Paper to Platforms: The Journey of Population Health Management

Ed Chung, MD

Physician Advisor

Edward.Chung@intersystems.com

Discussion points

• What is population health management?

• The three D’s of PHM

• The role of a health informatics platform

01

A historical perspective

We are in a post-data age

01

Yesterday’s challenge: get the data

01

Image credit: Juhan Sonin, flickr

Closer to the present

interoperability

01

analytics

business intelligence

informatics

benchmarking dashboards

silos

quality

Personal genomics

Photo credits: mjtmail, Ray_from_LA, Rev Stan – all on flickr

The ground is fertile

Predictive analytics

Rapid cycle improvement

The driver of PHM

01

Payment reform = move to fee-for-value

Payment reform

+ Fertile data ground

Population Health Management

What is Population Health Management?

01

Using data to optimize care for a well-defined

group of individuals

Why is it so hard?

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Why is it so hard?

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Instant Replay — A

Quarterback's View of

Care Coordination

Press MJ,

N Engl J Med 2014;

371:489-491

The three D’s of PHM

01

1) Data

2) Define

3) Drive

Data: Is it…

• Complete?

• Clean?

• Timely?

01

Key question: Do I have confidence in my data?

Why is it so hard?

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“Typical IT solution interface map”

• multiple formats

• multiple meanings

• multiple IT solutions

• multiple vendors

Define: Find the right patient population

• What is the clinical question?

• What measure am I trying to meet?

• Whom am I trying to target?

01

Key question: Do I have the ability to isolate and manipulate

this population?

Why is it so hard?

Then: Let’s look at our population of over-65 patients to make sure

they got Pneumovax.

Now: Let’s look at our Medicaid-eligible kids with inner city

residence, persistent asthma, and ED visit or inpatient admission in

the last year to make sure they’re on appropriate controller meds

and have an asthma action plan for school. And let’s slice the data

by their primary clinic and primary care provider to see where we

need to do the most reeducation.

01

Drive: Can I enable…

01

• Engagement?

• Action?

Key question: Can I put the right information in the right place

at the right time?

Why is it so hard?

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right

information

right time

right place

18

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Health Informatics Platform

• Enables the 3 D’s

• Strategic, foundational structure

• Minimize the number of pieces in your

foundation

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Health Informatics Platform

01

Image credit: Roger Perriss, Peter Curbishley, Vyacheslav Argenberg – all from flickr

Health Informatics Platform

• Success in PHM is directly proportional to

the strength of your health informatics

platform

• Achieve the 3 D’s (Data, Define, Drive) as

fully as possible

• Robust yet simple is the goal

01