Demographics, health status, diagnoses, services, costs and reimbursement across the care continuum are data prerequisites. While an integrated electronic health record would be optimal, work-arounds are available. Don't make the mistake of letting information technology integration become an obstacle on the critical path to population health; that's a certain strategy for losing the race.
Population health's goals require baseline measures of treatment costs and health status, and the tracking of costs and outcomes over time. Programs need to set goals, evaluate the impact of clinical interventions and monitor progress. A lack of project-management discipline, analytic capabilities, or a clear-eyed vision of goals are pitfalls that physician leaders should take steps to address.
Making an impact on population-health status and the cost of care requires care intervention designs. Choose specific subgroups that are outliers on cost and outcome metrics, and define changes to their care processes that will make a difference. This typically involves redefining roles, clarifying accountability and rethinking care paths across the organization.
Change-management leadership and the need for buy-in from the people on the front lines of care delivery will be critical here. Unfortunately, most people think change is a fine idea, as long as someone else does the changing. The ability to have constructive influence over the process will be essential to success.
A successful effort also requires building a comprehensive plan to capture, analyze, and utilize data on inputs and outcomes, which puts a premium on IT and analytic capabilities. Again, the EHR system doesn't have to be fully integrated to get effective efforts underway. Careful tracking of clinical interventions, costs, patient compliance, satisfaction and real-life outcomes (such as return to work, productivity, activities of daily living) will be critical. Even more important will be accountability for results from administrative and clinical leaders.
The role of “Dr. Population Health” also includes communicating progress to all levels of the organization, as well as creating a feedback loop that informs all stakeholders regarding plans, activities and results.
Organizations that don't own all of the components of the care continuum for their designated population will need to develop affiliations and partnerships with other providers. The central focus of those relationships should be on establishing accountabilities and demonstrating quality. Service-level agreements will play an important role in successful efforts. Such concepts are not “native” to the current healthcare system, so expect resistance and an extensive need for support.
Once the initial processes and expectations are in place, other new patient categories can be identified.
Population health management is a marathon, not a sprint—12 to 18 months is a reasonable amount of time to get an initial effort off the ground. The role of “Dr. Population Health” is ultimately to provide guidance on how provider organizations can develop and implement solutions that advance continuity of care and help manage costs.