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Automate Population Health to Manage Patient Care

Ten Ways Technology Can Make Providers Successful in PCMH and ACO Models

Issue:

Population health management is fundamental to every major health care reform initiative today, and is most visible in the Patient-Centered Medical Home and Accountable Care Organization. Although providers now have the incentive to implement Electronic Health Record (EHR) technology, EHRs alone are not sufficient to manage populations effectively.  Provider groups and health systems that automate the spectrum of population health functions will be best positioned to succeed. 

Purpose:

The purpose of the Automating Population Health Research Project is to help physicians and care teams understand how innovative use of technology beyond the EHR can make population management achievable. Automating population health management is a crucial step in achieving cost effective, patient-centered care.

Framework:

This project will help identify the key strategies to appropriately and continuously leverage technology to identify and engage a population, stratify risks, and measure outcomes within a primary care setting.  (See Diagram 1 below).   

Working with recognized health care leaders and researchers from a range of backgrounds and perspectives, the Automating Population Health Research Project will be focused on identifying practical and effective technology-based strategies medical practices and health systems can apply to the challenges of managing defined populations and not just individuals in an environment moving from volume to value.  The group will provide insights and recommendations in a variety of formats for industry consideration.  

The Automating Population Health Research Project is comprised of individuals from provider, health system, health information technology, academic, and health policy domains. This diverse group is well-versed in patient-centered care, health information technology and the imperative to transform health care delivery and performance in innovative ways.

Diagram 1.  Population Health Model

Contributing Executives:

Alide Chase, MS
Senior Vice President
for Quality and Service
Kaiser Foundation Health Plan, Inc. & Kaiser Foundation Hospitals

Robert Fortini
VP & Chief Clinical Officer
Bon Secours Health System

Connie White Delaney, PhD, RN, FAAN, FACMI
School of Nursing Professor & Dean
Academic Health Center Director, Biomedical Health Informatics (BMHI)
Associate Director CTSI-BMI
Acting Director of the Institute for Health Informatics (IHI)
University of Minnesota

Richard Hodach, MD
Chief Medical Officer
Phytel
Paul Grundy, MD, MPH
Global Director of Healthcare Transformation
IBM
President
Patient-Centered Primary Care Collaborative
Margaret O'Kane
President
National Committee
for Quality Assurance
Andy Steele, MD, MPH, MSc
Director, Medical Informatics
Denver Health
Michael B. Matthews
Chief Executive Officer
Central Virginia
Health Network
Don Fetterolf, MD, MBA
Principal
Fetterolf Healthcare Consulting
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