The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. This framework prescribes three goals that need to be simultaneously pursued to improve healthcare system performance, referred to as the “Triple Aim”:

1. Improving the patient experience of care (including quality and satisfaction)

2. Improving the health of populations

3. Reducing the per capita cost of health care.

The term “Triple Aim” refers to the simultaneous pursuit of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. IHI has developed a set of high-level measures that operationally define each dimension of the Triple Aim.

Based on six phases of pilot testing with over 100 organizations around the world, IHI recommends a change process that includes: identification of target populations; definition of system aims and measures; development of a portfolio of project work that is sufficiently strong to move system-level results, and rapid testing and scale up that is adapted to local needs and conditions. While the Triple Aim construct is being adopted by a number of leading healthcare organizations to frame their PHM strategies and operational plans, and IT framework across people, processes and systems to operationalize this is still a challenge for many organizations.

THE SIX (6) PILLARS OF POPULATION HEALTH MANAGEMENT (PHM) FROM A HEALTHCARE IT (HIT) PERSPECTIVE

So what is a systematic approach to adopting an IT model that will progressively enable an healthcare provider organization to enable population health management (PHM) and the ‘Triple Aims’ articulated above, without a high-risk ‘big-bang’ approach?

Given my conversations with healthcare industry thought leaders re: the state of population health management (PHM) it is clear that there is no end-to-end solution available today. However, there appear to be six emerging (some more mature than others) pillars enabling PHM at leading healthcare providers as below, and illustrated in this high level schematic below:

1. Population Health Analytics (PHA)

2. Population Health Segmentation (PHS) and Community Health Assessment (CHA)

3. Patient and Population Risk Stratification (PRS)

4. Patient Relationship Management (PRM)

5. Patient Care Coordination and Management (PCM) across the Continuum of Care

6. Population Health Integration Platform (PHIP)

Figure 1. The Six (6) Pillars of Population Health Management (PHM) from an Healthcare IT (HIT) perspective.

Let us take a look at each of these is some detail:

1. POPULATION HEALTH ANALYTICS (PHA) to monitor, measure, analyze, and improve metrics and KPIs associated with both Accountable Care Organizations (ACOs) (e.g. 33 ACO Quality Measures) and PHM such as PQRS quality and safety measures. It is a daunting challenge in most healthcare organizations to secure consensus on common definitions as basis for metrics and KPIs, with aligned incentives across the organization. Delivering an Analytics Platform across financial, operational, and clinical functions aggregating data from multiple disconnected Healthcare IT systems like EHRs, EDWs et al (see Population Health Integration Platform (PHIP) below) enabling simple reporting and analytics is a significant challenge today. Industry leaders like Intermountain HealthcareProvidence Health and the Cleveland Clinic have addressed these with self-service data discovery and visual analytics from Tableau Software. Providence Health (the second largest healthcare system in the US) has built a self-service data discovery, operational reporting and analytics platform called ‘Vantage’ leveraging Tableau, the brings together data from EPIC, Lawson, Press Ganey and other hospital systems to deliver 40 standard reports across 20,000+ users with adoption growing at over 15% per month. These standardized reports across financial, operational, supply chain and clinical functions (including physician scorecards) enables executives to monitor the financial health of the enterprise, operational supply chain efficiencies and benchmark physician utilization and performance. Adoption of this platform has increased physician productivity by as much as 8% in 12 months with measurable decrease in 30 day re-admission rates for PHM at Providence Health. As well, leveraging analytics has driven over a 100% improvement in colon, colorectal and breast cancer screenings impacting the lives of cancer patients in a measurable way. Adopting predictive and prescriptive analytics to augment PHM capabilities is on the horizon.

2. POPULATION HEALTH SEGMENTATION (PHS) AND COMMUNITY HEALTH ASSESSMENT (CHA) is a key enabler of PHM and is critical to assess the state of health of the population being served. Community Health Assessment (CHA) that is also referred to as ‘Community Health Needs Assessment (CHNA) refers to the process of community engagement, collection, analysis and interpretation of data on health determinants and health outcomes, health disparities, and identification of resources to fulfill these needs and ensure superior patient and population health outcomes. The CDC has identified and articulated 42 metrics for health determinants and health outcomes that if measured and analyzed, will provide healthcare providers with an accurate blueprint of the health of the population being served. These can then be leveraged to segment the population based on risk and cost to serve, to drive a pragmatic PHM strategy to deliver the highest quality of care cost effectively while managing risk. This is easier said than done today with many providers endeavoring to build out these solutions leveraging data from the CMS and other publicly available resources. Centra Force Health based in Austin, TX, offers solutions for Population Health Intelligence and Community Health Assessment, leveraging self-service data discovery and visual analytics from CentraForce’s technology allows for the location and quantification of nearly any population by disease type, payer type or other known at- tribute. Without risk or need for integration, providers and payers can leverage CentraForce’s non-PHI data to discover deep insights on populations of interest. Insights include behavioral/attitudinal, demographic, health conditions, health and healthcare provider data. All insights are provided for specific geographies – everything from zip code to county to city or state. These insights can be effectively leveraged for CHA and as basis for a data and insights driven PHS strategy and plan. It is estimated that effective CHA and PHS can help healthcare providers address PHM at a lower cost (5-10%) and risk thru proactive data insights driven strategies.

“Having an agreed-upon set of metrics can galvanize partners to work together to improve community health.” –  Community Health Assessment for Population Health Improvement, Centers for Disease Control and Prevention

Figure 2. This dashboard from Centra Force Health built on the Tableau Visual Analytics platform, is an example of a community health needs assessment (CHA) solution predicated on Population Health Segmentation (PHS). The data is segmented to identify female patients at risk for breast cancer within a certain population, as basis for proactive intervention.

3. PATIENT AND POPULATION RISK STRATIFICATION (PRS): is arguably, one of the most challenging aspects of PHM, demanding sophisticated machine learning, advanced predictive analytics software leveraging complex models to predict risk not only at an aggregate population level, but also at a discrete patient level. JVION, based in Atlanta, GA, has built out a comprehensive Patient and Population Risk Stratification platform with disease registries, quality and utilization analytics with benchmarking capabilities. The JVION platform leveraging visual analytics from Tableau, enables providers to typically reduce length of stay (LOS) by 10-12%, reduce 30 day re-admission rates by proactively identifying high risk patients for intervention, and improve total performance scores by 10%.

4. PATIENT RELATIONSHIP MANAGEMENT (PRM): To enable PHM, physicians, nurses and care teams must engage with and reinforce their relationships with patients across multiple online and offline platforms to ensure they are compliant with their appointments, medication etc. for preventive and chronic care. As well, these care teams comprising physicians, nurses, technicians, physician assistants, social workers et al. need to collaborate to optimize the quality and level of services offered. It is my observation that care teams are co-opting family and friends to enable a true ‘Patient Care Ecosystem’ to ensure a 360 degree approach as illustrated in the figure below. A PRM system needs to combine an electronic registry (drawing upon clinical data from EHRs and other clinical systems) and patient portals with automated communication and engagement leveraging call centers, video conferencing, tele-health, text messaging et al. to ensure optimal patient engagement. Leveraging sophisticated clinical decision support can trigger automated outbound calls, secure text messages and emails to patients to ensure they engage with their doctors and care teams on a regular basis. Companies like Greenway Medical provide PRM systems today.

5. PATIENT CARE COORDINATION AND MANAGEMENT (PCM) ACROSS THE CONTINUUM OF CARE: demands arguably, the broadest set of capabilities to support PHM, with some overlap with PRM. Coordinating care across care teams, providers, primary and ambulatory care settings, home and hospice based care is a huge challenge today. Integrating clinical decision support with evidence based clinical guidelines into patient focused care plans, with workflow and collaboration tools is key to metrics and KPI driven PHM. Proactive analysis of population health data to identify new candidates for program enrollment, and early identification and mitigation of potential gaps in care are key capabilities of these solutions delivered by companies like Caradigm and Wellcentive It is ironical that for small to medium sized healthcare providers, care management is still accomplished with rudimentary tools like Microsoft Excel that leads to a constant state of fire-fighting and loss of morale. Forward looking healthcare providers that are not yet ready for a complete PCM suite are embracing self-serviced data discovery and visual analytics solutions like Tableau to empower their care managers with real-time insights needed to coordinate and manage care across the continuum.

6. POPULATION HEALTH INTEGRATION PLATFORM (PHIP): will combine technologies like Extract-Transform-Load (ETL), Electronic Data Warehouses (EDW), Data Marts, Master Data Management (MDM), Business Process Management, Event Processing, Secure Web Messaging and Collaboration and similar technologies to enable the level of data integration, data management and data normalization needed to deliver real-time analytics and insights via the Population Health Analytics (PHA) platform (above) as well as the other processes articulated above, leveraging Big Data Platforms such as those provided by ClouderaHorton Works etc., and delivered for Healthcare by SI vendors like Clear Sense. It is anticipated that large healthcare systems and ACOs will bring together best-of-breed technologies and capabilities from multiple vendors to build their PHIP aligned with their Healthcare IT landscape, for the foreseeable future.

SUMMARY AND KEY TAKEAWAYS:

Population Health Management is still very much in its infancy and demands radical re-thinking of the status quo, not for the faint-at-heart. This demands a holistic approach across organization, culture, incentives and reimbursements, business models, people, processes and IT.

From an healthcare IT (HIT) and technology perspective, a framework for enabling PHM comprising six (6) pillars is emerging as we speak. These are:

1. Population Health Analytics (PHA)

2. Population Health Segmentation (PHS) and Community Health Assessment (CHA)

3. Patient and Population Risk Stratification (PRS)

4. Patient Relationship Management (PRM)

5. Patient Care Coordination and Management (PCM) across the Continuum of Care

6. Population Health Integration Platform (PHIP)

Does this framework and the six pillars resonate with your perspective for a pragmatic approach to Population Health Management (PHM)? What if anything has not been considered or discussed above?

As always, I welcome your comments and feedback here, on my blog, and on Twitter at @HITstrategy. If you have found these insights valuable, please subscribe to my Health Science Strategy Blog at www.HealthScienceStrategy.com with your email address or RSS reader.

Disclaimer: The perspective and views expressed in this Blog post are my own and do not represent those of my current or previous employers.