In the final blog post in our series on the six stages to successful population health management, Dr. Chris Hobson discusses the importance of taking Action on data-driven insights to deliver population level benefits. 

Each of the steps we have discussed so far in our 'Six As' blog series are important and serve to give providers a major benefit – controlled access to comprehensive information about their patients, accessible anywhere across their region.  In and of itself, this is very helpful to clinical decision-making at the point of care, as without these tools care providers are frequently challenged to make life and death decisions without complete information. After the initial five As have been laid, organizations need to take things a step further and leverage the information to guide clinical actions – targeting attention to the areas that matter most. This topic is key to delivering population level benefits, and therefore of interest to both clinicians and program managers. Luckily, there are great examples of putting these concepts into practice.

What Types of Clinical Actions Should be Considered?

In order for clinicians to make decisions and take action by leveraging complete patient information, further tools are needed and available today. These include up-to-date multidisciplinary shared care plans, guided clinical pathways that cross facilities and roles, shared clinical documentation, order entry, medication management, and much more.  Electronic systems should remind clinicians of overdue tasks needed for patients, and key gaps in care that need to addressed. Targeting and taking action on patients in this way can make a real difference to clinical outcomes and deliver overall population level benefits. They can also be adjusted and evolve over time as the patient population is better understood, so that efforts are made most effectively.

Additionally, for technology solutions to help us take action they need to include provider collaboration and patient communication tools such as secure messaging, Electronic Health Record integration and notifications of events as they happen across the region of interest. A referrals solution that helps providers create, receive, and track referrals electronically is also helpful and commonly requested. By ensuring traceability and “closing the loop”, electronic referrals ensure that specialists’ assessments and conclusions make it back to the referring physician. An additional benefit is the improvement that comes from better management of waiting times and waiting lists.

Ontario Takes Action

A healthcare provider in Ontario wanted to improve the coordination of care delivery for patients with complex chronic conditions. A key concept to achieve this goal was the development of a shared care plan that all members of the multidisciplinary care team, including the patient, could contribute to. With help with from Orion Health, a coordinated care plan was developed so that patients could have their circle of care be involved in all aspects of their treatment. These care plans evolve as the patient receives the exact care they require. The benefit of this type of care plan is that they are integrated into an existing comprehensive solution that provides assessments. Clinicians are able to see their patients' complete information as well the ability to create specific care plans in one easy-to-view form.

Other healthcare organizations have taken the concept of an electronic clinical document (such as an electronic discharge letter or progress note) and integrated it with the known clinical data in the shared record to achieve benefits beyond simply automating the clinical document. The ability to integrate data simplifies the process of completing the document, and the ability to share the document widely (though of course maintaining privacy controls) and appropriately improves the value of the document to all clinicians who can now view the document with ease. Previously they may not have had any access to the information at all.

This completes our blog series on the ’Six As’ of population health – Acquisition, Aggregation, Access, Adoption, Analytics and Action. Look for our next series covering the five steps to migrating to a new integration engine.