Redefining Population Health to Deliver Health+Care at the N of 1: Part 2

This the second part of an abbreviated three-part series. Part one of the series can be read here.

Population health management has a central role in accountable care and health reform, meaning it is incumbent on all systems, organisations, offices, and providers to develop programs based on large data pools to benefit the individual — or possibly face penalties resulting from preventable readmissions, or other avoidable negative outcomes. At the same time, personalising individual health at the N of 1 plays critical role.

The mobile generation is accustomed to having nearly everything in the palm of a hand. Whether we’re buying or selling, browsing or tracking, this appetite for anywhere, anytime access defines our society, regardless of age demographic.

We customise shopping; we customise retail sales; we customise entertainment delivery. Algorithms act as mind readers to deliver content and purchasing suggestions. Even personalised advertising based on our browsing history and social media engagement appears whenever we log in. The Internet knows us, and tailors our clicking experience to our interests and needs, much like our mobile devices.

Healthcare has been slow to adapt, falling far behind retail and other sectors. The Internet of Things (IoT) or the Internet of Everything (IoE) — or even the more aptly named, ‘Internet of Healthcare Things’ — in the end is an ‘Internet of Me.’ In the same way it empowered consumers in other sectors, it is redefining healthcare delivery and patient engagement with staggering implications. A highly personal, customised real-time online experience must take place in healthcare.

People who routinely find answers at light speed will expect the same of their healthcare provider. Moreover, just as algorithms show advertisements tailored to the user, the public expects medical recommendations precisely tailored to them: their medical condition, their schedules and habits, surroundings, beliefs, and identity. They also want appointments on their schedule — not the provider’s [6].

The Internet-empowered, mobile-driven patient-as-consumer means finding a new way to connect. Real-time video, asynchronous video, text, email, or chat must become part of the doctor’s black bag — tools that can enable a new type of house call, too.

Gone is the traditional provider relationship, in which the doctor or other provider possessed all the knowledge, offered restricted appointment windows, rarely disclosed complete information, and often failed to incorporate the patient’s concerns and wishes for treatment. That model is gone, replaced by the “Healthcare of Me.”

Pineault, et al, compares models of care with access alone (walk-in clinics) to models with continuity as well as integrated care [7]. Access alone does not contribute to improved outcomes for chronically ill patients, whereas continuity and access to multiple specialties does. It is important to provide accessible care, but that care has to be appropriately offered by a provider or group of providers well known to the patient [7].

While no medical provider is comfortable with exclusively consumer-driven treatment requests, it is important to keep in context this millennial generation of patients that are becoming adults and seeking care. They are the chronically ill patient of the present and future. Bringing health literacy, accurate information, and accessibility to the patient empowers them to make decisions about sustaining their health.

In a recent article in BMC Medical Education, Nimmon and Steforns-Hayes (2016) measured the perception of power between provider and patient. Providers from many specialties demonstrated that their responsibility to the patient to provide information about patient health remained the same despite a shift to “patient -centric” care [8]. Providers from all specialties felt that their role as provider, coupled with the patient’s desires, created a shared decision making process customised for the patient [8].

Institutions must develop patient care delivery channels that are both technologically advanced and personalised, while making care more affordable and more efficient. The triple aim (improving a patient’s experience; improving health; improving cost-to-value) is the new bottom line.

The old emphasis on codes and billable treatments left us with sicker patients — as providers and institutions collected more for acute patients. Packed schedules that satisfied revenue demands left out the needs of patients, and effectively silenced their voice and participation in their care and left the provider no time to discuss prevention or lifestyle modifications. Diagnosis-only approaches overlooked complex conditions behind the disease or illness.

Missed opportunities abounded.

Instead of working with the patient’s constellation of symptoms the industry coded for the appointment and moved on. The results were acute patients with increased morbidity, and higher costs that drove up overall expenses without increasing positive outcomes. These practices gave us today’s trend in which 5 percent of patients account for up to 50 percent of healthcare spending. Organisations must integrate the patient fully into the larger healthcare landscape, and that means accessible providers, accessible records, and accessible treatments. Healthcare must reach beyond the physical provider location; beyond the appointment; and beyond the diagnosis.

Ready or not, technology like smart phones, tablets, sensors, and other portable devices is taking us away from a centralised, location-specific delivery to a system that is decentralised and networked. In healthcare, if technology initially created barriers to engagement, it can — and must — now enable a closer relationship with the patient while extending provider care opportunities and capabilities.

In a larger sense, mHealth and digital health can lead to increased adherence, for instance, with medication reminders and follow-up information exchange; virtual, real-time, or asynchronous discharge instructions; follow-ups; and home visits. Already this trend is under way via a new age of telemedicine and telehealth technologies, and digital health tools.

While these innovations increase patient engagement and satisfaction, they take us back to the future in a sense, to a time when putting the patient at the centre of care wasn’t just a trend — carrying us forward to the person-centred future, with care provided by a 2.0 era of the family doctor. The benefits accrue in a triple bottom line (or aim) of healthier patients, better outcomes, and increased value for service.

This shift is the only way healthcare will get paddling in the right direction. But it will require consolidating data to allow analysis and clinical decision support — integrated without access barriers and optimised for workflows — and it will take sharing information with one another without fear of losing a competitive advantage.

Organisations have access to billions of data bits, but most lack the ability to sift through it and create meaningful analysis or datasets — information that leads to better diagnosis, treatment, and outcomes. Sure, some organisations are looking at limited basic analysis, and how it relates to local or regional factors, and even environmental contributors. We must go further.

Imagine analysing a chemotherapy drug for its effects on patient care and outcomes by population age (of course) — but also by the patient’s diet, exercise, risk factors, income, family status, and geographic location. Now imagine that dataset included payer information, such as insurance type, claims history, and other provider data.

This larger narrative creates a more scientific, evidence-based, approach to medical care. It also brings data from the background into the forefront of healthcare, via the provider. As long as data remains in the background, though, analytics will have limited effect on outcomes.

[6] E. J. Topol, The Patient Will See You Now: The Future of Medicine is in Your Hands, New York: Basic Books, 2015.

[7] R. e. a. Pineault, “Evolution of Experience of Care of Patients with and without Chronic Diseases Following a Quebec Primary Healthcare Reform,” International Journal of Chronic Diseases, vol. 2016, 2016.

[8] L. Nimmon and T. Stenfors-Hayes, “The “Handling” of power in the physician-patient encounter: perceptions from experienced physicians,” BMC Medical Education, vol. 16, 2016.