Population Health Management in Real Time

The team says that through a thorough collaborative effort, the application was not only developed, but has already become an early success, with 65 percent of Marshfield’s physicians and managers having already adopted it. Not only that, but because of the application, the Center for Medicare & Medicaid Services (CMS) has awarded Marshfield approximately $56 million for their shared savings of $118 million in its Physician Group Practice (PGP) Demonstration program.

“I don’t think the collaborative nature of this can be underestimated,” Praxel says. “There are times that Kate and I will be talking about something, and she’ll know where I want to go and say, ‘What if we do it a little differently?’ She’ll help me get the answer and display what I want in a way I wouldn’t have thought about because they understand the data better, but they also understand what we need to do to do the clinical job.”

NEXT ON THE HORIZON
 The work is far from done for those involved with Marshfield’s population health management dashboard application. Konitzer says one of the goals is to integrate the application into more point-of-care processes to create even more real-time feedback.

“Right now it’s pretty timely,” Konitzer says. “But we want to use the same data to facilitate the scheduling process more—to make sure patients are coming in and for instance, if they are diabetic, getting their A1C, LDL and microalbumins scheduled. That’s marrying population health with real clinical care, CPOE [computerized physician order entry], care plans and order sets.”

Praxel says the rise of accountable care organizations and working with managed populations will only create a “moving target.” Constant refinements, he says, will be necessary since there are always reasons to not treat a patient in the usual manner. “I think we’re just starting to scratch the surface of understanding how to turn data into actionable information and not just to make a piece of paper happy, but to benefit patients,” Praxel says.

For more on Marshfield's Population Health Management application, check out my podcast interview with Ken Letkeman.