Population Health

Population Health and Chasing the Care Management Dream

Healthcare is one of the most hotly debated topics ever to grace our dinner tables and Twitter feeds. Single payer or free market? Fee for service or value based? Enterprise or best of breed? The arguments could (and probably will) go on forever. But one idea is agreed upon by nearly everyone: what a patient should experience in healthcare facilities.

Imagine: You get a reminder from your PCP reminding you that it’s time to get a cancer screening. You’re able to book an appointment on the spot and quickly make an adjustment to your personal information (saved from previous appointments). At the appointment, your doctor administers the needed test and discusses your overall health with you. When you mention some persistent ankle pain, he asks a few questions and refers you to a local orthopedist. By the time of your appointment with this orthopedist, she has received your information. She eventually reaches a diagnosis and recommends surgery. Your information is seamlessly transferred to the hospital across town and, after your surgery, to a physical therapist.

Sounds great, doesn’t it? The picture of well-coordinated care is intuitive and looks nearly the same in everyone’s mind. So why isn’t this care management fantasy the reality everywhere? Because of disagreements and failures in the other five pillars of population health IT, as defined at KLAS’ Keystone Summit in 2016. Even a short list of roadblocks to care management can give us an idea of why the ideal eludes us.

Engaging the Patient

Nothing in healthcare gets done until the patient gets on board. That’s why patient engagement was identified at our Keystone Summit as one of the pillars of population health IT. Tools for secure messaging, patient outreach, and patient education are widely sought but rarely optimized by provider organizations.

Even when providers have tools for contacting us as patients, we don’t always make the process easy. Some of us are technology averse and have no patience for emails or patient portals, while others of us answer text messages but avoid phone calls like the plague. Providers can have a hard time pleasing and reaching everyone.

Addressing Gaps in Care

Once a patient makes it into the examination room, the provider’s responsibility shifts to addressing gaps in the patient’s care. But how does the provider find those? If the provider is exceptionally lucky, the EMR will present any gaps of care and suggestions for closing them without the provider having to leave the system or workflow. But this is advanced technology under the clinician engagement pillar of population health IT, and relatively few have access to it.

Financial models also come into play here. Many providers, particularly those working under a fee-for-service model, often receive pressure to see as many patients as possible in a day. They may feel too pressed for time to even look for potential care gaps, let alone address them during patient appointments.

Executing a Care Plan

The problems aren’t over when the provider reaches a diagnosis. Say the diagnosis is type 2 diabetes; the provider sees the need to help decrease the patient’s HbA1c levels but doesn’t necessarily know how to go about it. There have been order sets and care paths established for years; there are just so many options that the provider may not know which direction to take.

Digestible data about how other diabetic patients in the region have responded to certain care plans could certainly help. But that would require solid data aggregation and analytics (the first two pillars of population health IT). In addition, a care plan can’t be effective if it isn’t accessible across the entire continuum of care. Many of us know the pain of filling out the same paperwork at multiple facilities and retelling our diagnosis to multiple specialists. No wonder interoperability is hit so hard in the industry.

Bring on the Debates!

In considering the hurdles in care management, I have to commend care managers and care teams for their amazing work. The good they’re able to do, even with sometimes-stubborn patients and limits in technology, inspires me. But they shouldn’t have to face so many obstacles. That’s why I’m happy to listen to and even participate in the often-divisive discussions about healthcare. Only through making decisions, experimenting, and working hard in the other pillars of population health IT will we ever be able to achieve the care management dream we all desire.