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Using Technology to Optimize Population Health Care Coordination Outcomes

December 10, 2014
by Wendy Vincent, R.N., National Practice Director, Beacon Partners
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Wendy Vincent, R.N.
More than 2,600 hospitals will receive financial penalties in 2015 as a result of excessive numbers of hospital readmissions within 30 days of discharge. A recent analysis shows population health management initiatives can reduce readmissions, improve community healthcare outcomes, and increase revenues.
Yet many healthcare care coordinators are still using paper-based, manual processes, as well as juggling tasks and patient caseloads on spreadsheets and homemade databases. Although automated systems, improved data collection, and reporting advancements exist, healthcare organizations still need to do more to effectively use technology to realize the maximum benefits. We can no longer afford to take healthcare organization’s traditional “one- size-fits-all” approach to achieve affordable, high quality population health outcomes.
The question is: are healthcare organizations ready to make the commitment to support population health initiatives? The technology, expertise, and resources exist to make it a reality. National and state government waiver programs have also allocated a significant amount of Delivery System Reform and Incentive Payment (DSRIP) funding to provide health systems the capital needed to invest in managing their communities’ health.
Healthcare organizations need to dedicate resources to overcome the technology, staffing, and process challenges that prevent programs from moving forward. While electronic medical records (EMRs) have increased access to patient information, interoperability challenges remain in sharing data across multiple EMR platforms.  Using a health information exchange (HIE) with continuity care documents (CCDs) allows all providers access to patient data so that they can make informed decisions to improve care coordination. Emphasizing resource, procedural, clinical, and IT infrastructure investment is essential to creating a clinically integrated network to improve population health.
Below are steps you can take to effectively use technology to improve population health management efforts: 
    • Involve users in decision-making about technology investments and use. Include care coordinators from the start in planning new workflows and system designs to improve their job performance. As organizations move toward centralized care management systems, understanding care coordinators’ roles and responsibilities is necessary to achieving usable, familiar workflows that enhance productivity.
    • Automate workflows to effectively manage resources. According to researchers at Central Virginia Health Network and MedVirginia, healthcare organizations can quickly generate financial returns and maximize resources by replacing paper and manual processes with automated workflows. Many care coordinators are documenting notes on paper and then transcribing electronically, which wastes time. For example, two full-time equivalent workers were saved a week by automating patient caseload lists during a recent Beacon Partners’ project at a healthcare system.  Another academic medical center was able to recognize significant savings through the use of patient care navigators, who were essential to reducing 30-day readmission penalties. 
    • Use prospective quality reporting data to shape programs that identify high-risk populations’ needs. Tools are now available to shift from relying on retrospective data to near and real-time information, which provides actionable insight to make effective changes. For example, clinical dashboards can reveal if certain populations are refusing to receive flu immunizations, which can highlight the need to implement community health education programs to achieve outcomes quickly.
    • Recognize that health information exchanges (HIEs) and patient portals require efforts beyond implementation. While today’s IT population health platforms continue to become increasingly intuitive, standardized workflow processes, procedures, and staff education still needs to be developed and implemented to create effective patient-to-provider and provider-to-provider communication systems.
    • Drive patient engagement by integrating telemedicine and mobile devices in the care coordination mix. As the use of applications and mobile devices to access health information increases, healthcare organizations will need to assess how tools — such as Apple’s HealthKit — influence patients’ behavior and fit into the care coordination framework. Telemedicine monitoring and clinical data capturing on a near or real-time basis will also continue to grow as health systems look for ways to increase patient engagement. The need for real-time data from multiple disparate systems becomes increasingly critical to coordinating care so providers can intervene to prevent adverse health events. These systems are also effective with managing overall costs if you are in an accountable care organization (ACO) or in a risk-based sharing arrangement. With the ability to capture clinical, quality, and financial data from EMRs and claims – total costs of care coupled with complex algorithms can score and predict high-risk populations to target.  
    • Establish realistic metrics to measure success. State and federal waiver programs provide incentive payment programs that reimburse based on achieving specified outcomes.