How quickly and successfully are the nation’s medical groups transitioning to the emerging population health care delivery and payment arrangements? There is huge variation across the U.S. healthcare system, of course. And when it comes to the successful leveraging of information technology to support the shift over to population health- and accountable care-driven care delivery and payment, well, things are rather uneven in that sphere, too.
In that regard, Mark Werner, M.D., the director and national leader for clinical consult at the Chicago-based consulting firm The Chartis Group, and Bob Schwyn, a director at The Chartis Group, spoke this summer with HCI Editor-in-Chief Mark Hagland, as he interviewed industry leaders for the magazine’s September-October cover story on population health. Below are excerpts from that interview with Schwyn and Werner, as they shared their perspectives on the population health phenomenon, and in particular on the IT and analytics aspects of that phenomenon.
What are medical groups learning right now, as they forge ahead into population health work?
Bob Schwyn: My background and role is on the technology side of things. And part of what I think is happening in the trenches is that people are gradually realizing that [shifting into a population health management focus] is not just an IT initiative or a primary care medical home initiative, or an isolated-contract initiative, but rather that it really does require an enterprise-level effort to link to your strategic plan. Part of the problem is that there remains confusion about population health at the public health or community health level, since we’re trying to achieve some public or community health goals via what is still an acute-care-based health system. So you have to begin to stratify populations and realize you’re already taking care of multiple populations.
Does IT governance become an issue? Also, overall strategic governance becomes an issue as well, correct?
Schwyn: Yes, we find it’s both. IT governance helps us figure out where we should make our investments, etc. But if your organizational plan isn’t strong enough and clear enough, it’s hard for IT governance to respond to it. So the in-the-trenches challenge we get into is in helping people to get some clarity around what problems they want to solve, and want technologies they need to build. What do I need and when do I need it? That kind of thing. And we also see a lot of folks who are trying to boil the ocean and they try to huge some kind of huge analytics platform and care management capability, and then they can check off the technology, but it’s not that easy.
Do you gentlemen see more clarity beginning to emerge around the concept of population health now?
Mark Werner, M.D.: One of the things we’re learning is that it’s a phrase with a lot of meanings. Part of what I think is happening in the trenches is that people are gradually realizing that it’s not just an IT initiative or a primary care medical home initiative, or an isolated-contract initiative, but rather that it really does require an enterprise-level effort to link to your strategic plan. Part of the problem is that there remains confusion about population health at the public health or community health level, since we’re trying to achieve some public or community health goals via what is still an acute-care-based health system. So you have to begin to stratify populations and realize you’re already taking care of multiple populations.
Mark Werner, M.D.
What are your perspectives on the challenges of beginning by identifying rising-risk patients, those not yet in the highest risk categories, when beginning to move forward under a risk-based contract?
Werner: I think we have to be careful about starting out thinking from the physician/provider perspective. We have to start out thinking from the health plan member perspective: we need to figure out how to engage patients and members. Physicians tend to start out saying, tell me who they are and I’ll treat them. But instead, what can be getting in the way of improving their health? Maybe some of them want virtual care. I was talking with someone recently who has an ongoing chronic disease and he sees a specialist who only sees patients Tuesdays and Wednesdays in the morning. And this person travels a great deal and says, I actually travel all the time and can’t get in to see my doctor on Tuesday or Wednesday mornings. He really could benefit from virtual visits or phone visits. So we really need to engage people and find out how they prefer to access care and get information, and then design care management around that.
Schwyn: Yes, and it really does lead you to more tailored interventions around what the best way is to help, and how I coordinate care across the continuum, and focus on those things depending on where that patient is in terms of chronic care or possibly on the wellness side of things. And understanding those needs really helps to identify where the technology efforts and the spend in technology can best be leveraged.
So you’re simultaneously looking at two axes, right? Engagement and health risk?
Werner: Yes, you have to simultaneously think about the health management risk of your population of your patients, and then think about how they would prefer to access care and information, and then begin to map your strategies and interventions, around their particular health risks and particular personal references. So there’s a lot of work we’re beginning to do with clients around access to services, framed as you’ve said—that access is less now about access to appointments, but increasingly, about understanding your community’s preferences for how, where and why they want to get care, and figuring out how to provide that access and moving towards improved outcomes.
Some of the reasons the physicians are having struggles in the trenches is that they’re not yet thinking this way. They’re still provider-centric. The shift to population health is happening at the same time that consumerism is finally coming to healthcare. Technology is now enabling more consumer-centric approaches to care; the two very much intersect.
CVS and other disruptive players are coming into the market. How will that affect medical group leaders?
It will affect them a lot. We’re seeing a diversification of the trusted sources of health information. We’ve had the expert culture of the physician, where we expected that the only way to access health information and expertise was through a physician. And we’ve been shifting away from that, so that society is accepting that there are many possible sources. And I don’t want to comment on whether it’s right or wrong; it’s simply happening. And I think physicians and physician groups have to acknowledge that phenomenon and work with it, because that horse has left the barn. Think about how often the average diabetic sees a physician—maybe 3 or 4 times a year. But the CVS pharmacist sees that person 40 times a year. So there’s a certain reality to the nature of these interactions, and the technology is enabling that to happen. And if you have to wait three months to see the endocrinologist, you are going to ask your retail pharmacist clinical questions.
So what are the smartest medical groups doing around care management and analytics?
Schwyn: We’ve already discussed issues around limits to access for care; and there’s the issue of the appropriate way to engage. There are a number of organizations looking at wait times and coverage, and really looking at the opportunities to leverage technology to minimize those limitations. That’s a key area in terms of understanding how to start this population health journey.
What are some of the key analytics things medical groups are doing now?
Werner: As groups commit to contracts and are implementing technology, the smarter groups are learning to understand variations in clinical care through analytics, are learning how to create best practices; are sharing information with each other about clinical and cost outcomes; and are actively working together to figure out how to more proactively manage care. They’re really trying to do that well and leverage that. Similarly, organizations that are more advanced are applying similar analytics—health plans with members, providers with patients. And they’re trying to understand environmental factors for their plan members or patients—identifying the social determinants of health, but also trying to figure out how to psychographically group and categorize their patients.
They’re also trying to get a more detailed understanding of clinical risk and get away from purely descriptive analytics and move towards more predictive analytics. That is very difficult, and I’m not sure that anyone is doing it particularly well yet.
So you say, look, Mrs. Smith might be in trouble next month, and you get care/case management involved, right?
Werner: Yes, and it’s not necessarily next month, maybe it’s next year. The patient might be moving to a higher-risk profile. With diabetics, we often focus on hemoglobin a1c; whereas in fact one of the biggest predictors of risk is their high blood pressure. That means the patient probably is going into deeper risk. There clearly is a correlation between high blood pressure, rising blood pressure, and risk for hospitalization, for diabetics. But I don’t think anyone is yet leveraging technology well in that space. Remote monitoring and patient-provided data will certainly at some point become important in those efforts.
Might wearables play a role ?
Werner: Yes, wearables, and scales, and now, you have remotely monitored glucometers. Someday soon, remotely monitored insulin pumps. I was talking about remote monitoring of my blood glucose and insulin infusion, with a colleague, and we could see remote monitoring of my insulin pump and blood glucose that might automatically prompt me to adjust my pump, or might even do that on its own. That kind of emerging technology will come soon. And imagine how that changes care, where it’s no longer about going to my endocrinologist with my paper-based finger stick data.
Schwyn: And I think this is a challenge for healthcare IT leaders, as we talk about these new technologies that are coming from every venture startup and so on. The challenge is going to be that those organizations that are very nimble and can invest in new technology and have a spirit of innovation and a tolerance of [financial] risk—some of those organizations that are more mature are starting to think about how to build some structure around this. How do you consider that in the context of IT governance, and understand that you might want to take a certain level of financial risk and become a market disruptor in your market. There’s a lot of movement in this space, whether it’s developing partnerships with companies like Apple or whatever… I think that’s where some leaders will come out on this.
What should CEOs, CMOs, CIOs, CMIOs, and other leaders of medical groups be doing right now, around all this?
Schwyn: I think it’s important for an organization to really have a clarity around a strategic plan, and then really sort out the implications of what all those engagement components are—whether it’s engagement of the patient, the family, the physician, the care process—and really getting clarity around that and understanding how the organization is going to have to transform around changes in behaviors, processes, technology—and understanding not only what investments will need to be made in technologies, but also the skills in managing technology that will he to be developed. Understanding the connectedness around all this.
Werner: I agree with Bob. They should accept that the era of accountability continues to grow; and so they need to plan purposefully for how their group of physicians will begin to accept accountability for health, and develop competencies. I worry for the groups who are still debating whether this is real or not. I think we’ve been on this trajectory for a long time. And I don’t know that ACOs are the last word; they’re merely the latest iteration in this journey that we’ll be on forever.
Schwyn: And many people somehow think that there’s a fast track or easy button for transformation. But don’t underestimate the learning curve, which will take a long time to head towards transformation.