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PHYTEL | WHITEPAPER

Shifting to Value

Population Health Management Technologies


for Accountable Care
Authors:
Richard Hodach, MD PhD MPH
Karen Handmaker, MPP

Summary
As population health management takes center stage in healthcare transformation, its becoming clear that the medical neighborhood must
be better organized to improve care coordination and ensure that all patients receive the right care at the right time. The hub of the medical
neighborhoodwhich includes primary care physicians, specialists, hospitals, post-acute care providers, ancillary services, social service
agencies, and public health departmentsis the patient-centered medical home, which guides patients through the system. Health IT is the
glue that connects the providers in the medical neighborhood to each other and to their patients.
Care teams perform the work, not only of managing care for individual patients, but also of population health management. Besides the
clinicians within a practice who provide patient care, the care team should be expanded to include all of the providers who deliver care to
a particular patient. When electronically connected, this extended care team can continuously send and receive updates and can easily
exchange views on a patients condition and treatment.
Whether the medical neighborhood is organized by clinically integrated networks, health information organizations, or accountable care
organizations, it requires interoperable EHRs and advanced data aggregation, analytic and automation tools to manage population
health effectively.
The ten most effective health IT tools for population health management are as follows:
Electronic health records

Referral tracking

Patient registries

Patient portals

Health information exchange

Telehealth/telemedicine

Risk stratification

Remote patient monitoring

Automated outreach

Advanced population analytics

These applications can be categorized as population-level solutions or patient-level applications. The core of both categories is the
patient-centric registry, a frequently updated collection of patient data that drives both population-level analysis and care management.
Patient registries are the central database for population health management in the medical neighborhood. Populated by clinical and
administrative data, theyre used for patient monitoring, patient outreach, point of care reminders, care management and other purposes.
They can also be used for health risk stratification, care gap identification, quality reporting, and performance evaluation.
At the patient level, population health management requires an organization to reach out to and engage all patients who have care gaps,
whether or not they visit their providers. Physicians and care managers must also be alerted about those care gaps, and they must
have a mechanism for intervening with patients who need routine care, as well as high-risk patients who require immediate attention.
Traditional manual methods are too labor-intensive and time-consuming to do all of this consistently and comprehensively. So healthcare
organizations must deploy automation tools and integrate them with registries and other data sources to make sure that patients receive
appropriate services.
Among the automation solutions that have been shown to be most effective in population health management are automated messaging
systems for patient outreach; automated systems for alerting care teams about patient needs; and online health risk assessments,
customized educational materials, and self-care recommendations. Telehealth and telemonitoring can help monitor the health status of
high risk patients and can give all patients remote access to their care teams when they need it.
Anyone that is involved in healthcare transformationincluding healthcare system and insurance executives and frontline providers
should read this paper to get an in-depth view of where healthcare is heading and how it will get there. The more that healthcare
professionals understand about the medical neighborhood and population health management, the faster they can move the ball forward.

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Contents

Page 4

Introduction

Page 5

What is population health management?

Page 6

Population Health Management and the Medical Home

Page 7

The Care Team in the PCMH and PCMN


The Extended Care Team In the Medical Neighborhood

Page 8

Organizing the Medical Neighborhood

Page 9

Health Information Technology: The Nervous System of PHM


Information-Sharing in the Medical Neighborhood
Population Health Management Tools

Page 10

Population Level HIT Applications


Patient-Centric Registries

Page 11

Claims and Financial Analytics


Risk Stratification

Page 13

Advanced Population Analytics

Page 14

Patient Level HIT Applications


Individual Engagement

Page 15

Care Management
Virtual and Remote Monitoring

Page 16

Team-Based Care Collaboration

Page 18

Conclusion

Page 19
Notes

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Copyright 2013 Phytel Inc. All rights reserved. 3

Introduction
The U.S. health care system faces numerous
challenges in adopting a population-based
approach to health care delivery. This
transformation will require a critical shift
from the current approach, which focuses
mainly on individual patients and episodes of
illness, to an approach that emphasizes the
health needs of an entire patient population.
Providers will need to be aware of their
patients interactions with other providers and
health organizations (hospitals, specialists,
mental health, behavioral health, and
long-term care), as well as non-medical
factors that affect their health and capacity
to self-manage, including geography,
socioeconomic status, and risky behaviors
like smoking, poor nutrition, violence, and
substance abuse.
Population health has been defined as the
health outcomes of a group of individuals,
including the distribution of such outcomes
within the group.1 The term population can
refer to geographic regions, such as nations
or communities, but it most often describes
a specific subgroup of patients. Examples
include a population of patients with a
specific disease (e.g., all of the diabetic
patients in a practice), a group with gaps in
care (e.g., all female patients without up-todate breast cancer screening), or simply, all
of the people who identify Dr. Smith as their
personal doctor.2
While the term population health might
be seen as implying a disassociation or
a distancing from the individual patient,

the opposite is true. The population


health approach to care delivery strongly
emphasizes patient engagement, quality
improvement, and the coordination of care
for individuals across care settings.
Improving population health is one of the
principles of the Institute for Healthcare
Improvements Triple Aim, which seeks to
improve the experience of care, improve
the health of populations, and reduce the
per capita costs of care.3 The Centers for
Medicare and Medicaid Services (CMS),
along with many private payers and
healthcare organizations, regards the Triple
Aim as the key goal of healthcare reform.
Despite the importance of the population
health approach, however, it will not be widely
adopted until new financial incentives in
healthcare evolve and become prevalent.
A key barrier is the dominant fee-for-service
payment system, which rewards healthcare
providers for patient encounters and the
volume and complexity of the services
performed during those visits. This model
discourages providers from caring for
patients outside of face-to-face encounters
or proactively seeking out patients with gaps
in their preventive or chronic disease care.
The current transition from fee-for-service to a
budgeted payment model in which healthcare
providers take financial and clinical
responsibility for care is expected to facilitate
adoption of the population health model.
Additional barriers to the new approach

include the lack of an infrastructure in most


healthcare organizations for improving
population health; the inability of most
electronic health record (EHR) systems to
generate the data or provide the analytics
required for population health; and the
fragmentation of healthcare in most
communities. Because of this state of
disorganization, there is little coordination
of care within the medical neighborhood,
which includes primary care physicians,
specialists, hospitals, rehab and longterm-care facilities, home health agencies,
pharmacies, labs, and imaging centers.
Until these entities coordinate care and
communicate, not only with each other but
also with patients, social service agencies,
and public health departments, the
optimization of population health will remain
a distant goal.
For a medical neighborhood to optimize
population health, it must be organized
around the patient-centered medical home
(PCMH), a primary care delivery model
that is patient-centered, comprehensive,
coordinated, accessible, and committed to
quality and safety.1 The PCMH coordinates
the care of each patient across the spectrum
of care settings with the help of health
information technology. The objective of
this paper is to explain how this can be
done in the patient-centered medical
neighborhood (PCMN) and associate
important health IT infrastructure elements
with key functions required for effective
population health management.

For a medical neighborhood to optimize


population health, it must be organized around the
patient-centered medical home (PCMH), a primary
care delivery model that is patient-centered,
comprehensive, coordinated, accessible, and
committed to quality and safety.
1

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What is population health management?


The definition of population health management (PHM) encompasses both the population to be managed and
the approach chosen to accomplish that goal. For the purposes of this paper, we are going to use the Agency
for Health Care Research and Qualitys (AHRQ) definition of practice-based population health, or PBPH: We
define PBPH as an approach to care that uses information on a group (population) of patients within a primary
care practice or group of practices (practice-based) to improve the care and clinical outcomes of patients
within that practice. 4
Patient engagement is also critically important in PHM. The Care Continuum Alliance (CCA), an

association of stakeholders committed to PHM, defines population health improvement as a model


featuring a physician-guided health care delivery system designed to develop and engage informed
and activated patients over time to address both illness and long term health. Care Continuum Alliance
members believe that managing health requires the active, integrated involvement of all health care
professionals coordinated with the patient and their caregivers and families. 5
Key components of the CCA model include health risk assessments, health promotion programs,
patient-centric health management goals and education, self-management interventions aimed at
influencing the targeted population to make behavioral changes, and ongoing communications between
patients and physicians, ancillary providers, and health plans.
Care teams are also a key part of the PHM approach. Shifting the care model from an episode-based
model to a person-centered population health model requires a team of providers who diligently monitor
quality and outcomes, care for patients based on conditions and risk levels, and proactively manage
patients who may otherwise slip through the cracks by delaying or avoiding care altogether.
The ability to achieve the goals of population health management, however, only becomes possible
when health information technology applications underpin and drive the fundamental activities of
practices, providers and care teams. The 2010 AHRQ report first identified five domains of PHM that
depend on HIT applications. Although this framework was developed to operate at a practice level,
these domainsall of which require the use of ITcan be considered at a number of levels: patient,
provider, practice, integrated health system and the medical neighborhood.

The ability to achieve the goals of


population health management,
however, only becomes possible
when health information technology
applications underpin and drive the
fundamental activities of practices,
providers and care teams.
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Copyright 2013 Phytel Inc. All rights reserved. 5

Population Health Management


and the Medical Home
The goals of population health management
are compatible with the goals of the patientcentered medical home (PCMH). Like
PHM, the PCMH is a completely different
kind of care delivery model than that which
most providers are used to. Both emphasize
the need to proactively keep people healthy
instead of just providing care when theyre
sick; shift the focus from acute care to
preventive and chronic care; are predictive
and proactive, rather than reactive; are
continuous, rather than episodic; are wholeperson-oriented, rather than case-oriented;
and offer care to all patients, not just those
who present for care. An individual primary
care practice can achieve some of these
goals, but population health management as
a whole requires a foundation established
by the PCMH model, which becomes the
hub for collaboration within the medical
neighborhood.
AHRQ defines the patient-centered medical
home as an approach to the delivery
of primary care that has the following
characteristics:
Patient-centered: A partnership among
practitioners, patients, and their families
ensures that decisions respect patients
wants, needs, and preferences, and that
patients have the education and support
they need to make decisions and
participate in their own care.

6 Copyright 2013 Phytel Inc. All rights reserved.

Comprehensive: A team of care providers


is wholly accountable for a patients
physical and mental health care needs,
including prevention and wellness, acute
care, and chronic care.
Accessible: Patients are able to access
services with shorter waiting times, after
hours care, 24/7 electronic or telephone
access, and strong communication
through health IT innovations.
Committed to quality and safety:
Clinicians and staff enhance quality
improvement through the use of health IT
and other tools to ensure that patients and
families make informed decisions about
their health.
Coordinated: Care is organized across
all elements of the broader health care
system, including specialty care,
hospitals, home health care, community
services and supports.6
A fully developed PHM approach requires a
number of capabilities and functions that are
not yet found widely in the U.S. healthcare
system, although there are many examples
emerging as the number of PCMH practices,
ACOs and clinically integrated networks
continues to grow. These critical capabilities
include an organized system of care, care
teams, coordination across care settings,
access to primary care, patient selfmanagement education, a focus on health
behavior and lifestyle changes, and the use
of linked EHRs and patient registries.7

A fully developed
PHM approach
requires a number
of capabilities
and functions,
including an
organized system
of care, care teams,
coordination across
care settings,
access to primary
care, patient selfmanagement
education, a focus
on health behavior
and lifestyle
changes, and
the use of linked
EHRs and patient
registries.

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The Care Team in the PCMH


and PCMN
Perhaps the medical homes most
significant contribution to population health
management is the emphasis on a care
team model. A team-based model of care
ensures that all patients from the lowest

risk level to the highest risk level are cared


for in the right place, at the right time, and
in the manner most appropriate for the
patient. A medical home care team offers
24/7 access and alternatives to traditional
face-to-face visits, including e-consults,
group visits, and patient portals. The care
teams responsibilities may include activities
such as pre-visit planning, self-management
counseling and creating complex chronic
care plan for a patient with multiple illnesses

To support the objectives of PHM, the care

community resources and others in the

team also ensures that proactive processes

larger medical neighborhood. All of the

are in place to manage the health care


needs of all patientseven those who
have not scheduled visits, paying special
attention to subpopulations of patients with
chronic diseases, complex conditions,
and behavioral health issues. These
population management activities can
require the sophisticated use of electronic
health records and other population health
management tools to identify and track
cohorts of patients by risk level, adherence
to care plans, appropriate medication use,
and achievement of therapeutic targets.
Once identified, care teams can also
leverage technology-assisted tools to reach
out to patients via phone, secure messaging,
or email to encourage them to schedule

providers caring for a patient should be


regarded as part of an extended care team
that is connected electronically and can
continuously send and receive updates on
the patients condition. This care team should
work off a single care plan that can be
expanded and modified as the patient moves
from one care setting to another. Further,
a well-functioning medical neighborhood
would feature seamless sharing of clinical
information, reduced duplication and
waste, enhanced continuity of care, shared
decision making and strong community
linkages. When all this happens, the medical
neighborhood care team becomes even
more patient-centered.

To support the objectives of PHM, the care team also ensures that proactive
processes are in place to manage the health care needs of all patients
even those who have not scheduled visits, paying special attention to
subpopulations of patients with chronic diseases, complex conditions, and
behavioral health issues.
and medications recently discharged from
the hospital. High-performing care teams
often include a combination of clinical and
non-clinical staff. It is not uncommon for
some staff to have multiple roles and for

needed appointments, refill important


prescriptions or check in with their doctor
following a hospital admission or emergency
room visit.

One compelling reason why PHM requires this


close collaboration between the medical home
and the medical neighborhood is that patients
with complex, high-cost illnesses must be
managed by multiple specialists. For example,

or shared across multiple practice sites.

The Extended Care Team In the


Medical Neighborhood

Care teams, in various configurations,

To coordinate care and patient support

may include nurses, care coordinators,

beyond the walls of the medical home,

medical assistants, social workers, diabetes

HIT applications can be used by care

educators, nutritionists and/or health

teams to document and share information

coaches who are dedicated to supporting

electronically and bi-directionally with

patients as they navigate the health system

providers (primary care and specialists),

lead the care team that is providing holistic,

and strive to achieve their care plans goals.

caregivers, hospitals, home health agencies,

comprehensive care to the patient.

others to be embedded by a health plan

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a cardiologist may manage a patients heart


disease, but that same patient may also have
advanced diabetes and emphysema requiring
the attention of other specialists. The primary
care physician who serves as the patients
medical home may not be able to address
these conditions fully, but he or she should

Copyright 2013 Phytel Inc. All rights reserved. 7

In todays fragmented environment, however, it

quality and lowering costs, can also organize the

is highly likely that primary care and specialist

medical neighborhood into a network capable of

providers treating these complex patients may


not all be aware of each others involvement
and, even if they are aware, they may be on
separate electronic medical systems and in
different networks or health systems. AHRQ
notes that these and the following challenges
greatly complicate care coordination and the
development of medical neighborhoods and
effective extended care teams:
No (or few) financial incentives or requirements
for care coordination
Limited financial integration across providers
Practice norms that encourage clinicians to act
in silos rather than coordinate with one another
The complexity of coordination for high-need
patients
Patient self-referrals of which the PCMH is
unaware
Limited health IT infrastructure and
interoperability8

Organizing the Medical Neighborhood


There are several ways to organize a medical
neighborhood into a high-functioning system
capable of managing populations and their
health. A hospital system, a physician group, or
an independent practice association can form a
clinically integrated network (CIN) that adheres to
a single set of clinical protocols and has the health

managing population health. But ACOslike


12

CINs and HIOs--need primary care practices that


follow PCMH principles to coordinate care and
help patients navigate the healthcare system.
In the view of many observers, the PCMH is an
indispensable building block of the ACO.
In an ACO, the population to be managed
includes all of the people who receive their care
from the providers that participate in the ACO.
(For purposes of the Medicare shared savings
program, beneficiaries enrolled in the ACO must
receive most of their primary care from an ACO
participating provider.) But many of these patients
get some of their care outside the ACO, and
population health management encompasses
interventions that fall into non-traditional
categories, such as social services, nutrition,
and wellness programs.13 The ACOs medical
neighborhood includes not only the providers
whom patients encounter in various care settings,
but also many other actors in the community and
sometimes outside of it.14
The healthcare stakeholders that have the most
experience in PHM are payers, which have
long sought to influence patients and providers
to improve outcomes and lower costs. Both
government and private insurers and employers
have engaged in various aspects of PHM,
including disease management and health

IT infrastructure required for care coordination,

promotion. Recently, a number of health plans

care management, and patient engagement.9

have formed partnerships with large provider

Alternatively, a health information organization

organizations to form ACOs or ACO-like entities.

(HIO) can leverage the connectivity it provides to


participants by adding a layer of automation and
analytic tools.10-11

There are
several ways
to organize
a medical
neighborhood
into a highfunctioning
system
capable of
managing
populations
and their
health.

In some cases, the plans are taking the lead in


online patient engagement activities and/or are
placing care coordinators in physician practices.
In addition, as we explain later, many payers

Accountable care organizations (ACOs), which

are providing claims data that can be extremely

are groups of providers committed to improving

valuable to providers that are doing PHM.

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Health Information Technology:


The Nervous System of PHM
Comprehensive, reliable coordination of care
in a medical neighborhood is impossible
without health information technology.
Health IT is a primary, if not the most
important support tool available for medical
neighborhoods, according to the AHRQ
report.15 This report further points out:
Health IT has significant potential
for facilitating physician efforts to
coordinate patient care in the medical
neighborhoodInteroperable electronic
health records enable PCCs [primary
care clinicians] and specialists to share
information, such as a patients medical
history, current problem and medication
lists, diagnostic testing and laboratory
results, and care plans.
The AHRQ paper also notes that electronic
health records need to become truly
interoperable and must link with the public
health data infrastructure to achieve their
potential in the medical neighborhood. But
this only scratches the surface of what health

In addition, ACOs and other organizations

Beyond the sharing of information among

that seek to manage population health

providers and between providers and

need analytics to measure performance


across the entire medical neighborhood.
With providers who are part of an ACO or a
clinically integrated network, the challenge is
to integrate data from many disparate clinical
and financial systems so that analytics can
be applied to it. To track care provided
outside of the network, health plan claims
data will also be required.17
It should be noted that while AHRQ calls for
the use of interoperable EHRs, systems
from different vendors are unlikely to be
capable of exchanging discrete data directly
in the foreseeable future. Instead, healthcare
organizations and HIEs create data liquidity
by aggregating and normalizing data from
disparate EHRswhich is another form of

can facilitate care management, patient


outreach, health risk assessment, web-based

fully in their own care. Moreover, when an


ACO or a clinically integrated network takes
financial risk for care, it must have tools
for evaluating both clinical and financial
performance.18

Population Health Management


Tools
The commercially available PHM solutions
described below can be categorized as
population or patient level functions to
emphasize new and enhanced activities
required to fully implement population

evidence-based and predictive modeling

A wide range of health IT capabilities


are needed to knit together the medical
neighborhood in ways that facilitate PHM.

One way to do that is through health

priorities for care planning. Automation tools

care planning, and engage patients more

Information-Sharing in the
Medical Neighborhood

With data supplied by registries and

health risk, identify care gaps and set

the health status of patients, collaborate on

health management. Population level

This starts with the ability of providers to

can be used to stratify the population by

automation tools for care managers to assess

interoperability.

IT can do in population health management.

enterprise data warehouses, analytic software

patients, PHM requires analytic and

communicate with one another electronically.


information exchanges (HIEs) that connect
providers across communities. Another is to
use the direct secure messaging protocol to
transfer clinical data back and forth between
providers. Both approaches have drawbacks
that are discussed later.

tools integrate multiple data sources, apply


algorithms, and generate actionable
performance reporting. Patient level

tools use the output from population level

applications to inform patient engagement


and care team workflows. In most cases
these applications are complementary to
electronic health records (EHRs), which,
by and large, are not designed for PHM.19
EHRs, practice management systems, and
other clinical and administrative systems can
provide much of the structured data required
for PHM. But as well see, other data sources
and capabilities must also be included.

education, remote patient monitoring, and


other PHM functions.16

Comprehensive, reliable coordination of care in a medical neighborhood


is impossible without health information technology.

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Copyright 2013 Phytel Inc. All rights reserved. 9

Population Level HIT Applications


Patient-Centric Registries

Traditionally, a registry is a list of all the patients in a physicians practice who share a characteristic, such as a
certain condition (diabetes, asthma, hypertension) or medication regimen. As HIT capabilities have improved,
registries are now built to be patient-centricproviding a full view of all information associated with a single
patientbut the information can be filtered by one or many criteria such as diagnosis, medications, age, payer,
lab results and more. Dynamic registries help the care team keep better track of these patients by providing
care reminders and by identifying patients who are overdue for certain kinds of care, or who are not adhering
to care plans. Registries can be integrated with other tools such as automated messaging systems that remind
appropriate patients to schedule appointments with their provider.
Patient registries form the central database for PHM in the medical neighborhood. Populated by clinical and
administrative data, they are used for patient monitoring, patient outreach, point-of-care reminders, care
management, public health reporting, and other purposes. When combined with analytic tools, they can be
used for health risk stratification, care gap identification, quality reporting, and performance evaluation.
Registries can also provide feedback to physicians to benchmark their own performance and support
their continuous improvement efforts. And a registry can be the online platform that allows all providers
caring for the same patient to collaborate and coordinate care across the medical neighborhood.

Figure
A. Technologies
for Population
Health
Management in a PCMH-N
Managing
Populations,
Maximizing
Technology
Ten Recommended
Health IT Tools to
Achieve PHM:

Population in the Community

Care Management
Automated Outreach
Patient Portals

Electronic health records


Patient Registries
Health Information Exchange

Clinical Analytics
Clinical Decision Support
Patient-Centered Registry

Patient Engagement

Patient Population
of the Primary Care Office

Payer

Risk Stratification

Claims and Cost

Automated Outreach

Risk Stratification

Referral Tracking

Primary
Care
Office

Care of
a patient

Patient Portals
Telehealth/Telemedicine

Others who supply/require information and coordination

Remote Patient Monitoring


Advanced Population Analytics

Specialty Care Hospital


Referral Tracking/HIEs

10 Copyright 2013 Phytel Inc. All rights reserved.

Radiology, Lab, Rx

Distance Monitoring
Telehealth/ Telemedicine
Remote Patient Monitoring

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5% of the population accounts for nearly half of all health costs, but only
30% of the patients in the high-risk category were high cost a year prior.
A registry lists each patients demographic

the registry would have to aggregate the

characteristics, diagnoses, lab values,

information from these providers and then

medications, and other pertinent data.


Applied to the individual patient, a registry
can show when the person was last seen,
who provided what care to that patient, the
patients current health status, and when
the patient is due to visit again. Applied
to a population, the registry can show, for
example, how all of a particular providers
patients with type 2 diabetes are doing,
which diabetic patients are out of control,
or how well an entire organization is treating
patients with that condition.
Analytic applications can compare the
data in a registry with nationally recognized
clinical protocols or guidelines accepted
by an organizations providers. Such tools
can identify care gaps, help stratify the
population by health risk, and generate
outreach messages to patients in need of
preventive or chronic care. These analytics
can also be used to generate reports on
subpopulations, such as patients with
uncontrolled hypertension, and to alert
providers and care managers that particular
patients need attention. In addition, care
teams can leverage registry reports to
prioritize interventions with high-risk
patients, create pre-visit care plans, and
customize educational materials to patients
in certain categories.
A registry that draws its data exclusively
from a single practice or healthcare
organization is inherently limited because
it includes only information generated by
that entity. A more effective registry would
contain data from all of the providers caring
for each patient. However, the owner of

normalize all of the data to a single format

risk must have these figures in order to

stay within a budget and determine which


providers are most cost effective.21

so that it can be displayed and analyzed. Its


also essential to scrub and validate this data
to assure its integrity before it is used to
manage care or evaluate performance.

Claims and Financial Analytics


One way for a healthcare organization to
obtain information on patients who receive
care from outside provider networks is to
obtain paid claims data from health plans.
Health plans are increasingly finding
ways to share this data with providers to
help them reduce variations in care and
manage population health. Some payers,

If an organization does not have access

to paid claims data, it may use billing data


from its financial system as a substitute. In
an ACO or a clinically integrated network,
this pre-adjudicated claims data may

be drawn from the billing systems of all

participants. When coupled with lab values,


prescription fill information and other

clinical elements, the combined data set


can be used to populate registries, even

without EHR data or with data only from the


dominant EHRs in the network.

as mentioned earlier, are even collaborating

Risk Stratification

with providers to form ACOs.20

With 5% of the population accounting for

Claims data is less actionable than clinical


data because it can lag the date when
services were provided to patients by a
month or more. It also has deficiencies
because the information is based on
payment and excludes clinical lab results
and other pertinent information captured in
the clinical record. For example, a claim for
a test ordered to rule out a diagnosis might
include that diagnosis on a claim, but the
patient might not have that condition.

nearly half of all health costs,22 its critically


important for healthcare organizations that
are taking financial risk to know who those
patients are. In addition, only 30% of the

patients in the high-risk category were that

sick a year earlier.23 So organizations need a


method to stratify their population by health

risk and provide the appropriate interventions


to prevent people who are moderately sick
from becoming severely ill. They must also

identify specific care gaps in their population


to ensure that patients receive the preventive
and chronic care they need to maintain their

Claims information can also help an

health and control their conditions.

organization calculate the total cost of


providing particular kinds of care. A practice
management system or a hospital financial
system is not designed to furnish that
kind of information. But claims data, when
combined with analytics, can supply an
approximation of care delivery costs. ACOs
and other organizations that are at financial

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Risk stratification refers to the periodic and


systematic assessment of each patients

health risk status, using criteria from multiple

sources to develop a personalized care plan.


A patients health status may be reflected by
a score or placement in a specific category,
based on the most current information

Copyright 2013 Phytel Inc. All rights reserved. 11

available.24 The identification of a patients

and takes medications as prescribed would

health risk category is the first step towards

not be regarded as high risk.

planning, developing and implementing a


personalized patient care plan by the care
team, in collaboration with the patient. For
some, the plan may address a need for more
robust care coordination with other providers,
intensive care management, or collaboration
with community resources. The care teams
observations also play a vital role. The more
variables included in determining the risk
category, the more reliable and accurate the
prediction of future health risks and costs
can be.

Multifactorial stratification can also be


used to determine the resources required
to address risk reduction across the
organization and the most appropriate
allocation of those resources. For instance,
nurse care management might make
more sense than an increase in PCP visit
frequency, depending on the patients
particular profile. Thus, risk stratification can
guide the timeliness of responses required
by specific subgroups rather than applying
one standard to all patients.

Severity of medical condition has historically


been the primary factor for stratification. It
is the most readily identifiable and perhaps
the most useful in and of itself. However,
meshing severity data with patient specific
characteristics related to co-occurring
medical and behavioral health disorders,
patient confidence, and psychosocial risk
factors such as living alone or low income,
allows for a much more refined approach to
stratification and informed patient-centric care
management strategies and interventions.

To evaluate its
performance, an
organization that
engages in PHM
can leverage a
data warehouse or
population analytic
tools needed to
convert its data into
useful intelligence.

Organizations can use multiple means


to risk-stratify a population. Patients or
employees can be asked to fill out a health
risk assessment that may be online. If an
organization has a registry, it can apply
analytics to that database to identify patients
whose health indicators suggest that they
are high risk. The best approach is to do
both and to pull in any other available
data that will help the organization get an
accurate picture of a persons total health
situation. Some patients who may not yet

Stratification profiles can also identify


patients at high risk for poor compliance or
untoward outcomes that do not necessarily
meet high severity criteria; conversely,

be high risk could easily move into that


category because of psychosocial factors
such as living alone or having a low income
or poor access to care.

patients with an illness or symptoms


classified as high severity may be assigned
to a relatively low risk level if the patient
has other characteristics which suggest

In addition, the risk stratification can help


care managers determine the priority they
assign to their patients and the types of

that this single risk factor is not sufficient

interventions that are appropriate for each

to substantiate assignment to a high risk

one. For example, high-risk patients may

category. For example, a patient with a

need more personalized attention, whereas

history of elevated HbA1c who has well

those in the medium-risk category may only

controlled blood pressure and lipid levels

require automated messaging and online

12 Copyright 2013 Phytel Inc. All rights reserved.

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To truly manage financial risk, organizations must learn how to manage


population health effectively. And to do that, they must fundamentally
change the process of care delivery, using the appropriate automation
and analytic tools.
education. Low-risk patients may simply be
prompted to maintain their health and get
appropriate preventive care.
To identify care gaps, clinical analytic
tools automatically and continuously apply
decision support rules to the structured
data in a registry or data warehouse. These
analytics can generate exception reports,
which identify patients who do not meet

specific criteria for best practices. Examples


include patients with persistent asthma
who have not been prescribed an inhaled
corticosteroid, patients over 50 who have
not had a colonoscopy in the past 10 years
and elderly individuals with multiple chronic
conditions and recent hospitalizations or
emergency room visits.
In addition, the system should be able
to generate panel reports, which show
providers and care teams key indicators
about all of the patients they are responsible
for. These brief summaries facilitate
treatment review and care planning ahead of
patient encounters.

Advanced Population Analytics


To manage population health, a provider
organization or an ACO must measure
its clinical and financial outcomes. The
organization must track the health status of
its patient populationand particularly its
high-risk patientsto reduce the per capita
costs of care and improve the health of
populations. It can also use historical data to
predict what costs will be going forward.
To evaluate its performance, an organization
that engages in PHM can leverage a data
warehouse or population analytic tools

needed to convert its data into useful


intelligence. Besides the patient-level
reports described above, these reports must
be able to give providers, care managers,
and organizational management views of
how well the population is being managed at
a variety of levels.
At the top level, for example, managers
should be able to see the prevalence

HbA1c, and long-term outcomes. The


latter measures include both clinical
data and patient-reported data, such as
functional status and self-perceived health.
Organizations must also continuously
measure patient satisfaction. By tracking
progress on all of these metrics over time,
they can see whether they are improving the
health of their population.

of common chronic diseases in the


organizations population. They should
be able to risk-stratify that population by
condition and see how the portion of highrisk diabetic or hypertensive patients is
changing over time. Managers should also
be able to look at which segments of the
population are generating the highest costs
and how that changes, so they can shift
resources as needed. And their analytic
tools must enable them to evaluate the
performance of individual providers and
practices on both quality and efficiency.43

Furthermore, organizations that are taking


financial risk need to have the ability to
understand how the quality of care impacts
the cost of care and how that is likely to
affect future costs. To do this, they must risk
stratify the population as described above,
but must also focus on which individual
patients and population segments are likely
to generate future costs. Then interventions
should be designed to provide patientcentered care and shared decision making
with those patients to curb risk factors and
control chronic conditions.

A physician should be able to access reports


on his or her own population of patients with
a particular chronic condition and see how
those patients are doing over time. These
reports can help identify patients who are
outliers in terms of health status and those
who have not received appropriate care.
Providers should also be able to compare
their own performance on quality measures
with national benchmarks and with the
average for their practice or organization.

In addition, organizations must determine


which providers utilize the most resources
for particular types of care, risk-adjusting
that data for the relative illness and
compliance of their patients. With this
information, they can construct reliable cost
and quality profiles and steer patients to the
most efficient, high-quality providers.

To assess population health at a particular


point in time, organizations can use
measures that describe care processes,
such as how many patients with diabetes
received an annual eye exam, intermediate
outcomes such as blood pressure or

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By using risk stratification, predictive


modeling and provider utilization data,
organizations can obtain a perspective on
their current and future costs. But to truly
manage that financial risk, they must learn
how to manage population health effectively.
And to do that, they must fundamentally
change the process of care delivery, using
the appropriate automation and analytic tools.

Copyright 2013 Phytel Inc. All rights reserved. 13

Patient Level HIT Applications


Individual Engagement
A population health management approach requires an organization to reach out to and engage patients who
have care gaps to alert them that they need to make appointments with their providers or take other action to
close these gaps. Automation is crucial to systematizing this approach. Manual methods are too expensive
and time consuming to ensure periodic outreach to an entire patient population, including people who have not
sought care but need it.
An electronic registry populated with EHR and administrative data can be the basis of this kind of

outreach. When combined with evidence-based clinical protocols and analytic software, the registry can
supply the information that tells the automated messaging system when to call patients who are due for
particular services. Automated communications can also be used in a variety of patient education and
engagement activities.
A study of automated phone messaging to patients with diabetes and other patients with hypertension
showed that it was effective in encouraging many of them to seek appropriate care for their conditions,
including office visits and tests.33 Similarly, the use of automated messaging to promote adherence to
statin medications was shown to be effective in a large scale, randomized trial at Kaiser Permanente.34
The same kind of automation tool that triggers appropriate and timely messaging to patients can also
be used to alert physicians and care managers that particular patients need particular services or
urgent interventions. An EHR can provide some of these alerts, but only when its accessed, which
would normally be during a patient visit. These kinds of reminderslimited to a narrow range of
health maintenance, decision support, and chronic care alertsare insufficient for population health
management.

14 Copyright 2013 Phytel Inc. All rights reserved.

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Once an organization has reorganized its care processes within the context
of the medical neighborhood, a subsequent step in its journey to population
health management is to use technologies designed to provide care and
patient education remotely.
Care Management
One of the hallmarks of an organization
prepared to manage population health is
the use of care managers to coordinate
care and ensure that all patients receive
appropriate interventions. As they do in
traditional disease management programs,
these care managers work closely with
high-risk patients to reduce exacerbations
of their conditions that can lead to ER
visits or hospitalizations. But to optimize
population health, they must also maintain
contact with other patients who fall into
the low-risk and medium-risk categories.
It is impossible for them to manage the
care of so many patients without the use of
automation tools.
A few years ago, researchers calculated that
it would take 18 hours a day for a primary
care physician to provide all evidencebased preventive and chronic care to a
typical panel of 2,300 patients.25 Just to
deliver all recommended care to a panel
of 2,500 patients for the 10 most common
chronic diseases would take more than 10
hours per day, another study found.26
While there is no comparable published
research on the amount of time it takes care
teams to do that work, unpublished data
from a large Midwestern group indicates that
care management requires an average of
138 minutes of staff time per patient. When
that figure is compared to the prevalence
of complex chronic conditions in a typical
primary care primary care practice, it can
be inferred that a single PCP with a panel of
2,500 patients would require 1.35 FTE care

Most physician practices cannot afford

These applications fall roughly into three

so many care managers. Moreover, many

categories: telehealth, which automates

care management tasks are routine and do


not require the involvement of clinicians.
Automation can perform these routine jobs,
freeing nurses and doctors to care promptly

the process of keeping track of changes in


patient health status; telemedicine, which
permits patients to consult with physicians
or nurses through audio and video

for the patients who need their attention.

conferencing; and web portals, which can

Automated patient outreach and the

with patients online.

automatic alerting of care teams to


patient care gaps are examples of such
an approach. In addition, health risk
assessments can be offered online;
assessments, customized learning materials,
and self-care recommendations can be sent
to patients via web portals or secure e-mail;
and campaigns can be designed to improve

be used to share information and interact

Telehealth can include home monitoring,


mobile monitoring or a combination of
the two. Home monitoring is used most
frequently with high-risk patients such as
those with congestive heart failure or people
recovering from operations; but it has also
been used successfully to help people

the care of all relevant subpopulations.

control other chronic conditions such as

When applied to patients with chronic

can help inform care plans and can form

diseases, these campaigns can be


tailored for people in hundreds of different
subcategories. For example, a diabetes
population can be classified into patients
with type 1 diabetes, type 2 diabetes,
type 2 diabetes and hypertension, poorly
controlled type 2 diabetes, and so forth.
Different educational materials and self-care
recommendations would be sent to patient
populations in each cohort, using one or
more automated modes of communication,
including text, phone and email, as
preferred by the patient.

Virtual and Remote Monitoring


Once an organization has reorganized its
care processes within the context of the
medical neighborhood, a subsequent step in
its journey to population health management

managers, and a 10-doctor practice would

is to use technologies designed to provide

need 13 care managers.27

care and patient education remotely.

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diabetes and hypertension. Monitoring data


the basis for automated or live feedback to
patients on their health management.
A number of mobile apps designed for
smartphones and tablets also enable
consumers to monitor their own conditions.
The value of most of these apps has been
limited so far, because few physicians
are viewing the monitoring data.28 Thats
expected to change, however, as provider
organizations increasingly take financial risk
for care delivery.
Telehealth provides continuous data on a
patients condition and increases patient
engagement in their own care. Studies show
that this can improve patient outcomes and
that it is cost effective.29 But for healthcare
organizations to make good use of this
data in care management, they must
activate automated protocols so that care
managers and physicians are alerted only

Copyright 2013 Phytel Inc. All rights reserved. 15

to exceptions that require their attention


and disposition. Moreover, as Partners
Healthcare in Boston has shown, doctors
are more likely to pay attention to the data
if its integrated with their electronic health
records.30
Telemedicine, which has been around
far longer than telehealth, started off by
helping patients in rural areas connect with
specialists in metropolitan regions. But in

recent years, health insurers have begun


using telemedicine to enable their members
to consult with doctors hired by the plans
or by an outside service to diagnose and
treat minor complaints remotely. A number
of states also require health plans to cover
telemedicine services. And new technology,
such as smartphones equipped with digital
cameras and video chat features, makes
telemedicine cheaper and more accessible
than it once was.
From the perspective of population health
management, telemedicine can reduce
costs and improve care by keeping patients
away from ERs and costly specialists when
their problem is treatable outside of a
face-to-face encounter. But practices and
hospitals must figure out how these virtual
visits fit into clinical workflows.
The use of patient portals with EHRs
was uncommon until recently, when the
Meaningful Use Stage 2 regulations put
providers on notice that they might need
portals to meet the patient record sharing
criteria.31 These portals also provide a
method to automate communications with
patients and provide them with educational
materials. With 20-25% of providers already
using portals and financial incentives to
adopt portals, they must be considered an

16 Copyright 2013 Phytel Inc. All rights reserved.

increasingly important accessory of PHM.32


A study of Kaiser Permanentes patient
portal showed that a large portion of plan
members accepted and used it. Between
2004 and 2007, v isits to the portal tripled
to an annual total of 33 million. The portals
most popular functions were viewing lab
results, requesting prescription refills, and
e-mailing with doctors.33

Team-Based Care Collaboration


Nothing hampers care coordination in
the medical neighborhood like a lack of
communication among providers. But its still
the exception for primary care doctors to be
informed when their patients are admitted to
or discharged from the hospitalalthough
they may receive a discharge summary
days or weeks later. Lack of follow-up care
after discharge can result in complications
and a worsening of patients conditions.34
Referrals from primary care physicians to
specialists also represent an opportunity
for improved communications. Only 62%
of primary care physicians report getting
consult results from specialists, although
81% of specialists say they send the
information back to the referring doctors.
Conversely, 69% of PCPs report sending
a patients history and the reason for
consultation to specialists always or most of
the time, while only 35% of specialists say
they get that information most of the time.35

Changes in
payment models
and the structure of
healthcare delivery
are expected to
alleviate many
communication
problems. But
information sharing
mechanisms must
be improved to
provide the kind of
consistency that
population health
management
demands.

Changes in payment models and the


structure of healthcare delivery are expected
to alleviate many communication problems.
But information sharing mechanisms
must be improved to provide the kind
of consistency that population health
management demands.

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One lever for improving these


communications is the Meaningful Use
stage 2 regulations. These require providers
to exchange care summaries at transitions
of care, such as hospital discharges and
specialty referrals. But that exchange must
take place electronically in only 10% of such
transitions, and just once with a receiving
provider who uses a different kind of EHR
than the sender.36

supports notification of the specialist visit


back to the referring physician. It also gives
providers the ability to chat about the
patient via secure messaging.39

Health information exchanges can facilitate


the sharing of information between unrelated
provider organizations. But a recent study
found that only 30% of hospitals and 10%
of ambulatory practices participate in
such HIEs, which most often traffic lab
results, clinical summaries, and discharge
summaries.37 Private HIEs enable providers
within a particular healthcare enterprise to
exchange data, but that may be insufficient
when managing population health.

is sent, it is classified as emergent, priority


or routine on the tracking sheet, and referral
resources in the office keep track of which
of these appointments have been kept and
whether a report came back. If a specialist
recommends a test, the referral is kept open
until the results have returned.40

Secure messaging using the Direct Project


protocol is also being increasingly utilized
to send and receive clinical messages. But
many providers still lack access to Direct
messaging. Even those who have it cannot
use Direct to query the EHRs of other
providers for relevant patient data.38
There are other solutions that provider
organizations can use to fill some of these
gaps. For example, there are referral
management applications that can be used
to make and track referrals. Northwest
Physicians Group, a Seattle-area IPA, uses
a web-based referral service that allows
specialists to let primary care practices know
what information they will need for a referral.
Patient referrals are no longer lost, because
they can be electronically audited, and the
system enables a closed loop of care that

The Wright Center for Primary Care in


Archbald, Pa., also does electronic referral
tracking to improve care coordination. The
practice uses its EHR to create an open
referrals tracking sheet that a staff member
is responsible for monitoring. When a referral

Organizations can also use an application


that connects with patients shortly after
hospital discharge. This type of solution
can be used to ask patients if they have
questions about their discharge instructions
or medications, automatically transfer
patients to a care team member or trigger
outbound calls from their physician or
primary care practice. And it can help to
ensure a doctor visit has been scheduled
to improve the transition of care experience
and patient satisfaction.41
Studies show how important such IT tools
can be in improving coordination in the
medical neighborhood. Just 17%-20% of
primary care physicians report that theyre
routinely notified of discharges; 20%-40%
say they receive discharge summaries two
weeks or more after their patient leaves the
hospital. Sixty-five percent of discharge
summaries lack information on pending tests;
21% omit data about discharge medications;
and 14% dont mention follow-up plans.42

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Copyright 2013 Phytel Inc. All rights reserved. 17

Conclusion
To support the objectives of PHM, the care team can use technology to ensure that proactive
processes are in place to manage the health care needs of all patientseven those who have
not scheduled visits, paying special attention to subpopulations of patients with chronic diseases,
complex conditions, and behavioral health issues.
These population management activities can require the sophisticated use of electronic health records and other
population health management tools to identify and track cohorts of patients by risk level, adherence to care plans,
appropriate medication use, and achievement of therapeutic targets.

18 Copyright 2013 Phytel Inc. All rights reserved.

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Notes
1.

David Kindig and Greg Stoddart, What Is Population Health? Am J Public Health. 2003:93:380-383.

2.

Reference ii.

3.

Donald M. Berwick, Thomas W. Nolan and John Whittington, The Triple Aim: Care, Health and Cost,
Health Affairs, May/June 2008, 759-769.

4.

AHRQ, Practice-Based Population Health: Information Technology to Support Transformation



to Proactive Primary Care, July 2010, accessed at http://pcmh.ahrq.gov/portal/server.pt/gateway/
PTARGS_0_11787_945869_0_0_18/.

5.

Care Continuum Alliance, Advancing the Population Health Improvement Model, accessed at
http://www.carecontinuumalliance.org/phi_definition.asp.

6.

PCPCC website, Defining the Medical Home, accessed at http://www.pcpcc.net/about/medical-home.

7.

David M. Lawrence, From Chaos to Care: The Promise of Team-Based Medicine. Cambridge, Mass.:
Da Capo Press, 2003.

8.

Agency for Healthcare Research and Quality, Coordinating Care In The Medical Neighborhood:
Critical Components and Available Mechanisms, white paper, June 2011, accessed at
http://www.pcpcc.net/sites/default/files/resources/Coordinating%20Care%20in%20the%20
Medical%20Neighborhood%20%283%29.pdf.

9.

Premier Healthcare Alliance, presentation, Clinically Integrated Networks: a Population Health


Building Block, 2013.

10. Ken Terry, Caradigm Expands Health Information Exchange Capabilities, Feb. 28, 2013, accessed


at http://www.informationweek.com/healthcare/electronic-medical-records/caradigm-expands-health information-exch/240149713.

11. AT&T press release, Baylor Healthcare System Deploys AT&T Healthcare Community Online,


Oct. 26, 2011, accessed at http://www.att.com/gen/press-room?pid=21839&cdvn=news&newsarticle
id=33178.

12. AHRQ, Coordinating Care In The Medical Neighborhood.


13. Paul A. Nutting, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange, Elizabeth Stewart and Carlos

Jaen, Transforming Physician Practices to Patient-Centered Medical Homes: Lessons From the

National Demonstration Project. Health Affairs, 30, no. 3 (2011): 439-445, accessed at
http://content.healthaffairs.org/content/30/3/439.abstract.

14. Institute of Medicine, Crossing The Quality Chasm: A New Health System for the 21st Century, 3.

Washington, D.C.: National Academy Press, 2001.

15. AHRQ, Coordinating Care in The Medical Neighborhood.


16. Institute for Health Technology Transformation, Population Health Management: A Roadmap for


Provider-Based Automation in a New Era of Healthcare, accessed at http://ihealthtran.com/pdf/PHM
Report.pdf.

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com

Copyright 2013 Phytel Inc. All rights reserved. 19

17. Suzanne Felt-Lisk and Tricia Higgins, Exploring the Promise of Population Health Management

Programs to Improve Health, Mathematica Issue Brief, August 2011.

18. Institute for Health Technology Transformation, Population Health Management.


19. AHRQ, Coordinating Care in The Medical Neighborhood.
20. Ken Terry, Why Are Insurers Buying Physician Groups? Hospitals & Health Networks,


Jan. 1, 2012, accessed at http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/
Article/data/01JAN2012/0112HHN_FEA_trendwatching&domain=HHNMAG.

21. Institute for Health Technology Transformation: Healthcare Analytics: The Information Backbone of

Risk-Bearing Organizations, accessed at http://ihealthtran.com/healthcare_anayltics.html.

22. AHRQ, The High Concentration of U.S. Healthcare Expenditures, Research in Action, Issue 19,

accessed at http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html.

23. Ian Duncan, Healthcare Risk Adjustment and Predictive Modeling. Winsted, CT: ACTEX Publications, 2011.
24. Reference iv
25. AHRQ, Practice-Based Population Health,17.
26. Ted Wymyslo, The Role of a Registry in Achieving Health Cares New Focus: Population Health,

Focus, American College of Medical Quality.

27. Institute for Health Technology Transformation, Population Health Management.


28. Ken Terry, Strategy: How Mobility, Apps and BYOD Will Transform Healthcare, InformationWeek


Healthcare, July 10, 2012, accessed at http://reports.informationweek.com/abstract/105/8914/
Healthcare/strategy-how-mobility-apps-and-byod-will-transform-healthcare.html?cid=SBX_iwk_fture_
Analytics_Healthcare_healthcare&itc=SBX_iwk_fture_Analytics_Healthcare_healthcare.

29. Jared Rhoads and Clive Flashman, Teleservices for Better Health: Expanding the Horizons for


Patient Engagement, CSC white paper, accessed at http://assets1.csc.com/health_services/down loads/CSC_TeleServices_for_Better_Health_Expanding_the_Horizon_of_Patient_Engagement.pdf.

30. Terry, Partners Integrates Home Monitoring Data With EHRs, InformationWeek Healthcare,


June 28, 2013, accessed at http://www.informationweek.com/healthcare/electronic-medical-records/
partners-integrates-home-monitoring-data/240157431.

31. Pamela Lewis Dolan, Will meaningful use spur growth of patient portals? American Medical News,

Sept. 17, 2012, accessed at http://www.amednews.com/article/20120917/business/309179967/6/.

32. Terry, Patient Portal Explosion Has Major Healthcare Implications, iHealthBeat, Feb. 12, 2013,

http://www.ihealthbeat.org/insight/2013/patient-portal-explosion-has-major-health-care-implications.

33. Ann-Lisa Silvestre, Valerie M. Sue, and Jill Y. Allen, If You Build It, Will They Come? The Kaiser

Permanente Model of Online Health Care. Health Affairs, 28, No. 2 (2009):334-344.

34. AHRQ, Coordinating Care in the Medical Neighborhood.


35. Ibid.

20 Copyright 2013 Phytel Inc. All rights reserved.

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com

36. CMS, Stage 1 vs. Stage 2 Comparison Table for Eligible Professionals, August 2012, accessed


at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/
Stage1vsStage2CompTablesforEP.pdf.

37. Julia Adler-Milstein, David W. Bates and Ashish K. Jha, Operational Health Information Exchanges

Show Substantial Growth, But Long-Term Funding Remains a Concern, Health Affairs, July 2013,
10.1377/hlthaff.2013.0124.

38. Terry, Direct Clinical Messaging Surges in Multiple Contexts, iHealth Beat, Aug. 20, 2012, accessed

at http://www.ihealthbeat.org/insight/2012/direct-clinical-messaging-surges-in-multiple-contexts.

39. Puget Sound Health Alliance, Spotlight on Improvement: Effective Referral Management, May 2012,

accessed at http://www.clarityhealth.com/resources/PSHA-Spotlight-Improvement-Effective-Referral Management.pdf.

40. Qualis Health, the Commonwealth Fund, GroupHealth, Closing the Loop with Referral

Management, seminar slides.

41. Phytel website, Phytel Transition: Hospital Post-Discharge Management Tools, accessed at http://

www3.phytel.com/solutions/population-health-management-systems/discharge-readmission-solution.aspx.

42. Kripilani, et al. JAMA 2007. Bell, et al. JGIM 2008, cited in Closing the Loop with Referral Management.
43. Institute for Health Technology Transformation, Population Health Management.

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Copyright 2013 Phytel Inc. All rights reserved. 21