To see how values in medicine are shifting, let’s start with this example: Cardiovascular disease is currently the top killer in Mississippi, accounting for 41 percent of all deaths. That’s the highest mortality rate by cardiovascular disease in the nation. The problem is front and center for clinicians and leaders at the University of Mississippi Medical Center. Roughly one out of every 10 patients suffered a heart attack within 12 months of being discharged from the hospital.

A case study

Startled by that data, clinical and information technology leaders at UMMC in 2014 launched an initiative to better predict which patients are at risk of a heart attack and to find effective interventions. The data analytics project allowed UMMC to comb through its entire patient population and identify the 1.5 percent of patients most at risk of a heart attack over a 12-month period. From that subset, UMMC was able to predict 75 to 100 patients who would actually suffer a heart attack. Clinicians can now monitor those patients, act on interventions and improve care across a patient population.

A changing field

Health care is in midst of its biggest transformation since Medicare and Medicaid came onto the scene in the 1960s. The traditional volume-based model — hospitals and doctors getting paid virtually every time patients walk through the door — is being replaced by one that reimburses for outcomes and improved care across the continuum. A key goal is to keep patients healthy and out of the hospital, and population health management is a central part of that effort.

“A key goal is to keep patients healthy and out of the hospital, and population health management is a central part of that effort.”

The concept is not necessarily new, but it has become more widespread as payers and providers look for ways to improve patient care from one setting to another, and to reduce costs. It’s a pretty basic principle: aggregate data from across multiple information technology systems, crunch the numbers, locate trends and then begin to monitor and identify individual patients within a group for targeted interventions.

As with UMMC, population health management can target a specific disease. Or, it can be used to identify a broader set of needs. Leaders at Methodist Le Bonheur Healthcare, Memphis, Tenn., several years ago were able to locate the most medically underserved areas by zip code in their region. Patients in these communities were the most frequent emergency department users and suffered from multiple chronic and mental health conditions. The hospital partnered with local clergy to improve access to care and health for this population. In 2014, Methodist Le Bonheur Healthcare created a patient navigator program to promote wellness and reduce emergency department utilization.

Future challenges

However, shifting to new ways of delivering care is a challenge and hospitals and health systems are in the early stages of this transformation. Nearly 75 percent of hospital leaders in a July 2016 KLAS Research survey on population health said that they were still in the learning phase. Population health requires sophisticated tools, including data analytics and the ability to exchange information across the continuum. Yet 24 percent of respondents cited a gap in data analytics as a key technology barrier; 12 percent said that the lack of interoperability — the ability of one organization’s IT system to share information with that of another — was an inhibitor.

The ability to manage population health focusing care on those most in need and keeping patients from returning to the hospital — or even having to go in the first place — is a revolutionary change in the nation’s health care system. We must continue to work with health IT leaders and technology firms across the industry in an effort to accelerate the adoption of solutions that can improve information sharing and patient care. Only as technology systems become more sophisticated and data more readily available will clinicians and patients become equipped to deliver the big population-based results our communities expect and need.