Dr. Stephen Beck, CMIO at Mercy Health (formerly Catholic Health Partners) discusses how his organization has set the bar high when it comes to improving patient and population health.
Though “population health” means different things to different people, most definitions share a focus on improving the quality of care delivered across the community.
That’s certainly in keeping with our mission at Mercy Health (formerly Catholic Health Partners), Ohio’s largest health system, which serves communities across Ohio and Kentucky. Our population health efforts center on combining our Patient Centered Medical Home certification with deployment of embedded care coordinators across our enterprise.
Population Health Defined
In a March 2003 article for the American Journal of Public Health, David Kindig, MD, PhD, and Greg Stoddard, PhD, proposed defining “population health” as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” They argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.
At Mercy Health, we’ve set the bar high when it comes to improving the health of our entire patient population by focusing our efforts in two distinctly different directions:
1) leveraging the in-reach opportunity when clinicians can visit with a patient face-to-face or even virtually
2) capitalizing on outreach opportunities that happen across an entire patient population.
For instance, I can review an entire patient panel and communicate virtually using a specific message or reminder to everyone across the applicable panel. It’s just one way we can achieve our vision of raising the bar for a healthier community.
Our providers primarily focus on three specific disease states in their in- and outreach in addition to routine Health Maintenance:
- Diabetes
- Coronary artery and vascular disease
- Breathing disorders, like COPD or asthma
These conditions require regular follow-up for optimal management. Unfortunately, it can be difficult for patients to adhere to a strict follow-up routine because they are busy or simply cannot get to their physician’s office. Now we can come to them through communications that reach out into the community at large. Using the electronic health records, clinicians can search for a specific population within their panels — such as diabetic patients or those who recently visited the emergency department — to see who is due for follow-up testing and to review notes from the last provider. It also allows providers to check in with higher risk patients monthly if not weekly, depending on their health needs.
Sometimes patients need a push, something to motivate them to be accountable – this is easier when we have time to get to know the patients and understand their unique needs. Historically, the dental and veterinary fields have excelled with this type of touch with patients. Now, other medical fields are catching up as well.
Nurturing the Patient Centered Medical Home
By leveraging care coordination technology, we can focus on raising up the health of our entire community versus just working with one patient at a time. It gives us an opportunity to take some of the stress off both patients and care coordinators by replacing some of the in-person follow-ups with electronic communications.
Personal health devices, electronic communications and advanced health technology tools now make it possible for patients to take an active a role in their own health at home. In this way, the “patient-centered medical home” has taken on new meaning. By reaching patients at a population level, who are overdue for a visit or testing, we’re able to take the patient relationship to an entirely new level.
The Agency for Healthcare Research & Quality (AHRQ) defines the primary care medical home as one that provides primary health care that is relationship-based with an orientation toward the whole person. Decision-makers have abundant opportunities to promote patient involvement and to test new and innovative strategies for making healthcare more patient-centered.
Providers and staff like this functionality because there’s not enough time in the day to accomplish all they are tasked with. Right now, between Meaningful Use regulations, ACOs, quality measures, etc., they are asked to do more and more during visits with patients. All are tasks we want to do, but they each take significant time. What used to be a 10-minute visit is now a 30-minute visit and suddenly there’s not enough time in the day to see all the patients who are sick. That’s where coordinated care can help.
Coordinated Care At the Right Time
The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors, according to the Centers for Medicare & Medicaid Services (CMS) website.
To that end, over the past two years, Mercy Health has moved to an electronic health record system and has hired more than 30 nurse care coordinators so we can provide each patient with one-on-one attention.
Within the first quarter of implementing our focus on care coordination, we’ve made tremendous progress. For instance, we’ve seen a 66 percent increase (4,685 patients) in the number of patients in care coordination from January 1 to May 30, 2014. Admissions per 1000 (annualized) for patients in care coordination for more than six months has decreased by 24.1 percent; ER visits per 1,000 patients (annualized), by 27.6 percent; and inpatient days per 1,000 patients (annualized) by 24.8 percent.
The Future of Virtual Care Outreach
As we move closer to virtual care outreach, and as we integrate newer electronic tools and patient home devices like blood pressure meters, blood sugar monitoring and even the next generation of FitBits, our clinicians are able to gather significantly more patient-entered data. This, in turn, sends us in a direction that helps us better manage large groups of people. Nonetheless, we do look at this device integration with cautious optimism as there is always concern about the potential for data overload. But the ability to collect data we can then correlate, such as between weight loss and exercise or diabetes and blood sugar, has huge potential.
In the future, we’d like to continue to personalize messages to our patients. Part of this will be achieved through the use of electronic tools that enable outreach to patients due for certain types of tests or exams in a way that spurs them to action.
Each measure of patient care – from blood pressure to smoking cessation – adds up to improved care, so whether we’re encouraging the use of aspirin in patients with a history of coronary artery disease or advising weight loss or better nutrition for those with diabetes, we’re helping to encourage better health for the entire patient population.
Stephen Beck, MD, FACP, FHIMSS, currently serves as Chief Medical Information Officer at Mercy Health (formerly Catholic Health Partners). He has more than 15 years of experience in planning, implementation, training and follow-up of EHR installations in civilian and military populations and was one of the first physician users of a fully integrated EHR in Southern Ohio. Dr. Beck was among the first physicians to attain CPHIMS certification, has been a content reviewer for the HIMSS National Conference, and chaired the HIMSS National Professional Practice Task Force. He is a Fellow of both HIMSS and the American College of Physicians and serves on the HIMSS Clinical Decision Support Workgroup.
