Population health management: Part II

In my last post, I discussed the growing necessity of population health management to our healthcare system as a whole.

As providers face pressure to improve patient outcomes and manage performance-based reimbursement, influencing the population outside of the hospital is important. Service coordination that enables home-based care programs and mitigates socioeconomic challenges in chronic disease patients (including behavioral health) is at the crux of population health management. Caregivers coordinate a myriad of tools – data and analytics, pharmaceuticals, nutritional aids, medical supplies, diagnostics, multidisciplinary interventions – all with the goal of improving patient and health economic outcomes.

I’d like to focus this post on two key population health management factors – multidisciplinary interventions and remote monitoring. Multidisciplinary care involves both payers and providers, and begins with risk stratification. Targeting the riskiest members of a population provides those patients with the most attention and also affects the outcomes and costs associated with an overall population. This type of targeting can be done through a primary care clinic, a special group of providers, and/or through a payer. Case managers, nurses, doctors, pharmacists, medical technicians and other home health workers can work in tandem to keep their high-risk patients outside of the hospital 1.

Multidisciplinary care highlights everyone’s favorite topic, interoperability among healthcare IT systems. Delivering multidisciplinary care across settings (clinic, home, hospital) could be easier if accurate and timely information exchange could occur between providers, including home health providers. Interoperability could also cut down on the costs of repeat tests, missed information, and time spent recreating or verifying data. While this is a topic beyond this post, cloud-based analytic systems with end-user friendly interfaces are emerging. These data aggregators with analytical capabilities could solve some of the interoperability issues in health care, making it easier for stakeholders to assess, track and intervene in their populations. Providers don’t necessarily need more data, but data that isanalyzed for certain trends or warning signs could be make a difference in patient care.

Multidisciplinary care also calls for some providers to move outside of their clinics and hospitals and provide care in the home. Many frail patients have a hard time getting to their doctors’ offices and only receive care when events necessitate a hospitalization. Providers and payers are recognizing this, and there is an increase in the number of physicians making house calls. The American Academy of Home Care Physicians believes that home-based care has the potential to save Medicare 20 to 40 percent. The cost of 10 MD house calls could potentially offset one $1,500 ER visit 2.

In addition, the home (the least costly site of care) is benefiting from a variety of technological advancements in and out of healthcare. Mobile apps, miniaturized mobile medical equipment, tablets, and smartphones are all reasons that care can be provided more safely in the home. Remote monitoring devices in diabetic, hypertensive, pulmonary or congestive heart failure patients are doing more than emitting data; they are being coupled with analytics to provide early warning signs. Implantable devices are gaining monitoring capabilities that improve outcomes and decrease costs. For example, a recent study using an implantable device with remote monitoring for heart failure patients showed improved outcomes, likely due to the detection of trends allowing earlier intervention in a high-risk population 3.

As we continue to develop tools, products and services to meet the needs of Population Health Management, I will keep you up-to-date about new and innovative practices.


1.     Baldwin G. “Putting Together the Technology for Population Management Health Data Management” Health Data Management. August 2013 http://www.healthdatamanagement.com/news/population-health-management-chronic-care-stanford-clinic-46458-1.html

2.     Bouchard S. (ed) “Disruptive Innovators: Physician house calls making a return” http://www.healthcarefinancenews.com/news/disruptive-innovators-physician-house-calls-making-return?single-page=true July 2013

Marketwired. “IN-TIME Study Shows Significant Reduction in All-Cause Mortality in ICD and CRT-D Patients With BIOTRONIK Home Monitoring®” Sep 2013 http://www.marketwire.com/press-release/in-time-study-shows-significant-reduction-all-cause-mortality-icd-crt-d-patients-with-1826361.htm