Healthcare is undergoing a historic transition to value-based care (VBC). Success requires a holistic approach that keeps care teams closely connected with patients, delivering better care at lower costs.
Edward Sheen, M.D., M.P.H., M.B.A.
Chief Population Health Officer, Senior Vice President, Health Catalyst
Digital patient engagement technology enables care providers to overcome limitations in staffing, resources, and clinic capacity to reach more patients in the community. The Pew Research Center estimates that 97% of Americans own a cell phone. Automated SMS text-based communication is a means to securely communicate with patients, provide education, coordinate care, and motivate actions for their health. Gartner reports SMS open rates as high as 98% compared to 20% for email.
There are five foundational steps to improve care with these capabilities:
1. Aggregate multi-domain data
To accurately identify patients who will benefit from added support via engagement technology, combine data from many sources. For example, claims data specify patients due for an Annual Wellness Visit. HL7 Scheduling Information Unsolicited messages contain data to identify patients with upcoming scheduled appointments. Admission-Discharge-Transfer feeds alert providers that a patient needs transitional care management after hospitalization.
A robust collection of data sources, including claims, clinical, pharmacy, and social determinants of health data, provides a holistic view of populations. SMS-based survey tools should also be used to collect patient-reported data on health conditions and risk factors. A population health management (PHM) platform aggregates and normalizes all this data for predictive analytics.
2. Identify patient cohorts
Predictive risk stratification tools identify patients at different levels of risk. Identifying the largest cohorts who will benefit most from specific interventions will make your efforts most impactful. There are many different standardized and customized risk stratification models. Cost, predictive power, ease of implementation, and fit for your patient population are among the factors to be evaluated. Leading PHM platforms typically incorporate high-quality predictive analytics.
It is also important to understand current services, processes, workflows, and opportunities for improvement, such as:
- Clinic hours and appointment wait times
- Consistency of evidence-based practices
- Preventive care services
- Health literacy and barriers to care
3. Automate personalized communication
Once you have risk-stratified patient cohorts, using an integrated engagement platform automates communications and workflows to reduce administrative tasks. Care teams should focus on patient care. Leading digital patient engagement technology uses aggregated data, advanced predictive analytics, augmented intelligence, and machine learning to determine the content most likely to meet specific needs. It then automatically adjusts message content and delivery based on individuals’ responses to continually personalize and improve engagement.
4. Close gaps in care and keep patients healthy
There are many potential applications of this technology. One major function is automating personalized digital outreach for closing guideline-based gaps in care, including missed cancer screenings and vaccinations. When care gap information is embedded within electronic health records (EHRs) and workflows, care teams act on these insights to deliver the right care more reliably and efficiently.
5. Measure progress and deliver additional care
Dashboards and additional analytics allow organizations to measure progress and understand what is happening. As further needs are identified, such as coordination of care during or after a health challenge, additional personalized care plans can be automatically communicated to the right patients at the right time.
The transition to more accountable and higher-value care is complex. Success requires a holistic approach to transforming care that includes clinical leadership, care delivery redesign, quality improvement, operational excellence, patient engagement, aligned payment models, and additional innovations. Data aggregation, advanced analytics, augmented intelligence, machine learning, and personalized automated outreach keep care teams closely connected with patients, delivering better care at lower costs.
To learn how you can start transforming care today, visit healthcatalyst.com/offerings/population-health
