

Chapter 4

Clinical integration across providers and sites of care must come before ACOs and population health management. But most organizations lack the key components of clinical integration, including a robust IT infrastructure.

Chapter 5

The government’s electronic health records (EHR) incentive program is designed to transform healthcare delivery and dovetails with other healthcare reform initiatives.

Chapter 6

The use of data warehouses in combination with analytic tools falls short in the context of population health management (PHM), which requires comprehensive, scalable, and flexible health IT. To address the volume, velocity, and variety of data needed to support the manifold components of PHM, a big data solution is required. But this approach must be combined with other forms of IT to optimize care management, care coordination, and patient
engagement.

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Testimonials

Donald Fisher, PhD, President & CEO, AMGA

Donald Fisher, PhD, President & CEO, AMGA

"Dr. Richard Hodach’s book addresses the most critical elements for providers as they transform themselves to provide population health management. This book is a must read for anyone interested in population health."

Ashok Rai, MD, President & CEO, Prevea Health

Ashok Rai, MD, President & CEO, Prevea Health

"The key message of this timely book is that healthcare teams must adopt automation to deliver on the promise of population heath management. As my own organization has discovered, technology allows healthcare organizations to scale up quickly to prepare for value-based care. In this book are the practical strategies your organizations can embrace today."

Michael K. Magill, MD, Executive Medical Director, U of Utah Health Plans

Michael K. Magill, MD, Executive Medical Director, U of Utah Health Plans

“This book is a real gem! Health care transformation to improve health, quality, and cost (the Triple Aim) requires new payment for value, new delivery systems founded on patient centered medical homes, and new information systems to support care of populations. Dr. Hodach provides spot-on vision of how all three must work together, along with a detailed roadmap for success.”

Jeffrey Galles, DO, CMO, Utica Park Clinics

Jeffrey Galles, DO, CMO, Utica Park Clinics

“Dr. Hodach brings a wealth of knowledge and experience in the field of population health management. His keen insights into US healthcare transformation underscores the need for each healthcare system to have a well thought out and deliberate population health strategy.”

Don Fetterolf, MD, MBA, President, American College of Medical Quality

Don Fetterolf, MD, MBA, President, American College of Medical Quality

“While there are many books on this subject, the clarity of someone well-trained and experienced provides insight into the real, dysfunctional working of the healthcare delivery system while providing useful guidance on working within the rapidly evolving dynamic is has become.”

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About the Authors

Paul Grundy, MD, MPH, is Global Director, Healthcare Transformation at IBM, and President of the Patient Centered Primary Care Collaborative. Dr. Grundy is known as the “godfather” of the patient‐centered medical home. An active social entrepreneur and speaker on global healthcare transformation, he concentrates his efforts on driving comprehensive, linked, and integrated healthcare. Dr. Grundy’s work has been covered by The New York Times, BusinessWeek, Health Affairs, The Economist, The New England Journal of Medicine, and other newspapers, radio, and television stations across the U.S. He is a healthcare ambassador for the nation of Denmark and adjunct professor at the University of Utah Department of Family and Preventive Medicine. Dr. Grundy is a member of National Academy of Science’s Institute of Medicine, director of the ACGME, and member of the national advisory board of the National Center for Interprofessional Practice & Education, Mayo Clinic Center for Connected Care. He is a retired senior diplomat with the rank of Minister Consular U.S. State Department. Dr. Grundy graduated as valedictorian from the Southern California College, earned an M.D. from the University of California–San Francisco Medical School, and received a Masters of Public Health from the University of California–Berkeley.

Richard Hodach, MD, MPH, PhD, is Vice President, IBM Watson Health, previously serving as Chief Medical Officer and Vice President of Clinical Product Strategy at Phytel, now part of IBM Watson Health. Dr. Hodach has long been recognized as a leader of population health management strategies. He is responsible for providing strategic direction and clinical expertise for the development of Phytel’s solutions. Dr. Hodach is a regular contributor to prestigious peer‐review journals such as The American Journal of Managed Care, The Journal of Population Health Management, hfm (published by the Healthcare Financial Management Association), The Group Practice Journal, and more. He was instrumental in the CMS Innovation Award of a $20.75 million grant which Phytel, VHA Inc., and TransforMED received from The Center for Medicare & Medicaid Innovation (CMMI). In addition to his leadership position at Phytel, Dr. Hodach also serves on the board of directors of the American College of Medical Quality. Before joining Phytel, he held senior leadership positions at Matria Healthcare and Accordant, and co‐founded MED.I.A. Dr. Hodach has a Ph.D. in Pathology and an M.D. with Board Certification in Neurology and Electrodiagnosis, as well as a Master’s Degree in Public Health.

Anil Jain, MD, FACP, is Senior Vice President and Chief Medical Officer, IBM Watson Health, previously serving as Chief Medical Officer of Explorys (now part of IBM Watson Health), formed in 2009 based on innovations that he developed while at the Cleveland Clinic. In this role, Dr. Jain directs the informatics and analytics innovations, product management, and software development, as well as leading the life sciences business unit. In addition to serving on state and national committees focused on driving quality and research through health IT, he has authored more than 100 publications and abstracts and has delivered numerous talks on the benefits of sustainable
health IT innovation, clinical informatics, and big data analytics. Dr. Jain also continues to practice and teach medicine part‐time in the Department of Internal Medicine at Cleveland Clinic and had previously served as an Attending Staff and Senior Executive Director of IT. He is a former leader at Better Health Greater Cleveland and had served as co‐Director of Informatics of Case Western School of Medicine’s CTSA. Dr. Jain is an active member of the Health Information Management & Systems Society (HIMSS) and the American Medical Informatics Association (AMIA), and is a Fellow of the American College of Medicine (ACP), and is also a Diplomat of the American Board of Internal Medicine (ABIM). He received a degree in Biomedical Engineering and a degree in Medicine from Northwestern University prior to his post‐graduate training in Internal Medicine at the Cleveland Clinic.

Michael Weiner, DO, MSM, MSIST, is Chief Medical Information Officer at IBM. Prior to his current position with IBM, Dr. Weiner served as the Chief Medical Information Officer and Director of Clinical Informatics for the DoD VA Interagency Program Office, where he was responsible for creating a unified Interagency Electronic Health Record for more than 125,000 providers and 18 million beneficiaries worldwide. He is an active member of the American College of Physicians and the American Osteopathic Association, and is a former NASA Space Shuttle takeoff and landing physician. Dr. Weiner serves on the Philadelphia College of Osteopathic Medicine Alumni Board and the board of the American Medical Informatics Association, as well as having served on the Health and Human Services’ Office of the National Coordinator Health Information IT Policy Committee, helping create Meaningful
Use Stage 1. He has received numerous awards from the President of the United States, for his service in the Navy, including two Meritorious Service Medals, and two Air Medals. Dr. Weiner is an adjunct professor of Health
Information Technology at the George Washington University and is one of only a few physicians ever to have been certified as a Chief Information Officer by the U.S. General Services Administration. He is a graduate of the U.S. Naval Academy and attended medical school at the Philadelphia College of Osteopathic Medicine. Dr. Weiner is a board-certified practicing physician in Internal Medicine, and holds a Master’s degree in Management and a
Master’s degree in Information Systems Technology from George Washington University.

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