Electronic Medical Record (EMR) systems are a must have for any healthcare organization. They allow providers to have timely and easy access to information of the patients they are interacting with. This access includes many different aspects of their care such as diagnoses, test results and interventions. These are very good examples of transaction-based information that is collected and reviewed on a daily basis. Several of the more advanced EMR systems offer opportunities to take best practice actions as the providers document information about different activities. These Best Practice Alerts (BPAs) help improve patient care.

Population health modules in EMR systems have been developed to address existing gaps in transactional-based systems.

There are certain use cases that the above model of human-computer interaction can fulfill very well. The initial required step in these use cases is the fact that a patient needs to interact with a provider prior to the computer being able to augment her or his care. The problem is that many patients are not aware of their care needs – either because they do not know about general preventive assessments for common conditions, or they have not received specific risk assessment for other conditions that they may be prone to.

The concept of population health has been used in different contexts. In healthcare finance, it is mostly used for grouping patients based on their payors and managing contractual obligations. In the clinical world, patients are grouped based on their medical conditions. The move toward risk-based contracts such as NextGen Accountable Care Organizations (ACOs) bring these two classifications close to each other with the opportunity for penalty reduction based on the identification of pre-existing conditions.

Population health modules in EMR systems have been developed to address existing gaps in transactional-based systems. Gaps in care can be divided into two categories, gaps in diagnoses and gaps in encounters. Gaps in diagnoses are about confirming and documenting pre-existing conditions to improve quality measures and reduce financial penalties for complications. Some of the examples of gaps in encounters are post-discharge visits by primary care physicians, screening for different types of primary cancer, follow-ups for early detection of cancer recurrence, scheduled assessments for chronic diseases such as Hb-A1c for diabetic patients, kidney function test for patients with Chronic Kidney Disease (CKD) and spirometry for patients with Chronic Obstructive Pulmonary Disease (COPD).

In addition to these built-in modules, there are third-party companies in health analytics that ingest EMR data from different organizations and calculate the risk for gaps in care. Having already achieved a good market share, these companies can overlay information from different healthcare systems and provide a more holistic picture of patient care. Identification of opportunities is a great starting point for closing care gaps, but the level of success with them depends on additional factors.

The requirement for success in these initiatives can be modeled by the three-legged stool analogy in which misalignment of any of the legs leading to instability. One of the legs, identification of gaps has already been discussed above. The other two legs can be represented by capacity and patient compliance. Even by using a risk-assessment predictive model with a high level of accuracy, considering the wide range of risk items, a large number of patients, and limitation of resources, addressing every risk is simply not feasible. Every healthcare system is dealing with limitation in the availability of clinical providers or other resources. These limitations affect the likelihood of comprehensive coverage of gaps in care. This is the stage where priorities need to be set based on the severity of risks and level of penalties attached to them. It becomes even more complex when one considers that different payor contracts may mandate different focus areas, and they should be stratified at the organizational level based on the proportion of the population under each contract. The allocation of resources needs to be carefully aligned by each healthcare system. Although this can be adjusted based on risks and contract changes, the outcome of these activities follow a late-effect pattern and should be given enough time to materialize. Regular monitoring of these measures allows operational leads to course correct in case initial assumptions are not materialized.

The third leg, patient compliance, is an item that has not received as much attention as the other two. Issues such as no-shows are a common problem in any healthcare systems. In addition, patients are not very willing to perform some preventive assessments, particularly invasive ones such as colonoscopy. Assessing the likelihood of compliance by patients is an important factor that helps in setting more realistic targets and expectations and get the best return-on-investment from these activities. This assessment can be used for more intensive follow up with people in need and dynamic resource allocation.

In summary:

closing gaps in care is a very complex process. Achieving this goal requires implementing multiple IT solutions to ensure a balanced activity that will result in the highest return on investment.

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Connected care or technology-enabled healthcare can improve access to services and empower patients and families to take control of their health. However, who is getting left behind as we move to the digitization of patient engagement in healthcare?

The tech industry frequently touts that over 90% of Americans have smartphones, implying that hardware is no longer the limiting factor to spreading technology-enabled health solutions. As part of my role in an accountable care organization (ACO), I am responsible for our digital and technology solutions that will enhance how we deliver care and engage with patients in order to improve outcomes and quality, and lower costs. When we select patient engagement apps and tools to implement in our pediatric ACO of close to 100,000 Medicaid patients, we must consider the characteristics of and resources available to our entire patient population. We cannot let technology solutions create another barrier to receiving optimal and timely access to care for some of our most vulnerable populations.

Knowing the value that patient engagement technologies can bring to quality and outcomes among our population makes it all the more frustrating when the ability to reliably use these tools is not equal for all patients.

Many of our ACO families live in areas with barriers to reliable transportation, and we see high no-show rates in the clinic. Converting appropriate visits to a virtual option is a promising solution for many of these families. Almost all of our families have smartphones in the household, and sometimes this device is the families’ only way of using online tools or accessing the internet. However, we have learned that only a small proportion of our patients with smartphones also have a consistent data plan, and dependable connections to internet at home are limited. Clinicians often deem this population ineligible for digital programs due to the lack of reliable connections needed for video visits or remote patient monitoring, and will instead book a traditional in-person visit. We, as an industry, have to understand how to combat the underlying access issue to a reliable internet or data connection if we plan to succeed in broadening patient engagement through technology.

In addition to limited data plans, limited space on phones is an issue for many patients and families (honestly, though, who of us has not done a photo purge in order to load a new app?). Downloading new healthcare apps require sufficient storage space that many of our families do not have on their phones. Many individuals lack cloud storage accounts or laptops to offload photos from their phones. We hear from vendors about new tools that will keep families better engaged with their child’s care, or track medication at home to better inform providers to make real-time clinical decisions. These technology solutions sound like promising advancements in care, but for some families, the decision to add a new healthcare app will require deleting photos from the last birthday their child had before a diagnosis, or the app that allows them to check in with grandma who is at home with the other kids while they sit at the bedside with their sick little one. Vendors must consider the size of tools and apps when designing new digital options. And while we have seen a trend toward offering a browser option, some tools are not mobile-friendly.

Lastly, let’s briefly talk about cultural humility in digital health. Technology has facilitated strides in the healthcare industry for providing better culturally informed care, especially in the interpreter services and on-demand translation space (thank you for that!). However, many families can still be left out of some digital offerings because tools are not provided in their native language or are not compatible with third party translation options. Additionally, standard content in many engagement tools does not reflect the diversity of many populations. When a nutrition app does not include a popular dish of a certain culture that a family eats multiple times a week, a family will quickly disengage from tracking food habits, or be forced to identify a meal that sounds similar, providing incorrect information to providers trying to tailor their care.

These critiques, of course, are not intended to suggest outright dismissal of the many technological advances that have entered the healthcare industry. In fact, we celebrate and invest in them. This past year alone, the Boston Children’s ACO has implemented tools that support virtual delivery of initial and follow-up visits, allow patients to report information about their health and symptoms from home, and provide health-related non-emergency transportation rideshare. We have observed modest decreases in unnecessary utilization, better engagement in attending regular primary care visits, and higher than predicted patient and provider satisfaction of the digital experience. Our behavioral health virtual visits program alone has increased access to pediatric psychiatrists, a need that far outweighs the availability of providers in the state, and engaged patients in better following treatment plans.

Knowing the value that patient engagement technologies can bring to quality and outcomes among our population makes it all the more frustrating when the ability to reliably use these tools is not equal for all patients. We need to start to break down the barriers between innovators and our communities. As we move to digitizing the healthcare industry and playing catch up to other industries that are further along in the technology revolution, it is our responsibility as healthcare leaders to influence the investment and implementation of innovative technologies that do not further the unequal distribution of affordable, reliable, and timely care.

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