POPULATION HEALTH: Health determinants, Prevention & Health promotion
What is Population Health Management
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What is Population Health Management?
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Population health management (PHM) gives providers the ability to make informed care decisions based on their entire patient population at-a-glance and in near real-time. Learn about how PHM is disrupting healthcare and how it benefits both patients and providers.
Transcript of What is Population Health Management
What is Population Health Management?
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Healthcare is more than medicine, it’s a goal — we want the best possible health
for ourselves and those around us.
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“Today the average doctor in the U.S. manages more than 2,000 patients whose
health information is locked in a paper record.”
*http://www.annfammed.org/content/10/5/396.full
- Ryan Howard, founder and CEO, Practice Fusion
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It’s estimated that a doctor with 2,000 patients would have to spend more than 17 hours a day providing all of the recommended care.
*http://www.annfammed.org/content/10/5/396.full
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With so many patients and only so many hours in the day, it can become an
overwhelming task to try and keep track of things like ‘who is up-to-date on their
vacancies’ or the latest clinical recommendations.
Margie To
Would be good if we can find a quote for this if there is one.
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Typically, there’s no way to look across the patient population to see which diabetics are at goal, or who is due for a vaccine.
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Over 45% of diabetics are not at goal.
Every year, over 40,000 people die from vaccine-preventable diseases.
Margie To
Can we have a footnote at the bottom to reference where this stat came from?
Margie To
Same comment as above regarding referencing the stats.
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Population health management is making it more efficient to identify and help these patients.
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What is Population Health Management
YesterdayCare coordinators combing over thousands of charts and calling patients to provide support or schedule HCP visits
What is Population Health Management?
Information Week, Healthcare Edition. 11/2013.
Population Health Management is a systematic approach to optimizing the health of populations and preventing people from getting sick or sicker
“”
Today Leverage Health IT and point-of-care messaging to empower providers with actionable information to improve patients’ health
Margie To
Is this a quote from Information Week below?
Felipe Caldeira
Correct
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Population health management uses data and technology to drive better health
outcomes for patients by giving providers the ability to monitor their entire patient population at-a-glance and in real-time.
Core Components of Population Health Management
Population health management dashboard
DeliverCDS
Margie To
extra "n"
Margie To
Instead of "message provider" can we say "provide clinical decision support"?
Felipe Caldeira
Made change
Felipe Caldeira
Is it ok if we keep as is? We were trying to illustrate that we message the provider with a clinical decision support and then go on to explain later in the deck.
+ Patients are identified by demographics and chart values (i.e. labs, diagnosis) and applicable clinical quality measures which are evidence-based, clinical guidelines
Step 1: Identify the Appropriate Patients
Sample Diabetes Quality Measures
NQF# Measure Description
0059Diabetes: Hemoglobin A1c Poor Control
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
0055 Diabetes: Eye ExamPercentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1 and type 2) who had a retinal or dilated eye exam in the measurement period or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the measurement period
0056 Diabetes: Foot ExamPercentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period
Margie To
Let's say "evidence based" clinical guidelines.
Margie To
replace "can be" with "are"
Margie To
I am not sure that it is correct to say that the CQM are based on the targeted pateitn demographics and chart values. We target based on the CQM but the CQM is not based on the targeted demographics.
Margie To
Not a substantive point, but seems odd to focus on diabetes at the beginning and then switch to heart disease here?
Felipe Caldeira
Change made
Felipe Caldeira
I like it. Change made
Felipe Caldeira
Good point. I think the best way to resolve this is by removing "Targeted." We normally say that we identify patients based on the CQM. SInce we already say identify here, I think we should remove targeted.
Felipe Caldeira
Wanted to show how we can do various disease states but decided to stick with diabetes. The CDS is currently live and the CQMs are easier to read that the anticoagulant ones
+ Provide Clinical Decision Support, which is an actionable message to the provider during the office visit
Step 2: Provide Clinical Decision Support at Point-of-Care
Not an actual patient
Margie To
Can we say "Provide Clinical Decision Support at Point of Care"
Margie To
Is this a real patient or fake data? Recommend using a fake patient/data.
Felipe Caldeira
Fake patient. Replaced with a better screenshot of an actual live CDS in the system. Added disclaimer below
Felipe Caldeira
I'm cool with that change and have appllied it. JG and RS, up to you
+ Compares provider to peers
+ Provides guidance on performance
+ Engage patients through clinical email outreach pre and post visit
Step 3: Measure Outcomes of the Patient Population
PHM detail dashboard | Diabetes
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Practice Fusion providers
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Practice Fusion providers
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Practice Fusion providers
% of diabetic patients who have had an eye exam
% of diabetic patients with certain other disease complications and A1c ≥ 8%
% of diabetic patients withA1c ≥ 7.0%
Measurement period
You
Practice Fusion providers
You
Practice Fusion providers
You
Practice Fusion providers
% of diabetic patients withA1c ≥ 9.0%
% of diabetic patients with A1c tested in the last 6 months
% of diabetic patients who have had a food exam
Diabetic patients confirmed by ICD9 with and A1c test in the last 6 months (245/602)
Click here to engage your patients via email
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With population health management, patients get the care they need when they
need it, providers see better outcomes, and by reducing preventable critical care,
population health management lowers costs and save lives.
Margie To
"can lower costs..."
Margie To
I am not sure that it is true that PHM provides patients with the care they need when they need it. How about "with population health management, patients can get better quality of care..."
Margie To
"can see better health outcomes"
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Resources
+ For more information about Practice Fusion’s population health management offering, please visit: http://www.practicefusion.com/pharma/
+ For a quick, video overview of population health management: https://www.youtube.com/watch?v=C0w68xbDwEs
+ Set up a completely free, web-based EHR from Practice Fusion in less than 5 minutes: https://www.practicefusion.com/signup/
