Improving population health management

I chose to talk to the PHCSG regarding the changes that have been brought in by the recent Health and Social Care Act 2012, handing commissioning over to ‘clinical commissioning groups’, largely run by GPs. As the chair of the NHS Commission Board, Malcolm Grant recently said, the best clinical commissioning groups will be those with the best information systems. There is, therefore, an obligation on those who work in the area of primary care informatics, to step up to this challenge.

Traditionally healthcare has stood out as the one industry where the received wisdom is that spending and quality are inextricably linked. It is held by many to be self-evident that if you reduce cost, you must, by default, increase how long people wait for care and reduce the quality of the service.

No other industry can get away with this simplistic view, and the evidence shows that in healthcare the received wisdom isn’t true either. There are innumerable studies around the world to show that variations in quality are frequently nothing to do with the amount of money spent. Whether you look at the Darmouth Health Atlas showing the failure of higher spending to correlate with better outcomes in the US, or at the fact that many of England’s hospitals with the best clinical outcomes also have the lowest reference costs; you see that money can be spent wisely to get great outcomes at lower costs or badly to get poor outcomes at high cost.

Challenge
The challenge for informaticians is to show that we can break the received wisdom, that we can we reliably and repeatably reduce cost whilst improving access, quality and outcomes through the application of information and technology.

There are only two ways to drive cost reductions and quality improvement. Firstly,make individual healthcare institutions and services such as hospitals, community clinics and home nursing more productive. Secondly, make the whole health and care system more productive

The former is critically important and the NHS should not be distracted from the important task of driving waste and inefficiency out of its services. I have previously written a number of papers and given several talks on the potential for productivity improvement in hospitals through process redesign and the application of evidence-based care, supported by information and technology. In my talk I focused on the whole system and the opportunity to transform the economics of health and care by placing the patient at the centre of system design and using information and technology to improve their health and reduce their cost demand on the healthcare system.

The challenge is for IT to enable the whole system, not just the silos – stepping out of our narrow institutional interests and finding a way to deliver benefits for the population, the patient, the NHS and its staff. This needs to be based upon five pillars:

1. Strong electronic health record (HER) foundations in hospital care, primary care, community care and homecare – because without good, real-time clinical information, very little else is possible. There is a question about whether the purchaser or commissioner of care should worry about the EHR systems being used by their providers, or even whether they have a right to have an opinion. I would argue that if they are serious about managing quality and developing benefits through system integration they should insist that their providers have a digitised health record and are able to share this data in real time.

The next generation of healthcare information technology will apply knowledge algorithms such as prompts on the appropriateness of admission or the identification of patients at risk of being readmitted as an emergency, as the data is collected so that, for instance, preparation for managing their discharge can start as they come into hospital.

These, and the hundreds of other intelligent support algorithms that it would be possible to build and run to support staff and protect patients, are dependent on comprehensive EHR gathering data on patients as it is known, not two days after discharge. Furthermore, commissioners should insist of the digitisation of the whole care pathway because it will support the elimination of ‘memory based care’ and the distribution of clinical decision support to propagate the application of best practice. It is well known that one of the keys to better, safer, lower cost care is the application of evidence, but it is also understood that the adoption of new knowledge into routine practice is painfully slow - one study showing that it takes 17 years for new knowledge to be adopted into practice by half the physicians.

This is not because doctors are difficult and refuse to use the evidence in front of them. It reflects the fact that the volume of new evidence being produced, the complexity of care pathways and the number of professionals involved in providing care makes ‘memory based’ care a defunct approach to modern medicine. Einstein did not clutter his mind with ‘facts’ he could find in a book, he devoted his efforts to interpretation. The average clinic appointment doesn’t provide the time for a doctor to refer to a pile of clinical text books, so we expect them to provide care based on what they can remember. 

Prescribing errors
The consequences are seen in the waste and harm that is caused by prescribing errors - three to five per cent of all hospital admissions, £500M of unnecessary costs; and the myriad examples of where best practice care can deliver low cost, higher quality, but is patchily adopted. That is why, when commissioners think about redesigning a health system, they need to require their providers to use EHR technology effectively and then apply the ‘closed loop’ principle to quality management beyond the hospital and integrated care pathway processes.

2. Using a health information exchange to link the care system together – so that we don’t have silos of information, but clinicians can have access to all the relevant information at the moment of decision.

Digitising the silos is not enough to transform healthcare as a whole. Health information exchanges allow organisations to connect and exchange information across an entire health system. In Oklahoma, for example, a publicly managed Health information exchange called Secure Medical Records Transfer Network (SMRTNET) captures data on more than 2.6 million people or 72 per cent of the state’s population.

There are a growing number of published studies that support the clinical and economic benefits of this integration. One recent study showed that HIE access achieved a 230 per cent return on investment by reducing admissions through A&E; another showed efficiency saving in primary care from improved access to test results and less staff time handling referrals; and a third showed that 70 per cent of outpatient doctors forecast that a HIE would reduce costs, 86 per cent that it would improve quality and 76 per cent that it would save time.

The technology now exists to allow hospital doctors to see relevant patient data directly from the GP system and the GP to see data directly from the hospital EMR, allowing clinicians to share their knowledge about a patient in real time.

3. Gathering data together, outside of individual systems and organisations, to give a comprehensive view of the health of a population. Clinical integration through a HIE will improve quality and productivity in operational practice, but designing the health system of the future requires more than this. Advances in technology now mean that system-wide information design, which is the legitimate interest of commissioners, can move beyond retrospective reporting, into real-time patient and quality management. This requires us to lift data out of the institutions and bring it together at a higher level, in the cloud, to enable pain free health system reporting and benchmarking to drive process improvement, reduce bureaucracy and insurance income retrieval, real-time patient and system tracking to optimise the patient experience, predictive modelling to plan future interventions, and whole pathway decision support that is not encumbered by organisational boundaries.

This liberation of data allows the health system to maximise value by focusing on addressing the needs of the whole population and within that: stratify to identify patients with long-term conditions and ensure that they received locally agreed pathways of care, personalised to their own needs; ensure that episodic care is applied according to best practice evidence and that quality and cost are monitored; and that specialist care is supported by the appropriate experts and advanced decision support tools.

4. Support the direct management of patient care, so that community services address the right patients, in a timely way, supported by the information and evidence that they need.

In an EHR enabled health system, population level information analysis isn’t simply for information and reporting. To drive changes in population health it needs to be integrated directly into frontline patient care. The data from risk stratification and by tracking the clinical data collected in hospital, community, primary and home care, as well as by the patient themselves, can be used to prioritise cases for a case manager, telephone based health coach or home nurse’s schedule.

It can then guide the conversation that they have and the vital signs that they need to collect, applying decision support algorithms in the background to prompt advice to the patient or decisions to refer to another professional. It can alert the hospital or primary care clinician if a patient is deviating from their expected recovery or disease management pathway and therefore provoke an intervention. And it can ensure that patients, their carers and the clinical team are kept informed about decisions made in other parts of the care pathways.

5. Use technology to support the patient in being a partner in maintaining their own health. There is considerable experience around the world to suggest that simply giving patients access to their clinical record adds little value. Some highly motivated patients are interested and access it frequently, but most look once and then very rarely.  To make a personal health record compelling it needs to be interactive and supportive.

The PHR should provide a simple and user friendly record of the patient’s notes in different organisations for them to view.  Most patients have GP records and several hospital records. The PHR should bring these together in one place, and not be tethered to a single institution or software vendor. It should prompt the health maintenance activities that patient should be undertaking, such as exercise or taking their own measurements. It should integrate with home monitoring devices such as scales, pedometers and blood pressure cuffs.

Through its interface to the cloud-based population health platform it should link with data captured at home and with data captured in primary care or at the hospital and provide real-time alerts with advice on what to do next – such an online evisit questionnaire, and share this data with their GP, case manager or practice nurse.

What is needed
Population health improvement requires more than retrospective public health analysis. It requires a platform of electronic health records in all parts of the health system so that data can be accurately captured, shared and used to provide decision support prompts that encourage the application of best practice. These platforms need to be integrated through an HIE to allow clinicians to share information and gather the data to support analytical tools. An information infrastructure is required that allows automated retrospective reporting and submissions; real-time patient tracking; predictive modelling, risk assessment and population segmentation; patient prioritisation, and; the application of evidence based decision support algorithms.

Care management tools need to support the management of patients across all settings and the proactive intervention to support health. Patient tools need to assist them in managing their own health and to engage them in decision making.

The NHS will not deliver 20 per cent productivity savings without this investment in information and technology. The challenge is whether we have the skills and the courage to change the way medicine is practiced, with the help of IT.

Further information
Matthew Swindells is chair of BCS Health. For further information, visit 
www.bcs.org/category/6044