Tracking population health data at your practice

December 15, 2016

Population health management demands tracking patient information beyond claims and clinical data.

In the next phase of population health data analytics, primary care physicians can expect that there will be a greater focus on patient-related information generated from socioeconomic and environmental factors that impact groups of patients’ health and wellness.

Population health analytics 2.0 is expected to go beyond claims and clinical data. It will include data from smartphones, telehealth equipment, remote monitoring systems and wearable devices, but will also include technologies such as big data tools and artificial intelligence to interpret patterns of behavior that will enable physicians to make better decisions faster.

To get the benefit of tracking population health data, providers will have to build on their investments in electronic health records (EHRs), which do a good job of monitoring patients’ blood pressure, documenting a diabetic’s A1C levels and updating changes to patient’s medications after hospitalization.

However, to advance population health, physician practices will have to seek technologies that capture more data associated with the social determinants of health to help them map out a plan that evaluates not only where patients receive care, but what health risks are present in the places where groups of patients work, live and socialize.

“Small physician practices need to think about what happens beyond a hospital or physician office,” said Cynthia Burghard, research director at IDC Health Insights, a division of Framingham, Mass.-based IDC Research Inc.

She added that technology is increasingly tracking patients at every stage of their episode of care such as after hospitalization when they are recovering at home, in a nursing home or at a rehab center. Technology is also monitoring social determinants like the air quality in a particular neighborhood where asthma patients reside.

“The whole notion of population health is moving the focus from the micro level of following up with a patient to manage their chronic illness to a much wider view of health that looks at the broader group of patients,” Burghard said.

Next: What the future holds

 

Looking forward

As efforts to meet an ever-changing, value-based care system mature, technologies such as telehealth, mobile devices and health apps, as well as remote monitoring systems and wearable devices have facilitated patient access to care in a convenient way.

Looking ahead, Burghard predicts healthcare decision-makers will increase their use of cognitive technologies such as natural language processing to assess unstructured patient related data. The use of artificial intelligence to identify patterns of behavior, such as medication adherence, will further help physicians understand and predict a patient’s health choices, and will help them make better health management decisions for their patients.

One example Burghard points to is Intermountain Healthcare’s partnership with CognitiveScale, which provides cognitive software that enhances customer engagement.

In this case, Intermountain Healthcare, a not-for-profit health system based in Salt Lake City, Utah, will use CognitiveScale’s software to analyze data associated with adolescents that have type 1 diabetes. The structured and unstructured data being analyzed includes information found in EHRs and claims systems, social media and remote sensing devices.

The goal is to successfully transition these patients to adulthood by analyzing their data and delivering personalized recommendations in real time to help them develop strong self-care habits as they manage their condition.

“In general, we are probably just beginning to understand how patient data can be useful in clinical care and how we can use that data to improve care today,” Burghard said.

She added that providers must keep in mind that aligning a value-based care and reimbursement model with developing a technology platform that supports population health management will affect many aspects of their practice.

“The most challenging part of the change small group practices will face is the change management that will need to occur,” Burghard said. “Physicians will have to learn a variety of approaches, and apply the appropriate technology to learn what is most effective for the different populations they intend to track, treat and care for as they work toward improving outcomes for specific groups of patients.”