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Population Health: The Path Forward

Population Health: The Path Forward | Healthcare and Technology news |

What does the future hold for the population health management concept? The present moment in U.S. healthcare is filled with both challenge and opportunity in this absolutely critical area of endeavor. On the one hand, the population health idea has taken off as it has never before. It is embedded in virtually all the main policy initiatives coming out of all the major public and private purchasers and payers of healthcare, whether in some of the mandates coming out of the Affordable Care Act (ACA), or embedded in the value-based purchasing (VBP) initiatives coming out of the federal Centers for Medicare and Medicaid Services (CMS) for the Medicare program, or from nearly any of the major VBP programs sponsored by virtually all of the major U.S. health plans.

Yet the reality of the moment is that, despite all the policy incentives forcing providers to begin to take action, most patient care organizations are still in the very early stages in terms of leveraging healthcare IT and data to support and facilitate population health. Indeed, on the journey of 1,000 miles, most industry observers agree that we are in the first steps of that journey.

Not surprisingly, mixed sentiments were on display among the industry leaders participating in the 15th annual Population Health Colloquium, held on March 23 at the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, and chaired by David Nash, M.D., dean of the Jefferson School of Population Health.

“I expect us to talk more about data [in the next couple of years], because I think people are going to be drowning in data,” said Drew Harris, director of the Jefferson School of Population Health. “We are generating so much data that the question is, are we going to be able to turn that data into knowledge and actionable intelligence? We need to have new systems in place to better help clinicians use the data so they can figure out what to do with that Fitbit on somebody’s wrist or the Apple Watch that folks are going to expect somebody to help them analyze.” He also urged fellow participants to focus on patient engagement to make population health become truly successful.

Still, Brian Silverstein, M.D., president of HC Wisdom, a Glencoe, Ill.-based consulting firm, cautioned attendees that, “While I would like to be optimistic, I think next year is going to be tough. We are either going to be schizophrenic or bipolar. I am not sure which one. There is such great work going on and people are going to be aware that it is possible to do things to deliver better care at a lower cost. But some organizations are going to be entrenched in something and not getting results, so there is going to be an increasing level of frustration.”

In that context, said Mark Wagar, president of the Northridge, Calif.-based Heritage Provider Network, which encompasses more than 30,000 physicians in several states, “Sorting and stratify data to focus on a population doesn’t require perfect data. If you are waiting for someone from a big data company to come in and produce it all at once, it is not going to happen. We have 30,000 independent physicians. They are not all on one EMR, and are not going to be anytime soon, and we have patients to serve in the meantime. We have created some off-the-shelf systems combined with some proprietary systems where we can cross-match and collect as much data as possible,” he noted.

Making the Health IT Connection

That discussion in March at Thomas Jefferson University mirrors countless discussions around policy, strategy, process, and tactics taking place these days. Within the broader context of the push towards population health, industry leaders agree that the healthcare IT needed to facilitate pop health is just now being implemented, and is being implemented very unevenly at that.

For example, says Charles Kennedy, M.D., chief population officer at Healthagen LLC, a subsidiary of the Hartford, Conn.-based Aetna, and a health insurer executive helping to guide dozens of accountable care organizations (ACOs), “Health IT systems which offer the equivalent of a clinical navigation system are woefully under-deployed.  Achieving the required information state requires a new HIT infrastructure, supporting integrated administrative, claims and clinical data from all sources reorganized and optimized to assist with value-based care interventions for each individual’s health and care.  These records must be not only semantically interoperable, but must also be structured in such a way that provides useful and usable information on each individual patient,” he urges. “Today, however, many EMRs function like electronic file cabinets. “

The key to successfully leveraging health IT for population health management, says Judy Murphy, R.N., is that “The success is not just in the measurement and analytics, but in the ability to impact the health of populations. It’s leveraging the health IT for actual care coordination.” In October 2014, Murphy became chief nursing officer and director, Global Business Services, at IBM Healthcare. Prior to that, she had been chief nursing officer and director of the Office of Clinical Quality and Safety in the Office of the National Coordinator for Health IT (ONC). On a practical level, Murphy says, “It all starts with capturing the correct data in a data warehouse. And 80 percent of healthcare data today is not structured. So they either have to structure it or run it through natural language processing, or Watson.”

What should CIOs and other senior healthcare IT leaders be thinking about as their organizations begin to pursue population health? “They need to be thinking about what is involved in information-sharing with the post-acute world,” says Charles E. “Chuck” Christian, vice president and CIO at St. Francis Hospital in Columbus, Georgia, and the current chair of the board of the College of Healthcare Information Management Executives (CHIME). “There are a lot of new post-acute care settings we need to think about. Part of the problem,” he notes, “is that some post-acute providers, especially nursing homes, haven’t fully automated yet; but we’re getting there. And we’re developing data sets. So it’s a symbiosis: we’re helping nursing homes and other post-acute providers to help us. If we can appropriately transition the patient to their level of care, that is what’s important.”!

Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare

Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare | Healthcare and Technology news |

As Healthcare Informatics reported last month, the Office of the National Coordinator for Health Information Technology (ONC) released a report in early April that highlighted what the federal healthcare IT agency referred to as “information-blocking.” As Senior Editor Gabriel Perna noted in his April 10 report immediately following the release of the ONC document, “The report’s authors and researchers detailed several examples of electronic health record (EHR) developers and health systems blocking health information sharing between each other. The act of information blocking occurs when an entity or person knowingly and unreasonably interferes with the exchange of electronic health information. Examples of this,” he noted, “are charging prices and fees for data exchange; creating terms of a contract that restrict individuals access to their health information; developing health IT in a non-standard way that dissuades information sharing; and developing health IT in a way that locks in information.”

The ONC cited examples in its report of anecdotal evidence suggesting that “EHR application developers are breaking several of the rules in this regard,” Perna’s report noted. “Using interviews with people at regional extension centers (RECs), the authors detailed complaints from industry sources on how developers are charging fees that make it cost-prohibitive to send, receive, or export electronic health information stored in EHRs. Some EHR developers even charge a substantial transaction fee any time a user sends, receives, or queries a patient’s electronic health information, the report says. The variation in prices reported to ONC suggests that some are taking advantage of the situation.”

In announcing the availability of the report, National Coordinator for Health IT Karen DeSalvo, M.D. noted in a blog on the agency’s website that it is difficult to pinpoint concrete evidence of information-blocking. “The full extent of the information blocking problem is difficult to assess, primarily because health IT developers impose contractual restrictions that prohibit customers from reporting or even discussing costs, restrictions, and other relevant details,” she noted. “Still, from the evidence available, it is readily apparent that some providers and developers are engaging in information blocking,” she said.

Given all this, I read with interest a May 20 blog in Health Affairs online by Julia Adler-Milstein on this subject, because of the clear way in which she frames the dynamic tension taking place right now in the industry between the forces that would restrict information for profit or proprietary gain, and those that would advance it for the common good. AsAdler-Milstein, who is an assistant professor of information in the School of Information and an assistant professor of health management and policy at the School of Public Health at the University of Michigan, states very bluntly in her blog, “When it comes to sharing electronic patient health information, public good should trump private gain. While it may seem like an obvious statement, it represents a tectonic shift in the narrative surrounding health information exchange,” or HIE.

As Adler-Milstein notes, “For more than a decade, our federal strategy has largely left HIE to the market under the assumption that, if there is benefit to be created (and estimates suggest that there is), we should see the emergence of ways to capture that benefit. In practice, this means that HIE efforts have sprung up in various health care markets across the country, and where public money has been spent on HIE (largely at state and community levels), it has come in the form of one-time start-up funding, not a commitment of ongoing support or regulatory mandates for HIE participation.”

Here’s where Adler-Milstein really scores a home run on this, in my view: “What has been substantially underappreciated, however,” she writes, “is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not doing so. And as a result, these actors may behave in ways that interfere with the free-flow of patient information that is needed to improve health and health care.”

Instead, she says, “With the release of the information blocking report, which was produced in response to a 2015 Omnibus bill request that introduced the term ‘information blocking,’ ONC makes plain that this behavior will no longer be tolerated. This enormously exciting development means we might see real progress after decades of investment that has failed to convert into sustainable approaches to robust HIE. The key to such progress, however,” she warns, “lies in how well we can identify when information blocking is occurring. This will not be easy.”

And in those short paragraphs, we can see some of the core opportunities and challenges moving forward in this critical area. In this arena as in so many others in healthcare, we see a dynamic tension based on conflicting incentives within the U.S. healthcare system. On the one hand, there is broad consensus that data- and information-sharing will be essential to accountable care organization (ACO) development, population health management, bundled payment-facilitated care delivery, patient-centered medical home work, and indeed, every iteration of the new healthcare. Yet at the same time, there are many elements embedded even in those concepts that speak to at least short-term—and certainly arguably, medium-term as well—market advantages that can be gained through data- and information-hoarding.

It is this clash of incentives that we are collectively burdened with at this early stage of the trajectory towards the new healthcare. The rhetoric around healthcare policy right now is all about sharing for common gain, and yet the incentives in the moment are far from purely conducive to—well, purity.

That’s why it’s good to be reminded at times like this by elegantly concise writings like those of Julia Adler-Milstein. Adler-Milsteiin’s blog reminds us what the ultimate prize is, on which we should at least theoretically all be setting our eyes. This is not to engage in the laying of blame on those working for specific market advantage, but rather to affirm the need to continue to push forward collectively as an industry and indeed as a society, towards a more mature healthcare system—one in which all the incentives really all will be aligned. In other words, keep watching this space.

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Is This Population Health’s Moment? Time for Data and Analytics

Is This Population Health’s Moment? Time for Data and Analytics | Healthcare and Technology news |

Every year, the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information and Management Systems Society, offers its attendees a kind of conference-based snapshot of where the U.S. healthcare industry is with regard to the forward evolution of healthcare information technology adoption, as well as a sense of the overall policy and operational landscape of healthcare. Attendees can get a sense of the healthcare IT Zeitgeist through attending keynote addresses, educational sessions, association meetings, and networking-focused gatherings, as well as by wandering the exhibit hall and simply by having meaningful conversations with fellow attendees.

HIMSS15, held at the vast McCormick Place Convention Center in Chicago the week of April 12, offered perhaps the clearest portrait of the current moment that has yet been offered to date. Session after session focused on the shift beginning to take place from volume-based healthcare reimbursement to value-based payment, across a very wide range of mechanisms, between providers and both the public and private purchasers and payers of healthcare, and the implications of that shift for healthcare IT leaders.

Further, as part of the keynote session on Thursday, April 16 in the Skyline Ballroom at McCormick Place, Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), made the intentions of federal authorities crystal clear, when, referencing the statement of Health and Human Services Secretary Sylvia Mathews Burwell in January that she wanted the bulk of Medicare fee-for-service payments to providers to shift as quickly as possible over to quality- and value-based payment, Slavitt said, “Our priority is simple: to drive a delivery system that provides better care, smarter spending, and keeps people healthier. The success in the first five years since the Affordable Care Act has been very encouraging… Our agenda now,” he said, “is to get busy strengthening these gains. That will mean that more providers in more communities will need to be able to transform the care they provide so that they will benefit from value-based reimbursement. And they will need technology to help them get there.”

What’s more, in his keynote address two days earlier, Humana CEO Bruce Broussard had told HIMSS attendees, “We have to change the conversation on what we are doing in healthcare from a supply-based system to a system around demand, a system where we put the customer first as opposed to the system. Over the years,” he added, “healthcare has been built by creating more and more supply. I hope I leave today by convincing you that we have to change the focus towards how we improve health for our customers, members, and patients.”

The good news on the solutions side of this landscape is that vendors are rushing forward to provide population health- and accountable care-driven analytics solutions, at a time when such solutions are most desperately needed. Certainly, the hype at HIMSS15 was all around population health, care management, and accountable care solutions. The only question now, as the U.S. healthcare industry hurtles forward into the near future, is, is this a breakthrough moment for population health efforts? And if so, are provider and health plan leaders ready to effectively leverage the tools to make pop health really happen?

The long journey ahead

Leaders from all sectors of healthcare understand that the journey to population health and value-driven care delivery and payment success is going to continue to be a long, challenging one. Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA), says he and his colleagues are putting the vast bulk of their efforts into helping prepare physician group leaders for the transition. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says.  “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.”

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