I read a recent report from The Advisory Board, called Three Key Elements for Successful Population Health Management. It focused on information-powered clinical decision-making; primary care-led clinical workforce; and patient engagement and community integration.

The Advisory Board briefing suggests that healthcare organizations must prioritize these things to succeed. This is great news for our clients, because our solution strategies at Allscripts align well with these elements:

1. Information-powered clinical decision-making

We must integrate systems to talk with one another across the healthcare continuum. It’s essential to deliver actionable insights and clinical decision support at the point of care.  However, it’s critical to have access to information that lies beyond the four walls where the patient happens to be receiving care.

We’re applying our clinical analytics assets to community-level data, in addition to just information from a single care setting. Our recent acquisition of dbMotion enables Allscripts solutions to access a patient’s key clinical information (the longitudinal health record) aggregated from different care facilities.

Here’s a basic example of how access to the whole patient record saves lives: An unconscious patient arrived at the emergency department. The hospital’s electronic health record (EHR) did not contain any relevant data, but caregivers leveraging dbMotion could view the patient’s records from across the community of care. Critical information from outside the hospital about the patient’s history of chronic liver failure was now available. It enabled the care team to more quickly diagnose the cause and contributing factors of the patient’s condition and effectively lower the patient’s life-threatening ammonia level.

Simply put, interoperability enables better patient care.

2. Primary care-led clinical workforce

The primary care physician is more than ever becoming the central player on a patient’s care team. As low-cost treatment and access options continue to increase (e.g., retail clinics, telehealth, remote monitoring), care coordination technology will help these physicians oversee a growing care team and proliferating health data inputs across traditional and non-traditional settings.

We must recognize that the Patient-Centered Medical Home (PCMH) model is foundational to value-based operations. Caregivers will need tools, such as Allscripts Care DirectorTM, to facilitate workflow across the Connected Community of HealthTM and scale PCMH models to manage larger populations.

Another care management tool is Collaborate, a module within dbMotion that enables users to view gaps in care for at-risk populations. Through a dashboard interface, Collaborate can help a primary care provider identify patients with chronic conditions that haven’t scheduled follow-up office visits and help get them back on track with their care plan.

It’s all about integrating the tools with a community view for populations at risk. Primary care-led management teams need to be as empowered as possible.

3. Patient engagement and community integration

Patients are at the center of all we do. We must remove barriers so patient information is accessible and can move freely across the continuum of care, but not just for providers. Our solutions must help clinicians better engage with patients and caregivers for better clinical outcomes.

Our recent acquisitions of dbMotion and Jardogs are critical pieces to the Care Coordination puzzle.  As noted above, dbMotion provides a powerful platform for community integration aggregating and harmonizing patient records across participating provider networks. Jardogs adds to the story by facilitating appropriate data sharing with the patient, enabling them to add to their community record in an interoperable format, and facilitating communication with their caregivers in a secure environment.

More than ever before, Allscripts can deliver a care coordination solution for caregivers and patients, enabling better health care, better health and lower cost.

It’s not a surprise that the Advisory Board research aligns with our efforts, but it is nice validation of our strategies. Our clients are excited about where we’re headed, too. We recently held a forum with about 15 of our largest, most progressive Enterprise clients.  Their reaction to our story has been extremely positive.

We’re on the right track. Our solutions align with what the industry needs to improve coordination of care across communities.  As the transformation to value-based care continues, we must execute on plans to optimize how our portfolio comes together. But we can look forward to facilitating our clients’ success with delivering effective population health management.

What else do you think is necessary to succeed in population health management?

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About the author

Bruno Nardone is vice president of solutions management at Allscripts. He is responsible for development and delivery of Care Coordination and Analytics for clients interested in the transformation from traditional fee-for-service to value-based care models. Prior to joining Allscripts he held positions at SAIC and IBM Global Services, where he led high-performance teams in delivery healthcare strategy and innovative solutions. Bruno’s roots in health care are grounded in his early studies in human nutritional science and work as a hospital administrator in the New York metropolitan area. Bruno is a Fellow in the American College of Healthcare Executives and is active in his community as Lacrosse Coach for the Central Massachusetts Bay State Games team.



Ines Q. Barlow says:

06/29/2013 at 9:55 pm

The health system usually doesn’t fully utilize community programs that care for chronically ill patients. Health systems should know about and even partner with local community centers that provide support groups and exercise classes as an option for patients. Health departments—both state and local–often have patient education material that is very good. National patient organizations are good at both offering support and promoting self-management strategies.


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