Next-gen population health: mHealth, social determinants, prescriptive analytics

Population health is increasingly viewed as a key to the successful delivery of healthcare in the future, especially as more hospitals and health systems fall under value-based care contracts.

Fortunately for provider organizations, there already are plenty of population health information systems on the market to help them navigate the challenges of managing the health of a population and not just an individual. And the next generation of population health IT will have more features and functions to help ensure success with pop health efforts.

Mobile technology is leading the race to better population health, said Paul Cerrato, an independent writer who has collaborated on three healthcare books with Beth Israel Deaconess System CIO John Halamka.

“There are now scientifically supported smartphone apps to help manage type 2 diabetes, asthma, clinical depression and other disorders,” he said. “Provider organizations that do their homework and separate the digital snake oil from apps that are supported by good evidence will find the right apps will help them provide more cost-effective care across at-risk populations in their care.”

Several mobile apps and electronic pre-diabetes programs have been shown to help obese, at-risk populations avoid full-blown diabetes. Other apps, used in conjunction with blood glucose meters that send readings to a smartphone, are having an impact on patients who already have the disease.

And mobile apps and sensors to monitor asthma will feature prominently in the future, Cerrato said.

“There are apps to teach kids to better manage their condition by incorporating gamification features,” he explained. “Over 170 studies have already been done on gaming applications and asthma alone with many more studies in the works as well as asthma games being developed, according to the American Lung Association.”

Creating one virtual system will be important to the next generation of population health IT, said Ryan Bohochik, director of value-based care at EHR kingpin Epic Systems.

"With increasing interoperability and better capabilities to share information across the healthcare spectrum, a patient’s data follows them wherever they go."

Ryan Bohochik, Epic Systems

“When patients move around in the healthcare system, key pieces of information about their health history can all too often get left behind,” he said. “With increasing interoperability and better capabilities to share information across the healthcare spectrum, a patient’s data follows them wherever they go. This access to deeper, more comprehensive information about a patient allows all care providers to make more informed decisions with their patients.”

One example of this would be access to all previous lab results and X-rays performed by everyone who has seen the patient before, thus allowing a specialist to pick up where those providers have left off the first time they see a patient, he added.

And getting social determinants of health into the health IT equation will be another key to next-generation population health, Bohochik said.

“It’s generally agreed upon that only a fraction of someone’s overall health and wellness is impacted by the care they receive in a traditional health facility,” he said. “By incorporating a person’s social determinants of health into the electronic health record, we enable them to work with their patients on these key factors that have such a strong impact on their ability to get healthy and stay healthy. This comprehensive health record will also extend to other, more non-traditional members of the care team, including community-based organizations like support groups that play a key role in the overall well-being of an individual.”

As the industry transitions to value-based care models, organizations are learning to deliver care in new ways, integrating care-team and care-plan paradigms into existing workflows to improve patient outcomes. While care coordination techniques are starting to show some measurable results, many organizations don’t know what to do next.

In the future, technology will step in and recommend the best course of action for patient circumstances, said GSI Health Founder and CEO LeRoy Jones.

“Prescriptive analytics will help determine what should go into the care plan for a specific type of patient, providing guidance within the workflow on the steps that will likely help care teams achieve a desired outcome,” he said. “This is more than simply providing content such as care pathways, protocols or best practices – it is integrating this guidance content with the tools that manage workflow to create a unified approach critical to successfully and proactively managing population health.”

Put another way, today’s tech is often focused on identifying gaps in care and subsequently addressing them, whereas the next generation of population health management technology will prevent them in the first place, he explained.

On another front, as value-based care evolves, it is becoming clear that healthcare needs a new generation of process and outcome measures that can independently evaluate results from medical activities and those from care management activities, Jones said.

“Care managers do not treat patients and cannot control medical procedures, so metrics based solely on patient outcomes do not adequately measure everything that is being done to make sure all patient needs are addressed and barriers to good outcomes are removed,” he said. “By isolating the factors for outcomes – i.e., separating what is attributable to medical versus care management actions – organizations will be better able to attribute results to the right activities and find the right path to improving patient outcomes.”

The accepted collection of measures will shift from just assessing population health, he said, to assessing population health management and the components that support it.

Twitter: @SiwickiHealthIT
Email the writer: [email protected]

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