By and large, the healthcare industry talks about Population Health as care across populations of people. While Pop Health has evolved to drive the IHI Triple Aim across those populations, successful Pop Health efforts depend on care given on a patient-by-patient basis. From a clinical care perspective, Pop Health drives care at the Person level – the second “P” in the 3Ps of Pop Health. The paradox in Pop Health lies in that how we deliver care on an individual and personalized basis actually drives population results.
Pop Health is driven on a person-by-person basis. A patient, by definition, is a person receiving care. However, in reality, external and personal factors greatly affect how a person maintains their health and gets their healthcare. This all-encompassing understanding of the person is becoming more important to drive clinical outcomes and Pop Health successes. No longer can providers afford to view people solely as patients – providers who want to drive true global results will have to understand the patient as a person. Ironically, Pop Health has forced us as an industry to get better at data and care on a personal level.
Understanding the Patient as a Person First and foremost, personal factors like financial and family concerns play a large role in how people interact with the healthcare system. The Patient Protection and Affordable Care Act (ACA) has increased the number of covered individuals and also has created more narrow networks, high deductibles and increased healthcare utilization. High deductibles mixed with lower incomes could become a barrier to care, particularly if those individual patients need to obtain services and goods outside the clinical setting (think wheelchair ramps, dietary advice, a divorce or family death and how those factors can affect a person’s ability to get proper care). Even a family dog that a person does not want to leave alone at home during a hospitalization can prevent such a person from getting recommended preventive care. I have personally experienced these as barriers for patients, and I continue to hear those stories as I meet providers and systems across the country. All too often as providers, we are guilty of treating patients, when we really need to be treating the person. Until socio-demographic issues are better understood and addressed, they can hamper the benefits that Pop Health can provide.
A Person’s Personal “Big Data” The world of truly personalized medicine will also continue to evolve. On top of sensor data (Fitbits, Apple Watches, Bluetooth Scales, Bluetooth Glucometers), we are also seeing an explosion in genomic and proteomic data. All of this creates a more detailed, intricate and nuanced picture of a person as a patient. Collecting, analyzing and integrating this intelligence into clinical care will be one of the next large challenges healthcare faces. As an industry, healthcare may need to consider this information as a critical part of a person’s foundation that will guide personal care.
High Quality and Value Care at the Personal Level Many providers have contracted via ACNs, ACOs, MSSPs and the like to deliver care for a certain dollar value and to a quality standard. Those quality measures vary from population-by-population and contract-by-contract. Ultimately though, each person receiving care in the health system has a set of quality measures and gaps in care that need to be addressed. Put another way, there is no way for a gap in care to be closed without working at a patient level. This may seem obvious, but all too often providers talk about Pop Health and care metrics and gaps in care at a high level (i.e., how is our quality as a system?) vs. a patient-person level (i.e., how are our patients doing?).
Making it Personal Overall, understanding a person and his or her personal situation is critical to their clinical care and therefore paramount to Pop Health achieving the Triple Aim. The practice of Pop Health has a foundation in technology and data. Traditional systems like EMRs and other hospital-based technologies have not been designed to capture the full picture of a person and oftentimes these systems struggle to create a unified clinical record – a longitudinal patient record (LPR) – for a patient’s clinical information. Health systems, in the future of the risk-based model, will need to not only understand the LPR and the complete socio-demographic situation of a patient in order to drive to the desired results. I will address a vision for that technology in my next post. In the meantime, the paradox of Pop Health – that it truly is all about the individual, the person, remains of utmost importance in the current evolution of Pop Health and healthcare at large.