Electronic health records (EHRs) have been utilized extensively for “meaningful use” among health information technology for addressing health disparities and improving efficiency of Population Health Outcomes.

Population Health Management (PHM) works towards improving the patient health outcomes of a group of individuals by collating and analyzing patient data into actionable patient records through which care providers can provide better Patient Outcomes and government can draft better policies and improve the Public Health System. These individuals are a part of a large group of a particular geographic area, those sharing a similar characteristic. For example – individuals with specific diseases.

The Background & Approach

Population health management programs utilize an EHR or Business Intelligence (BI) tool to populate patients’ data and provide a detailed report on data of each patient to identify trends and improve Patient Outcomes, lower the cost for Public Health Systems, and develop a cohesive delivery network. The objective of PHM is to develop new methods to improve Patient Outcomes by applying Public Health concepts for disease management such as Chronic Disease Management with the help of comprehensive data analysis.

Most EHRs utilized, lack meaningful interoperability as they are designed to simplify and organize the workflow of physicians and clinicians. They fail to provide all clinical data required to provide quality person centric care; and to manage population health effectively hospitals and government need many other kinds of information. However, the major impediment in achieving this goal is rarely the same EHR system or BI tool is utilized to aggregate the data across the continuum of care which requires accumulating various information including – inpatient data, outpatient data in hospitals and ambulatory settings. The PHM goes beyond collecting clinical data and collates clinical, financial and operational data that provides actionable insights and predictable analytics. What’s even less common is utilization of an EHR system for PHM that provides a holistic picture and integrates all necessary information on Patient’s Medical Record, insurance claims, billing, labs and pharmacies.

To create a cohesive delivery network, in case of Public Health System – the PHCs, district health centers and district hospitals all have to utilize an EHR system supporting meaningful interoperability. Utilization of disparate EHR systems at hospitals, PHCs, and DHCs creates roadblocks in achieving the objective of effective PHM. Despite the wide use of EHR, interoperability – (sending, receiving, finding and using a common set of clinical data) remains a challenge. Health data is not easily available and confined in hospital silos, and incompatible EHR systems. Complex regulation makes it even more difficult to exchange patient data.  

EHR inadequacies for effective PHM

EHRs were traditionally designed to support physicians’ workflows and maximize billing and generate the clinical document to meet regulatory compliance requirements. These systems captured a fragment of Patient’s complex health history which lacks the complete view and they lack the robust registries needed for Chronic Disease Management and care management across population. A Paper published in Population Health Management in 2015 observed that EHRs lack many elements of infrastructure required for PHM. Organizations pursuing PHM have observed that investing in certified EHR system is beneficial for PHM. However, they lack the requisite IT infrastructure to support the technology and analytical requirements to integrate the system. To overcome this challenge, the leading EHR vendors have introduced PHM modules. However, they lack automated tools and agile analytics required to interpret data received from various places and to manage subpopulation and individual patient data effectively. Also these systems are not equipped to pull discrete data from non-interfaced system and they don’t provide comprehensible, actionable insights that providers and government need at the Point of Care.

In a PHM IT solutions report, Chilmark Research observed EHRs are developing and reaching a state of maturity and will play a role in PHM initiatives as a core system for medical records. A HIMSS analytics survey of 200 healthcare organizations found two-third of companies had PHM programs in place, of which only 25% had purchased the solution from PHM vendors, the rest of them utilized EHR platforms and internal systems.

Bridging the Interoperability Gap or Bridging the Care Gap

For a successful PHM program real time data and insights is required for both clinical and administrative; social determinants and claims data to identify and address existing Care Gap within the Patient Population. This requires utilization of an EHR system that can track, analyze and submit data required for creating a complete report on clinical and financial determinants.

EHR system providing patient risk scores regarding health, lifestyle and medical history would help in creating subpopulation, utilizing this method of risk stratification helps both government and the providers to understand population’s healthcare needs and trends.

For providers, the data gathered utilizing an EHR system supporting meaningful interoperability will help in arriving at better Patient Outcomes and pursue Population Health Management to support value based care initiatives. HIEs needed for PHM is more than just interoperability between clinical systems. Patient generated health data from multiple sources should be included in the mix and data of social determinants of health (SDH), environmental and genetic data and these data should be shared with the care teams when required. The EHR systems should be able to exchange this information seamlessly. The purpose of HIEs is to drive action and intervention with patients. One of the cases of effective interoperability is ability of care team to interact with the team at remote location that prompts timely intervention for better patient outcomes. For example – a patient suffering from congestive heart failure is getting treatment at a remote DHC center and the onsite care team notices that person has started to gain weight and this prompts a video call to the cardiologist at the offsite team for intervention and timely care.

Other example of the need for interoperability for PHM is as follows. HIEs have to provide vital patient information needed to achieve population health goals. For example – a patient is suffering from Lung Cancer Stage-4 and during a time span of two years he has visited different types of healthcare providers in acute and ambulatory settings for specialty care and during each visit and hospital stays the patient has had numerous lab tests, MRIs, chemo therapy, radiation therapy, and procedures. All of these encounters have generated significant patient data. However, as the data is stored in silos in the EHR system and not made available to the other care providers & HIEs, these hospitals would have some information about the patient and not all and it severely affects patient outcome. If all the hospitals utilize the same system or use the system that supports interoperability – patients will be able to receive better patient care.

Summary –  Making PHM effective

HOPS EHR system supports various PHM modules that enable providers to improve Patient outcomes and reduce the cost. Our system enables care team irrespective of the location to participate across the care settings. It can easily connect public and private HIEs utilizing different systems. One successful implementation case study of interoperability and HOSP EHR is for a Government Health Program in Gujarat, Vadodara, Mota-fofaliya Sinor taluka (in collaboration with University of Utah) for antenatal and post-natal care initiated by Shaktikrupa, NGO.

The system is integrated with a mobile application for the Asha workers deputed by CHC for capturing vitals of pregnant women and malnourished infants during field visits. The APP is designed to fill the vitals and meets both antenatal and post-natal care needs, it can record vitals and BMI for mother and the baby.

Any pregnant woman with low vitals identified during field visit was immediately referred to district health centers. Doctors & the staff at Community Health Center don’t have to fill the details of the patient again as the system is integrated with patient app that creates seamless access to Patient Data. This helped in saving doctors time and avoiding duplication of data.

Many women with low weight and infants suffering from undetected and undertreated malnutrition were identified during field visits and were admitted to District CHC for treatment. In a year, Sinor taluka saw fourfold improvement in survival of low birth infants from 3.5 % to 20%.  

 HOPS EHR system utilized by Mota-fofaliya CHC supported data aggregation from field visits and captured all SDH and analytics through dashboard to support the population health outcome of a subpopulation. The study led to improvement and effective utilization of government schemes. More than 15000 pregnant women & mothers benefited through examination, guidance & health education by expert doctors & free distribution of Iron folic tablets & tetanus toxoid injections in the Ante-natal & Post-natal clinic on every Monday.