Improving patient healthcare outcomes with population health management

---

As healthcare providers struggle to improve services while keeping a lid on costs, many are turning to the concept of Population Health Management for help.

---

Synonymous with a range of terms including clinical integration, public health and value-based care, Population Health Management (PHM) involves the use of aggregated and analysed data to deliver targeted care to individuals and groups.
However true PHM means much more than simply applying advanced analytics to achieve lower costs and improve outcomes. It also means providing secure access to accurate, complete health records, and coordinating care to ensure the best possible outcomes for patients.
The growing data deluge
The healthcare sector is awash with data - and levels are quickly increasing. Electronic patient records, specialist reports and patient reported data is growing and becoming a management challenge for care providers. It’s “big data” on an epic scale.
This situation is going to become more acute with the rise of wearable consumer devices. Designed to collect everything from temperature and heart rate to blood sugar levels and other vital signs, these devices will create another large stream of data that needs to be collected and analysed.
For care providers, the challenge of clinical integration becomes significant. How can all these disparate sources of data be collected and analysed to improve patient care? On a wider scale, how can this information be used to track health trends across larger population groups?
Some in the sector believe a centralised electronic health record (EHR) is the answer. They see this as a single repository in which all patient data is stored and accessed as required.
However, this approach won’t work within this growing data deluge. EHR systems are not designed to accept data coming from multiple sources and in multiple formats. Their ability to combine, for example, patient reports with sensor-based data from wearable devices , or unstructured data from clinical images, is limited at best.
The promise of Population Health Management
The solution is the introduction of a more dynamic patient record which can cope with data from many sources and in different forms. These records work for care at an individual patient level but can also be aggregated to allow analysis of trends at a group and community population level.
This is the real promise of PHM - the ability to apply modern analytics to data drawn from an entire population to help all its members enjoy an active and healthy lifestyle.
To achieve this goal, it’s essential for providers to undertake six critical steps. By following this process, the true benefits of PHM will be realised. The steps are:

1. 
   Acquisition
   Throughout the healthcare sector, vital data resides in a wide range of internal and external disconnected systems. Different electronic patient records and other clinical systems store and share data in different ways. This complexity is multiplied when data is also brought in from practice management systems, claims systems and patient monitoring devices. Acquiring all this data and storing it in a single secure location is vital.


2. 
   Aggregation
   Each of the myriad systems providing data for a PHM system contributes to it in a different format. Even common electronic patient record systems often alter their data formats from version to version of the software. These differences become even more dramatic when you start to bring in data from labs, health plans, pharmacies and tertiary care sources. Having an effective data aggregation structure in place is key to ensuring the correct information is associated with correct individuals and organisations.


3. 
   Access
   Because there are multiple stakeholders involved in the management and operation of any healthcare system, each will require secure access to various portions of the data contained with the centralised PHM system. Stakeholders include healthcare providers, administrators, management professionals, patients, family members and insurers. Each group will require its own unique set of priorities and permissions. Various levels of technical and clinical sophistication also need to be considered.


4. 
   Adoption
   Every stakeholder in the healthcare process requires access to patient data that provides an accurate and up-to-date picture. However, often there is a deep resistance to change and getting stakeholders to alter the way they have been operating can be challenging. The issue of adoption is both a technical and behavioural one and also one of ‘chicken and egg’. If clinicians and care coordinators fail to adopt the new systems, key information will not be used for decisionmaking and outcomes will suffer.


5. 
   Analytics
   Analytics is where the real value of a PHM system lies. By mining the collected data, healthcare professionals can gain insights into a population’s health that previously would not have been possible. Actionable insights can be discovered that drive improvements in quality and efficiency of care, while at the same time keeping up with ongoing and everincreasing regulatory reporting requirements. Together with efficient acquisition and aggregation, analytics allows those involved to act on data in very powerful ways.


6. 
   Action
   Collecting and analysing data is important, however the most critical step is using the insights gained to take action. Naturally there is a risk that having too much data and too many ways to use it can become overwhelming and result in little progress. For this reason, it is important to put in place a robust infrastructure that supports effective data-driven actions. This can be achieved by providing care providers with the tools and information they need to add value.

Putting PHM to work
Orion Health has been working with stakeholders across the healthcare sector to develop and deliver the systems and infrastructure that underpin PHM. Built on a robust architecture, the Orion Health Open Platform scales to deal with massive data derived from multiple and varied sources.
By continually liaising with healthcare providers and understanding the ways in which they can use data to improve the services they provide, Orion is dedicated to ensuring the full promise of PHM is realised.
For more information visit www.orionhealth.com/au