The Next Step—Population Health Care Management

For the last couple of years, much of the population health market has been focused on data aggregation and analysis. Those are both big pieces; organizations absolutely need to have most of their necessary data together, and they need to have proper analysis on top of that in order to do anything useful with the information.

But now, the market is realizing that it needs more of the next step: the care management piece. There is some adoption, but there is not widespread adoption. However, there are some vendors out there, such as Enli, whose care management piece is their bread and butter. A lot of the other players in this space have either a newly developed platform or a limited adoption of it. The market is moving in the direction of care management, but it is still very much emerging.

Our recent Population Health Care Management 2019 report takes a closer look at what is happening in this space.

A Quality Longitudinal Record

Within care management, there are a few different facets that we wanted to dive into. One is the quality of the longitudinal record. We wanted to know whether these records provided actionable insights for their care managers. When done right, these records show the whole story of a patient and not just what is happening in the moment. For example, a patient could have a high A1c test result. However, if the provider only sees that one data point, is that result necessarily good or bad? If there is a longitudinal record that shows that this patient has a high A1c result, but it is down from where it was three months ago, then the real story is that the patient is actually showing some progress.

longitudinal record vs provides actionable insights

Care Gaps

We also asked providers about the vendors’ abilities to help close care gaps. Closing care gaps is a big deal because health systems must hit a certain percentage in order to meet the quality metrics that CMS requires. There are two ways to approach closing these gaps. One way is to get the information in front of the doctor when they're seeing the patient; that’s the most dominantly used way. The other way is to put the information with the care managers so that they are aware of what gaps there are. The care managers can then potentially reach out to someone to notify them of needed exams or procedures.

 Social Determinants of Health

Another big movement in the industry right now surrounds social determinants of health (SDoH). We had a lot of questions about the current state of SDoH capabilities for care management tools for population health. In the context of care management, what is being done with social determinants? Who's doing what? Are they bringing in the data? Are they doing that through assessments? Are they making a difference with it? It is intriguing to see that people are really interested in this area, but right now, despite all the buzz, there's not a lot happening. The biggest place we see that happening is in states that are doing Medicaid reform.

To learn more about the current and specific capabilities of each of the vendors in each of the areas, I recommend reading the full report.

What’s Next?

It is interesting to see that the list of vendors in this report is only about half of what we normally see in a population health report. Only two of the vendors—Enli and Epic—have tools that are fully rated. Then we have vendors like Arcadia and Innovaccer that have pretty new platforms, and their customers are really happy.

That being said, I think we will start to see greater adoption of care management modules in population health tools. Aggregating and analyzing data will only get you so far in value-based care. Much of that has to do with the goals of the health systems that are using population health tools. Maybe one system’s goal is to reduce their ED utilization in order to cut costs. Or, in another organization, the focus might be on reducing readmissions. How do you tackle these goals? A lot of the work can be done through care management.

One key thing that this report shows is that we need the EMR vendors to improve because providers are already looking to their EMR vendors for these tools. We know that some people are going that way because they've already invested in their EMR vendor and have little interest in adding a third-party tool. Population health care management needs the EMR vendors to step up their game in order to provide a better experience. The other thing that makes me excited about our findings is that those people that aren't in this report can step up their game for next year. We need them too.




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