The American Journal of Public Health defines Population Health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”. It is an approach to health that aims to improve the health of an entire human population.
"Since patients see a number of different providers and hospitals over time an incomplete health status is the norm for many patients in these systems"
Traditionally healthcare providers and health insurance organizations focused their Population Health efforts on their own patients. Some have invested significant money and resources in an effort to measure and improve the health status of their “population”. This turns out to be rather narrow and limited and not terribly useful from a Population Health perspective.
Since patients see a number of different providers and hospitals over time an incomplete health status is the norm for many patients in these systems. Also, it is not uncommon for a patient to change health plans every few years or when changing jobs and there is frequently no handoff of the health status history to the new provider or health plan. Further, a plan change sometimes causes patients to also change doctors and hospitals.
Compounding these realities is that others outside the immediate care team or health plan are not in the loop. Public Health, Behavioral Health, other healthcare providers such as Safety Net Clinics, Ancillary Facilities and care provided out of area represent missing pieces from the patients’ health status. Increasingly capturing Social Determinants of Health (SDOH) open up an opportunity to include community social service organizations that can assist with transportation, housing, nutrition and financial services to name a few.
Health Information Exchange, both the noun and the verb promises to dramatically improve the picture. In theory, the act of moving health information electronically from point to point (verb) could contribute to presenting the overall picture of the patient’s health status. While an improvement over the silos of data in one system, success relies on near perfect matching of patient identity and does not take into account variations on the content of what is being exchanged. Content vocabularies are not entirely standardized across systems and important content cannot be consumed and incorporated without significant human involvement.
Enter the Health Information Exchange Organizations (the noun). There are about 100 Health Information Exchange organizations nationally and a significant number of them are providing Population Health solutions to their participants. This approach allows a far more complete and productive Population Health solution across the entire community of providers, hospitals and other places where a patient receives care.
The Santa Cruz HIO (SCHIO) where I work has been exchanging data since 1996. This regional exchange serving about 300,000 patients offers robust Data Exchange, Care Coordination and Population Health solutions. It enables exchange to more than 100 organizations representing 2,000 health care staff. Starting with just the basics and serving a few key organizations with 275 providers, the effort has grown to include virtually all local health care organizations, County Public Health and now is beginning to connect social services organizations.
Recognizing that health status is dependent on what happens outside the four walls of the immediate care setting and is influenced by many social factors, the County of Santa Cruz Health Services and longtime participant in the SCHIO was awarded a four year grant from the State of California named “Whole Person Care”. This program utilizes the Social Determinants of Health to engage case workers and care navigators to better serve patients taking into account not just the clinical status but also the social status of a patient. For example, if a patient is discharged and has transportation challenges, these efforts seek to arrange transportation to facilitate follow up visits thus avoiding a painful and expensive visit to the hospital. Or a patient may have housing, food or other need that can be addressed by these non-traditional providers thus supporting better health outcomes.
Regional data sharing and Population Health analytics is a good thing but what about when a patient seeks care while on vacation or has moved here from other parts of the country. SCHIO is part of the “Patient Centered Data Home” (PCDH) project that alerts the HIO when a patient receives care out of area. When the patient returns home their home care team can query and find out what care was delivered out of area.
All of this is built on a strong privacy and security foundation and follows HIPAA and California laws governing the exchange and use of patient data.
Population Health systems can be used to support quality programs seeking to make sure patients receive timely preventative care and screenings. These quality programs work with participants and Public Health and the CDC to further measure and provide better care. Additionally we aggregate and send de-identified data to the CDC program named Biosense. The County Public Health and CDC use this data to track and measure outbreaks affecting the population such as flu and food borne illnesses.
While all this sounds rosy, it is a significant effort that is constantly evolving driven by advances in the underlying standards and adoption and workflows of the participation organizations. Our health system is on a journey to improve the health status of all patients and Population Health programs will play an increasing role in achieving that goal.