BLOG: Will you rise to the real population health management challenge?

Population health management encompasses the proactive application of strategies and interventions to defined groups of individuals, with the goal of improving the quality of care and outcomes whilst managing costs. Along with staff engagement this is the Quadruple Aim of health.

Dr Justin

Population health should be viewed as part of a wider health and wellbeing strategy that includes wider determinants of health, such as housing, the environment and employment. This is where I feel the UK and other European countries like the Nordics have an advantageous opportunity. Our socialised medicine systems are place-based, with integrated/integrating social care systems, and as such we can bring together a full battery of healthcare, social care, community assets and the citizens themselves in a truly integrated and holistic system of care.

For example, there is a 12 year discrepancy in life expectancy across the Wirral peninsula, with key opportunities to improve outcomes for chronic diseases such as diabetes, COPD, asthma, and depression. The region also has areas of deprivation, areas with high rates of smoking and alcoholism, poor housing and low employment rates. The population health opportunity is to establish new care models that holistically address health, care and social determinants of wellbeing.  

Accountable Care Organisations

Advocate Physician Partners is a good example of a high performance Accountable Care Organisation that has successfully leveraged a Population Health Management (PHM) technology platform and solutions. The introduction of an integrated and comprehensive strategy to support value-based care delivery helped increase asthma control rate to 65.4%, save $4.3m (£3.3m appox.) annually in medical cost and save 39,684 days from absenteeism and lost productivity.

There is no doubt that informatics is a key capability required for PHM. A lack of data and ability to manage individuals hampered early efforts such as managed care initiatives in the US in the 1980s and integrated delivery systems in the 90s. The 2014 Kings Fund review of successful Accountable Care Organisations identified key issues and success factors including care management, new working relationships, new support tools, patient engagement and cost and quality measures that I encourage everyone to take note of as the applicability is high.

Informatics is the enabler

PHM informatics are rapidly evolving to step up to these opportunities but it is by no means clear what a full set of informatics capabilities will be. A KLAS Keystone Summit has brought health systems and vendors together to help define a common framework of capabilities across: data aggregation and normalisation, analysis, care co-ordination and health improvement, financial, patient engagement, and clinician engagement. We need near real-time operational approaches that are anticipatory and predictive enabling proactive action to be taken. This is the transformative opportunity that modern informatics offers.

The UK is at a very early stage with most geographies and their Local Digital Roadmaps focused so far on health information exchanges, patient portals and business intelligence tools. This will help identify where the population needs are but will be insufficient for Accountable Care Systems (ACSs) taking accountability for populations where they will need to engage citizens, carers and families to take action and manage to outcomes. ACSs will need PHM platforms and their informatics services - this will need to be a key focus of the forthcoming NHS Target Architecture informatics strategy. Healthy Wirral Partners in the Wirral Peninsula has implemented a population health management platform through its work as a New Care Model Vanguard, and others are following.

It will only work with whole system change

In PHM, as any other area of health and care, informatics is a key enabler - it is necessary but it is certainly not sufficient. The informatics has complexity, no doubt, but sophisticated approaches now exist. I believe the harder challenges lie in maturing the other key capabilities required. To name a few: leadership with a clear vision and set of agreed priorities; partnership, legal forms and governance, new care models and system redesign, organisational redesign with new and evolving staff roles, payment reform and incentives, citizen engagement strategies, information governance, and above all else, cultural change. The trick for ACSs will be to mature these capabilities in parallel else risk getting stuck. I am calling for the UK to establish a PHM maturity model to work to, and consider the advances being made by organisations such as the Accountable Care Learning Collaborative. PHM requires a whole system change so let’s rise to it!

Dr Justin Whatling

Vice President, Population Health, Cerner

Dr Justin Whatling joined Cerner in 2012 as the the Vice President of Population Health and focuses on population health management and clinical transformation for Cerner in Europe. He worked as a hospital physician in world-leading health centres including King's College Hospital, Hammersmith Hospital and Queen Square National Hospital of Neurology and Neurosurgery. Dr Whatling is also a Fellow of BCS, The Chartered Institute for IT, the United Kingdom professional body for IT, and an independent member of the NHS’s National Information Board (NIB).

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