JoAnna Haugen

A successful population health strategy emphasizes a patient-centered model focused on quality care. However, it is virtually impossible to offer each and every thing to each and every individual. For small practices, in particular, this reality requires evaluating staffing needs and prioritizing areas to optimize support staff optimally to the benefit of patients.

"When a population strategy is instituted in a practice, scheduling and workflow changes are required," says Yomi Ajao, vice president of COPE Health Solutions. This may mean, for example, setting aside certain hours to see high-risk patients to ensure appropriate care coverage is available and minimize disruptions for other patients.

In making any changes to staffing within a practice, always keep the patient-physician relationship in mind, experts say. Before adding or reducing staff, or shifting responsibility around a medical team, ask how these changes support that relationship. As in most industries, customer service is essential to creating trust and rapport, which helps strengthen and empower patient care in population health.

Practices hoping to maximize fee-for-service revenue by meeting value-based performance thresholds may be able to meet their goals using existing or minimal new staff. In order to add more preventative care services, increase wellness exams and close care gaps, practices can strategically expand care teams with nurse practitioners qualified to conduct exams and screenings, and provide immunizations and transition-of-care support. "The new positions tend to be cost-neutral or even net-positive due to the revenue generating services they provide, decreasing the reliance on a larger health system for funding," says Lillian Lee-Chun, a manager at ECG Management Consultants.

However, small practices hoping to provide comprehensive population management across the entire care spectrum may find themselves overwhelmed. "Given the growing complexity of the patient population, patients are increasingly seeing specialists and require care in acute settings," Lee Chun says. Bearing the responsibility for the total cost of care for a patient requires a system-wide perspective and connected information system, and it puts physicians at risk when other providers in the system may not be aligned or incentivized by the same outcomes as the practice, she adds. As such, any comprehensive care will most likely require integration with the larger medical system in which patients interact.

In addition to hands-on care, small practices may benefit from collaborating in other areas. For example, leveraging technology-related resources for data connectivity and data analytics from an affiliated management service organization (MSO) or clinical integrated network (CIN) would be effective, experts say.

Staffing changes focused on population health will not happen overnight. As such, small practices need to recognize and take advantage of resources available through affiliated population health partners or larger systems.

Experts say practices need to reevaluate staffing needs, and look for opportunities to offload appropriate activities from higher licensed staff to lower licensed staff. "If coupled with patient identification protocols, safe and high-quality care can be maintained," Ajao says. Finally, make small adjustments to the practice's scheduling process to minimize disruption, always keeping the patients' needs at the forefront.

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When engaging in new population health initiatives, ensure your practice is properly allocating its staff and expanding strategically. 

Staffing Right for Population Health in Small Practices

Physicians are increasingly turning to technology to help address population health. It's being used to manage clinical data, streamline care coordination, identify potential health risks and empower patients to address their healthcare needs, and as value-based care becomes standard practice, technology will play an even bigger role.

Unfortunately, selecting the right technology for a small practice is not simple. Hardware, software, licensing and maintenance all come with a price tag. Moreover, training staff requires additional financial resources and it can be understandably - and especially - difficult for small practices to justify purchasing technology.

So where can practices get the most bang for their buck? Gaby Loria, senior market researcher at Software Advice, a consulting firm based in Austin, Texas suggests physicians consider their primary patient profile. "The best way for physicians to prioritize tech investments for population health is to evaluate which solutions will make the biggest impact on their patients' well-being," she says. For example, physicians who have particularly proactive patients may benefit from a patient portal while those who see many people with chronic conditions may find a solution that can detect gaps in care to be more advantageous.

Though a lot of technology requires a financial investment, this is not always the case. For physicians who are just starting to dabble in tech investments, there are some free EHR systems that have built-in population health tools and functions, such as patient portals and clinical reporting. Additionally, those working in small practices may want to seek out others making similar technological decisions. Working with like-minded independent physicians in a growing group practice, or through an independent physician association or network, can help spread the cost, says Clive Fields, president of Village Family Practice and chief medical officer of VillageMD.

Cost issues aside, when deciding what technology is best suited to a practice's needs, it is imperative that physicians understand how different types of software will work together, especially with your EHR. Technology needs to play a support role within the practice to help advance clinical outcomes, improve quality and lower costs.

"I advise primary-care physicians in small practices to try not to fall in love with the latest app or newest gadget and be practical about technology they purchase," Fields says. The fanciest technology available isn't going to be efficient if it doesn't allow for seamless integration with tools and solutions currently in place. Patient data should seamlessly and securely move among and between systems in or near real-time. If it doesn't, consider the cost and manpower that may be required for manual entry, thereby negating any cost savings the technology may have offered.

Decision-makers at small practices need to have honest conversations about their needs with all vendors before purchasing any technology. "If they can't guarantee the products will interface with one another, it may be more trouble than it's worth," Loria says.

Ultimately, Fields says, the physician-patient relationship is the utmost priority for any practice, and if a new technology solution can benefit the relationship, it may be worth consideration. However, he says, "if a solution hurts the relationship or completely gets in the way of it, it's probably better to pass."

Find the tech solutions that are correct for your practice's patients and don't get lured by the fanciest gadgets and apps, say experts. 

Tech-enabled Population Health at Small Practices is Complex

Those in healthcare are all too aware of the high financial and personal costs involved if something goes awry. This is especially true as EHRs are woven into everyday care and one electronic misstep can lead to disaster.  

“IT in the healthcare industry is so much different than IT in any other industry. What other industries do we have where IT can lead directly to patient harm, injuries, or death?” asked Trish Lugtu, CPHIMS, associate director of research at MMIC, a medical liability insurance company in Minneapolis. Lugtu presented a session examining the potentially harmful effects that can result from EHRs at the annual Healthcare Information and Management Systems Society conference in Las Vegas.

Though EHRs are relatively new on the industry scene, Lugtu said it is important to realize that blame for issues that arise from them cannot be placed wholly with the technology. “If you’re familiar with risk management, you know this is not new, but it is a new story with EHRs. EHRs work like machines because they are machines, and they do their job very well,” she said.

The top EHR-related factors that lead to patient harm can be divided into two categories: unsafe use (user-related issues) and unsafe technology. User-related issues include inappropriately copying and pasting information, inputting incorrect information, and routing electronic data wrong; while technology problems may include pre-populated data that is inaccurate, incorrect system or software design, or system dysfunction or malfunction.

Lugtu emphasized risk management and IT remain at the forefront of reducing patient harm, even in the face of potential user-related issues. “Even though we’re not directly interacting with patients directly, we’re maintaining those instruments for patient care,” she said.

To do this, healthcare teams need to build a common language. Both the clinical and IT sides use a vocabulary that isn't easily understand by those who work outside their particular space in the industry. “Our language doesn’t sync up, and we don’t even realize it,” Lugtu said. With all the parties involved in patient care, it is important to establish a shared language for communication across the entire team.

Additionally, organizations need to establish rights and responsibilities of EHR users. For example, if physicians have uninterrupted access to records, and they have access to see all necessary data to make clinical decisions, they need to be held accountable for security and accurate and up-to-date records. From the IT side, offering training and assistance to the organization on proper EHR protocol means technology staff should be available to answer questions and help others in the organization maintain proficiency and stay updated on changes in the system.

To address unsafe technology and unsafe use, Lugtu suggested putting protocols in place that examine issues such as system design/configuration, electronic routing of data, pre-populated data and defaulted data. In creating these detailed checks and balances, she said that both the IT team and clinicians need to make these decisions. “Both clinicians and health IT people need to be at the table,” she said. “The IT people don’t understand the intricacies of patient care, and the physicians feel intimidated by the technology, but they need to be communicating.”

Not doing so is a serious issue: “Accidents and oversights aren’t just unintended consequences,” she said. “These are patients’ lives.”

Practices have to take responsibility for potential liability issues surrounding use of the EHR. Not doing so can have disastrous consequences. 

Preventing Medical Liability through EHR Missteps 

Simply by nature, healthcare contains a wealth of data -not just medical records, but credit card numbers, social security numbers, and personal contact information. Combine this with a web of technology that connects internal and external parties, ever-evolving hardware and software, multiple wireless networks, and a proliferation of people that are interacting with all of this data, and there is little surprise that the industry is a popular target for cyber criminals.

Just a few years ago, healthcare security threats focused on lost and stolen devices, but cyberattacks today include hacking, phishing, unleashing malware, extortion, and additionally in the last few months, ransomware (holding data for ransom), have all become increasingly popular. “The threat paradigm we live in today is very different than the one we used to live in. Cybercrime is very real in the health industry,” said Chuck Kesler, MBA, chief information security officer for Duke Medicine in Raleigh-Durham, North Carolina.

Not only is cybercrime a real threat, it is also more pervasive than what most people realize, said Mac McMillan, FHIMSS, CEO and chairman of CynergisTek, based in Austin, Texas. “There are a lot more incidents going on than what we see in the news,” he said. And, Kesler added, “the patients are the real victims here, and they often aren’t even aware of what is going on.”

To address the issue of cybersecurity, Kesler and McMillan presented a session on best practices for protecting against cyberattacks at the Healthcare Information and Management Systems Society (HIMSS) conference in Las Vegas.

Too often, organizations think they need to protect attacks from the outside, but, as McMillan said, “walls don’t work all by themselves. You need to think from the inside out, not just from the outside in.” Cyberattacks do not happen overnight and are works-in-progress, often taking place over the course of 12 months to18 months before data is actually extrapolated. During that time, attackers look through data logs, gather information on network architecture, watch traffic, examine security measures in place and, only then, begin extrapolating data.

Building an information security program for your practice requires much more than anti-virus software and encryption. An organization’s risk assessment needs to include myriad security controls at the administrative, technical, and physical levels. Company policies and procedures need to address not just ways to protect data and prevent breaches, but also how to respond to and recover from an attack. “The bottom line is that breaches will happen,” Kesler said, “and you need to plan ahead before they happen.”

Technically speaking, organizations need to use two-factor authentication, sophisticated password systems, intrusion detection, and log systems -and these systems need to be monitored. If something out of the ordinary is taking place but no one sees it is happening, these tools offer no protection. “From a risk perspective, I don’t care that these things are there,” McMillan said. “I care that they are working.” The same is true for physical protection from security threats: Fencing, locks, cameras, guards and back-up power can all help protect from cyberattacks.   

One of the most valuable tools organizations have to fight cybercrime is their staff. Good information security isn’t just based on high-quality technology, but also on relationships and open communication among departments, including medical staff, IT engineering and management, compliance officers, and counsel. If people note something unusual regarding data storage or transmission, they need to feel empowered to say something. “If you think you only have one or two people on your security team, you’ve already lost,” McMillan said. “Everyone in your organization is a part of the security team.”

Healthcare cyberattacks can put your patients and medical practice at risk.  The good news is there are both high-tech and no-tech means to be safe.

Protecting Your Practice and Patients from Cyberattacks

The evolution of sophisticated technology has the opportunity to offer many benefits to both care providers and patients, especially when it comes to population health. But this high-tech capability can be daunting and confusing for some people, especially those who are older, have chronic conditions, or encounter social determinants such as socioeconomic conditions or logistical issues in regard to health. However, a “high-tech, high-touch” care approach using navigators can help empower patients.

“There is a lot of patient-focused software out there, but it can be difficult for patients to adopt this for themselves. This approach is actually patient-centric,” said Merrily Evdokimoff, RN, PhD, an adjunct professor of community health nursing at the University of Massachusetts-Boston and a consultant for IT/ software provider Kinergy Health. Evdokimoff presented a session on patient activation using technology-supported navigators at the Healthcare Information and Management Systems Society (HIMSS) conference in Las Vegas.

The high-tech component of this model includes a HIPAA-compliant extension to the existing EHR to facilitate communication with patients, and the high-touch component consists of trained patient advisors – “navigators” – who address non-clinical issues. “I love the name navigators, because that’s really what this is about. This is about helping patients get through and understand the system,” Evdokimoff said. Navigators work particularly well in certified home health agencies, physicians’ offices with chronic care management, call centers and in hospital case management.

A navigator’s role is multi-faceted and adaptable, depending on a coordinating organization’s and patient’s needs. Tasks may include identifying community resources, helping address chronic illness as a lifestyle disease, recognizing warning signs that may require escalating care for the patient with a physician and communicating with a patient’s family members.

Additionally, navigators work with patients to set realistic, achievable goals as they relate to health and wellness. “We find out what the patient wants to do,” Evdokimoff said. A 2013 study of 230 patients who received telephone follow-up with a care guide in a weight management program found that they achieved more goals than usual care patients (82.6 percent versus 79.1 percent), and they met more individual goals, which resulted in higher patient satisfaction, healthier habits and an improved quality of life. 

Though the relationship is health-centric, customer service is at the forefront of this model, especially because much of the work can be done over the phone. One of the most important aspects of navigators is the ability to address potential problems right away. “The navigator is able to get immediate patient satisfaction feedback, which helps identify things before they are escalated and patients are unhappy,” she said.

Some practices or health systems may be hesitant to institute a high-tech, high-touch program due to cost concerns, but, Evdokimoff said, the return on investment is high. A study by The Center for Health Affairs & Accenture showed there are more kept appointments, and fewer cancelled or no-show appointments when navigators are utilized. When used in hospital case management, patients are better able to understand medication schedules and discharge instructions, which results in a lower re-hospitalization rate. “Intervention, especially shortly after discharge, can be very significant,” she said. And, for home care, “prolonged engagement with the patient over a long period of time results in a very small cost,” Evdokimoff added.

The combination of high-tech and “high-touch” patient advisors can not only improve health outcomes, but produce a return on investment.

Empowering Patients with Health Navigators

Developing a technology-driven population health management system to manage the care of patients isn’t cheap, but luckily, Delaware-based Christiana Care Health System was at the right place at the right time.

In 2012, Christiana was in need of a care management system that improved communication between practitioners when it received a three-year, $3 million grant from CMS focused on ischemic heart disease. This grant, which established the 

, led to a larger-scale population health management system, which Christiana developed using standard, off-the-shelf tools so others could replicate the program and fit it to their own needs.

“We knew we needed to implement a strategic system, and our journey began at a conference not unlike this one,” said Terri H. Steinberg, MD, MBA, chief health information officer and vice president of population health informatics at Christiana. Steinberg presented a session about the evolution of population management, using Christiana as an example, on March 1, at the Healthcare Information and Management Systems Society (HIMSS) annual conference held in Las Vegas.

Christiana has since expanded its care management programming to include predictive analytics with full-data integration and is now embracing an increased number of risk contracts. Along the way, the healthcare system has seen improved patient well-being and a decrease in depression among patients from the clinical side, and a 50 percent reduction in the number of process steps required for care managers as well as an increase in productivity. Steinberg also noted a 43 percent reduction in overdue tasks, boosting productivity at Christiana.

There are three key components in creating a population management system: sophisticated technology that can handle the data load, analytics that allow for extrapolation of detailed data from a large population, and care coordination across a healthcare system, starting with a team of people including medical directors, pharmacists, and social workers who are able to identify potential health concerns before they bloom into legitimate medical problems. At Christiana, Steinberg said, these people are clinically trained to “respond to technology triggers.”

The system implemented at Christiana was designed to sort through an immense amount of data to pull out specific information about specific people in the population so care coordinators could take action. “Technology that can determine who needs care – and sometimes a lot more care – is very important,” she said.

In putting together a comprehensive population care management system, one of the biggest challenges is the fact that many people see multiple healthcare providers. “If you’re a provider, you only know about the data collected within the walls of your business, and there are a lot of things you don’t know,” Steinberg said. Christiana was able to address this to a certain extent by tapping into the Delaware Health Information Network, though Steinberg noted this may difficult for other healthcare systems without a similar resource

Additionally, she said data are not integrated across healthcare organizations, and communication to and between providers across business entities is difficult. “Communication is very fractured,” Steinberg said.

For healthcare organizations interested in implementing a similar system, Steinberg pointed out a few key things that have made Christiana’s care management system particularly successful, starting with its frontline of care coordinators. “I really want to underscore the importance of a strong, well-trained care management team,” she said. Well-maintained, appropriate technology that fits into an organization’s needs, in addition to support and buy-in from key stakeholders and executives is also essential.

Steinberg noted that, despite how far Christiana has come, there is always room to learn and improve. Nonetheless, she said, the organization’s population care management system has allowed it to become more efficient and productive. “This technology is not cheap, but care coordination is no longer fragmented,” she said.

Christiana Care Health System has relied on health IT tools, care coordinators, and stakeholder buy-in to drive its care management success.