How Small Practices Should Use Population Health Tools

By: on October 26, 2016

Small practices are ready for a big opportunity to improve patient care and offer better service. In other words, it’s the perfect time for them to adopt population health tools.

If you don’t know what that is, don’t worry—the term can be confusing and is more commonly associated with hospitals than private practices. In this article, we’ll break down what independent physicians need to know about population health.

Thanks to research firm Gartner’s Market Guide for Healthcare Provider Population Health Management Platforms (available to Gartner clients), we were able to evaluate key capabilities for population health systems.

We then chose the five that are most accessible for small practices, broke down how they work and gathered some real-world examples of EHR vendors that offer them.

Population Health and the Small Practice

It can be tough to predict whether a health IT initiative will take off or die out. For example: just when practices were getting used to the meaningful use incentive program for EHRs, it was replaced by a different program that’s raising concerns about physician participation.

All this uncertainty makes some small practices wonder what’s the best use of their limited IT budget. Why should they consider much-hyped population health solutions if there’s a chance they’ll become obsolete in a few years?

Well, population health is more than a buzzword—it’s a multi-faceted approach to health care with real staying power.

To explain why, let’s start with some important definitions:

According to the report “Understanding the Shift to Provider-Directed Population Health Management” (content available to Gartner clients), population health management (PHM) improvements include “decreasing disparities, improving access, increasing quality and lowering cost.”

Hospitals have been making big investments to achieve those results by spending money on new software to interpret clinical data, adjusting physician workflows and giving patients greater access to care teams.

Small practice physicians can’t afford to sit back and see how this all goes for the hospitals before they make their own PHM investments. That’s because population health tools will be necessary once value-based care reimbursements become the norm for all physicians.

Value-based care is a payment model that focuses on quality of care as opposed to the current fee-for-service model. It’s easier to report on care quality when you have technology that is designed to measure health outcomes. Below, we’ll show you five PHM capabilities accessible to small practices today.

Capability 1: Care Path Enablement

Care path enablement—The ability to enable care paths into the clinical workflow.

Source: Gartner Market Guide for Healthcare Provider Population Health Management Platforms

What does it mean?
There are many “care path” definitions out there, so we’ll keep it simple: A care path includes all the steps you need to treat a patient’s particular condition while taking into account wellness goals, evidence-based best practices and expected clinical outcomes. (See an example of an “obesity prevention and management” care path here.)

In EHRs with population health functionalities, you can create custom care paths for patients based on determining factors, such as diagnosis, lab results and age. So when a patient displays symptoms that correspond to one of the care paths you’ve created, the EHR’s workflow will automatically adapt to the appropriate order of clinical tasks.

What’s the benefit?
Care path enablement can be a huge time saver because it streamlines your care delivery, potentially allowing you to fit more patients into your schedule while maintaining a high quality of service for everyone. This is beneficial since most small practices need to see a certain number of patients per day to cover costs.

Example population health tool:
AdvancedMD’s HealthWatcher allows users to create customizable health plans based on clinical decision support and parameter-based triggers. Plus, appointment reminders like the one pictured below can be automatically sent to patients following a particular health plan.

A follow-up appointment reminder being set for a patient in AdvancedMD

Capability 2: Risk Stratification

Risk stratification—The ability to clinically and/or financially risk-stratify patient populations to understand risk profiles and areas of opportunity.

Source: Gartner Market Guide for Healthcare Provider Population Health Management Platforms

What does it mean?
From the clinical perspective, risk stratification is a way of identifying and predicting which patients are at risk of developing a worsening health condition. For example, which of your patients are at risk of contracting Type 2 diabetes based on their weight and exercise habits.

An analysis of the clinical data captured in your patient records can determine the level of risk among your entire patient panel, so you can dedicate extra resources (e.g., patient education materials, follow-up appointment reminders) where they’re needed most.

Thanks to PHM platforms, providers don’t need to hire data scientists to do this type of analysis. The program can automatically crunch the numbers for you based on EHR data so you can deliver targeted care.

What’s the benefit?
Risk stratification makes it easier to see who needs clinical interventions so you can make a positive impact by identifying potential illnesses early. Some practices even use the risk assessment itself as a clinical intervention.

That was the case in a university study that found patients who received personalized risk assessments for cardiovascular disease were twice as likely to consider risk-lowering options (e.g., lipid-lowering medication) than those who did not receive an assessment.

Example population health tool:
NextGen software allows users to group patients by chronic conditions, the severity of their illness and/or their demographics. Then, the system identifies which patients are at risk of developing a worsening condition. They are flagged “low,” “medium” or “high” risk so physicians can decide what the appropriate next step should be.

Patients’ risk level in NextGen’s population health solution. Source: NextGen

Capability 3: Gaps-in-Care Analysis

Gaps-in-care analysis—The ability to understand when a prescribed treatment protocol has been missed, and to identify this for a specific patient, as well as understanding trends in the broader patient population.

Source: Gartner Market Guide for Healthcare Provider Population Health Management Platforms

What does it mean?
Patients aren’t perfect. Even if you explain why a course of treatment is necessary to their well-being, they won’t always adhere to it. That’s why it’s called a gap in care: there’s a void between what you advise a patient to do and what they actually do.

A gaps-in-care analysis can help you see how many of your patients are complying with their treatment plans. In an interview with Austin Diagnostic Clinic CEO Dr. Ghassan Salman, he explains how their PHM-enabled EHR helps perform this type of analysis:

What’s the benefit?
This is really a win-win: You get to provide a more personalized level of service while keeping patients accountable for their own care. It shows patients you’re invested in their treatment plan and are committed to helping them when there’s a slip-up.

Example population health tool:
Athenahealth’s population health solution is capable of “delivering clinically relevant messages to the right patients at the right time to address preventive and chronic care gaps,” according to a product description submitted to Gartner researchers.

Capability 4: Value-Based Compliance Measures

Value-based compliance measures—For U.S. customers, the ability to report on measures such as the U.S. Centers for Medicare & Medicaid Services’ (CMS’s) 33 accountable care organization (ACO) quality measures.

Source: Gartner Market Guide for Healthcare Provider Population Health Management Platforms

What does it mean?
Value-based care models, which we touched on earlier in this article, are especially relevant to ACOs. ACOs are groups of medical providers and (in some cases) insurance companies that band together to provide higher-quality patient care, improve coordination and make more cost-efficient decisions. They must meet 33 quality measures in order to share any health care cost savings the group generates. (Read more about small practices and ACOs here).

Some PHM solutions come equipped with reporting functionalities that let you see your progress on individual ACO measures. This allows you to course-correct if you see deficiencies in a particular area.

What are the benefits?
Even if you’re not part of an ACO, you’ll still reap the benefits of easy-to-use, robust reporting technology. Unless you plan on becoming a concierge medicine practice that doesn’t take insurance, you will need to collaborate with payers that increasingly expect you to report on care quality measures. Software will only make this transition easier on your billing staff.

Example population health tool:
The eClinicalWorks CCMR solution features a dashboard with a series of charts that gives physicians a visually rich representation of the status of their ACO measures and other analytics data.

Source:  GroupOne Health Source

Capability 5: Patient and Consumer Engagement and Outreach

Patient and consumer engagement and outreach—The ability to provide some level of communication and information sharing between the provider and patient

Source: Gartner Market Guide for Healthcare Provider Population Health Management Platforms

What does it mean?
This capability is all about leveraging technology to give patients more fast, easy and HIPAA-compliant ways to connect with your office and access their health records.

An increasingly popular PHM tool is the patient portal. These are secure websites that give patients 24-hour access to medical services, messages and information. Portals can even help your office cut costs by digitizing manual tasks (e.g., billing and scheduling).

What are the benefits?
Portals provide greater opportunities for patient engagement. A study in the Journal of Medical Internet Research found that patients who used a portal to access their doctors’ notes were more likely to stick to their prescribed medication regimens.

Example population health tool:
Practice Fusion’s patient portal is included in its free EHR. It updates health data in real time so it’s up-to-date every time patients want to see information about their diagnosis, medication, immunizations and procedure history.

Source: Practice Fusion

Conclusions and Next Steps

“Population health” might seem like a nebulous concept at first, but we hope this article shed some light on it.

While big hospitals may have more resources to dedicate to PHM initiatives, small practices have the advantage of being more agile. Smaller teams means fewer people to train and fewer workflow integrations to figure out. Use this strength to your advantage and start brainstorming how PHM can become part of your practice.

In summary, here’s what we covered:

Population Health Capabilities and Benefits for Small Practices

Capability Small practice benefit
Care path enablement More efficient use of time
Risk stratification Better care for vulnerable patients
Gaps-in-care analysis More personalized service
Value-based compliance measures Easier reporting for reimbursements
Patient and consumer engagement and outreach Improved patient engagement

You probably noticed the example tools in this report came from EHR vendors. If you’re not ready to replace your system in favor of a more PHM-friendly one just yet, that’s alright. You can ask your product’s support team whether any of these capabilities are included in your software package or if you need to upgrade to a more comprehensive suite.

You can also sign up here to receive our monthly newsletters for more advice, articles and research to help independent physicians make sense of the changing health IT landscape.

The example tools featured in this report come from a list of the most commonly used EHR systems among solo practitioners. The data used to compile this list came partly from a 2014 survey of U.S.-based EHR software users and an analysis of Software Advice interactions with potential buyers.

Our advisors regularly speak with buyers who contact Software Advice seeking new EHR software. The data used to create this list was collected by our advisors during those interactions for business purposes, rather than for market research. We selected interactions with U.S. single doctor practices during June 2014 to June 2015, and counted the most commonly cited products they used.

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