Clinicians shape the future of population health platforms.
Health Plans

Asking clinicians to make a better population health platform

June 26, 2019
Clinicians shape the future of population health platforms.
Ronda Rogers

It’s no secret -- folks on the front lines of healthcare bear an inordinate technology burden. As members of the healthcare technology industry, we take that burden personally. We’ve been at the forefront of identifying and tracking physician satisfaction trends and witnessed the physician misery index’s ongoing rise. It is our mission to help restore the joy of medicine to physician practice.

This is, in part, what makes our collaborative approach with client clinical teams so special to Geneia. Having clear, unfiltered voices of those frontline care team end-users is crucial to Geneia's ongoing success. We understand that technology is a tool that brings together clinical, business and quality teams to improve the lives of the people they serve.

Let me share with you two typical ways technology and clinical services come together:

Identifying and prioritizing people by risk, especially those with rising risk

I’m first and foremost a nurse. I like helping people. As Geneia’s population health and consumer engagement director, I am able to help a lot of people. One of my biggest challenges and opportunities is getting ahead of disease and chronic conditions. All too often, people are unaware of the subtle signs and symptoms of pending disease until it is too late. Knowing who these people are and what is potentially ahead is a game changer.

Traditional identification and stratification technology is limited by the ability to only detect broad categories of risk, such as low, medium or high. This is a universal starting point, but it isn’t enough. The biggest opportunity to help people is before they become high risk. Identifying and stratifying populations based on rising risk is key to having the biggest impact on population health.

Meet Lucy

By way of example, meet Lucy* – she’s in her early 40s, is the mother of two teenagers, and the primary caregiver to her elderly father. Like so many Americans, she was unaware of her condition of prediabetes. Thankfully, she belongs to a health plan using the Theon® Platform for Population Analytics.

The plan’s HEDIS director regularly leverages the platform to review care gaps and key trends, such as body mass index (BMI), to generate lists of members with rising risk indicators for a metabolic syndrome diagnosis. These lists are shared with value-based physician partners, one of whom is Lucy’s primary care physician.   

Lucy’s physician ordered a fasting glucose test and confirmed the suspected diagnosis. The pre-diabetes diagnosis was shared with the health plan and that’s when the plan’s clinical team met Lucy. The team invited Lucy to participate in care management services, and found her to be willing and motivated. A care coordinator worked with her to understand what mattered to her on a personal level and together, they created a care plan that fit within her demanding lifestyle and was achievable for her. The strategy is small, manageable steps that empower people to reach their health goals. For example, one integral part of Lucy’s plan was a nutritionist who helped Lucy learn how to prepare quick and healthy meals for her and her family.

Over time, and with coordinated effort, Lucy’s prediabetes was reversed.

The elusive longitudinal patient record (aka 360o patient view)

Healthcare lags behind when it comes to understanding, anticipating and meeting people’s needs. Unlike the ubiquitous ATMs that all seem to know exactly how much money you have in the bank at any given moment, or retailers that excel in personalized shopping experiences, our nation’s healthcare system is largely a disjointed mess.

Don’t get me wrong, it’s getting better. Lucy’s story above is a great example of how it can – and often does – work. There are two key components that set Lucy’s experience apart:

1. Unified data source underpinning everyone’s view of the patient record.

When population health platforms combine and share clinical, claims and social needs data, then each end-user is better positioned to help the patient and the populations in front of them. Over the years, I’ve struggled with reconciling information between plans and multiple sites of care just to get a better understanding of immediate needs, never mind future needs. Having access to the same data as everyone else means patients get better care, every single time, wherever they go.

2. A patient record that makes sense

This shouldn’t be a big ask. We want our data and insights presented in a way that makes sense and is actually helpful in a clinical setting. We need to see care gaps to address, risk factors to consider, and social needs that create barriers to care.

Further, each member of the care team needs slightly different data and insights, presented in slightly different ways. Our social workers have data needs that differ from our nurses and nutritionists and these differ from the needs of primary care physicians and specialists. Clear, modular dashboards that allow each end-user flexibility, favorites and customization should be standard fare.

Patient experiences like Lucy’s should be the norm and, together with my team, we are driving improvements across clinical services and technology to make it so.

*Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.