Processes, Tools, Technology

Processes, Tools and Technology of Pop Health

Here are some brief definitions of several Population Health processes, tools, technologies:

The Processes:

  • Chronic disease management:
    • Chronic diseases relate to conditions such as congestive heart failure, diabetes, and renal failure, which consume a large percentage of the U.S. healthcare dollar.  Two-thirds of Medicare beneficiaries have two or more chronic diseases; 14% have six or more (3, CMS data).  While Medicare states the average annual per capita spending is $9,738, it falls to $2,025 for those with one or none, $12,174 with four to five conditions, and to $32,648 in those with six or more.
  • Preventive maintenance
    • Immunization schedules ( begin at birth and continue through adulthood to help prevent communicable diseases.
    • The U.S. Preventive Medicine Task Force publishes guidelines for health maintenance interventions such as colonoscopies, mammography and other screenings.
  • Care coordination
    • The process by which healthcare providers and organizations coordinate treatment/interventions longitudinally. This includes
      • Transitions of care - helping patients as they more across venues of care, such as inpatient/hospital to home care,
      • Palliative Care - including Hospice and comfort care measures for patients with end-stage terminal diseases/conditions, and
      • Patient-centered medical home (PCMH) - such as primary care physician leading a team-based approach to manage patient populations within their practice.
  • Patient engagement
    • Getting patients actively participating in their healthcare through improving access, transparency and patient satisfaction.
    • Includes allowing patients full access to their electronic medical record.

The Tools

  • Patient-reported outcomes - Tools to directly collect patient-generated data such as self-assessments and home collected data.
  • Social determinants of health (SDOH) - Collecting/determining factors such as income/poverty levels, living environment, work and social supports and correlating them to health risks and outcomes.
  • Telehealth - Use of technology to connect patients to healthcare resources including virtual care, education and public health.
    • Telemedicine - Subset of Telehealth dealing with clinical care.
      • Virtual (video) visits - physician/clinician visits typically requiring broadband Internet access and secure video conferencing to patients, not in the same location.
      • Virtual consultations - ability for patient-physician and physician-physician collaboration to occur via video conferencing, with neither in the same location.
    • Connected Health - Using technology to collect data from the home (and other remote locations) and importing it into the healthcare decision processes.
      • Remote patient monitoring - Use of FDA approved devices to record, transmit and monitor data such as vital signs, weight and oxygen saturation.
      • Consumer fitness/health monitoring - Use of consumer-grade devices for patients to voluntarily collect and share activity levels, weights, pulse and other metrics.
  • Electronic Health Records (EHR) - Digitalized medical records which are collected and stored within an electronic medical record (EMR) rather than on paper.
  • Comprehensive Health Records (CHR) - Contents of EHR plus genomic data (Personalized medicine), patient-collected data, and references to population baselines.  Essentially everything we know about our patients and their care.
  • Data and Analytics - Collection of data from the above sources analyzed to observe trends, and provide monitoring of the population to quantify outcomes.

The Technologies

  • Artificial Intelligence (AI) and machine learning - Using computing power to look at large amounts of healthcare (operational, financial and clinical) data to discover new correlations and advise on opportunities for improving outcomes.  (See AI in Medicine, Chang, 2016).
    • AI applications include "predictive analytics" for determining risk for potential hospital readmission or identifying other high-risk populations needing interventions.
  • Clinical Decision Support - Reminders and rules within information systems such as EHRs to monitor data and provide "real-time" triggers and actions, such as sepsis alerts.
  • Data visualization - Use of graphs and innovative methods to visually display data/information in a way that promotes understanding and produces a call to action.
  • Enterprise data warehouses - Collection of data from a variety of sources compiled for many uses including clinical business intelligence of the organization.  In healthcare, this typically includes revenue cycle information (e.g. registration, demographics, and claims data) as well as data from the electronic health record (EHR). Data visualization techniques produce reports and dashboards for the end-users.

[Return to Population Health Definitions]

Graph showing the percentage of Medicare recipients by number of chronic conditions. See Population Health Definitions
(2011 CMS data)

(2011 CMS data)

Bar Graph showing annual per capita Medicare spending based on number of chronic conditions to explain population health definitions.
(2011 CMS data)

(2011 CMS data)