Managing the Data of Population Health Management Programs

Advance for Health Information Professionals 12.05.2013

By Bill Walker

The American healthcare community has been embracing the digital age in a big way, due in large part to mandates and incentives offered by the federal government. Meaningful Use dollars have motivated thousands of medical offices to install electronic health records that enable them to store patient data digitally. Medicare has been requiring that claims be submitted electronically for several years now. As a result, hospitals and health systems around the country have been moving onto electronic medical records and abandoning the traditional paper chart in droves.

The passage of the Affordable Care Act (ACA) has been the most powerful impetus yet for compelling health systems to store and manage patient data electronically. The ACA created a relatively new model of care delivery─ when in 2009 the Accountable Care Organization (ACO) was added to the ACA – that aims to bend the curve by cutting costs and improving quality. Both of these lofty goals hinge on having reliable data that can be analyzed, compared and synthesized down to its most essential elements. And the ACA ushered in a new philosophy of care – population health management – that puts ACOs at financial risk for not keeping people healthy.

In this environment most health systems have become adept at analyzing inpatient data to lower costs and improve quality. They are using the data to identify gaps in care, trend best practices, coordinate services after discharge, and prevent medication errors and re-admissions. Hospitals literally have more data on inpatients than at any other time in history. And much of it stays within the four walls of the facility, awaiting additional data on new episodes of care when patients are again admitted.

In the new model of care that is population health management, tracking a patient’s entire health history is critical. To attain that goal, some visionary health systems are using technology to implement sophisticated data-driven strategies that reach beyond the walls of the hospital and into the community, where people work, play or worship. Using online patient portals these organizations are helping to create a mindset focused on wellness, health-risk mitigation and chronic disease management that aims to keep people out of the hospital.

Presenting as a website with a unique URL, population health portals offer the ideal health management tool to allow people to take better care of their health. After they create an account, users can enter and track important health metrics such as blood pressure, glucose, cholesterol, health and exercise habits, and more. The portals can generate recommendations for addressing health concerns and empower individuals to take charge of their personal health — before these issues become chronic and costly.

Although EMRs were not created to handle consumer-based data ─ but rather, patient data ─ some portals bridge the gap between the information consumers put into their personal health record and a health system’s inpatient data. These portals are compatible with the HL7 ADT platforms and can link to the data maintained in hospitals’ EMRs. This linkage allows hospitals to “listen” to the data contained in consumers’ health accounts; analyze it to build outreach programs; and, in turn, create effective database marketing strategies built around health conditions such as obesity, diabetes or heart disease.

Growing Healthier Populations

Population health portals are essentially a way of linking consumers with the health services they need – sometimes, before they even know them need them. While many health systems have been offering health education and wellness programs for decades, they rarely have linked people who have attended them to actual hospital services. By going out into the community─ local businesses, senior centers, shopping malls, county fairs, schools ─ and proactively encouraging people to document their health status through basic vital metrics, health systems can identify who needs their services most. This is the data ACOs need to truly fulfill their mission of keeping a defined population healthy. By extending population health strategies out into the community, ACOs and hospitals can find their next patients … or prevent them from becoming one.

Case Study in the South

A health system in the South, has been innovative in its quest to keep people healthy. Looking for a way to broaden its community outreach in a manner that promoted better health, the system began providing health screenings to state fair attendees in 2012. However, they found that the methodologies used didn’t allow for outreach and relationship building beyond the fair.

That all changed in 2013. The health system deployed a population health portal that it used at the fair along with mobile biometric assessment tools to collect individual’s real-time results on lipid profiles, weight and blood pressure screenings. Attendees also completed a quick health risk-assessment questionnaire. The results of their assessment and biometric data were imported directly into the portal account created for each participant. Nurse practitioners were on hand to offer advice to individuals with acute health risks.

During the event, more than 1,400 people participated in the screenings and assessments. The aggregated results of participants’ health risks were startling.


  • Three out of every four are overweight or obese.
  • 12.9 percent have diabetes – more than double the market.
  • Nearly half have above normal glucose screening levels.
  • 30 percent have hypertension, and another 45 percent have “pre-hypertension.”
  • Almost 40 percent meet three or more conditions for metabolic syndrome.

With these findings, the health system now has targeted prospect lists to use in promoting wellness programs and screening services. These may include educational programs, medical resources, and requisite screenings or other follow-up. Participants have personal, password-protected profiles they can update 24/7, share with their physicians, use to access health improvement tactics and trend their progress over time.

The ability to merge health system inpatient and outpatient data with individual health-risk profiles has another great benefit: health systems can now seamlessly and definitively track return on investment (ROI). By identifying people who have participated in outreach activities and then subsequently became patients, health systems have a clearer picture of what they are spending on outreach, and how effective those strategies are in terms of ROI.

It is clear population health portals are a vital technological component in the age of ACOs. By tracking an individual’s health data outside of the acute care setting, health systems are positioned to make a greater impact on overall health status. Through the information gathered into these portals, health systems are able to identify and act on health risks before these individuals become patients. By merging patient data and consumer data, health organizations can finally manage overall population health, one person at a time.

Bill Walker is chief technology officer for Aegis Health Group.

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