This e-book focuses on Health Management Solutions the value it adds alongside other systems that are already in place throughout the care lifecycle...

1. White Paper
Importance of Population
Health Management
INFOSYSTEMS
LEVERAGING INTELLECT
NOUS

2. Abstract
Introduction
The revised healthcare regulations in US
markets like the Affordable Care Act (ACA)
law, the demands of providing Physician
Quality Reporting System (PQRS) details
for incentive and regulatory programs or
engaging the patient to achieve the
outcome based incentives, are not easy
accomplishment unless right systems are
in place. The Population Health Manage-
ment (PHM) serves a great deal in all
these activities for both individual health-
care settings like physicians' offices,
outpatient clinics, nursing homes, skilled
nursing facilities or any care facilities and
for the network managements.
Ever heard of the eradicated diseases like
Smallpox, Rinderpest? Know how the
diseases like polio, malaria are tackled by
different countries in a combined effort?
Heard how regional diseases like Hook-
worm, measles are eradicated? The
Health authorities and policy makers, with
the concern over citizens devise different
health programs, which could otherwise
not just cost the individual patient, but the
society in whole.
Think about the modern day concerns like
Obesity and Smoking. The ill-effects may
not only limit to the individual, but others in
the circle of influence. How will the
government work over such items, though
they are all lifestyle-based and individual-
istic?
In this white-paper, we explore the differ-
ent elements involved in population health
management which have major implica-
tions for public policy decisions, Care
continuum, Healthcare Economics and
Total Health Care outcome. We explain
Population Health Management in short
and how can it can add value alongside
other systems that are already in place
throughout the care lifecycle. – Population
Health Management can be explained in
simple terms as the categorizing Patients
into different population categories based
on risk levels. It also, analyses the reasons
for the diseases and engages the patients
with programs that could result in improv-
ing care quality and reducing overall
healthcare costs.
Similarly, how should the stakeholders in
the Care Continuum like Payers, Providers
engage in achieving the generalized
goals? The answer is Population Health
Management. This white papers tries to
explain different activities involved and
then the means to achieve those goals of
PHM, in a modern day technology-driven
lifestyle.
Importance of Population Health Management 2

3. Are the incentives only
reason for implementing
Population Health
Management (PHM)?
Population Health Management is the
managing and improving of the care quali-
ty and outcomes of a defined population
as a whole. The targets set for the defined
population can be achieved by targeting
interventions to sub-groups, thus helping
to improve individual outcomes which
in-turn improve outcomes measures of
the whole group or population for the
given health goals. This can be used to
manage the resources for right areas and
achieve better ROI and quality of care.
This betters the outcomes of the high-risk
patients, by reducing common incidents
and high-cost complications in additions
to ensuring incentives or incomes through
Pay-for-Performance (P4P) programs.
Meaningful Use Stage 2 and stage 3
require meeting targets for clinical
measures and care providers must submit
all the defined care given information into
Patient Quality Reporting System (PQRS).
Having a PHM system helps in knowing
population requiring interventions thus
improving outcomes without having to list
for each categories through systems that
are not designed for this activity.
Payer organization processing the claim
settlements come across such data from
the clinical and claim information, about
the likelihood of the patient's condition in
the near future and resulting clinical and
financial consequence due to it. If a seam-
less system to manage these are built to
alert the care managers to know them, the
overall cost of the care is reduced for all
involved. Over the years, the payers and
providers have gained lots of insights
about the trends and patterns about the
patient or consumer behavior, but very
little is done with it, as they did not form
the core to the area they were working.
Importance of Population Health Management 3

4. Major activities
of Population Health
Management
Let us consider an example of Obesity as
a case for Population Health Manage-
ment, without delving much into the exact
activities and detailed considerations, but
as a mere example to understand. For to
consider someone as obese, there needs
to be definition of what condition qualifies.
In this case, it can be measure of BMI. BMI
measurement alone can be a consider-
ation and will require waist measurement.
But both have limitations. However, they
form the ground for classification.
Now, how serious is the condition of the
patient? And how to control the ill-effects?
Does the patient require a Bariatric
surgery? What are the predicted risks of
having a surgery or not having a surgery?
How should the care giver engage the
patient before or after the surgery? What
are the behavioral or Lifestyle changes
required by the patient? And how to
engage the patient to observe those
recommendations? How are the
outcomes of the engagement measured
and controlled? These are some of the
activities that will go into the population
management. It includes, whole Program
design, communication, incentives, physi-
cal activity programs, nutritional
programs, devising innovative interven-
tions, etc.
Importance of Population Health Management 4

5. Using the data collected through different
systems bucket them to different popula-
tion groups based on the target criteria.
Challenge is to collate what is structured
and what is random data and convert it
into useful data. Data from every possible
system source should be considered.
The classification can be based whatever
the system is generally considered. Popu-
larly they are classified into four catego-
ries –
The percentage categorization is again
part of the design criteria. This stage calls
for well managed Data Mining and Analy-
sis of different data like Demographic
Data, Clinical Data, and Pharmaceutical
Data. There could chances of missing
information or collating issues. With the
help of insights gained, Health managers
need to device strategies and justification
for classification of population. Using
various mathematical models and avail-
able data, the categories could be classi-
fied, for example like - High-Cost Patients
5%, Rising-Risk Patients 20%, At-Risk
Patients 40%, Healthy Patients 35%; or so.
These would be used in working further on
cost effect, care gaps, analysis, etc.
Based on the need for granularity, this
categorization can still be sub-divided into
smaller groups and narrow down on the
interesting cases and conditions.
The PHM implementation mainly involves
following activities.
Defining population -
Categorize patients into
key population groups:
High-cost Patients;
Rising-risk Patients;
At-risk Patients; and
Healthy Patients.
Importance of Population Health Management 5
1

6. Giving due consideration for broader set
of risks, and with the knowledge and
insights gained over the years, determine
the risk causing factors and finding out
which care interventions will give most
desired outcomes.
Based on the trend and pattern formation,
use different data analysis techniques, to
gain a better understanding of which
interventions will actually make a differ-
ence. Population health managers should
consider a broader set of risks, like social
risk, geographical risk, and behavioral risk.
In addition, the degree of patient engage-
ment through different channels, this can
make a big difference in which interven-
tions are most appropriate and most
effective.
Identify care gaps
and stratify the risks -
Analyzing to locate risk
causing sources:
Importance of Population Health Management 6
2

7. As there needs to be different kind
intervention requirements for each popu-
lation group of patients, a properly catego-
rized population group allows the popula-
tion health manager to engage available
limited resources on groups where they
will do the most good. Each population
segment has an intervention strategy
appropriate for its level of risk. Close
interaction between Care Managers, who
have insights of different care conditions
and population group.
Based on the need of the category,
High-Cost Patients engaged through
Health Coach Assignment; Rising-Risk
Patients through Behavioral Health
Consultant; At-Risk Patients through Peer
Group Connections and Healthy Patients
with Preventive Care Outreach activities.
Though engagement is done based on
need, efforts should also be spent to
understand the actual outcome of this set
of engagement. Flexibility should be main-
tained to accommodate any changes to
the co-ordination based on the outcome.
Enough consideration should be given for
improving the clinical and financial
outcomes, through disease management,
case management and demand manage-
ment.
Constant deployment of analysis over
Clinical measures and health outcomes to
reduce the care costs and effectiveness of
care quality.
Engaging patients,
Managing care and
Measuring the
Outcome -
Intervention and patient
engagement of the
focused population group:
3
Importance of Population Health Management 7

8. Other activities
of Population Health
Management
An EHR has been built to store patient’s
data, support documentation needed for
billing and for creating a care plan but
when it comes to retrieving meaningful
data to identify patients with critical risk, it
requires someone to make use of dispa-
rate systems and manual reconciling is
needed. The challenge here is, it is
multi-step, cumbersome and complex. It
is almost impossible for any EHR to create
a meaningful data itself, or to get this data
into a
PHM system.
Payer organization processing the claims
settlements come across such data from
the clinical and claim information, about
the likelihood of the patient's condition in
the near future and resulting clinical and
financial consequence due to it. If a seam-
less system to manage these are built to
alert the care managers to know them,
then overall cost of the care is reduced for
all involved. Opportunities to engage the
patient for appropriate care management
program or suitable intervention be
explored all the time. The system should
be flexible enough to accommodate any
changes required on the criteria being
considered.
Current established systems like EHR or
PMS can only provide capabilities specific
to their job function and little can be lever-
aged in terms of predictiveness of the
patient conditions and thus risk levels.
Suitable employment of the PHM not only
helps in identifying the patients, but also
streamlining the process with the
evidence. Well-built predictive models not
only eases the function but provides
options to measure and control the activi-
ties.
All options to automate any activity
involved should be considered. Surveil-
lance systems in claims processing and
such will lead to less intervention by Care
Managers on daily basis, except only for
over-seeing the functioning of the system
and make modifications based on the
need.
Data processing will not be limited to
finding the critical patients or the prospec-
tive benefits, but also in the controlling the
costs of a plan and predict the financial
state and readiness to meet any adverse
events. The responsibility of the care giver
and payers are not limited to per incident,
but also on the outcome of the treatment.
This requires engaging the patients or the
consumers constantly and understanding
the risk levels of managing the member.
Importance of Population Health Management 8

9. With the popularity of the smart phones
and social media, the engagement and
communication is quicker and less expen-
sive. Think about a case, where an alert
had to be communicated to a member or
a group of members. The traditional
means of contacting would not have yield-
ed good results and would not have put
the member in the comfort. With the
automated feedback systems with
integration to Social media and smart
devices. Use of multi-channels like Mobile,
Portals, Devices, Kiosks, apps, etc., have
led to diversity and boundless opportunity
for communication. Automated systems
can take care of raising the alerts, sending
communication to the members.
What happens when a drug is recalled by a
drug company, how the existing patients
prescribed with those medicines are
notified about it. How to re-issue the
prescriptions for the same and engage the
patient in such cases? All this could be
managed easily should there be a PHM
solution in place, which helps with Push
notifications or group alerts or personal-
ized alerts.
The core objective of PHM is also to build
a seamless communication, delivery of
service and engagement of the patient/-
consumer irrespective of the patient’s
location. To meet these goals, it definitely
requires the usage of mobile health and
telehealth technologies. Few other areas
that help to attain this phase of PHM is
mobile application, interactive web-based
application, customized education
programs and Personal health records.
Importance of Population Health Management 9

10. Programe Outcomes
Psycho-social
Outcomes
Behavior
Change
Clinical and Health
Status
Productivity,
Satisfaction, OOL
Financial
Outcomes
Revenue Cycle
Management
Provider Network
Management
Care Continuum
No or Low Risk Moderate Risk High Risk
PHR
Patient Portals
Telehealth
Device Integration
Care Management
Wellness Programs
Risk Stratification
Patient cost and
Utilization
Predictive Modeling
to Stratify Population
Health Assessment
Population Analytics
Clinical Databoards
Population Monitoring / Identification
EHR
Data Analytics
Data Werehouse
Health Promotions,
Wellness
Organizational Interventions
(Culture/Environment)
Tailored Inventions
Community Resources
Health Risk
Management
Care Co-ordination/
Advocacy
Disease/Case
Management
Operational Messures
Define
Population
Identify
Care Gaps
Stratify Risks
Engage Patient
Manage Care
Messure
Outcomes
Person
Stages and Components of Population Health Management in Care Continuum

11. Conclusion
Population Health Management not
necessarily targets individuals, but tries to
manage the outcome of the whole popula-
tion to the desired target goals and thus
bringing down the overall cost of all. Any
opportunity to implement population
health management in any healthcare
settings should be readily adopted and
overall goal of reducing cost and meeting
quality care standards should achieved.
How are these data generated being
analysed to understand if there are any
trends formation or changes required into
the algorithm applied or strategy
employed, collecting metrics and visual-
ization of the trends, patterns to meaning-
ful insights should be employed. Employ-
ing either metric-based dashboards or KPI
based dashboards to monitor the prog-
ress should form an integral part.
Authored By:
Ravi Prakash H S, Business Analyst,
Nous Infosystems
6
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