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Population Health Driven by Technology in Delaware


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

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 Bridging the Divides program, 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.

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