As Donald Trump prepares to take his presidential oath, one of the biggest questions surrounding his first 100 days is how he and Congressional Republicans will attempt to supplant Obamacare. Politics aside, it’s inarguable that the Affordable Care Act forever altered the national dialogue surrounding health care, which, as of last month, now accounts for 17.8% of the nation’s gross domestic product.

One of the major philosophies behind Obamacare was that, by extending more and more coverage to those traditionally uninsured, the high costs of unnecessary emergency room visits would be substantially cut. While this hasn’t necessarily worked out the way the ACA’s architects would like, the debate has continued to explore more innovative ways to reduce ever-rising costs. This is where tech picks up the ball. How? Population Health.

What is Population Health?

In a 2003 article published in the American Journal of Public Health, David Kindig, MD, PhD, and Greg Stoddart, a health-care economics professor, helped to define Population Health as we understand it today: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” As for Population Health as an actionable system, Kindig and Stoddart summed it up as “health outcomes, patterns of health determinants, and policies and interventions that link these two.”

How does tech step in?

A phrase like “distribution of such outcomes within the group” should key you in on one of the major ways tech can redefine health care in America — Big Data. The more we know about each person’s health-care habits, or lack thereof, the more we can understand about unnecessary costs and how to remedy them. This 30,000-foot view is best expressed as Population Health Management (PHM).

But don’t forget about devices, either. And we’re not talking just high-tech surgical tools. We’re also talking innovation in delivery of service. If the home and the hospital can be efficiently connected, such as eliminating in-person visits that can be just as easily solved at home, or providing comprehensive at-home evaluations and diagnoses, then costs are bound to drop significantly. The question is, however, what is the best way to implement the complexities of PHM. So let’s take a look at a particular health care network that’s already heavily transitioned to the Population Health model.

Partners Healthcare

Founded in Boston in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital, Partners Healthcare has evolved over the past two decades into a network of hospitals, community health centers, health-care programs, international programs, and collaborations with other health care institutions and universities.

In 2012, Partners began to implement its own PHM system, which has expanded into five points of care: primary, specialty, non-hospital, patient engagement, and analytics and technology. As the US transitions further toward Population Health ideals, Partners’ PHM model can be utilized as a template for designing and refining nationwide systems of health care facilities and programs that provide more comprehensive care while tempering costs. The key areas in which Partner combines its efforts are listed below:

  • Patient-Centered Medical Home (PCMH): Not “home” as in physical location, but rather “home” as in the structure of a care delivery system for an individual patient. This includes the team of medical staff, social workers, care coordinators, and educators that work in tandem with the patient, the patient’s family, and coordinating the patient’s trajectory throughout the variety of on-site, off-site, and virtual care.
  • Integrated Care Management Program (iCMP): This focuses on patients who are either chronically ill or suffer from complex medical conditions. The patient is paired with a nurse case manager who, along with the patient’s family, builds a customized care plan and acts as a liaison between the patient and other care providers within the PCMH, while ensuring the patient has access to the most appropriate services.
  • Behavioral Health Integration: Another team-based care model where psychiatrists, social workers, and non-clinical care providers integrate their services. The idea is that, when mental health is poorly addressed, it ripples throughout the patient’s entire relationship with health care systems. Through this model, mental disorders can be diagnosed sooner and unnecessary costs avoided by placing the patient in the proper points of care more immediately.
  • Specialty Programs: If the primary-care delivery system for a particular patient is his “home,” then the surrounding avenues of specialty care are his “neighborhood.” A primary care physician may request the help of a specialist through an E-consult, which not only avoids the lag of unnecessary in-person visits, but also better prepares medical staff should an in-person visit be needed. Virtual visits and eVisits are also utilized, the former being a video-based encounter in real-time, and the latter an online question and response system to keep providers abreast of the patient’s current conditions.
  • Non-Hospital Care: This area aims to reduce unnecessary emergency room visits through the Partners Mobile Observation Unit. For both long-term patients and those recovering from acute episodes, nurses are assigned to make home intensive home visits to monitor current conditions, diagnose further, design a treatment plan, and order necessary testing.
  • Patient Engagement: Partners offers a three-phase support system for patients to monitor their conditions from home. One, patient-engagement videos are short, one-topic videos made by that patient’s care provider to address frequently asked questions. Two, “shared decision making tools” provide patients with evidence-based decision aids to ensure they’re pursuing the proper course of treatment. Three, online patient communities, like Partners’ PatientsLikeMe network, allow peers to advise each other based on their own experiences with a condition.
  • Analytics and IS: This is essentially Partners’ Population Health Management infrastructure at-large, and how actionable data is harvested from the varieties of treatment and communication mentioned above. Partners is currently moving to a single uniform platform, Partners eCare, which unifies all health, administration, and financial data into a single hub.

What’s next?

It’s inevitable that health care and tech will continue to redefine each other in the coming decades, regardless of what Washington does to help or hurt this progression. But what’s most important is that medtech hubs around the nation continue to arise, where hospital networks can work closely with the brightest minds to help ensure not only that more people can be responsibly covered by insurance, but that our various deliveries of service are sustainable and adaptable.

With medtech as one our three core focuses at tekMountain, we are committed to honing a cutting-edge health care community in southeastern NC. Contact us today about how your company can accelerate this vision.

This blog was produced by the tekMountain Team of Sean AhlumAmanda SipesBill DiNome, and with lead writer Zach Cioffi.

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