Welcome to Population Health, Population Health and the Application of Health IT. This is lecture b. The objective for this session is to summarize the potential for health IT to improve the health of populations within public health programs and integrated healthcare delivery systems. One of the reasons that population health has received increased attention over the last five years is that the Institute for health Care Improvement, IHI has made its achievement a top line mission. This influential quality improvement institute, which most large hospitals and health systems actively participate in has developed something called the Triple Aim. It states that in addition to focusing on the clinical quality of the care they deliver, providers must also keep front and center a series of broader aims. They have been promoting an organizational mission framework where every major provider, such as an ACO, HMO or large hospital system needs to develop a quote, balanced performance scorecard with three key objects of the organization. These are the health of the population, the consumers experience of care and a sensitivity to the cost of care. These three Triple Aims compliment the more traditional clinically oriented quality improvement approach that focuses mainly on processed guidelines and achievement of clinical outcomes. Included here are some specific measures that IHI recommends for organizations that want to monitor how well it achieves the three aims. Another reason there's a great increase in population health management is the growth in chronic care management within insurance organizations or integrated delivery systems wanting to use holistic population-oriented approaches to increasing quality and decreasing costs, and bad outcomes for cohorts of patients for whom they are responsible. This used to be termed care management or disease management, because these programs often focus on cohorts with specific conditions such as diabetes or congestive heart failure. For years, there were companies that helped clinicians improve care often by applying public health and quality improvement techniques and they were often called disease management companies. The professional trade association of these organizations, which used to be called the Disease Management Association of American changed its name to the Care Continuum Alliance. And recently, they changed their name again to Population Health Alliance. This sequence represents the new appreciation of mainstream medicine and health insurance companies for the field of population health. Today, they prefer the term Population Health Management, because these programs are focusing on the entire target population usually enrolled in a specific health plan or cared for by a particular accountable provider. This graphic, adapted from the Population Health Alliance shows the continuum of care offered to groups of individuals who have or are at risk for a particular chronic condition. Understandably, both for the patient and bottom line of the insurer, it is better to care for someone say with an early low risk stage than at a more severe higher risk stage where a bad outcome is more likely. We will have a unit on this topic later in this component. Very common for those working in the field of population health is one type of so-called risk pyramid or another. Using this paradigm, we can think about any population group as having persons who fall onto rungs of the pyramid with more people at lower risk levels to a smaller high-risk group at the top of the pyramid. The population to be arrayed in this manner may be defined geographically or by other organizational selectional criteria, such as all those persons with one or more chronic diseases who are enrolled at a large physician group practice or ACO. The depicted version of the risk pyramid is an interesting one adapted from the National Health Service in the UK. Here, everybody in the population fits into one of the three levels of the pyramid. And generally, it is best not to focus only on a single disease or group of diseases, because few human beings have only a single disease. They generally have multiple morbidities. Moreover, as we will discuss in another unit some organizations such as in the UK also include multiple environmental or social factors, such as poverty status or housing status that may also impact health. In addition to portraying how members of a population may fall into different risk levels, this pyramid also acknowledges that people can care for themselves, receive regular clinical care or require more intensive case management interventions. In general, the higher the population segment's risk, the higher the proportion of persons in need of more intensive care. In later units of this component, we will talk about approaches to risk management to identify risks and the need and also types of care management interventions for those at greatest risk. The data and analytic incentive tools are generally used to identify risk levels of individuals within the population are often term predictive modeling, because these methods are used to predict not only where people are today in terms of their needs for services, but also where they will be in the future. HIT can support various population health activities within an integrated delivery system, like an HMO or ACO. The first use, as just described is the use of EHR or clinical aspects of claims data, such as diagnoses or prescriptions to array people at the various levels of the pyramid. Elsewhere in the ONC HIT curriculum, the tools for predictive modeling and risk segmentation are discussed. The next area where HIT tools hold great promise is consumer education. Note that at levels of the pyramid, self-management and behavioral interventions, such as diet and exercise are really critical for everybody. Increasingly, consumer education is something that is done on a population basis. We're not just focusing on a single person who asks to see a nutritionist, but rather we use public health principles of outreach for individuals and also provide programs that can impact many individuals, such as offering better food options in so-called food deserts. EHRs and other HIT are increasingly central to population-based quality of care improvement programs. If you have a person with multiple chronic conditions, it is important not only that they get exercise and have healthy activities outside the visit, but also that the clinician and his or her team is involved in providing care that meets guidelines. Clinical decision support CDS tools built into the EHR are mainly considered the domain of clinical informatics, but they also have important tie-ins to population informatics when they involve risk algorithms and outreach. Integrate prevention and help address non-medical, social or geographic factors. As we will also discuss later, something very exciting in Maryland is that all hospitals are being required to follow something like the IHI Triple Aims in terms of achieving community-based population and social health outcomes. And through pay for performance, or P4P programs, some of their payment is linked to this. Electronic data are being used to accomplish all of this. If one doesn't know what outcomes are linked to what, services or interventions cannot improve, so understanding what is associated with better or worse outcomes at the population level is really critical. This is also the essence of the so called learning health system, which does have an analog in the population health domain. What we can call the learning population health system. So by capturing information from a variety of digital sources from the community, one can develop a whole picture of the health of a population and see what can be done to constantly improve that. A couple of years back, when EHRs and Health Information Exchanges, HIEs, were gearing up, the Centers for Disease Control and Prevention, CDC, came out with a vision for the future of the US HIT system entitled Public Health Grid. For a public health professional this is an exciting, if a bit ambitious framework. The conceptual model reflects a population health vision where HIT is all networked together and public health ways of thinking are at the core. The framework of the model shows providers, consumers, insurers, and public health agencies all sharing information in a comprehensive, interoperable manner, with public health agencies as equal partners. As alluded to before, the term population health is a controversial one for some public health professionals. Some in the public health community believe that the medical care system and insurance organizations have co-opted the term population health, where in fact public health departments and practitioners are the ones toiling in the field with limited resources, trying to serve the entire community. And that medical and insurance providers with far more resources are only concerned with a subset of the community. One can actually sympathize with this argument when we review some of the numbers both in terms of overall resources and resources devoted to health IT. Let's review some of these numbers. The US delivery system is the richest in the world. As of 2012, we were spending approximately $2.2 trillion on direct services medical care. This compares with about one thirtieth of that amount for community targeted public health services at local, state and federal levels. Recently, medical care focused IT investment has run as high as $30 billion to $40 billion annually. In contrast, the HIT investment for public health agencies is perhaps one seventieth of that amount. For this reason, if one wants to impact the health of populations using public health-oriented approaches, there is no other way to achieve this objective without encompassing the entire healthcare system, including both medical care and public health. The classic domains of traditional public health services worked together in rotation, with research at their core. It is worth reviewing the assessment, policy, and assurance domains and their sub domains. The sub domains of assessment include monitor health, and diagnose and investigate services. Policy development includes the services to inform, educate, and empower, mobilize community partnerships, and develop policies. Assurance services include enforce laws, link to / provide care, assure competent workforce, and evaluation. Although the term population, encompassing both medical care and public health is relatively new, for many years, a group of activists, family doctors, mainly abroad and also in the US, have been developing a concept that they term community oriented primary care, or COPC. Although the term isn't used so much of late, a lot of good material has been developed from the perspective of how family doctors and basic medical care, primary care that is in public health, can be integrated with the community's health in mind. Some believe that COPC was a precursor or predecessor not only for the current domain of population health as discussed in this unit, but also for the recently popular new primary care model generally termed as a patient centered medical home, PCMH, which is sometimes also called a primary care medical home or just a medical home. Although this is a term that predates the wide use of VHRs in almost every practice, PCMH practices have from the start been early adopters of health IT. COPC and then PCMH practices were among the first to promote the epidemiological mindset of a target denominator population rather than just focusing on those individual patients who walk in the door. This graphic reflects the Centers for Medicare and Medicaid services, CMS, paradigm of the PCMH, or the medical home, for short. It is in many ways an HIT-supported, community-oriented, primary care model of a few decades ago. In other words, it is a melding of primary medical care and population health supported by sophisticated IT tools. They term this prototype Medical Home 2.0. This was developed not by a group of HIT specialists, but by those concerned with the transformation of medical care. When we go around the circle of this model, in laying out the criteria for an effective medical home for seniors, we are for the most part talking about population health IT. And as you can learn elsewhere in the ONC-HIT curriculum, the PCMH is really at the core of the ACO. Let's go around the graphic wheel clockwise, starting at the top, to see the various types of HIT supported functions that CMS identifies as central to the medical home. The first central function is advanced chronic care management, which is covered in greater detail elsewhere in the ONC HIT curriculum. Next, to the right and closely related is the patient registry. We haven't used that term yet in this lecture. Patient registry is a term that is often used pre HR. It is pretty much synonymous with the term denominator or even target population, and implies that all patients served by the practice, usually with a specific condition like diabetes or congestive heart failure, are registered so the practice knows who they are, even if they do not come in for care. This is difficult to do without an EHR, and it has become far easier and can now often be determined with the click of the mouse, as long as information on the person is in the practice's EHR. It gets more complicated if a patient gets care from a specialist with a separate EHR as well, and the target condition has not yet found its way into the medical home's database. Sure enough, further along the wagon wheel at the 9:00 position, you will see that to be an effective medical home, the practice's electronic health record must be interconnected and interoperable through the health information exchange. Otherwise, you can't possibly look at the complete picture of care for the patient unless he or she only uses a single provider. Interoperability and it's implications on population health are discussed elsewhere in the ONC HIT curriculum. As we return to the 3:00 position on the right of the wheel, we see HIT-supported clinical decision support systems or CDS. This is really more clinical informatics, but as discussed earlier, increasingly, CDS can also be used to support the population health functions, and we might term it population-focused CDS. More on that later. Next on the graphic is the importance of electronic communication with the patient, generally with a patient portal that provides the consumer's electronic entry into the HIT-supported medical home. Continuing on the wheel, CMS as an insurer is interested in assessing eligibility to receive covered care electronically. That's really more of a business activity, but it also can expedite access, coordination, and accountability, all important to population health. Next on the graphic, at the 7:00 position, is two-way quality and performance reporting. That means that the information goes into the medical home and out of the medical home through various electronic channels. This is also very important for population health and is part of many key population health functions, and supports a learning healthcare system. Even though this is CMS's model for medical care delivery right from the start, they also view connectivity and collaboration with public health agencies as key as presented by the surveillance criteria at the 8:00 position on the wheel. In this case, this would include reporting to the public health agency to ensure that a picture of the full community's health can be obtained. Assuming all practices in the region are participating between public health government agencies and primary care medical providers. There's a lot happening in the field of population health and population health IT, and it's a very exciting domain. We encourage you to learn as much about it as you can through all of the units that are part of this ONC-supported population health component and other available components. Because things will likely be changing rapidly, if you are or will be working in this expanding field, it will be important to adopt various lifelong learning strategies to keep up with the technological as well as organizational change that will be likely in the near and more distant future. These are some of the areas that will likely represent important areas where HIT will be increasingly adopted, and adapted to population health in the future. The first is the growing big data, which is a linkage of numerous diverse large electronic databases in many sectors within medical care, health insurance, and public health, and outside of the health sector but with implications for health. This will not always be easy, but each year, this linkage will increase, and will likely become more seamless. Another population HIT application area that will be the subject of future work and research is how we define the numerator and denominator. That is, who is the target for intervention? Who is at risk? What is the community? There's often no easy answer to these questions, but at least we can use the growing number of electronic sources to explore various alternatives and then to act on those alternatives where the chances of maximizing health improvement for the community with the resources available will be greatest. The next area of potential and growth are tools that add the population health perspective into clinical decision support systems within the clinical setting. Examples are effective population CDS programs for outreach, systems that acknowledge non-medical factors, and systems that facilitate the community perspective such as geographical analysis of a provider's patients. These tools could also be shared by public health officers and hospital directors to enlarge the team trying to use community interventions as well as system interventions along with the more standard one-on-one medical intervention. The last future-oriented development is that of many disciplines that are coalescing around a theme of informatics and population health. Many data science and public health and medical colleagues are developing new tools and approaches using the growing HIT systems now available in many communities. In addition, population health professionals are increasingly working with disciplines from outside of public health and medical informatics. Such as with computer scientists, social scientist, and clinical specialists, and geographers, and demographers specializing in studies of communities. Some of the advances and tools that will be needed to move the field forward are noted here. It will be important that we have population health IT standards and frameworks that are widely accepted across providers, agencies, and different geographic jurisdictions. It's one thing for a single hospital, or a single EHR vendor, or a single city health department to develop a data system, or a measurement system, or a way of communicating across parties. But these systems will not do much good unless everyone uses the same core standards so that all of this can be tied together to manage the health of the entire population comprehensively. Standards are wide scale in the insurance industry, and both private and public insurance claims data systems have been able to talk with one another across all US providers and insurers for several decades. In this case, arguably, the financial incentives are an important factor. Although not as far along in the process, over the last several years, standards for electronic health records have come a long way. But our work is still cut out for us in the public health and population health domain, the public health community. Speaking of financial incentives, in the US healthcare system, both financial and regulatory incentives and mandates are central to most major sustainable change. That needs to be applied in this field, as it has been in the general medical HIT domain through the meaningful use program. As discussed, by adding population health metrics and data systems to pay for performance incentive programs, such as the Triple Aim approach, standards are likely to spread more rapidly. This is beginning to happen in a number of places with support from CMS and others. For example, in the next unit we will discuss a unique model in Maryland where all payers, including Medicare, have collaborated to provide incentives to all hospitals in the state. To focus on providing population health to those residing in their communities, whether or not the consumer has ever been a patient in the hospital. It also goes without saying that human collaboration will be important along with the technology and policy integration. Public health agencies, clinical providers, private and public payers, government regulators, the IT industry, and academia must all work together in partnerships. So whatever roll you might play in the future system, we're glad that you're listening to this component. Population health will require many different parties. Finally, once these tools, methods, and partnerships are developed, we have to find a way that is viable financially to support future research and development in this area. The research and development effort for public health and population health activities including population health IT, is not likely to attract private investment, because the return on investment may impact the collective more than any individual party. This concludes Lecture b of Population Health, Population Health and the Application of Health IT. In summary, you have learned why population health has received increased attention in the US over the last five years. Why the term population health is a controversial one for some public health professionals. Some areas where it is likely that HIT will be increasingly adopted and adapted to population health in the future. Some of the advances and tools that will be needed to move the field forward. We hope that you have found this introductory unit of interest. And more importantly, we hope it will help you in the coming months and years in this new rapidly evolving healthcare system. Where the intersection of health IT and population health will be increasingly important. In summary, in this unit we've learned about the terms and perspectives related to population health and public health. We've explored paradigms and strategies relevant to improving the health of populations. And finally, we've examined the potential for health IT to improve the health of populations within public health programs and integrated healthcare delivery systems.
