Successful population health management blends predictive analytics, chronic care management, a timely feedback mechanism and measurable outcomes. It's a tall order, to be sure, but at the Healthcare Information and Management Systems Society's annual conference in Chicago, the Marshfield Clinic offered some insight into making it all work.
For starters, providers must see population health management as a lifecycle, said Kori Krueger, M.D., medical director for the Institute for Quality, Innovation and Patient Safety at the Marshfield, Wisconsin-based health system. Each step presents its own set of challenges but also an opportunity to incorporate technology tools to improve the care process.
Predictive analytics, for example, helps providers identify patients who might not otherwise present a risk of hypertension, Krueger said.
Hypertension is a specific area of emphasis for the Marshfield Clinic, which now ties quality metrics on controlling patients hypertension into physician salaries, according to Kate Konitzer, the system's chief informatics architect. Marshfield Clinic assigns care plans to patients, and physicians will see bright red notifications in their dashboards if a patient has yet to meet a goal within the care plan.
Then there's patient engagement, which is a growing priority for healthcare providers, according to the latest HIMSS Leadership Survey. Krueger pointed out that patients are all over the map. Some never contact the doctor's office. Some call every day. Some in rural parts of the state still lack broadband Internet.
To address this, the Marshfield Clinic encourages the use of electronic messaging--and 80 percent of providers now do, Konitzer said, compared to just 1 percent last year. This improved engagement, especially in between office visits, lends itself to a more timely and efficient feedback loop, she added.
Through the focus on hypertension, Marshfield Clinic has increased its blood pressure control rate--patients with a BP of 140/90 or lower--from fewer than 50 percent to more than 75 percent. Applying this information about patient health improvement to Centers for Disease Control and Prevention estimates, Krueger said the health system will be able to prevent 674 heart attacks and 169 strokes over the next decade, which will save the system close to $88 million.
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