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Description
Provider-Led Population Health Management: Key Healthcare Strategies in the Cognitive Era, Second Edition draws connections among the new care-delivery models, the components of population health management, and the types of health IT that are required to support those components. The key concept that ties all of this together is that PHM requires a high degree of automation to reach everyone in a population, engage those patients in self-care, and maximize the chance that they will receive the proper preventive, chronic, and acute care.
While this book is intended for healthcare executives and policy experts, anyone who is interested in health care can learn something from its exploration of the major issues that are stirring health care today. In the end, the momentous changes going on in health care will affect us all.
Table of Contents
Acknowledgments vi
Foreword xiii
Introduction 1
Section 1: New Delivery Models 9
1 Population Health Management 11
What Is Population Health Management? 13
Key components 14
Obstacles to PHM 16
The Beginnings of Change 17
Examining the crucial role of automation 18
Managing the entire population 19
The Three Pillars of PHM 20
Conclusion 22
2 Accountable Care Organizations 25
The ACO Environment 27
Government support 28
ACO snapshots 29
Population health management 31
The role of information technology 32
Automation and analytic tools 33
Conclusion 35
3 Patient?-Centered Medical Homes 37
Initial Results Are Promising 38
Managing the Medical Neighborhood 40
PCMH Background 40
Medical home certification 41
Challenges and solutions 43
Building the medical neighborhood 44
How much will it cost? 45
Role of Information Technology 46
Automation tools 47
Conclusion 50
Section 2: How to Get There 51
4 Clinically Integrated Networks 53
Clinically Integrated Networks 54
Current definition 56
Basic requirements 56
Automation tools and CINs 58
Risk stratification 59
Patient outreach 60
Care management 60
Patient engagement 61
Post?-discharge care 63
Performance evaluation 63
The Need for Speed 64
Conclusion 64
5 Meaningful Use and Population Health Management 67
Meaningful Use Overview 68
Meaningful Use nuts?-and?-bolts 70
Upping the ante in Stages 2 and 3 71
PHM Components of Meaningful Use 71
Clinical decision support 72
Patient engagement 72
A leap forward for PHM 73
Health information exchange 74
MIPS and MACRA 76
Conclusion 77
6 Data Infrastructure 79
Data Sources 83
Administrative data 83
Clinical data 84
Claims data 84
Patient?-generated data 85
Provider attribution 86
Patient matching 87
Unstructured data 87
Data governance 88
Big Data’s Role 88
Data lake approach 89
Data normalization 91
Analytics 91
Registries 92
Work lists 93
Predictive modeling 93
Risk stratification 94
Performance evaluation 95
Timely Response 95
Other Big Data Directions 96
Conclusion 97
7 Predictive Modeling 99
Predictive Modeling Basics 101
Turning Predictions into Action 103
Prescriptive analytics 104
Risk stratification 104
Directing resources 105
Making a difference 105
Automation tools 106
Clinical judgment and culture 107
Provider Attribution 108
Risk Adjustment 109
Financial Risk 110
Data Sources 112
Claims data 113
Clinical data 113
Patient?-reported data 114
Broadening the data palette 115
Conclusion 116
8 Automation Solutions and the ROI of Change 119
Transition to value?-based payments 121
The new return on investment 123
Automated Population Health Management 124
How Automation Produces ROI 126
Patient outreach 126
Analytics 127
Care management 128
Patient engagement 128
Transitions of care 129
How to Calculate ROI 130
Patient outreach: Additional visit revenues 131
Pay-for-performance: Maximizing incentives 131
Risk contracts: Lowering overall costs 132
The bottom line 132
Conclusion 133
Section 3: Implementing Change 135
9 Care Coordination 137
Defining Care Coordination 139
The Physician Group Practice Demonstration 140
The Patient?-Centered Medical Home 141
Technology solutions 142
NCQA criteria 143
Technology Use in Care Coordination 145
Key building blocks 146
Continuum of care 148
Conclusion 149
10 Lean Care Management 151
A Lean Foundation in Health Care 154
High?-Performing Practices 157
Performing at top of license 158
Care?-coordination approaches 159
Lean Care Management 160
Automation in Lean Processes 162
Basic automation tools 163
Top?-of?-license approach 166
Downstream value 166
Conclusion 167
11 Patient Engagement 169
The Physician?-Patient Relationship 171
How to Engage Patients 172
Activation models 173
Obstacles to patient engagement 174
Care Management 175
Patient outreach 175
Risk stratification 176
Patient education 177
Telemedicine 178
Mobile health apps 179
Personal health records 180
Social media 181
Conclusion 182
12 Automated Post?-Discharge Care 185
New Government Incentives 186
Gaps in Care Transitions 188
Poor educational techniques 188
Poor handovers 189
Best Practices 190
IHI’s patient?-centered approach 190
Coleman Care Transitions Intervention 191
Naylor Transitional Care Model 191
Automation 192
Assessing patient risk 193
Patient education and engagement 194
Connecting providers to each other 194
Conclusion 195
13 Social and Behavioral Determinants of Health 197
SDH Impact on Health 200
Approaches to SDH 201
Model 1: Targeting health behaviors 201
Model 2: Referral to community services 203
Model 3: Targeted social support within a healthcare framework 204
Model 4: Patient?-centered medical homes 205
Model 5: Holistic care management 206
Behavioral Health 208
Advantages of integration 209
Solving the SDH Puzzle 210
Team?-based approach 212
Harnessing technology 213
Other data sources 214
Conclusion 216
14 Cognitive Computing: The Future of Population Health Management 219
Cognitive Computing 101 223
IBM Watson arrives 224
Natural Language Processing 225
Unstructured EHR data 226
Medical literature 228
Data Types 228
Genomic data 229
Imaging data 230
Monitoring data 230
Non?-healthcare data 232
Population Health Management 232
Predictive modeling 233
Patient engagement 234
Care coordination 235
Workflow integration 235
Conclusion 236
Conclusion 239
End Notes 241
