The 12 Criteria of Population Health Management

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The 12-Criteria of
Population Health Management
By Dale Sanders

Contact Information
Dale Sanders, Senior VP, Strategy, Health Catalyst
dale.sanders@healthcatalyst.com
@drsanders
www.linkedin.com/in/dalersanders/
Carrie Ivers, The Advisory Board, Crimson Product Line
iversc@advisory.com
512-681-2383
www.linkedin.com/pub/carrie-ivers-reeuwijk/0/692/824
2

Agenda
• Dale Sanders: 35 minutes
• Description of the 12 Criteria for Population Health
Data Management
• Carrie Ivers: 25 minutes
• Description of Crimson’s capabilities and strategy
related to the 12 Criteria
• Q&A
• We will stay online as long as it takes to answer all the
questions
3

Our Philosophy
4

The Supporting White Paper
Google: ―12-Point Review of
Companies‖
5

Overview
• Evaluate healthcare IT vendors and their PHM offerings
• Develop internal strategies and roadmaps for Accountable Care
Organizations (ACO)
Focus is on the data management of
Purpose
• Not the processes of PHM, per se
• Not on activity based costing and fixed-price (bundled
pricing) contract management– that’s a separate webinar

Today’s Key Takeaways
• The ROI of Population Health Management (PHM) is
still in debate
• Investment is costly, returns are challenging
• 40% of healthcare is patient lifestyle related
• Focus on the highest ROI areas of PHM for now
• Stratifying population risk makes no sense without a
strategy for intervention
• And focusing on the highest risk patients might have the
lowest ROI
• No single vendor meets all PHM needs
• You’ll need a patchwork of solutions to fill the gaps
• ―So you offer PHM, eh? OK, which parts?‖
7

True
Population
Health
Management
8
Robert Wood
Johnson
Foundation,
2014
Requires a collaborative
strategy between leaders in
healthcare, politics, charity,
education, and business

The Ordered Checklist for Your 3-5 Year Journey
1. Registries: Evidence-based definitions
of patients to include in the PHM
registries
2. Attribution & Assignment: Clinician-
patient attribution algorithms
3. Precise Numerators: Discrete,
evidence based methods for flagging
patients in the registries that are
difficult to manage in the protocol, or
should be excluded from the registry,
altogether
4. Clinical & Cost Metrics: Monitoring
clinical effectiveness and total cost of
care (to the system and the patient)
5. Basic Protocols: Evidence based
triage and clinical protocols for single
disease states
6. Risk Outreach: Stratified work queues
that feed care management teams and
processes for outreach to patients
7. External Data: Access to test results
and medication compliance data
outside the core healthcare delivery
organization
8. Communication: Patient engagement
and communication system about their
care, including coordination of benefits
9. Education: Patient education material
and a distribution system, tailored to
their status and protocol
10. Complex Protocols: Evidence based
triage and clinical protocols for
comorbid patients
11. Coordination: Inter-physician/clinician
communication system about
overlapping patients
12. Outcomes: Patient reported outcomes
measurement system, tailored to their
status and protocol

CRITERIA
Precise Patient Registries
Evidence-based definitions of patients to include in population health registries
1
Must go beyond
ICD codes, which
are likely to miss
30-40% of the
population

CRITERIA
Patient-Provider Attribution
Strategies and algorithms to assign patients to accountable physicians or clinicians
2
Generally accepted options for assigning attribution
Patient selection of
physician during
open enrollment
―Most frequently
visited‖ physician
over the past two
years
Random assignment
of patients to primary
care physicians in
the same geographic
area
Random assignment
of patients in an
employer group to
primary care
physicians in the
PPO or HMO

CRITERIA
Precise Numerators in Registries
Discrete, evidence-based methods for flagging the patients in the registries
that are difficult to manage or should be excluded from PHM, altogether
3
Reasons why a patient may not be able to fully comply with clinical protocols
Language barriers
Cognitive inability to participate in a care protocol
Physical inability to participate in a care protocol
Economic inability to participate in a care protocol
Willing and informed refusal to participate in a care protocol, e.g. religious reasons
Medication contraindications to participating in a care protocol
Geographic inability to participate in a care protocol
Mortality (it can be surprisingly difficult to identify these patients)

CRITERIA
Clinical and Cost Metrics
Monitoring clinical effectiveness and cost of care to the system and patient
4
Measure practice of medicine against these protocols
Measure the variabilityin care
Builddashboards around specificpatientsand populationof patients
Musttrack the total cost of care for specificpatientsand a per-capita basisacross the population
Provide quality,outcome, andcost variance feedback to physicians,risk adjusted,at the point of care
Ultimatelythisprepares an organizationfor fixed-feecontracting in a true value-basedsystem

CRITERIA
Basic Clinical Practice Guidelines
Evidence-based triage and clinical protocols for single disease states
5
Number of patients
In the population
The Average Total Medical
Expenditure (TME) per CapitaX( ) ( )
Measure the practice of medicine against these protocols
Current evidence-based medicine lacks applicability outside the specific clinical trial
In the future, clinical trials’ “evidence” will be displaced by derived evidence from the analysis
of local data sourced by the EDW
In the meantime, the industry must make-do with existing evidence and guidelines
Many external commercial sources and commercial vendors
Health systems need to establish a “Clinical Practice Guidelines” governance body and select
their source(s) and processes
Start by defining clinical practice guidelines for patient cohorts and process families that offer
the highest opportunity for improvement and cost savings
High Opportunity =

CRITERIA
Risk Management Outreach
Stratified work queues that feed care management teams and processes
6
First need to stratify and monitor the registry
patients
Then develop strategies to identify and intervene
with high-risk trajectory patients
Ultimately need to profile and proactively treat
patients before becoming members of the registry
Risk stratification enables an organization to analyze and minimize the
progression of a disease and the development of comorbidities

Be Careful What You Ask For
Correlation
Patients with the highest satisfaction scores =>
• Higher rate of hospital admissions
• Prescribed more medications
Unpublished, internal data analysis; Northwestern University Medicine
Enterprise Data Warehouse, 2008
We were not the first or only organization to see this trend

Strategies for PHM Intervention
1. Disease management — Example: Diabetes management
programs
2. Catastrophic care management — Example: Programs to reduce
risk for individuals with a high risk of developing conditions that lead
to catastrophic healthcare costs (e.g., cancer, brain injury)
3. Demand management — Example: Nurse call lines
4. Disability management — Example: Employer-sponsored
programs to reduce disability days and costs
5. Lifestyle management — Example: Seat belt compliance
campaigns, smoking cessation programs, weight management
programs
6. Integrated care management — Example: Programs that integrate
other types of interventions (e.g., catastrophic care
management,disease management and demand management for
cancer patients) with shared outcomes and monitoring over time
17
From Becker’s Hospital Review. Connie Evashwick and Ann Scheck McAlearney, at the American College
of Healthcare Executives' 57th Congress on Healthcare Leadership.

Caution of Paradox
―…population strategies which focus on reducing the
risk of those already at low or moderate risk will often
be more effective than strategies which focus on high
risk individuals at improving population health in the
long run.‖
18
Recommended reading: Geoffrey Rose, “Sick Individuals and Sick Populations”,
International Journal of Epidemiology 1985;14:32–38.
Gordon Norman
Chief Medical Officer, xG Health Solutions

CRITERIA
Acquiring External Data
Access to clinical encounter data, cost data, laboratory test results, and
pharmacy data outside the core healthcare delivery organization
7
Contrary to current national strategy and focus, acquiring external data should
be a secondary focus in today’s market
It is geometrically more complicated to manage a patient
population beyond the core healthcare delivery organization
Start with in-house process and data quality first
Then, carefully and deliberately expand the data ecosystem
HIEs are the most visible technology associated with ACO
external data exchanges, but only address a small portion of
the data puzzles required for PHM
The ―A‖ in M&A will shift from bricks-and-mortar acquisition to
data acquisition

CRITERIA
Communication with Patients
Engaging patients and establishing a communication system about their care
8
Current solutions are fragmented and immature but will improve dramatically in
the next 3 years
Today’s typical patient engagement solution is through a
personal health record (PHR) tightly associated with a
healthcare delivery organization EMR
The future patient engagement solution will be completely
patient owned, decoupled from an EMR or single
healthcare organization
The PHR will evolve into a personal project management
system, with a combination of project management,
knowledge management and social support.
Take advantage of current PHRs, but be prepared to
jettison current PHRs for something more informative,
customized, collaborative and functionally rich

CRITERIA
Educating and Engaging Patients
Patient education material and distribution system, tailored to the patient’s
status and protocol
9
Our current patient education system is hampered by the lack of highly
personalized materials and an effective distribution system
Often, today’s patients receive no education material about their condition
PHRs tend to present generic education information
No certified, widely available method of evaluating material quality
Widely used vehicles like Twitter, Facebook, Zite, and Amazon have yet to be fully embraced
• Low-income, preteen girl with type 1 diabetes
likely to receive same education material as a
middle-aged executive man
• Materials are not tailored to blend comorbid
conditions together

ACO vs. ACP:
Accountable Care Patient
22
From Eric Topol’s Twitter feed, @EricTopol

23
American Journal
of Preventive
Medicine
Volume 46, Issue
3 , Pages 237-
248, March 2014
Graph from The
Atlantic, March,
2014
Obesity Rates by Occupation

CRITERIA
Complex Clinical Practice Guidelines
Evidence-based triage and clinical protocols for comorbid patients
10
Establishing protocols for comorbid patients is complicated
Few industry sources for clinical protocols for
comorbid patients
Physicians often left to build their own guidelines,
or chain individual disease treatment protocols
together
Medicare patients on average affected by at least
chronic diseases at the same time
Organizations that optimize comorbid care will be
in a strong position to differentiate themselves in
the market, both financially and clinically

CRITERIA
Care Team Coordination
Inter-clinician communication and project coordination
11
We need to treat every patient as if they are at the center of a project plan
All members of a patient’s care
management team should be able to quickly
and easily see the patient’s overall project
plan, next milestones, and responsibilities
Acute encounters should show recovery
milestones and assigned people
Chronic diseases should show a lifetime
project plan for health
The ideal system would function like a
project management tool (like Basecamp)

CRITERIA
Tracking Specific Outcomes
Patient-reported outcomes measurement system, tailored to the patient’s
status and protocol
12
Patient-reported outcomes data is one of the most important pieces of data
missing from our ecosystem today
Our best efforts today is assessing patient
satisfaction, but that data falls short as an
aid for measuring actual clinical outcomes
This is also the most culturally and
technically difficult criteria to implement
Currently, no reasonable options exist in our
industry
A future patient-reported outcomes system
must have a closed-loop data relationship
with the EMR, and then exported to the
EDW for analytic purposes

Vendor Evaluation and Scoring
No single vendor today offers an integrated and fully functional
population health management solution that meets all 12 criteria
How did I come up with these scores?
Personal experience as a customer of the vendors’ products
Personal experience as an executive in the company (i.e. Health Catalyst)
Conversations and interviews with current and past customers of the vendors’ products
Market reports from, and conversations with, industry analysts at KLAS, Chilmark, IDC,
Gartner, and the Advisory Board
Publically available information on the vendors, including their own case studies, white
papers, on-line product demos, and product information
Conversations with current and past employees of the vendors

Focus on the framework & criteria,
not the scores
Score these and other vendors
yourselves

Crimson Explorys
Health
Catalyst
Lumeris
Optum
Humedica
Phytel Premier
Average
Score
Criteria #01:
Precise
Patient Registries
5 5 9 3 3 3 3 4.4
Criteria #02:
Precise
Patient Attribution
5 5 8 5 6 5 5 5.6
Criteria #03:
Precise Numerators
in the Patient Registries
0 0 5 0 0 0 0 .7
Criteria #04:
Clinical and
Cost Metrics
7 7 9 6 5 4 5 6.1
Criteria #05:
Basic Clinical
Practice Guidelines
0 0 0 3 5 5 0 1.9
Criteria #06:
Risk Management
Outreach
1 0 0 5 7 5 0 2.6
Sub-Total 18 17 31 22 26 22 13
First tier evaluation scores

Crimson Explorys
Health
Catalyst
Lumeris
Optum
Humedica
Phytel Premier
Average
Score
Criteria #07:
Acquiring
External Data
0 5 6 0 4 2 7 3.4
Criteria #08:
Communication with
Patients
0 0 0 4 5 6 0 2.1
Criteria #09:
Educating and
Engaging Patients
0 0 0 2 3 4 0 1.3
Criteria #10:
Clinical and
Cost Metrics
0 0 0 0 0 0 0 0.0
Criteria #11:
Complex Clinical
Practice Guidelines
0 0 0 0 0 2 0 0.3
Criteria #12:
Tracking Specific
Outcomes
0 0 0 0 0 0 0 0.0
Second tier evaluation scores

Asset Allocation and Timing
Recommended asset allocation as the market and organization evolve and
mature in population health management

Asset Allocation and Timing
Recommendations
• Build a population health management roadmap
• Start as soon as possible with the first six criteria while the latter six
develop in the market

Conclusion
Key points to remember
• Follow the lead of the IDNs which have been practicing PHM for years
• Reference this presentation and the CCHIT framework when developing
an organizational strategy and evaluating vendors for PHM
• NQF has a new PHM initiative… keep an eye on that
• There is no single vendor that can provide a complete PHM solution
today
• Sequencing is important. Focus on the first six criteria over the next
three years while the context evolves

Other Population Health Resources
Click to read additional information at www.healthcatalyst.com
The Evolution of Care Management to Population Health Management
This covers the evolution of the care management market to the population health management, the data needs for effective
population health management, and population health business models
Why the Solution to Population Health Management Woes Isn’t an EMR
Healthcare systems are struggling to figure out how to shift to a value-based model and remain competitive. This will require
hospitals to identify and reduce waste in three categories: the variation in 1) the care that is ordered, 2) how efficiently that care is
delivered, 3) in care delivery that causes preventable complications .Clearly, EHRs aren’t the answer.
The Best Way to Prioritize Your Population Health Management Efforts
Effective population health management starts with clearly defining a subset or cohort of patients and determining on which clinical
processes to focus improvement efforts. The Health Catalyst Key Process Analysis (KPA) application determines the highest
variation and highest resource consumption by integrating and analyzing clinical and financial data.

Other Population Health Resources
Click to read additional information at www.healthcatalyst.com
Case Study: Using Data and Reporting in Population Health Efforts
How a healthcare system went from manually pulling together reports with varying data to having near real-time data that one
executive says, "enables our care coordinators to drive preventive care and ultimately lower our population health costs"
Case Study: Using Advanced Analytics to Manage Primary Care Population Health
Population health management is largely being driven by the 5 percent of the population accounts for 50 percent of healthcare
costs. Being able to identify these patients, provide high-quality care and reduce their utilization is a pressing goal for many of
today’s primary care providers (PCPs). Learn how one organization used health care analytics to meet this challenge.
Implementing a Successful Population Health Management Strategy
A White Paper by Dr. David Burton
Based on 25 years of experience, first as a senior executive at Intermountain Healthcare and later as the Chairman of the Board of
Health Catalyst, Dr. Burton shares his in-depth learnings about how to systematically implement population health management in
a long-term, sustainable way.

The 12 Criteria of Population Health Management

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