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Population health addresses the particular wellness needs of a local or regional community. This could include age-related illnesses like heart attack or high blood pressure, or environmental factors such as air quality or prolonged stress. Population health management refers to the improvement of regional health outcomes through the identification and monitoring of individuals within a target group. Providers collect and analyze relevant data to create a comprehensive view of individual patients and local populations.
Physicians and providers throughout the healthcare continuum use various tools and methods to collect patient data. This includes information tracked by EHR systems, insurance claims, lab results, prescription patterns, referral data, and more. Successful population health management programs offer providers real-time data and updates that enable them to address gaps in care as well as new issues that may arise.
Fig 1 Data from Definitive Healthcare and Health Catalyst
When managing population health, it is essential that your practice or facility has a plan in place. The data you collect, as well as the methods you use, will depend on the results you’re aiming for. Before you begin gathering data, your practice or facility should be able to answer these questions:
If you’re looking to decrease the instance of COPD or lung cancer in your community, your practice could sponsor a smoking cessation campaign or host a support group for smokers. The purpose of this data collection is to understand the root causes of smoking, as well as the lifestyles of your patient population. Relevant data could include stress levels, socioeconomic class, individual and family health history, etc. The goal of this program would be to decrease the number of cigarette smokers in order to reduce the overall risk of tobacco-related illnesses.
Additionally, your physicians may have data on the length of time a patient has smoked cigarettes, but lack data on a patient’s employment—which could have an effect on smoking habits. Perhaps your patients don’t return surveys sent out in the mail, but respond well to surveys sent via email. Consider using incentives, like a gift card or free follow-up visit, to encourage more patients to share relevant information.
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|Newport Health Solutions||23|
Fig 2 Data from Definitive Healthcare based on hospital reports
Nurses play a critical role in treating patients and spotting trends in population health. They’re the first care providers that patients encounter, establishing a rapport and earning patients’ trust. Nurse practitioners can gather data and glean insights that a physician may not notice or have time to fully process. They are also more likely to hear patient concerns and frustrations regarding the check-in and appointment-making process, which are valuable insights and can be used to improve patient experience.
Additionally, because nurses see so many patients, they are more easily able to note when multiple patients are coming in with similar symptoms, or have similar environmental factors affecting their health. Nurses can tip off physicians if a large number of patients are visiting urgent care clinics between primary care appointments, which can indicate chronic health conditions or a spike in infectious diseases. Clear and efficient communication between nurses and physicians is important for patient and population health to improve care delivery as well as to improve data collection and understanding of a patient population.
Similarly, forging partnerships between physicians in the same geographic location or with those whose patient populations are facing comparable health issues can be valuable in many ways. Building affiliations with local hospitals and care providers allows physicians to refer patients to capable specialists, and can include the bonus of keeping a patient within one care network. Remaining within one care network holds financial benefits while making it easier for providers to coordinate care.
From a population health standpoint, data sharing between providers within one region can highlight widespread problems or common illnesses. It could also alert providers to specific regional health issues, such as low air quality, water contamination, or other environmental factors. Providers whose patient populations are facing similar health and wellness issues, even in distinct locations, can benefit from shared data on treatment methods and care outcomes.
Data collection and sharing has been made even easier with the near-ubiquitous adoption of electronic health record (EHR) systems, wearable fitness trackers, and other technologies. EHR systems allow providers to easily access and record patient data, which follows them to whichever care facility they visit. The ease of data collection also improves the reporting process, and offers greater insight into health and wellness patterns on a small scale within a community, or on a larger scale nationally.
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Fig 3 Data from Definitive Healthcare visual dashboard on Technology Vendor Market Share.
Ensuring patient access to their own health history and giving them improved access to their care providers increases the probability that they will be more involved in their care. Patient investment leads to better care outcomes, including lower readmission rates and reduction in care costs. Technology and communication enables providers to collect even more useful data on individual and population health. However, there is still no standard method of measuring the value of data that’s been collected—and such a method isn’t likely to debut any time soon.
What constitutes valuable or actionable patient data is very specific to the goals of an individual provider or care facility. Useful information could mean learning more about patient lifestyles, or it could mean analyzing historic claims data from counties with high rates of opioid dependence. Regardless, the role of technology in collecting, sharing, and analyzing data is unlikely to decrease in the near future.
Keep an eye out for the second part of this blog, covering technology implementations and physician burnout, which will be published next week.
To view a sample Visual Dashboard on population health, visit our database and click on the “Population” tab.
Read the Definitive Blog for more information on How to Leverage Big Data for Patient Care Management.