The concept of population health was first defined in 2003 by David Kindig and Greg Stoddart who proposed the definition: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” The researchers state that the field of population should include “health outcomes, patterns of health determinants, and policies and interventions that link these two.”
A response to a recent Healthcare IT News survey further defines population health as “identified by demographic differences, health needs such as chronic diseases or disabilities, or the health needs of the underserved.” Generally, for independent physicians, the challenge is to manage the health of their specific patient populations as a small practice.
Several options are available for the independent practice. Joining an Accountable Care Organization (ACO) enables small, independent physicians to share resources. ACOs are groups of independent physicians and other healthcare providers who coordinate to provide healthcare services to Medicare patients under the Centers for Medicare & Medicaid Services (CMS) value-based program. Practices within the ACO may have access to population tracking resources they would not normally be able to as a small independent practice.
Population health management requires patient data management. Maintaining patient information in electronic health records (EHRs) enables the independent physician to holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time. Elation’s Clinical First EHR, in particular, helps the independent physician quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.
Follow-up, including managing a patient’s medications and ensuring the patient is following post-visit instructions, is a critical step in the independent physician’s approach to population health. Communicating with the patient on a regular basis, particularly being responsive to patient questions, is also a critical element in population health management. Understanding the specific needs of the patient population, including the need for ongoing support outside the office visit, can reduce costs and improve patient health outcomes.