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Population Health Cornerstone Summit 2017 Population Health Cornerstone Summit 2017
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Population Health Cornerstone Summit 2017
Pop Health Definition, Outcomes Measurement, and Best Practices

author - Mark Allphin
Mark Allphin
author - Taylor Davis
Taylor Davis
November 21, 2017 | Read Time: 13  minutes

As a follow-up summit to the 2016 Population Health Keystone Summit, executives from 23 healthcare services and software firms, along with leaders from 27 provider organizations and 7 payer organizations, gathered just outside of Salt Lake City. This white paper is a synopsis of the Summit activities and findings.

Population Health Definition, Outcomes Measurement, and Best Practices


As a follow-up summit to the 2016 Population Health Keystone Summit, executives from 23 healthcare services and software firms, along with leaders from 27 provider organizations and 7 payer organizations, gathered just outside of Salt Lake City. This white paper is a synopsis of the Summit activities and findings.

Summit Accomplishments

Updating of the 2016 Population Health IT Framework:
Participants reviewed data collected using the 2016 Population Health IT Framework and made updates in order to optimize research and provide clarity for future validations.

Creation of Population Health Services Framework:
A focused group of summit leaders created a services framework (similar to the Population Health IT Framework) that can be used for market clarity and 2018 research.

Provider-Success Best Practices:
Keeping in mind some common challenges identified in the 2016 Summit, vendor and provider Summit attendees collaborated to identify key best practices that enable provider success in the adoption of population health technology.

Vendor-Success Best Practices:
Keeping in mind some common challenges identified in the 2016 Summit, provider and vendor Summit attendees collaborated to identify key best practices that enable vendor success in the deployment of population health technology.

Creation of Population Health Vendor Outcomes Tool:
Summit participants created a research tool for measuring vendor-driven outcomes in population health IT and services engagements.

Population Health Technology and Services Framework

Provider organizations managing risk have access to a broad array of services and technology that can help assist the organizations in their efforts.

The functionalities and services that risk-bearing organizations need in order to manage risk are broad and interconnected. While the list below does not exhaust the functionalities and services that risk-bearing organizations may need, the items listed are needed by many of the organizations. Six key layers of functionality/service stand out as somewhat independent.

Functional capabilities and services that many providers require are grouped into three broad categories:

Advisory Services
While an organization can choose to draw on internal experience to build their strategy, it is critical that the organization starts with a strategy for approaching their population health efforts. In many instances, provider organizations must draw on outside expertise to create alignment and clear strategies for their specific situations, and occasionally, support the implementation of various valuebased care initiatives.

Technology can be a facilitator for organization strategy. Because many organizations have common strategies, organizations often require common functionalities. In some cases, services vendors operate the technology for these capabilities.

Managed Services
Organizations without the required manpower to implement their strategies can draw upon services firms, who can alleviate temporary or long-term gaps in expertise and staffing.


Data Aggregation

Definition: Compilation of disparate clinical/administrative data sources to support population health

Advisory Services

  • Data-gap analysis—assess the sources, structure and quality of the data
  • Development of a data-governance strategy
  • Development and implementation of data-governance training
  • Structural setup and training to ensure data integrity (i.e. data accuracy, completeness, timeliness)
  • Creation and implementation of data-use agreements and standards


Blue Text: 2017 Changes

Basic Functionalities

Aggregation of Tier 1 Data Sets:

  • Ability to incorporate data using common industry standards
  • Timely aggregation/incorporation of:
    • ADT feeds
    • Claims/payer data

Aggregation of Tier 2 Data Sets:

  • Inpatient clinical (EMR) data from disparate systems
  • Outpatient clinical (EMR) data from disparate systems
  • Incorporation of platform-generated data (such as assignments to registries)
  • Ability to normalize and clean incoming data
  • Reliable MPI (including duplicate-record merging/deletion)
  • Compilation of a longitudinal record (multi-sourced, longitudinal summary of all clinical activity, including clinical, claims, and care management interventions)
Advanced Functionalities

Aggregation of Tier 3 Data Sets:

  • Integration with other organization MPIs
  • Data-quality-monitoring tools
  • Advanced data-quality monitoring tools (automated recognition and flagging)
  • Aggregation of:
    • Patient-sourced data
    • Community health data/social determinants of health
    • Nontraditional data sets (i.e. public data sets, genomics, bio-marker structures, etc.)
    • Imaging data

Managed Services

  • Outsourced data aggregation services
  • Outsourced-data steward
  • Data-hosting services
  • Attribution services


Attribution services

Definition: Segmentation of aggregated data to present actionable insights

Advisory Services

  • Quality-measurement advisory services
  • Benchmarking
  • Prioritization planning and analysis of clinical and financial opporunities—identify priority list
  • Change readiness assessment


Blue Text: 2017 Changes

Basic Functionalities
  • Functionality to assign patients to registries (patient/risk stratification)
  • Configurable functionality to attribute provider to care team
  • Quality measures and analytics (including MIPS, MACRA, etc.) scaled down to individual facility/caregiver level
  • Consumable performance reporting (e.g. dashboards, visualization tools, etc.)
  • Common predictive analytics (i.e. readmission risk)
  • Goal targets/simple benchmarking (internal, static), including customized outcomes-measurement tracking
  • Regulatory-reporting compilation and submission (when applicable)
Advanced Functionalities
  • Advanced benchmarking (including external and dynamic benchmarks)
  • Tailored, advanced predictive/prescriptive analytics (i.e. AI, machine learning)
  • Analysis of data on social determinants of health

Managed Services

  • Data science as a service
  • Reporting as a service
  • Analytics as a service


Care Management

Definition: Scalable care management support for standardized interventions

Advisory Services

  • Care-plan redesign
  • Development of integrated population health campaign
  • Care management workflow design (i.e. how care managers use the care management tools)
  • Risk-adjustment consulting services
  • Analysis of care-settings gaps, strategic planning


Blue Text: 2017 Changes

Basic Functionalities
  • Configurable care plans
  • Program management (including care coordination and care management)
  • Ability for vendor/tool to compile patient’s care plans and import/export care-plan data
  • Tools for care managers (intrateam communication, reference materials, consolidated patient view, ability to identify and close care gaps)
  • Tools to manage care managers (monitoring of care management team, including time spent, members reached, programs initiated and completed, etc.)
  • Chronic-disease management
  • Online health-risk assessments
  • Care-manager view of longitudinal data
Advanced Functionalities
  • Ability to provide referral management guideline

Managed Services

  • Care management—outsourced care managers and care coordinators
  • Management and execution of integrated population health campaign
  • Behavoral health coordination
  • Risk-adjustment services (i.e. improve HEDIS, STAR, etc performance)
  • Transitional care management services
  • Disease management services
  • Quality management services


Administrative/Financial Reporting

Definition: Analysis of internal and external strategic programs

Advisory Services

  • Understanding total cost of care
  • Governance-model assessment
  • Network-strategy development
  • Assessment of clinician alignment and readiness
  • Network design and build
  • Development of contracting strategy
  • Insurance-product development
  • Employer-engagement strategy
  • Payer-contract negotiation


Blue Text: 2017 Changes

Basic Functionalities
  • Total-cost-of-care analytics
  • Financial-performance tracking under risk-based contracts
  • Integration into organizational-reporting dashboards (export/import capabilities into visualization tools)
  • Executive-quality performance tracking, including standard quality metrics (such as MIPS, UDS, HEDIS/Star Ratings)
  • Role-based dashboard reporting (clinician, executive, administrative, etc.)
  • Tools for tracking ROI of care management activities and programs
  • Dashboards with drill-down capabilities
  • Network-utilization tracking (including leakage tracking, steerage tracking, multiple-network tracking
Advanced Functionalities
  • Actuarial-contract risk analysis
  • Network-optimization analysis/modeling
  • Timely support for medical-economics analysis (opportunity and performance tracking within episodic and procedural bundling)
  • Service-line modeling (including activity-based costing)
  • Identification and management of high-cost care options (medication, procedures, diagnostics, etc.), including ability to authorize
  • Gainsharing tracking/windfall tracking

Managed Services

  • Provider-performance management
  • Quality reporting
  • Provider reimbursement from value-based care contracts
  • Network management—outsourced clinical and administrative leadership
  • Contract-management support
  • Certification services
  • Provider-sponsored health-plan administration
  • TPA services
  • Member-benefit coordination
  • Cost-management services
  • Actuarial and financial reporting
  • Utilization management
  • Pharmacy-benefit management


Patient Engagement

Definition: Patient-centric communication and alignment with health goals and improvement

Advisory Services

  • Develop patient engagement strategy
  • Benefit design
  • Wellness-program design


Blue Text: 2017 Changes

Basic Functionalities
  • Secure messaging between patients, care providers, and care managers
  • Tool set for automated, one-on-one patient outreach (via phone call, email, text messaging, etc.)
  • Patient education delivery (integration or native content)
  • Monitoring of patients’ satisfaction with providers and programs
  • Ability to stratify patients and tailor messages accordingly (precision questionnaires)
  • Tracking of patient preferences for communication
Advanced Functionalities
  • Full CRM tool set that includes an integrated patient portal and tools for patient outreach, education, satisfaction monitoring, and precision marketing (social media)
  • Management of unique circumstances (behavioral health, adolescence data)
  • Tracking of outreach efforts, including event tracking, management of closed-loop communication, and tracking of conversion/response rates
  • Interactive&nbps;patient-health dashboard with patient goals
  • Ability to show/estimate patient out-of-pocket costs (or ability to connect to a third party that can show/estimate costs)
  • Patient permissions for data sharing, data gathering, etc.
  • Virtual-engagement tools focusing on bidirectional communication and patient-generated health data (e.g. video visits, telehealth tools, and the intersection of apps and EHRs)

Managed Services

  • Consumer engagement and outreach services
  • Education and support for providers on end-of-life services
  • Health plan services (i.e. billing, member services, denials and appeals management)
  • Employer engagement—screening and wellness program with employer
  • Coordination of patient education programs
  • Member enrollment services
  • Call center
  • Patient-satisfaction measurement


Clinician Engagement

Definition: Actionable workflow integration for clinicians

Advisory Services

  • Design of clinician incentives and compensation
  • Facility-layout design in order to improve clinician efficiency
  • Development of strategic staffing plan
  • Physician-capacity planning (i.e. reduce workflow overload), optimization of MA workflow, identification of care gaps before physician intervention
  • Optimization of physician workflow to value-based care measures
  • Integration of analytics into clinician workflow


Blue Text: 2017 Changes

Basic Functionalities
  • Supports single sign-on integration with patient context
  • Workflow integration between the EMR and population health tools (including presentation in the EMR of care gaps and actions that may be taken)
  • Ability to integrate with multiple EMR platforms
  • Ability to track clinician usage and activity
  • Provides prioritized, role-based guidance to clinicians within a team-based care environment
Advanced Functionalities
  • Real-time, prioritized guidance on patient-specific care gaps and statuses
  • Integration of population health tools and EMR so that population health data and alerts are displayed within the EMR workflow and stored in the EMR
  • API-based integration with EMR solutions (FHIR or other API)
  • Functionality that encourages appropriate clinicianbehavior changes within a value-based care setting (quality measurements, personal income, patient cost of care, competitiveness with peers)

Managed Services

  • Co-physician leadership, building relationship (i.e. identifying who performs physician training and showing benchmarks for clinical leadership)
  • Clinician recruitment
  • Clinician education programs

Provider-Success Best Practices

In the 2016 Keystone Summit, vendors identified several common provider failures that hamper the success of healthcare provider organizations in adopting population health technology and advancing in risk-bearing activities.

The 2017 Summit explored these common failures further by identifying best practices for overcoming these challenges.

CIO, CMIO, and CEO Relationships: How can CIOs, CMIOs, and CEOs best work together to make population health efforts successful?

  • CEOs Must Lead Out on Strategy: Summit participants agreed that when the CEO does not lead out with a clear organization strategy, the organization’s leadership will almost always be misaligned.
  • The Board Can Help: If a leadership team is poorly aligned and lacking a clear strategy, the board can help cultivate discussions so that a clear strategy can be created.
  • First Step—Identify: No organization is perfect, but organizations can identify where they are and where they want to be. Leaders can agree that, for instance, clinical leadership is not being brought in early enough. Just identifying organization misalignments is a critical step.

Prioritizing Strategy Over Technology: How can provider organizations better align their strategies for population health?

  • Planning: Provider organizations need to decide now that they will not purchase technology until a clear strategy and proper alignment have been achieved. This disciplined planning helps provider organizations start with the end in mind. Participants indicated that a provider organization should identify the outcomes and the measures they want to uncover and then build a plan backward from there.
  • Key Stakeholder Involvement: Summit participants debated over who should be involved in the building of a population health strategy: executives or physicians? The consensus was that both of them, as well as everybody in between, should be involved. All key stakeholders need to be involved early in the planning stages of a value-based care strategy. While this process can be taxing, it can help speed the organization’s progress in the implementation of technology and services.
  • Governance: Summit participants suggested that stronger governance be established by providers. A provider organization should assign an executive leader, establish roles, and even align incentives in the form of compensation to ensure that the plan is implemented effectively.

Committing to the Future of Value-Based Care: How can provider organizations elevate risktaking activities from a side business to a core organizational focus?

  • Commitment: "Just do it" was a sentiment widely repeated by summit participants. They recommended that provider organizations start small and practice with initiatives that benefit both value-based care and fee-for-service efforts. Organizations should also take advantage of small at-risk contracts, such as MSSP, bundled payments, and contracts with employers/employees before moving to larger patient populations.
  • Incentives and Education: Organizations must create aligned incentives that drive physician-behavior changes and educate physicians on the importance of value-based care. Providers should align incentives to drive outcomes, which may include bringing in additional revenue from value-based care and improving gaps in care
  • Share the Risk: Provider organizations cannot accomplish value-based care alone. Several questions were posed about having vendors and providers share the risk for driving successful outcomes.

Vendor-Success Best Practices

In the 2016 Keystone Summit, providers identified several common vendor failures that hamper the successful deployment of population health technology solutions.

The 2017 Summit explored these common failures further by identifying best practices for overcoming these challenges.

Anticipating Complexity: How can vendors better understand and appreciate the complexity of these areas?

  • Discovery Phase: Before a vendor contracts with a provider, there must be a discovery phase during which vendor and providers honestly communicate about both what needs to be done as well as why an organization has specific goals. Vendors and providers must both insist on this phase. Vendors must give providers feedback when providers' eyes are larger than their wallets.
  • Tight Engagement Facilitating Communication: Vendor and provider leaders need to be tightly engaged and very honest with each other. This tight alignment allows each group to communicate candidly and often so as to identify where disconnections are occurring.
  • Overinvest in Implementation and Be Willing to Walk Away: Several vendors reported that their customer-success teams are larger than their engineering teams because they understand that every customer is very different. When a vendor realizes that a provider is unwilling to invest similar resources, they need to be willing to walk away. Specific examples might be when a provider organization has no resources dedicated to data governance or when a provider organization does not agree upon their own core workflows.

Getting the Right People into the Room: How can vendors better engage all key stakeholders and avoid limited engagement?

  • Vendor Empowerment: It is critical for vendors to have decided on situations in which they will call an all-out stop or pause when the right people are not in the room. These predetermined situations should include checkpoints to ensure that stakeholders are aligned and engaged.
  • The Right Stakeholder: Many participants said there needs to be a methodology from the vendor side to identify the right stakeholders. Other participants provided a list of questions to ask to get there. One provider suggested that vendors should ask whose lives the project will impact and then get those people at the table right from the beginning, even before the executive team, so that those stakeholders will not get blindsided.
  • Accountability: Once the right people are defined on each side, participants said both groups need to have a structured method to hold each other accountable on a consistent basis. This format should be periodic and cultivate deep discussions and feedback.

Avoiding Overpromising: How can vendors better align sales teams with delivery realities and still remain competitive?

  • Tie Incentives For Sales to Customer Success. The best situations exist when the salesperson is tied to all steps of the implementation and his/her compensation is tied directly to the go-live, customer satisfaction, retention rates, and success of the clients. Other incentive opportunities could include shared-risk agreements between vendors and providers.
  • Honesty (Candor) Is the Best Policy. Providers should be careful not to make an RFP so strict that it could prematurely eliminate a vendor without opportunities for explanation and understanding. One provider stated, “It’s a breath of fresh air when a vendor tells me a project will be really difficult or take double the time that a competitor claimed, and they stand out to me as an honest vendor. I want my vendor to be brutally honest with me.”
  • Clarity in Terms. Vendors should set clear contract terms and not rush the sales process. Providers are interested in knowing today’s reality as well as the road map for the future.

Amy Amick,CEO, SPH Analytics

Mary Alice Annecharico,SVP & CIO, Henry Ford Health System

Matthew Aug,President, Cox HealthPlans

Michael Barbouche,Founder & CEO, Forward Health Group

Mason Beard,Chief Solutions Officer, Philips Wellcentive

Rich Berner,SVP & GM, Sunrise, Allscripts

Tom Burton,Co-Founder & SVP, Health Catalyst

Kevin Carr,Partner & Physician Lead, PwC

Sean Carroll,CEO, Arcadia Healthcare Solutions

Donald Casey, Jr.,Chief of Clinical Affairs, Medecision

Dan Cerutti,GM, VBC Foundation & Population Health, IBM

Patrick Cline,CEO, Lightbeam Health Solutions, Inc.

Kevin Conroy,CFO & Chief Population Health Officer, CareMount Medical

Rachel Dunscombe,g>&nbps;Director of Digital, Salford Royal Group

Kirk Elder,CTO, Philips Wellcentive

Tina Esposito,VP of Information and Technology Innovation, Advocate Health Care

Keith Fernandez,Senior Physician Executive, Privia Health

Dody Fisher,Chief Clinical Officer, Forward Health Group

Dan Garrett,Partner, PwC

Art Glasgow,President & COO, Lumeris

Tee Green,Executive Chairman, Greenway

Shawn Griffin,VP of Enterprise Analytics, Premier

George Reynolds,Principal, Reynolds Healthcare Advisors

Bruce Rogen, MD, MPH,Chief Medical Officer, Employee Health Plan, Cleveland Clinic

Hoda Sayed-Friel,EVP, MEDITECH

Scott Schell,Managing Director - HealthPlaNET, UPMC

Amanda Wilson,Director, Clinical Program Administration, UPMC Health Plan

Patrice Wolfe,CEO, Medicity

Marvin Harper,CMIO, Boston Children's Hospital

Susan Hawkins,SVP, Population Healthh, Henry Ford Health System

Jon Hersen,VP of Care Transformation, Legacy Health

Jacquelyn Hunt,Chief Population Health Officer, Enli Health Intelligence

Alan Hutchison,VP of Connect & Population Health, Epic

LeRoy Jones,Founder, President, & CEO, GSI Health

Arthur Kapoor,President & CEO, HealthEC

Ken Lawonn,SVP & CIO, Sharp HealthCare

Sarah London,CPO, Optum Analytics

Kevin Lunn,Healthy Planet Implementation Team, Epic

Luis Machuca,CEO, Enli Health Intelligence

Mike McAfee,AVP of Technology Solutions & Population Health, Allscripts

Bridget McKenzie,CNO & VP of Medical Management, Conifer Health Solutions

Lee Milligan,CMIO, Asante

Melinda Muller,Clinical VP of Care Transformation, Legacy Health

Justin Neece,President & COO, i2i Population Health

Megan North,President of VBC, Conifer Health Solutions

Deborah O'Dell,VP of Business Intelligence, Catholic Health Initiatives

Brian Patty,VP and CMIO, Rush University Medical Center

Corbin Petro,President & CEO, Benevera Health

Katherine Schneider,President & CEO, Delaware Valley ACO

Shawn Stinson,SVP Managed Care and Population Health, BlueCross BlueShield of South Carolina

Mark Thomas, VP of Population Health, Washington Regional Medical System

Micky Tripathi,President & CEO, Massachusetts eHealth Collaborative

Amy Urban, DO,Physician Advisor, UPMC Enterprises

Russell Vinik,CMO, University of Utah Health Plans

James Whitfill,CMIO, Innovation Care Partners

Marc Willard,President, Transcend Insights

author - Robert Ellis
Project Manager
Robert Ellis
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.