Population Health Management

Health Information Technology and Population Health Management

In order to achieve the goals of better and more affordable health care that leads to improved population health, a strong health information technology ecosystem is required. These systems must support informed patient and provider decision-making, and transform health care systems to enhance access and input from coordinated care teams beyond the traditional confines of clinical providers and hospital facilities. There is clear evidence that the burden of illness goes well beyond health conditions themselves, and includes a comprehensive array of biological, social, and behavioral determinants.

According to the Office of the National Coordinator (ONC) for Health Information Technology, over 50% of office-based professionals and more than 80% of hospitals are meaningfully using electronic health records (EHRs), which requires them to electronically exchange standardized patient information to support safe care transitions. At least 50% of hospitals are able to electronically search for patient information from clinical sources beyond their organization or health system. In addition, all 50 states have some form of health information exchange (HIE) services available to support care. And, more than half of individual consumers and patients are able to access at least some of their own health information electronically via the combined contributions of providers, health plans, pharmacies, and labs.

Is this report from the ONC good news, bad news, or potentially missing the mark? It can be argued that there is a fundamental flaw in this approach that limits the capacity of health systems to truly engage in population health management. The gap is the perpetuation of siloed electronic health records that are proprietary to the individual provider or facility. While providers may have some limited access to other health system information, they do not have an integrated way to coordinate information and communicate across physical, behavioral, and community based social service providers. Many might argue that it is necessary to maintain separate clinical records that are specific to different providers and systems. However, this makes care coordination difficult and stifles truly integrated care involving all aspects of the care team including the patient and their care-givers.

Integrated care coordination requires effective technology platforms that bridge the data sharing gaps across multiple provider systems, provide access for real-time care team communication, and establish workflows that direct and support the full spectrum of healthcare, social systems, and others who care for individuals. The result is that traditional EHRs are inadequate for population health management, and care coordination tools are required to support the sharing of information, communication, and workflows across all care team members. This includes the comprehensive spectrum of clinical health systems and providers, community based resources that impact the outcomes of care, payers and managers of care, and quality management and improvement resources.

An upcoming webinar from InfoMC addresses information technology concerns and resources for population health management.

Electronic Health Records have shown limited capacity to support integrated health care for individuals with chronic health conditions. Challenges have been noted for the coordination of care among multiple providers (primary, specialty, and behavioral health) across different clinical and community settings, and over time. This includes supporting integrated care teams developing and working from shared care plans, coordinating workflow documentation from providers of multiple clinical disciplines, and linking caregivers and community supports. Effective population health outcomes require technology solutions capable of coordinating care across providers, care teams and multiple provider systems.

This webinar provides attendees with an overview of the tools and resources that must be in place to support effective care coordination and population health management. To register for this webinar please Click Here!


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