As a primary care physician with long experience in healthcare informatics, I have a pretty unique perspective regarding population health management. I know what it means to take care of patients every day, and I know what it takes to design and implement a population health initiative that works.
So, while I can see the value of such initiatives for organisations and patients alike, I understand where my provider colleagues are coming from when they see the buzz around population health and ask: 'What's in it for me? Why should I care?'
Primary care physicians (PCPs) in particular function as the 'quarterbacks' of healthcare in terms of coordinating patient care. PCPs oversee the big picture: they know the patient, their social background and family history, as well as what specialists they are seeing and the complete list of medications they are taking. With so many new medical advances and so many patients to see, PCPs need tools to help keep up. Transitions of care are especially dangerous points in the care process for our patients, where incomplete or misunderstood information can cause errors or safety risks.
Comprehensive population health solutions should include support for care coordination, and in this role can help PCPs fill that quarterback position efficiently and reduce the likelihood of clinical mistakes. An ideal solution would:
- Create a complete longitudinal patient record, drawing from all the multiple, disparate sources where patient information is currently stored – including different hospitals, practices, labs and even payer systems – when patients interact with the health system;
- Help physicians move to value-based purchasing and care delivery models while alleviating some of the time-wasting (and often non-billable) tasks associated with new payment models. For example, it can help with the annual process of identifying all the members of a practice diabetes registry at the push of a button, rather than having us comb through hundreds of patient records to re-identify these specific individuals; and.
- Enable a smarter simpler referral process, ensuring that all relevant information is included, knowing whether or not the patient has actually been seen by the requested referral recipient and helping assure that all of the information and recommended actions from the referral get into the patient record and the clinical workflow.
This support would allow physicians to focus solely on providing the best care possible for all of our patients. This is also a big benefit for referred physicians who appreciate fewer missed appointments and more referrals well aligned with their specific skills.
PCPs also usually realise the benefits of population health solutions from the patient's perspective. The so-called 'problem patients' tend to be a problem for a reason – typically, these patients face social barriers to achieving their full health potential. This aspect is as important as their underlying medical conditions in terms of improving their clinical outcomes, and many need more or different resources than they are currently receiving.
Population health technology gives providers the tools and information they need to advocate for groups of patients that need more frequent and more specialised care. An effective population health solution creates a single version of the truth so that doctors and administrators can work together and agree on patient status, who received what care and when, and related issues so that everyone is on the same page. With such effectively coordinated care, patients can expect better outcomes and physicians will have more peace of mind.