Population health management is a problem term because it can mean something different to each person who hears it. However, I believe that the words capture the overall spirit and energy of healthcare reform in a unique way. Providers are thinking big when it comes to a patient’s engagement, responsibility, and preventative care, and they’re leveraging technology to do it. I discuss an overall picture of PHM, present some useful technology, and tell a few PHM stories herein.

1. © 2015 Dr. Gordon Jones | Page #1
Curating
The Best of
Digital &
Population Health
Gordon Jones, DHA, MHSA, PAHM

2. © 2015 Dr. Gordon Jones | Page #2
What is Population Health and
Who are the Companies
Leading & Enabling It?

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Overview of PHM
1. Evolution of Population Health Management (PHM)
2. Why PHM Now
3. Elements of PHM
4. Visualize: Population Health Solution Stack
5. How Technology fits into PHM
6. Patient Outreach Focused PHM
7. Stories of PHM

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The Cost Problem

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The Payment Problem

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“Soon the Web-browser will be
as important to the physician as the
stethoscope.”

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“Michael Messer, MD in 1997”

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“Trusty stethoscope faces threat from
portable hi-tech.”

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“BBC article 2014”

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“Communication is not only important, but
without it, human life would be non-existent.
We have to be able to communicate on a
personal level, both verbally and non-verbally. If
we cannot have a face-to-face encounter, then
this requires access to clear audible and visual
capabilities enabled by technology.”
It all Begins with Communication

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% of 5,000 internet health users surveyed said
they would change doctors to one who would
communicate with them over the Internet – at
the time that translated into…
DHA Research on Health Communication
50
11
$3
%+ Americans not satisfied with the availability
of their physicians
Billion primary care dollars

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% of patients reported that results or medical
records were not transferred from one place to
another in time for an appt
% of patients do not get lab tests, special
referrals or follow up care that they need
% of adults report problems with care
coordination, notification of test results, and
communication among their doctors
20
36
50
Current State of Health Communication

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Current State of Health Communication

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% of doctors say non-critical paperwork has
caused them to spend less time with patients
% of doctors feel they are overextended and
overwhelmed, not good non-verbally
% of hospital executives said they still gather
outcome data by hand, hard to know their
patients in a timely manner
63
76
79
Current State of Health Communication

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Current State of Health Communication
“Hello,
I’m your
new
Primary
Care
Physician”
“Say ahhh
please”

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• Categorized by major
domains of healthcare
communication.
• Multi-channel approach for
client and patient support.
• Connecting patients with
the entire healthcare
world.
Current State of Health Communication

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Current State of Health Communication
DEVICE
SENSOR
GATEWAY MOBILE
NETWORK
CLINICAL
DECISION
SYSTEM
NURSE CALL
CENTER
DOCTOR EMR
PATIENT
PHARMACY LAB
TEC
NODES
l i n e a r t h i n k i n g

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“Its agreed,
we’ll teach
them how to
grow corn,
A History of Health Communication
but no one
says a word
about how to
get free
healthcare.”

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DEVICE SENSOR
GATEWAY
MOBILE NETWORK
CLINICAL DECISION
NURSE
CALL CENTER
PHYSICIAN
EMR
LAB
PHARMACY
Patient-based Communications
PATIENT
PROVIDER

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The Rise of the Engaged Patient

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Remote Patient Monitoring (RPM)

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RPM & Real-time Communications
Note: The marketing term “real time”is currently up for debate. Usually this means near real time (hourly or nightly). EHRsandlabs tend to refresh nightly or
weekly. However,the overall trend is for faster refresh rates across all data types.

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Honesty in Health Communications
I’d Never Admit
That to My Doctor;
But to a
Computer? Sure…
Hello Watson!

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Stratifying populations by risk
Identifying high-cost conditions
Deploying member engagement
strategies
around disease management
HMO vs ACO

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Defining Population Health Management
• Population health management is the process of
proactively monitoring and caring for defined
patient groups and includes these components:
• The central role of the primary care provider;
• The patient focus of care coordination provided
through wellness, disease and chronic care;
• The critical importance of patient activation,
involvement and personal responsibility.

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Evolution of PHM
• Payers/Employers deployed elements of PHM:
• Hired disease management and HMO firms
• Sponsored wellness and cessation programs
• Health coaching and alerted people to unmet needs
• Obstacles to Success:
• Mistrust of Insurance companies
• Low level of Physician involvement

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Evolution of PHM
• Health plans embraced vehicles designed to engage
physicians and healthcare organizations:
• Shared savings models, IPA, PHO, MSO
• Patient Center Medical Homes with financial
incentives
• Partnering to build Accountable Care Organizations

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Why PHM is Needed

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Why PHM is Needed
• Healthcare reform is driving a change in the way
healthcare is delivered– forcing providers to focus
on improving quality and reducing cost (shift from
volume to value).
• A plethora of new models:
• Meaningful use [of EMRs] is a “carrot and stick”
penalty/incentive program for providers who have
Medicare and Medicaid contracts.

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Why PHM is Needed
• Accountable Care Organizations (ACO) are groups of
doctors and hospitals banding together with payers
to assume responsibility (and risk) for a defined
POPULATION. The ACO earns rewards when they
demonstrate improved quality, lower costs.
–ACO Types:
»Medicare ACO
»Commercial/Private ACO, or other collaborative

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Why PHM is Needed
• Medicare ACO requirements and MU requirements
both have specific focus on prevention & wellness
and chronic disease management…because:
– 5% of the POPULATION is driving 49% of the cost (focus on the 5%)
– The name of the game here is: keep healthy patient POPULATION
healthy and keep the chronically ill patient POPULATION out of
expensive ER/hospital stays
– High cost chronic disease management: Hypertension, Diabetes, CHF,
COPD, etc.
– Prevention & Wellness: screenings, vaccinations, immunizations…

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Maximizing the Value of PHM
Primary Pillars of Population Health Management
Data
Aggregation
Combine patient data
from disparate
sources to achieve a
single view of the
patient
Risk
Stratification
Segment population
into sub-populations
(healthy, chronically
ill) to identify &
prioritize
interventions
Care
Coordination
Combine prioritized
patient lists with
care plans to
facilitate the right
interventions with
the right patients
Patient Engagement
& Outreach
Add scale & capacity to care
coordination & activate
patients with
omni-channel
communications
Data Integration  Communication Technology Infrastructure

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Elements of PHM

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Elements of PHM
Population
Stratification and
Segmentation
Propensityto Engage
in Health Programs
Enrollment
Consent
Preferences
Care Plans and
Work Flows
Clinical Care Pathways
and Application to
Manage Care and
Wellness Workflow
around Patients
Progress
Patient
Engagement
Omni Channel
•Voice
•Text
•Email
•Chat with a Nurse
•Talk to a Provider
•Remote Sensors
•Fitness Devices
•Video Consults
Measurement and
Outcomes
Improvements in
Efficiencies and Health
Outcomes
Improved Revenue and
Cost Reductions
Chronically Ill, Wellness and Prevention
Data Integrationand Communication Technology Infrastructure
GREEN: West solutions and services including
inbound/outbound IVR, call routing and
notifications, services for deployments and
integration to all major PHM platforms
Purple: Population healthcare platform
functions. (Current partnerships with
Healarium, WellCentive,IBM Curam)

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Healthcare For

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In any given
year, about
18% of
rising-risk
patients
become
high-risk.
Healthcare For

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Healthcare For

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Evolution of the PHM Affiliated Network

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Evolution of the PHM Affiliated Network

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PHM’s Affect on Physician Employment

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What do Providers Want
Source: Population Health Management 2013, KLAS

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Source: Population Health Management 2013, KLAS
Where PHM is Headed

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The Power to
Understand the Market
Breakdown of the Marketplace

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Central Themes of PHM
Data Aggregation: Combining patient data
from disparate sources
Risk Management: Segmenting populations to
prioritize interventions
Care Coordination: Directing providers’ efforts
Patient Outreach: Engaged, informed &
connected

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Population Health – CITI Overview
Citi makes a very early effort in the population health managementtrend to identify winners and losers (for
their investors),where most of the leaders are starting from an advantageous competitiveposition:
• Cerner - well establishedand growing footprint in the EMR market, already building out its vision (Cerner
Synapse brand) and population health managementsuite of solutions.
• Allscripts – clear vision for delivering a person-centric population health solution and has started to cobble
together an impressivecollection of assets. The growth in Population Health Managementcould prove an
important pivot point for the new managementteam;client retention remain risks.
• McKesson – a smart collection of assets and has a dominant exchange position through RelayHealth. Risks
include the company’s ability to retain its EMR and financial systemscustomers and execution at delivering
an integrated solution.
• Optum (UnitedHealth) – amassedan interesting collection of assets and has advanced payer tools, but a
cohesive provider strategy remains unclear. Partnerships with large IDNs and ACOs are an advantage.
• Healthagen (Aetna) – assets in exchange and patient engagement, plus in house development and savvy
business development initiatives. It remains to be seen if technology will be used to enhance their risk
book or if Healthagen can be payer-neutral and sell to ACOs.

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Population Health – IDC Overview
While a few leaders are identified in the
IDC report, the population health
managementmarket opportunities are
so dynamic that we will likely see new
entrants.
With the exclusion of just two vendors
(Wellcentive and Explorys), the rest of
the vendors are owned by companies
with multiple healthcare applications or
horizontal technology suppliers.
As a result, IDC believes consolidation of
the market is likely to be slow.
Note: PhyTel is not on this list

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Population Health – KLAS Overview
The most prominent market
analysis is provided by KLAS who
interviewed 78 providers about
their use of 23 vendors.
Points of note:
• Remains manual
• Patient reminders needed
• Limited stafffor PHM
• No consistent communication
• EMRs getting into PHM
Best of Care Coordination*
Strongest Owned Portfolio**
**PHYTEL
**MCKESSON (MEDVENTIVE)
*/**I2I SYSTEMS
**HEALTHAGEN
**PREMIER
**WELLCENTIVE
*EXPLORYS
OPTUM: HUMEDICA
THE ADVISORY BOARD COMPANY
CONIFER HEALTH SOLUTIONS
OPTUM: CARE SUITE & IMPACT
ECLINICALWORKS
VALENCE HEALTH
ALLSCRIPTS (DB MOTION)
COVISINT
*FORWARD HEALTH GROUP
TRUVEN HEALTH
VERISK HEALTH
ATHENAHEALTH
EPIC
NEXTGEN
CARADIGM
CERNER
EARLY LEADERS
PROVEN POTENTIAL
EMERGING STORIES

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Aetna
Aetna
Optum
Advisory Board
Humana
Humana
CareFX
Medtronic
Axolotl
Care Coordination and Patient OutreachFormation & Advisory
Data Aggregation and Intelligence Risk Management & Clinical Analytics
End-to-End
Population Health – End-to-End Overview

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Electronic Medical Record & PMS

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Data Analytics and Stratification

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Care Coordination

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Healthcare Communications

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mHealth, tHealth & Remote Monitoring

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Wellness, Rewards and Gamification

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Transparency Cost and Quality

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“Without automation,
PHM is an
impossible dream.”
Quote of the Day

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The Power to
Understand the Market
Health Information Exchanges
Understand the Market

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ONC HIE Program

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Private HIE Venders
KLAS Report Leaders:
• EPIC Care Everywhere
• Orion Health Collaborative Care
• Siemens MobileMD
• Covisint
• Cerner
• eClinicalWorks
• RelayHealth
• Medicity
• Optum HIE
• Dell

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Apple HealthKit & Health |Touch ID

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Apple & IBM
Mobility
Big Data
Analytics
Personalized
Healthcare

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Google Fit

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Consumer Data for PHM

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Consumer Buying Habits for PHM
Frequent credit card purchases at pizza
shops and fast-food outlets
Cigarette purchases at grocery stores
by consumers with bronchial problems
Frequent purchases of large amounts
of alcoholic beverages
No vehicle ownership
registration on file
May need advice on weight control or
diabetes and high blood pressure risks
Increased chance of visiting an ER to an
asthma attack
Possibly a sign of depression or
alcoholism
Could presage difficulty in reaching
schedule care appointments
Fallout in the frequency of drug refills
shown on a charge card
May require a reminder notification
from the PHM or a call from a nurse
The Data The Analysis

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Hospitals Are Mining Patients' Credit Card Data to Predict Who Will Get Sick
No need in trying to hide
anything fromme, I know
about your 2am Papa
John’s deliveries
Predicting Patient Health Risks for PHM

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The Power to
be Prepared Now
For The Coming Tide
Don’t let Patient Engagement…

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Don’t Be Your Hospital’s Global Warming

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Defining Patient Engagement
• Patient engagement is the process by
which patients become invested in their
own health. Health systems with effective
patient engagement programs provide
patients with the information and tools
needed to take control of their care.

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Patient Engagement Framework

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Myth #1: It’s Next Year’s Problem

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Myth #2: It’s an IT issue

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Myth #3: It’s Expensive
A 5% reduction in admissions,
readmissions and ER visits can
drive an additional
$25M in shared savings
in a patient-population of 100,000.

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Myth #4: People don’t like engaging
Patient channel preferences
(Frequency per year)
Not at all
1 time
2 times
3 - 4 times
>4 times

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Myth #5: Only the young use Digital
Digital interaction with
Payor or Health System
(at least 1 interaction)
today
future

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Myth #6: Mobile is the Game Changer

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Myth #7: Patients want features
Ranking of criteria for success of online/mobile proposition

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Myth #8: A comprehensive offering

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The Power to
Engage the Right Authority
The Power to
Ask the Right Question

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Patient Stratification for PHM

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Investment for PHM

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Market Segments for PHM
•Hospitals and Medical Centers
•Health Plans/Insurance Companies
•Home Healthcare
•Disease Management/Care Coordination
•Pharmacy and Pharma
•Accountable Care Organizations
•HMO | PHO| IPA | CIN | AN

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Executives to Engage about PHM
•CEO | CFO | CMO
•Chief Medical Officer
•Chief Information/Technology Officer
•Chief Transformation Officer
•Chief Nursing Officer
•Director of Patient Discharge
•Director of Case Management
•Office of Patient Outreach

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Some questions to ask on PHM
•What does it mean to you to engage a
population?
•Who in your market is responsible for
managing the population?
•How are you looking to use PHM to promote
your corporate strategy, it’s scalability and
sustainability of the system expansion?

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Some questions to ask on PHM
•How will you be using PHM to improve
coordination and information exchange
across all sites of care?
•Are you planning to use PHM to drive process
improvement, better patient outcomes,
minimize cost growth, stabilize existing costs
structures while improving efficiency of the
health system?

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Technology Strategies for PHM
1.Have a comprehensive technology Vision and Strategy;
2.One Size Does Not Fit All: A single method of physician-
patient communication will miss a lot of patients;
3.Leverage Technology for Provider Efficiency: Providing a
comprehensive view of all patients and efficient tools to
manage the care each population needs;
4.Workflow Integration: Align People, Process, and
Technology;
5.Security and Compliance Risk Mitigation: Manage liabilities
with the right security framework.

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Now You Know Me

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You’re Showing
Me You Know Me
Now You Know Me

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You’re Showing
Me You Know Me
Now You Know Me
You’re Showing
Me You Care

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All Populations
Healthcare For

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For More Information, please contact:
Dr. Gordon Jones
Curator of the Best in
Digital & Population Health Strategy
drj@curatinghealth.com
706-383-3776