Hospitals in Indiana have a steep climb ahead of them to build sound foundations around the proactive, preventive approach to getting and keeping people healthy known as population health management. One of the biggest challenges will be to identify people with serious illnesses and follow them when they’re both in and out of medical settings. That requires comprehensive information.
What’s unusual for Indiana, in a good way, is that multiple health information exchange (HIE) operations have significant data repositories of intelligence on current encounters and trend-generating history of a good portion of the population, says John Kansky, president and CEO of the Indiana Health Information Exchange (IHIE).
In no other state could health care organizations go to HIEs and expect to find data they need “sitting there in a pile, ready to be utilized by population health initiatives,” he says. Combined with the Michiana Health Information Network (MHIN), exchanges have tremendous assets covering nearly the entire state, he says. Making use of the assets, though, requires specific objectives and deft reorganization.
Population health management comes in two basic varieties. The first includes initiatives to take on broad health-related challenges, such as reducing infant mortality. The second includes organized efforts to improve certain categories of care, patient by patient, such as staying vigilant to prevent the sickest of patients from having to be rushed to an emergency department or readmitted to a hospital days or weeks after a previous inpatient stay.
MHIN has developed a regional strategic plan that lays out clinical objectives for which to scan the entire population on a regular basis for the most pressing health care needs and develop information services to address them, says Al Gutierrez, MHIN chairman and president and CEO of St. Joseph Health System – Mishawaka Medical Center. Initial priorities include improvement of fetal and infant health, integrating primary care and behavioral health and close attention to transitions of care.
Concurrently, the information network is coalescing actionable data pertaining to performance indicators common to contracts with payers adopting value-based payment formulas, says Gutierrez. Multiple factors drive readmission rates, for example, everything from care disparities among minorities to socioeconomic impediments to post-inpatient recovery.
Both IHIE and MHIN have the capability to detect and issue alerts when patients show up in an ED, are admitted to a hospital or are about to be discharged. Software engines at MHIN recognize these separate pieces of information, check whether an accountable provider is associated with the patient in question and alert an assigned person in charge of coordinating the next step in care, says Kelly Hahaj, CEO of MHIN.
An analysis capability takes it further, such as picking up on situations in which home care is supposed to be arranged but wasn’t, making a patient vulnerable to not following treatment directions because of being home alone, says Gutierrez.
Every organization manages the receipt of data a little differently, says Hahaj. Most have a triage function for taking in and responding to the notifications their own way. “We find that some organizations are light years ahead; they have a care coordination team; they have their workflows and processes pretty well defined. And then we find other organizations that love the concept but are not ready to take that information because they don’t know how to internalize it and manage it.”
Health systems that IHIE talks with know that population health is important, but now they have to put the infrastructure in place to have an impact in that pursuit, says Drew Richardson, IHIE clinical data specialist. The vision starts big and gradually becomes more focused on specifics of the population and how to go about managing the challenge with systems, databases and research, he says.
Community Health Network is completing the first year of a complete redesign of primary care, including a close-knit array of care coordinators and clinicians who support activities directed by a network of about 250 physicians. Part of the plan is to identify first thing in the morning the high-risk, complicated patients that practices are about to see that day, says Douglas Stratton, CEO of Primaria, a separate company formed by Community to develop and manage a primary-care approach to population health.
Information support was an important component of the effort, marshaling data from both the practices’ internal electronic health record systems and from IHIE. Primaria helped the practice records capture patient acuity or level of complication and then summon recommendations on best practices for a particular condition, says Stratton. A full understanding of a patient’s recent history, wherever it occurred, is part of the preparation. “If a physician doesn’t know what’s happened outside of his involvement–his clinic and his office and exam room–there’s no way he can have the ability to do anything about it.”
Office staffing under the information-fueled redesign includes an additional registered nurse, a social worker, pharmacist and dietician. These professionals may support as many as 20-25 primary care physicians and cover multiple clinics, some of which may include up to 10 physicians, others four or five. Six months into the program, emergency department visits had decreased in the range of 15 percent, an early indicator that problems are being addressed up front, Stratton says.
The economic motivation to know all about high-risk patients extends to their contact with social services. In the scenario of the 85-year-old woman, she might have other struggles not readily known, such as lack of transportation or family support, that should have been flagged before she went home, says Hahaj. Many community organizations track such personal situations. Like hospitals that employ similar EHRs, social services use the same software system, but they’re still separate agencies tracking similar information, Hahaj notes. MHIN is gaining insight into the data collected and how to leverage the existing technical infrastructure to integrate community data under a memorandum of understanding with those agencies.
Whether medical or socioeconomic, data produced by a hospital system alone won’t suffice, says Craig Kinyon, president and CEO of Reid Health, Richmond. With links to IHIE, as well as HealthBridge–under which it monitors a service area extending into all or part of four counties across the Ohio border–Reid is able to broaden the radius in which patient data is accessible, he says. “Population health management is the ability to know that somebody has certain issues, diseases and so forth, and then be able to find them and then connect assistance to them to keep them from being admitted and then readmitted.”
That wide-area view is beneficial to two population-management initiatives operated by Reid at the nexus of information and care coordination: a transition coach program for patients in the first 30 days after discharge and the use of care coordinators stationed in each primary care office associated with Reid.
Both programs seek to keep people out of the hospital and have patients receive the bulk of their care in the primary care office instead of at the hospital, says Kay Cartwright, chief nursing officer and vice president for continuum of care. Reid has experienced a dramatic reduction in its all-cause readmission rate since the start of the programs, from 13.2 percent to 9.9 percent in three years.
As Reid moves forward with its accountable care organization and Medicare Advantage, says Cartwright, “being able to see that a patient was discharged from another facility that we didn’t know about would be beneficial. Our belief is that anytime a patient makes a transition, they’re at risk. So if we can pick up when a patient is transferred from one to another, then we can help them during this time.”