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    Making population health work for small practices


    If a practice buys a population health management application designed to work with EHRs, he advises, “Tinker and get experience and see how it’s working, and begin the self-evaluation that’s necessary to effectively use the tool.” 


    Core software requirements

    The core domains of population health management are care management of high-risk patients, disease management to slow chronic disease progression and utilization management to control costs. To perform these functions, practices need the clinical data in EHRs, additional data from outside the practice, analytic tools to target practice resources where they will be most effective and software focused on care management, patient engagement and performance measurement. 


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    EHRs are at the center of these efforts, because they provide most of the data and the clinical workflow that physicians and practice staff use every day. But despite the recent efforts of EHR vendors to expand into population health management, experts say, systems still don’t support many of the key functions that this new approach to care delivery requires. 

    Farzad Mostashari, MD, the chief executive officer of Aledade, a company that manages 16 small primary care ACOs, says he thought that EHRs were going to be population health tools when he was National Coordinator of Health IT. 

    However, Mostashari says he realizes now that these are not population health tools, and that another layer of information technology is needed above multiple EHRs in ACOs.

    Most major EHR developers offer population health modules as add-ons. Some of these vendors, Barr notes, have obtained the National Committee for Quality Assurance (NCQA) “pre-validation” of their population health management modules. Under this program, applicants receive credits toward medical home recognition from NCQA for using these applications. 

    But Leah Kaufman, the organization’s external relations manager for recognition programs policy and resources, says that “a lot of EHRs don’t have the functionality necessary to identify high-risk populations and to implement evidence-based decision support and point of care reminders. So many practices are looking at [third-party] population health solutions that will interface with their EHR.”


    Workflow changes

    Health IT plays only a supporting role in the care redesign that has to occur in practices to manage population health effectively. 

    “Even if you had the best software in the world, that would be only 20% of what’s needed for population health management. Eighty percent is going to come from configuration, implementation and internal workflow and training,” says Holly Miller, MD, chief medical officer of MedAllies, a company that supports the use of Direct secure messaging nationally and does practice transformation work in New York, New Jersey and Delaware.

    For example, practices must hire the appropriate staff and make process changes to accomplish routine population health management tasks such as calling patients about follow-up care and tracking referrals. They must also learn how to use care managers to work with high-risk patients, how to identify those patients, how to improve transitions of care and how to manage care between visits. And most important for the bottom line, they must provide feedback to providers about their performance.


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    It is probably not possible to tackle all of these challenges at once. But by taking one step at a time and making good use of their EHRs, some of these groups have gotten to the point where they can use population health management software and have figured out a way to finance it.


    Government funding

    SAMA Healthcare used Medicare’s CPC demonstration project to fund much of its infrastructure for population health management. Under CPC, SAMA formed care teams and received monthly care coordination payments from multiple payers, including Medicare. The practice used that money to hire care coordinators and to transform itself into a patient–centered medical home.

    Next: How the software helps


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