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Are Current Population Health Tools Becoming Outdated?

Posted on May 18, 2016 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

These days, virtually all hospitals and health systems are looking at ways to manage population health. Most of their approaches assume that it’s a matter of identifying the right big data tools and crunching the numbers, using the data already in-house. Doing this may be costly and time-consuming, but it can be done using existing databases, integration engines and the appropriate business analytics tools, or so the conventional wisdom holds.

However, at least one health IT leader disagrees. Adrian Zai, MD, clinical director of population informatics at Massachusetts General Hospital, argues that current tools designed to enable population health management can’t do the job effectively. “All of the health IT tools companies call population health today will be irrelevant because the data they look at can only see what goes through hospital, which is far too narrow in scope.”

Zai points out that most healthcare organizations attempt to leverage claims data in doing population health management analyses. But that approach is far from ideal, he told Healthcare IT News. Claims data, he points out, is typically one to two months old, which significantly limits the value healthcare providers can generate from the data. Also, most hospitals’ claims data only covers about 20% to 30% of the area’s population, he notes.

Instead, organizations need to study real-time data drawn from a significantly broader population if they hope to achieve population health management goals, Zai argues. For example, it’s important to look at the Medicaid population, whose members may get most of their care through community health centers. It’s also important to collect data from other consumer touch points. (Zai doesn’t specify which touch points he means, but mobile health and remote patient monitoring data come to mind immediately.)

I think Zai make some excellent points here. In particular, while achieving true real-time analysis is probably well the future for most healthcare organizations, the fresher data you can use the better. Certainly, analyzing archival data has a purpose, but to have a major impact on outcomes, it’s important to foster behavior change in the present.

However, I’d argue that few providers are ready to roll ahead with this approach. After all, to achieve his goals means establishing some new definitions as to what data should be included in population health analysis. And that’s not as simple as it sounds. (For a recent look at how providers look at population health, check out this survey from last summer.)

First, providers need to take a fresh look at how they define the term “population,” and develop a definition that takes in a more comprehensive view of patient data. Certainly, claims data analysis is start, but that by definition is limited to insured patients seen at the hospital. Zai recommends that population health management efforts embrace all patients seen at the hospital, insured or not. In other words, he’s recommending hospitals address the community in which they are physically located, not just the community of patients for whom they have provided care.

Just as importantly, hospitals and health systems need to consider how to collect, incorporate and analyze the exponentially-growing field of digital health data. While some middleware solutions offer to serve as a gateway for such data, it seems likely that providers will still need to do a lot of hands-on work to make use of these data sources.

Finally, providers need to continually improve the algorithms they use to pinpoint problems in a given population, as well as the ways in which they create actionable subsets of the population. For example, it may be appropriate to target patients by disease state today, but other ways of improving outcomes might arise, and providers’ IT solutions need to be flexible enough to evolve with the times.

Over time, the industry will evolve best practices for population health management, and definedthe IT tools best suited to accomplish reasons. And while some existing tools may work, I’d be surprised if most survive the transition.

Population Health Survey

Posted on August 28, 2015 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the themes we’ve been writing a lot about recently is incorporating more social and behavioral health data into the EHR and healthcare. I think we’re at the start of a trend around using data in healthcare that is not going to stop. While we currently have more access to data than ever, it feels more like getting beat down by a wave on the beach than it does surfing a wave that provides an amazing thrill and speed. I guess I’m saying that we haven’t learned to harness the power of the wave data yet.

Much of the work we’re doing with healthcare data is around population health. I was intrigued by the findings of a population health survey done by Xerox. Here are some of the insights they shared with me:

What is population health? Definition components were ranked in the following order:

  1. Facilitates care across the health continuum
  2. Supports providing the highest quality of care at the lowest cost
  3. Uses actionable insight for patient care based on a variety of data
  4. Targets a specific population of individuals
  5. Enables patient engagement

Is population health management necessary?

100 percent of polled providers agree that population health management is necessary as the U.S. shifts to value-based care. 81 percent indicated they “strongly agree” with the statement, while the remaining 19 percent indicated they “somewhat agree” with the statement.

What is driving population health? Driving factors were ranked in the following order:

  1. Improved health outcomes
  2. Improved patient relationships and experiences
  3. Cost containment
  4. Increased revenue opportunity
  5. Brand and competition with others in market

What challenges exist in population health management? Challenges were ranked in the following order:

  1. Data management and integration capabilities
  2. Lack of financial incentives, too much risk
  3. Poor care coordination across care providers
  4. Creating actionable intelligence from available data
  5. Lack of provider expertise or knowledge
  6. Low patient engagement

When will population health management be a reality?

81 percent of polled providers believe their organizations will deliver fully scaled population health management programs within 5 years, which includes 16 percent who indicated they already are.

What this survey tells me is that we’re still trying to figure out population health. Plus, people have a really broad definition of what’s considered population health. Does that mean the word no longer has much meaning?

The final stat might be the most telling. Almost everyone believed that their organization would be able to deliver a fully scaled population health management program. Maybe there’s some arrogance bias in who participated in the survey, but I’m quite sure that we’ll have a lot more stragglers in the population health world than 18%. It’s taken us how many years to get 60% EHR adoption? I won’t be surprised if population health takes us even longer.

All of that said, the best organizations are going to leverage healthcare data to improve population health. That’s a powerful concept which isn’t going away ever.

Do Hospital #HIT Leaders Need Business Coaches?

Posted on May 4, 2015 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

Though they don’t always cop to it, a goodly number of senior business leaders pay very good money — I’ve heard quotes as high as $10,000 a year — for the help of an executive coach. Part high-end consultant, part amateur therapist, executive coaches help VPs and C-suite execs make better decisions by giving them an unvarnished view of their current situation and the inspiration to carry out their most ambitious plans.

This may have something in common with bringing on a partner like, say, Deloitte, but it’s decidedly different. While executive coaches may have worked in a bigshot consulting firm like PwC, their relationship is decidedly with the individual, and a trusted one at that.  The process of executive coaching sounds like a very useful one. (I’ll probably try it someday — when I have $10,000 to spare!)

The thing is, while I could be missing something, I’ve never heard so much as a hint that senior HIT executives are retaining executive coaches. It makes me wonder whether CtOs and VPs of IT still define their job largely by technical skills rather than their capacity for making strategic decisions with hospital- or system-wide implications.

The inescapable reality is that HIT execs have long outgrown supergeek status and are increasingly a key part of their healthcare organization’s future. So if they’re open for growth, HIT leaders may very well want to test out the executive coaching model, particularly in working out the following:

  • ACO development:  While the ACO contracting and development process may be led by other departments, health IT leaders have the power to make or break these agreements by how they support then. A VP of business development may spearhead such efforts, but it’s the health IT exec who will make or break how effectively the ACO handles population health support, risk management, data analytics and more.
  • Managing digital health: I hardly need to remind HIT execs of this, but the most important directives as to how to work with digital health tools aren’t going to come from the CEO down, but from the CIO or VP up. With the healthcare industry just beginning to grasp the value app-laden smartphones and tablets, smart watches, sensor-laden clothing, telemedicine and other rapidly emerging  technologies can bring, it’s the health IT exec who must lead the charge. And that means knowing how to solve critical business problems that extend well beyond IT’s boundaries.
  • EMR transformation: As hard as you’ve worked on implementing and tuning your EMR, it’d be nice to think you could stick a fork in it and consider it done.  But EMRs are having new demands placed on them seemingly every day, including integration of massive volumes of wearables and other patient-generated data; number-crunching and making sense of population health data; connecting revenue cycle management functions with EMRs and much more.  Deciding how to handle this spectrum of issues is the job of a business/tech thinker, not solely an IT guru.

Look, I’m not suggesting that the executive coaching is for everyone, health IT executives included. But I do believe that the right kind of executive coaching relationship could help HIT leaders to make a smoother transition into the even more critical role they are inheriting today. And anything that supports that transition is probably worth a shot.

ACOs Need Population Health Help From EMRs

Posted on February 13, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

It’s hard to argue that without an EMR, Accountable Care Organizations would be somewhat adrift. After all, any structure that demands a high level of coordination between multiple organizations benefits from a shared EMR backbone.

But do EMRs do a good job of managing population health, the other key responsibility of ACO clinicians?  Let’s take a look at the criteria suggested by David Nash, MD, MBA, who’s Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University. Dr. Nash notes that primary care physicians in an ACO need the following:

  • A registry to monitor and evaluate my patients – not just individually but as a population
  • Relevant data on my patients who share a specific diagnosis such as hypertension or asthma
  • Information on how my medical management and patient outcomes compare with other local practices
  • Information on where my practice stands in comparison with national benchmarks

Let’s see.  Do leading EMRS offer a registry to monitor patients as a group?  Automatically serve up data on patients who share a specific diagnosis?  Offer means of benchmarking outcomes with other local practices or national standards? No, no and no.

I can hear EMR vendors out there saying, “Hey, wait a minute. That stuff is not our problem!”  And historically, they’d probably be right.  After all, it’s a formidable enough job creating usable, flexible, reliable medical record analogues in digital form.

The truth is, however, that population health measures are central to the medical home, ACOs and the future of medicine generally.

My guess is that for the next few years, hospitals and large medical practices — even those who have launched an ACO — will be preoccupied enough with meeting Meaningful Use  measures that they won’t be demanding more extensive population measures soon.

Still, enterprise EMR vendors will need to offer tools that meet broad population health goals eventually, as the large organizations that buy their products will soon be demanding these types of functions.  The only question is when.

Population Health Management Is No Fad

Posted on August 6, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

I have a bone to pick with you, Mr. Paul Cerrato of InformationWeek. Your recent column suggesting that population health management is a fad is well-argued, true. But I think you’re missing the forest for the trees.

In his column, Cerrato argues that population health management (PHM) is a trendy concept which is being pushed down physicians’ throats without docs having the tools to pull it off.

He relies partly on a report from the Institute for Health Technology Transformation, which argues that providers need not only EMRs, but also telehealth platforms, electronic registries, data management software and analytics systems to conduct PHM. There’s some truth to that.

And he notes that even existing tools, like the increasingly ubiquitous EHR, don’t have the ability to interoperate with other systems and so don’t have any information about care outside of a given provider’s practice. Again, that’s true.

But Cerrato seems to think that we’re putting the cart ahead of the horse to engage in PHM until all of that tech is in place.

Here’s where he loses me:

Physicians have been trained to provide individual care, not population care, and while PHM proponents might counter that population care is simply individual care multiplied by X, it’s more complicated than that. Many of the interventions needed to improve the health of a large population fall more into the realm of education and public safety than they do into medical practice.

While physicians may indeed have been trained to provide individual care, it’s time they embrace PHM basics. Simply screening the chronically ill patients get preventive care, if nothing else, isn’t beyond the reach of any practice with an EMR.

And as for fobbing off the population health improvement on public education, well, just tell me this: just how successful was Nancy Reagan’s “Just say no to drugs” campaign? (That one was about as hip as your grandmother’s nightgown, wasn’t it?)  While some interventions may work from a governmental level, there’s a graveyard of others that never even enter the consciousness of individuals.

No, I refuse to believe that doctors can’t look at their patients as a population until they can do big-time data aggregation and the like. They need to think about their patients as a population now, especially PCPs, not only because it’s the right thing to do, but because it feeds back into daily practice to know what common patterns emerge.

The new, emerging emphasis on population health may challenge physicians, but I think they’re up to it, especially if hospitals support them in their efforts. Even if what we do now is a pale shadow of what we can do over time, there’s no excuse not to get started.  PHM will be a critical part of medicine’s future, so let’s step to it.