Viki Field, RN, MSN, is a program manager for Chordline Health, the leading provider of fully integrated workflow and analytics software for managed care. She has nearly three decades of experience in managed care, utilization management and the ability to leverage data to strengthen population health. We spoke with Viki about how the right approach to population health analytics is vital in managing healthcare utilization and driving better outcomes for all.
When it comes to managing population health, what’s holding healthcare’s key stakeholders back?
It’s hard to manage what you don’t understand. Often, health systems and health plans encounter blind spots when it comes to a patient’s health needs, from whether the patient is taking medications as directed to the social determinants of health (SDOH)—from housing insecurity to lack of access to healthy food—that affect health outcomes.
Research shows 52% of U.S. adults have at least one SDOH risk factor, and patients with certain chronic conditions, such as diabetes, feel the impact of SDOH more intensely. For example, adults with diabetes typically face high rates of food insecurity, which is disturbing given the potential for food to serve as medicine for blood sugar control.
Yet health systems and health plans struggle with inconsistent approaches to SDOH data capture. And even when they do have access to information regarding a community’s SDOH risk factors, they lack the population health analytics to dig deeper. Such capabilities are crucial when it comes to managing healthcare utilization, such as by helping people with chronic disease avoid unnecessary emergency department visits and avoidable hospital stays.
It sounds like the challenge starts with access to data. Could you talk about the barriers health systems and health plans struggle with in gaining access to comprehensive information regarding patients’ health needs?
Healthcare organizations sit on mountains of data, yet they struggle to leverage this information to pinpoint which patients are most at risk, gain a big-picture view of their population’s social needs and respond in ways that improve population health.
Today, 80% of healthcare data is unstructured, which means it isn’t directly available to clinicians through their workflows, such as via the EHR. This type of information includes handwritten notes, open-note fields in the electronic medical record, faxes and images. Without the capability to transform this information into structured data and analyze it, healthcare organizations lose vital opportunities to determine health needs by population and by individual.
It also takes trust for patients to share sensitive information that could impact care decision making with their provider. A survey by the Office for the National Coordinator (ONC) for Health Information Technology—shared during the ONC’s annual meeting this past December—found four out of 10 people are not comfortable sharing SDOH. Some patients fear the data will be used against them. That’s why it’s critically important that providers share why they are asking for information around social determinants and how they will use this information. The more a patient trusts their physician or clinician, the more likely they are to share information regarding their SDOH needs.
But there are also missed opportunities for health systems and health plans to collaborate with each other to uncover gaps in patient’s health needs. For instance, by sharing claims data with providers, payers can help clinicians see whether a patient is adhering to their medication and visiting a recommended specialist. With this comprehensive view, clinicians can then develop targeted health interventions that matter.
Once providers and health plans have the right data in hand, how can they use it to improve population health and address utilization management more effectively?
The value of access to SDOH factors becomes diminished when healthcare organizations can’t use it to pinpoint where the greatest needs exist and design a plan for better outcomes at reduced cost.
It starts with the ability to incorporate data from a wide range of systems and sources. Once these data “speak the same language,” advanced population health management software can provide a next-level view. Such software can help identify patients’ health status, pinpoint opportunities to strengthen chronic care management, and make it easier for health systems and health plans to identify and respond to risk.
The right managed care platform will empower clinicians to identify risk areas at the individual and community level and strengthen their ability to respond in the right ways at the right time. It will describe and predict a population’s past or future utilization of healthcare services and their associated costs. Perhaps most important, it will deliver analyses that clinicians can understand at a glance.
What are the keys to making population health information actionable for those on the front lines of care?
We’ve found that seamless access to actionable population health data—delivered directly within clinicians’ workflows and in an easy-to-read view—makes a significant difference.
It starts by adopting intuitive dashboards that put population health information at clinicians’ fingertips. This at-a-glance view makes it easy for clinicians to spot trends that prompt cause for concern, such as the top 10 drugs prescribed to a given population over the past year and the lead indicators for unexpected pharmacy costs.
The most advanced population health platforms also leverage predictive analytics to project risk by population and by member—and offer insight into right-now actions that could make a difference.
At Chordline Health, our ability to link SDOH with a predictive modeling program designed by Johns Hopkins gives clients access to a regional and national view into health risks. With this information, health systems and health plans can evaluate where they stand when it comes to the health of their population and their ability to mitigate risk. They can also leverage learnings from peers on ways to strengthen support for better health. These actions ultimately reduce utilization management and healthcare costs by ensuring the right care is accessed at the right time and in the right settings.
In your view, once healthcare organizations are on a path to success around analytics for population health management, how can they sustain these gains?
Ultimately, innovation around population health management, including data-informed innovation, must translate at scale. To get there, healthcare organizations must have a clear vision of what they want to achieve and how. As one panelist shared during ViVE, “If you have a really clear understanding of the direction that you want to go, where you’re aiming toward, and the foundation you want to build, then you’re going to be able to make much better decisions.” It’s time for healthcare leaders to create a vision for population health success and invest the right data tools and resources to make a broad impact.
