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Predicting Patients’ Next Healthcare Moves: How HIT Stakeholders are Keying in on Advanced Population Health Management

July 28, 2017
by Rajiv Leventhal
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Population health is hardly a new term in health IT circles, but a recent report from Black Book Research has shed some light into how serious stakeholders are about being able to holistically under­stand patients as they move across the care continuum.

The report, which included responses from 140 chief information officers (CIOs), 159 chief financial officers (CFOs) and 448 hospital managers involved in planning and executing population health initiatives at their or­ganizations within the next year, revealed that in an ideal world, next-generation population health management systems will be able to identify a plethora of patient groups and predict where, when and how to best en­gage them. In addition, they should have the ability to coordinate care across the entire healthcare continuum, support care team collaboration and measure the ac­tivities, outcomes and overall performance of providers within the network, according to the report’s authors.

While many IT systems have long been developed with fee-for-service healthcare in mind, a shifting landscape (EHR) vendors to tap into new, non-fee-for-service teth­ered platforms for population health. According to the Black Book report, 90 percent of healthcare leaders said that future population health management systems will essentially be projected to perform as next-generation patient accounting systems. Said Doug Brown, manag­ing partner of Black Book Research in a statement that accompanied the report, “Some EHR systems have handled managed care for years, and those that have deep experience with capitation and managed care will be better able to translate that knowledge into value-based initiatives. Systems like Epic that were developed from the start as a single, longitudinal patient record spanning inpatient, outpatient, post-acute and billing will have the advantage.”

What might these “next-generation” systems look like and how will they be tailored to a value-based care environ­ment? Brown, who was also interviewed for this story, says, “We will have to start working on predicting all the coordi­nates of care where patients might end up and when and where they might engage.” He adds, “We have to support the collaboration from the differ­ent care teams. Did the activity happen? Was it ordered and not performed? What were the outcomes? How was the performance of the provider, be it a physician or an outpatient facility? All that data now has to be mea­sured, not for fee-for-service, but it now becomes all of these other data sources that need to be pulled in. So it becomes a patient accounting system.” Brown notes that Epic, Cerner and Allscripts, either via acquisition or through needs from other clients, “are putting funding into building what this appears to be.”


In Great Neck, N.Y., Northwell Health (formerly North Shore-LIJ), is the largest integrated healthcare system in New York State with 22 hospitals, 6,675 hospital and long-term care beds, and more than 550 outpatient fa­cilities. Simita Mishra, Ph.D., director/service line lead­er at Northwell, oversees the organization’s strategic population health initiatives from within the office of the CIO. Mishra says her job is to work in partnership with whoever is providing care management operational ser­vices on a day-to-day basis within Northwell.

“We [are] their strategic and advisory partners. We look to understand what would be the best business case so we can provide them with an IT infrastruc­ture that will help them provide evidence-based care management to the population that they are serving,” Mishra says. She adds that it’s not just about technol­ogy; rather, her team sits at the leadership level with clients and has councils where they work with them to better understand their requirements. “At times they don’t even understand their own requirements since they are primarily on the clinical side and don’t have that [business expertise]. So we will help in that re­gard,” she says.

Simita Mishra, Ph.D.

Mishra, who doesn’t have a technology background but has worked in population health and consulting for 14 years, has two core population health groups roll up to her leadership within the office of the CIO: the first is the standard population health management team at Northwell; and the second is the team in charge of the Delivery System Reform Incentive Payment (DSRIP) pro­gram for Medicaid patients. These two groups are kept separate, notes Mishra, since the DSRIP grant from New York State mandates that resources not be co-mingled, but essentially DSRIP is a subset of the broader popula­tion health organization.

One of the biggest focuses of Mishra’s work right now is the development and roll-out of Northwell’s homegrown Care Tool software. The tool is developed by the service line team and then designed to meet the requirements and features that are based on what the user wants, Mishra notes. The Care Tool might ca­ter to multiple programs such as a bundled payment program, the New York State Health Home program, or DSRIP.


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