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Are We Going About Population Health The Wrong Way?

Posted on March 29, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

For most of us, the essence population health management is focusing on patients who have already experienced serious adverse health events. But what if that doesn’t work? At least one writer suggests that though it may seem counterintuitive, the best way to reduce needless admissions and other costly problems is to focus on patients identified by predictive health data rather than “gut feelings” or chasing frequent flyers.

Shantanu Phatakwala, managing director of research and development for Evolent Health, argues that focusing on particularly sick patients won’t reduce costs nearly as much as hospital leaders expect, as their assumptions don’t withstand statistical scrutiny.

Today, physicians and care management teams typically target patients with a standard set of characteristics, including recent acute events, signs of health and stability such as recent inpatient admissions and chronic conditions such as diabetes, COPD and heart disease. These metrics come from a treatment mindset rather than a predictive one, according to Phatakwala.

This approach may make sense intellectually, but in reality, it may not have the desired effect. “The reality is that patients who have already had major acute events tend to stabilize, and their future utilization is not as high,” he writes. Meanwhile, health leaders are missing the chance to prevent serious illness in an almost completely different cohort of patients.

To illustrate his point, he tells the story of a commercial entity managing 19,000 lives which began a population health management project. In the beginning, health leaders worked with the data science team, which identified 353 people whose behavior suggested that they were headed for trouble.

The entity then focused its efforts on 253 of the targeted cohort for short-term personal attention, including both personal goals (such as walking their daughter down the aisle at her wedding later that year) and health goals (such as losing 25 pounds). Care managers and nurses helped them develop plans to achieve these goals through self-management.

Meanwhile, the care team overrode data analytics recommendations regarding the remaining 100 patients and did not offer them specialized care interventions during the six-month program.  Lo and behold, care for the patients who didn’t get enrolled in health management programs cost 75% more than for patients who were targeted, at a total cost of $1.4 million. Whew!

None of this is to suggest that intuition is useless. However, this case illustrates the need for trusting data over intuition in some situations. As Phatakwala notes, this can call for a leap of faith, as on the surface it makes more sense to focus on patients who are already sick. But until clinicians feel comfortable working with predictive analytics data, health systems may never achieve the population health management results they seek, he contends. And he seems to have a good point.

Why Do Chronic Patients Not Access Their EMR?

Posted on June 10, 2014 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.

What a fascinating picture and result. For those who can’t see the Twitter image, it says that 55% said “I don’t know how to access my medical records” and 17% said “I trust that my medical records are accurate, so I don’t need to access them.” The later number is probably lower than reality as well. I expect that more people feel that way, but most don’t want to admit it since there’s a chance they’d be wrong.

These numbers are interesting after writing my post, “Do you hate portals?” I wish they would have asked how many people didn’t access them because they hated them (ie. they didn’t enjoy using them).

I’ve often said that most patients don’t care about portals, but chronic patients are the exception. These numbers seem to largely illustrate that, but it also looks like many with chronic conditions want to use them but not enough to actually figure out how to use them. I hope that these numbers are tracked over time. I wonder if 3 years from now those numbers will be dramatically different.