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Michael B. Matthews
Richard Hodach

In the world of healthcare reform, population health management is increasingly a requisite core competency for healthcare organizations. But for a number of compelling reasons, health organizations would be well advised not to try to build the technology necessary to automate population health management. Most of the necessary tools are already commercially available, and few healthcare systems have the kind of expertise needed to create and maintain systems required to improve the health of their entire patient population.

To effectively provide population health management, a healthcare organization's care teams need to do more than simply attempt to address patients' care gaps during office visits. Automation tools are required to track the health of all patients continuously, whether or not they visit their physicians. For an organization to perform this tracking cost-effectively, it must use patient registries based on clinical and administrative data, as well as automated outreach, care management, and patient engagement programs.

Even academic medical centers have found it difficult to manage population health effectively for more than one or two chronic conditions. And if an organization tries to build its own population health management infrastructure one condition at a time, it runs a great risk of ending up with an impractical array of nonintegrated, nonscalable applications.

Providers that try to build their own population health management solutions must address myriad challenges: To start with, hundreds of clinical protocols must be imbedded in the registries to generate reports on population segments, stratify patients by risk, and measure performance. Data quality can also be a problem if, for example, data are missing from key EHR fields, have been entered in the wrong fields, or have been attributed incorrectly to providers. And already overtaxed IT departments must execute the mapping from EHRs and practice management systems to the registries.

Beyond creating their own registries, providers seeking to perform population health management need to be able to connect the care gap reports with outbound messaging to alert patients that they need to be seen. Without an automated way of making this connection, staff will tend to let patients fall through the cracks because they have more pressing tasks than calling the patients on the phone. Care managers, too, need automation software to help them perform interventions with the many patients who need different levels of support and attention.

There are additional compelling reasons for organizations not to build this complicated infrastructure themselves. These include development costs, knowledge acquisition, integration with other technologies, and the ability to comply with federal regulations, including the rules for meaningful use and accountable care organizations. In the end, however, the primary reason to buy rather than build tools for population health management is that developing and maintaining this type of technology is not the core competence of a healthcare organization.

Michael B. Matthews is CEO, Central Virginia Health Network and MedVirginia, Richmond, Va. (mmatthews@cvhn.com).

Richard Hodach, MD, PhD, MPH, is chief medical officer, Phytel, Dallas (Richard.hodach@phytel.com).

For more information, see Matthew's and Hodach's "Automation Is Key to Managing a Population's Health," hfm, April 2012


Publication Date: Thursday, April 05, 2012

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