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PHM - Critical Success Factors

Precise Patient Registries

Precise evidence-based definitions of patients in population health registries.

Active Wellness works by building precise population registries that are the foundation for effective population health management. These registries act as gatekeepers to managing health of populations of groups. Lack of precision defining of the populations health needs and concerns impacts adversly the strategy.

Traditionally, population cohorts have been defined using claims data, specifically ICD-9 codes. This limits the precision. Defining the patients in these cohorts, means organizations will likely miss out on 30 to 40 %of the patients that should be included into the registry. This inaccuracy in a fixed-price contracting model, will be financially devastating to the provider network / ACO.

Active Wellness Approach: Population Segregation Based Upon Clinical Data Such As

  • Lab results
  • Functional status measurements
  • Diagnostic imaging results
  • Medications
  • Claims data
  • Assessments & Health event data
  • Procedure codes
  • Clinical data on encounter and chronic disorders.

The active wellness solution allows collection of data in a single data repository. There is limited dependence on data, extracted and filtered from diverse data sources in an enterprise data warehouse (EDW). This allows the build of an accurate profile of a health state or disease (or other) patient state.

Data flows from transaction systems to the disease registry inference engine, then into the registry itself where along with other data about those patients, it is associated with the appropriate clinician, and made available for analysis in the context of population health management.

Patient-Provider Interaction

Strategies and algorithms to assign patients to physicians/clinicians.

Active Wellness resorts to a multipronged to address the most complicated aspects of population health management that is defining which provider is responsible for the patient. The creation of the patient’s care team is a multipronged multifunctional care team in the patient’s care. The Kin also form a part of the care team. The patient's relationship is defined in different ways. Physicians are either allotted by the the insurance company or by the organizations offering managed care packages. The Primary care doctor does not represent the reality of accountability regularly. Even though one doctor is assigned as primary care provider (PCP), the patient might consult other doctors at more frequent intervals—a specialist for instance, like an ENT or endocrinologist. Specialists are also assigned depending upon the care needs. The patient can have a say in the selection of his providers in the care team.

A common method for appropriately assigning and creating clinician-patient relationship is by using algorithms that can analyse a patient’s visit patterns. Determining the care needs. This kind of sophisticated assignment becomes necessary even more essential—and challenging—when assigning performance incentives back to the physicians that are managing the care.

We use multiple ways to create and assign care team members in a patient relationships. They are:

  • Patient selection of physician during open enrolment
  • “Most frequently visited” physician over the past two years
  • Geographical contiquity areas may determine assigning of primary care physicians
  • Employer population health plans assign primary care physicians randomly.
  • Assign specialist depending upon the care needs.

The patient can add his primary care physician into his care team if he has made a consultation with him

Precise Numerators In The Patient Registries

Discrete, evidence-based methods exist for flagging the patients in the registries that are difficult to manage or should be excluded

It is challenging to precisely define the patients that should be included in a population registry and assigning those patients to the right physicians. Identifying patients in the registries that are particularly difficult to manage is important. There are multiple reasons a patient may not be able to fully comply with clinical protocols. The Active Wellness platform address this. The Active Wellness PHR- EHR is capable of capturing data that reflects the non-medical indicators impacting health, and can impact delivery and compliance. These include:

  • Language barriers
  • Medication/Drug contraindications to participating in a care protocol
  • Physical disability to participate in a care protocol
  • Cognitive incapability to participate in a care protocol
  • Economic incapacity to participate in a care protocol
  • Geographic incapability to participate in a care protocol
  • Mortality (it can be surprisingly difficult to identify the patients)
  • Voluntary and informed refusal to participate in a care protocol, e.g., religious reasons

To be effective, the population management system must be able to flag such patients. They need special care management plans and processes to accommodate these patients and the physician’s time spent. Patients having these special limitations and needs , require a combination of subjective human judgment and sophisticated analytic technology. For example, it is not always easy to objectively assess whether a patient lacks the necessary cognitive ability to participate in a protocol. A clinician or a care manager who reviews the patient needs can flag and get the patient moved into another care process. The system allows them to manually flag these needs. We move these patients into home care, special outreach clinics, or assigning health coordinator.  

Clinical And Cost Metrics

Monitor clinical effectiveness and total cost of care for stakeholders

The next step in population health management is to measure the effectiveness and measure the variability in care in the practice of medicine. This is done through interactive dashboards that not only give details around specific patients but around patients populations.

Physicians have access to the quality, and outcome and also clinical variance with other providers. Physicians' performance may be highly variant in one area of care but their total care for all patients is low. In other words – the spend may be more in one area and this is not necessarily bad.

Basic Clinical Practice Guidelines

Evidence-based triage and clinical protocols help manage disease states

An effective population health management system describes how it will manage each population cohort. The use of evidence-based guidelines and clinical care pathways helps in achieving consistency in care. At the start, significant improvements in quality and cost of care are achieved by simply measuring and reducing variability in care. After standardizing shifting the common practice of that care to the right of the quality curve. The journey starts by encouraging the use of clinical practice guidelines for the patient cohorts and families that offer the highest opportunity for cost savings and improvement. The simple way to for identify theareas of opportunity is:

(Number of Patients in the Population) x (The Average Total Medical Expenditure (TME) per Capita)

Risk Management Outreach

Access to encounter data, laboratory, investigation results, and pharmacy data and clinical data.

Active Wellness platform has a comprehensive data acquisition and secure storage. Thus complicated integrations with multiple provider systems is not required and thus not a high priority. The comprehensive set of tools allows seamless integration of Lab and pharmacy data into the application. Start locally and then carefully and deliberately expand the boundaries of the care delivery ecosystem from those patients within the immediate influence of the organization to those at a regional level.

The Active Wellness Data repository allows a single comprehensive view of a patients data to all the stakeholders.

Acquiring External Data

Access and Integration of clinical encounter data, laboratory test results, and pharmacy data from hospital encounters

Active Wellness enables acquisition of hospital data by allowing on boarding of treatment done and discharge summary instructions. We do not suggest creating interfaces for on boarding hospital transactional data beyond what has been specified.

The future grounds for excellence in healthcare will be in data and optimal execution on the analytics of that data-- bricks and mortar care delivery sites will be the execution points of the clinical analytics.

Communication With Patients

Collaborative Care by engaging patients & establishing a communication system about their care.

The patient Portal takes the 3E's to the patient that allows his active engagement, enablement and empowerment for active participation in his health. — Active Wellness system combines the features of cloud-based health management tools with knowledge management tools (personalized health content, advice, suggestions and prompts), and ability to join patient support groups. The technology platforms allows easy access and is akin to ways they access in their everyday lives. A robust community network for sharing and networking by consumers with a robust communication system that allows patients to exchange email, text messages, and posts with members of his care delivery team. Patients own their health information and take more control and proactively participate in their own care.  They are no longer loyal to a physician; they are loyal to themselves and their finances.

Educating And Engaging Patients

Patient education material and distribution system, tailored to the patient’s status and protocol.

This is, of course, is closely related to criteria #8. The ability to deliver targeted content that is related to the patients conditions can be personalized and delivered to the patient. Today’s patients receive no education material about their condition—more likely, the extent of the educational material comes from the pharmacist about a medication. The built in drug, disease, condition and test knowledge libraries allows patient to know more about their conditions. The content is curated and focussed and is not an information overload.
The patients social network has focussed groups and forums where they can share their experience with other patients and get to know the treatments and learn from the experience of others. The community learning and sharing leads to active engagement of the patients.

Complex Clinical Practice Guidelines

Evidence-based triage and Care Pathways for comorbid patients.

Active Wellness brings access to Clinical Care Pathways. This reduces the need for establishing protocols from the start. Establishing protocols for comorbid patients is much more complicated than applying protocols for single disease states. Unfortunately, the reality of healthcare is that a large percentage of the patients which population health management should target are comorbid. It is an established fact that older age groups, are affected by at least three chronic diseases at the same time. As a first step reliance should be on multiple single-disease protocols applied to a single patient till multimorbid condition protocols are available.

Care Team Coordination

Inter-clinician communication and care management system.

The Active Wellness Communication manager is an effective system for managing populations. It is a futuristic robust communication system that automates and makes communication between patients and his care team in real time a reality. This replaces faxes, referral letters, the EMR Inbox, and telephones.

Our patient centric approach puts the patient at the centre of a care plan. Here all encounters preventive or acute sick event encounters have like in the care of projects goals and task assigned to them. The progress is tracked based upon the completion of these task successfully. Here care teams build and set recovery milestones and special care coordinator's help patients reach these milestones. For patient with chronic disease like diabetes, hypertension etc. we build care plans that address short term and long term objective and actually are lifetime care plan for remaining healthy and adverse event free. If they is a deviation and the health of the patient starts falling out of the expected and projected trajectory for his health state there is an Early Warning System that alerts the care teams to make proactive interventions. Through this proactive approach we bring the patients back on the charted path.

All members of a patient’s care management team shall be able to quickly and easily see the patient’s overall project plan, next milestones, and the responsibilities of each member.

The Active Wellness Ecosystem thus establishes close coordination between the care team members. The unique PHR-EHR interface is beyond the EMRs that are designed for the limited purpose of being encounter management tools (and aren’t even particularly good at that). The Active Wellness PHR- EHR is more like a Care Plan project management. Here the ecosystem interface allows building of Care Plans that would also display the individual encounter. It is the long-term care plans and goals for chronic condition management or health maintenance for that patient, and the patient’s population that deliver value to all. There is complete transparency and every member of the care team—including the patient or a designated family member—would be able to monitor what everyone else was doing along the care plan.

Tracking Specific Care Outcomes

Patient-reported outcomes measurement system, tailored to the patient’s status and protocol.

An engaged patient can generate outcomes. The patient reports and updates his health state through alerts and easy to answer questions or capture of data. This is through devices and measurement systems. Coupled with the methods of engaging and communicating with patients, the outcome of every therapy and medication is captured. This Patient-reported outcomes data is one of the most important pieces of data missing from our current ecosystem that Active Wellness addresses. This goes beyond the patient satisfaction surveys, but captures data that aids in measuring actual clinical outcomes. The clinician has the ability to initiate an outcomes survey automatically, tailored for the patient based upon the patient’s diagnosis and treatment plan. This additional outcomes data that is collected is integrated back into the patient’s record in the PHR-EHR and then exported to the EDW for analytic purposes. 

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