Population Health Management: What if it included Patients?

Being efficient at population health management that doesn’t include the patients that comprise the population is pointless. 

Suppose that on Thursday a meteorologist, or a sociologist, or a philatelist came to my little town located west of Philadelphia with the mission of reporting to their constituents the weather in Downingtown, Pennsylvania.  From three days of observation they would report the following—it doesn’t snow, the grass is always brown, and they skies are always grey.

Would they be able to produce a report that provided an accurate assessment of the weather of Downingtown, or would they only be able to produce a report of the weather for those three days?  If those individuals tried to forecast Downingtown’s weather for the year based on three days of extrapolated data they would be ridiculed, even worse, they would be wrong.

The biggest problem with most population health management efforts is that they overlook a critical success factor—the health of their patient population throughout the year.  It is too easy to scrutinize a patient during the short brief period prior to their visit, during the visit, and just after discharge.  Those are only snapshots of someone’s health, snapshots that discount what is happening during all of the days and weeks and months when the patient is not front and center.

Perhaps the second biggest problem when it comes to tackling population health management, managing the health of the population, is that the effort must include the population. Mustn’t it?  What I mean by this is the following.  Let’s say a hospital has a registry of three thousand OBGYN patients, and it discovers that one thousand of them are overdue for a mammogram.  It contacts those one thousand, and five hundred women respond and schedule their mammograms.  

Clearly, scheduling those five hundred women is a good thing.  Addressing their needs passes the test of being necessary, but it does not pass the test of being both necessary and sufficient. Doesn’t it beg the question about what is being done to manage the health of the other two thousand women?  Doesn’t it beg the question of what is being done to manage the health of the other women in their radius of service?

The problem lies with providers’ inability to interact all of the time with all of the people—patients, discharged patients, former patients, and prospective patients, that comprise the population.

Most population health efforts are based upon what the hospital knows about you, the patient.  These efforts rely solely on the data they have about you; business analytics, data warehousing, EHR—Healthcare Information Technology.

The can slice and dice your data, and the more they have the better they can manage you.  If the hospital sees you once this year, they get more data to slice and dice.  If they see you twice this year they may have twice as much data.

But for how many days of each year does the hospital not know anything about the health of the patient it is managing?  Three hundred?  Three hundred and sixty?

Glenn Steele, Jr., MD, president and chief executive officer of Kiesinger Health System stated “Another really good example: When we, as a group of providers, whether it’s docs or PAs or nurses or pharmacists, when we hand an individual who’s got a chronic disease a prescription, we assume that they, number one, agree with our recommendations for the treatment, and we assume they’re going to get the prescription filled. Those assumptions are wrong between one-third and 50 percent of the time. Isn’t that amazing?”

Hospitals have no way of knowing if their patients refill their prescriptions or take their medications.  If hospitals knew this information they would do a much better job managing the health of those patients who make up their populations.

For hospitals to know this type of information the model for population health management would have to change. It would have to go from a 1-way model to a 2-way interactive model.

One of the critical success factors for population health management is getting patients to take ownership for those parts of their health for which they can self-manage.  Twenty-one percent of American adults, more than fifty-five million people, use healthcare apps, and half of them use those apps more than once each day.

I use MyFitnessPal, a run-tracker app, and count my steps using my phone.  The last time I interacted my hospital was to schedule my annual appointment, and I had to call them to do it.

What if population health management were two-way?  Me to the hospital and the hospital to me.  What if my communication to the hospital was daily?  What if my hospital had a way for me to upload information about my workouts, my diet, my weight, pulse and blood pressure?  What if I could upload daily when I took my medication?

What if the hospital had a way of monitoring and responding only to data I submitted that was an exception?  What if the hospital could email or text me attaboys?

Twenty percent of the population are using apps and smart devices to manage their health.  Almost none of those twenty percent are using apps developed by their hospital.

What if?  What if they could?



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