iPatientCare Blog - How does EHR complement the Population Health Management System

How does EHR complement the Population Health Management System?

Population health focuses on interrelated conditions and factors that influence the health of a group of individuals over the life course. It is a field of study of health determinants. The health determinants along with social components (income, culture, education, employment) include medical care, public health interventions, genetics, and individual behavior. Population health is also concerned with the environment – clean air, water, urban design.

Why Population Health?

Healthcare professionals partner with populations to improve the health of populations by promoting health, preventing disease, and addressing health inequities. Some of the outcomes include:

  • Improving health outcomes of populations in need
  • Implementing cost-effective strategies to address health disparities
  • Executing educational approaches to improve clinical decision making and evidence-based practice
  • Policy making to address health disparities
  • Developing practice guidelines
  • Advocacy to decrease health disparities

How does Population Health Management work?

The PHM is supposed to bring clinical, financial and operational data together, providing actionable analytics to the providers to improve efficiency and patient care. Delivering PHM requires a robust care management, a cohesive delivery system, and a well-managed partnership network.

A successful Population Health System will give real-time insights to the providers and allow them to identify gaps within the patient population. A well-developed care management program is the key to better outcomes and cost savings, especially in populations with chronic disease.

Care management is a critical component of Population Health Management. It tends to revolve around improving patient self-management, improving medication management, and reducing the cost of care. It delivers measurable results and helps providers in cost-effective way.

The system can identify data patterns across the population and use those insights to get more optimal care. To manage the Population Health, cognitive computing can provide the personal care at scale within the context of the overall population. It also helps the providers to match patients’ unique needs collaborating with the other similar patients. The providers have the access to data and other factors from patient’s care team, thus improving patient engagement through this shared decision-making process.

How EHR assists Population Health?

The EHR helps to claim data. This centralized platform continuously ingests and synthesize data from care managers and other relevant observations. The EHR helps to uncover full patient information through unstructured data such as procedure notes, observations and discharge summaries. Even more intelligent processing such as NLP (Natural Language Processing) gives a more vivid picture of a patient’s situation.

Having a successful Population Health System

The Population Health extends beyond the current patient care. Applying population health, the providers will know their high-risk patients from the clinical perspective. The healthcare industry needs to collect true patient outcomes data; for example, if a person with diabetes has a foot exam, and during examination if open wound is discovered. The providers must understand cost at an individual level. Thus, it is important to understand the cost in a population health and manage that cost while ensuring patients’ awareness.

Though the EHRs are designed for fee-for-quality care, it makes it difficult for the populations to understand the cost of care. The Population Health is currently managing on a per-member, per-month basis.

By the end of 2018, the centers for Medicare and Medicaid Services says that half of its payment will go to ACOs and PCMH. To succeed under the new payment models, the practices must manage population health and demonstrate value by delivering lower-cost, higher-quality care. Building a right infrastructure and interoperability is usually the first step in developing population health management programs. The iPatientCare EHR gives the right supplement and right solutions for your practice. Some other problems faced by the providers are; some providers have created self-contained ACOs with a common EHR, others have the majority of ACOs that consist of multiple business entities having different EHRs like Psychiatry EHR for Mental Health etc. And this is how they face variety of challenges. Thus providers pursuing Population Health have understood that certified EHR provides necessary foundation. iPatientCare provides the necessary actionable information that providers need at the point of care.

Another problem faced by the providers – the kind of HIE required for PHM. All the health data collected from the different sources must be available in the information exchange. As the healthcare systems start using environmental and genetic data, as well as other data sources, cognitive computing will be even more essential to deliver comprehensive, personalized and timely interventions.

It is important to understand the history as well as other challenges that have forced the healthcare industry to look beyond the EHR for population health. The effective Population Health Management is growing quickly as value-based reimbursement increases and so does percentage of providers’ revenues. Traditional EHRs were not designed to anchor Population Health. But the iPatientCare EHR captures all the patient’s complex medical history and has robust registries needed for chronic disease management and care management across a particular population.


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