Population health technology is the engine that drives innovative value-based care models. It brings data from across the care continuum to achieve clinical integration, performs advanced analytics and facilitates efficiency and quality improvement.  At Valence Health’s further 2016 conference on value-based care last week, Children's Mercy and HealthChoice shared insights on population health technology: the key technology barriers, functionality that delivers the most value, and how technology is being used for value-based strategies and to achieve better health care at lower costs.

The key components of population health technology are quality-performance measurement, point-of-care workflow applications, care management and care coordination, payer financial analytics and advanced patient engagement.

The biggest challenge in population health technology is data integration. Luke Harris, director of network operations for Children's Mercy Integrated Care Solutions in Kansas City, Mo., says, “Integration is an extreme sport.” Ask about the value of the electronic health records data, know your vendor capabilities and look at the quality of the data. Prioritize and determine what EHR data components are most useful to standardize and normalize data across the continuum and develop a comprehensive patient profile from hospitals, community-based practices and third-party laboratories. Data integration requires detailed and action-oriented leadership and management in an ongoing effort to establish new data feeds, monitor data quality and resolve issues with the data.

Population health data infrastructure has two primary component data feeds: (1) clinical integration, and (2) payer data and pre-adjudicated claims. For payer data feeds, “Secure raw claims data directly from the payer,” recommends Daniel Clark, vice president of clinical informatics and analytics at HealthChoice LLC, a physician-hospital organization joint venture between Methodist Le Bonheur Healthcare and MetroCare Physicians in Memphis, Tenn. Unraveling payer and vendor payer data issues is complex. Find out who owns the data including related nondisclosure agreements. Negotiate what data are required vs. what data are available. Make sure that service line data are included; it’s often missing and is essential for bundled payments.

To find the opportunities for improvement, use quality-performance measures and then develop strategies. Harris says to allocate time for providers to develop trust and understand the data — four to eight weeks. Data transparency, recognizing and communicating data limitations, is a founding principle at Children's Mercy. With the emphasis on data transparency came changes in physician behavior. “Don’t underestimate the ability to motivate and influence physicians with transparency,” says Harris.

Clark adds, “Understand the gaps in the data and communicate the limitations to physician leaders.” He recommends regular drive-by reporting on what’s in the metrics and why it matters. Let performance variation reports and transparency drive discussion about quality and use value-based contracts to align on common targets.

“Population health technology is useless unless it reaches the point of care,” says Harris. To concisely and efficiently communicate the patient profile at the point of care, Children's Mercy uses a one-page face sheet with recommended care, conditions, care team members, recent inpatient, emergency department and specialty ambulatory visits. Technology must support the workflow and management of outreach activity. Patient outreach workflow is essential to drive cost and quality improvement. 

The care management and care coordination platform must deliver timely, specific, relevant data to support prioritization of high-risk and high-cost patients, readmissions prevention and optimal setting. To work, it needs staff resources from the practice or the network to support collaboration between care settings.

“To bend the cost curve, primary care providers need cost and utilization data,” says Harris. Cost and utilization reports need to be simple, meaningful and actionable with consistent representation regardless of payer.

The Uber revolution is underway in health care with virtual direct-to-consumer health care e-services for a more meaningful care coordination relationship and management. Advanced patient-engagement tools, such as health care mobile apps, hold much promise for remote monitoring to quickly identify and respond to deteriorating health conditions.