Redesigning Care Models for the Future of Population Health

The healthcare industry is an ever-evolving environment. Not only are there changes in digital health and advancements in innovation, but there are other factors such as new, non-traditional players and new legislation. At times, the many changes being researched and implemented can be so overwhelming that we may lose focus on some of the key points.

A few of the HIMSS Physician Committee members created key questions, and we collected answers from a handful of healthcare leaders to assist in putting these changes into perspective, and highlight what matters in healthcare today, and in the future.

Looking toward the care settings of the future, what do you think the mix will be between in-person care, care at home, and virtual care?

Dr. James Lin, Hawaii Pacific Health

Telehealth is here to stay. The COVID-19 pandemic established video, e-visit, and remote care options as successful methods to deliver convenient and quality care. We will likely see an increase of care at home, but the factors of community health support, payment transformation, and patient expectations will need to be addressed first.

Dr. Katherine Behan, FACP, Jefferson Health

It’s hard to tell, as reimbursement models will need to change in order for current and future healthcare providers to invest in building care delivery infrastructure in the virtual and home settings. It will be a more gradual transition, and eventually, acute care facilities (hospitals, emergency departments) will be for our sickest patients, and outpatient services and virtual services will be able to deliver services to treat a majority of patients. Acute care home services will be too difficult and expensive to scale within our current infrastructure and technological capabilities.

What are your thoughts on a patient identifier, its benefits and risks, as we look to the future of population health?

Dr. James Lin, Hawaii Pacific Health

Data science and population health go way beyond the interoperability of systems communicating with each other. Patient identifier discrepancies between systems are more troublesome than the connection and require a lot more time and effort to “clean up” the data. A universal patient identifier would go a long way but standard minimum requirements of existing patient identifiers and descriptors across government, insurers, and healthcare would also get us there. Standardized data exchange definitions and, ideally, integrated data exchange between systems already reduce unnecessary tests and procedures. Enhancing “clean” data exchange between payors, health systems, and state public health agency databases would make a sizeable dent in the time spent in duplicate efforts in each area.

Dr. Katherine Behan, FACP, Jefferson Health

A patient identifier (PI) would allow for better identification of patients, improve safety in healthcare interactions, and enable better informed diagnostic and therapeutic decisions for physicians and other clinicians. It would also significantly reduce unnecessary harm and costs that come with redundancy in testing and possibly procedures. A PI would also allow patients greater access to their own healthcare information.

What innovations do you see now that show the most significant promise?

Dr. James Lin, Hawaii Pacific Health

Research into best practices is already showing results with sharing normalized and de-identified patient data. Diseases, evaluations, and treatments for conditions normally take years to collect enough patients and data. Nowadays, clear and reliable information can be collected and applied, not only in research, but at the point of care based on millions of similar patients. Data-driven decisions at the point of care is another large area of opportunity. Epic’s Best Care for My Patient tool will enable clinicians and patients to make informed decisions about their health, based on similar patients across the world.

Dr. Katherine Behan, FACP, Jefferson Health

Digital and technological tools will enable shifting lower acuity patients currently seen in the emergency department, or in observation level care, into other settings that are less expensive. Staffing shortages and overall increases in costs to deliver care in hospitals will make treating lower acuity patients in these traditional facilities financially untenable. Digital and virtual care that enables meaningful, high value, effective patient-care team interactions will be critical in accelerating adoption. Reimbursement and simplification of billing processes will be critical to enable this. 

What roles do you see in the future for public-private partnerships in new models?

Dr. James Lin, Hawaii Pacific Health

Social determinants of health are the intersection of everyday life and healthcare. Transportation, food or housing insecurity, and availability of health foods are where private enterprises can partner with healthcare systems to target. Focus needs to be on the highest priority of locally identified needs to improve the health of the community. Better community health leads to a more productive workforce and economy, which benefits both ends of the public-private partnership.

Dr. Katherine Behan, FACP, Jefferson Health

Community-based organizations partnering with more traditional healthcare providers will be more and more prevalent, given the recognition and acceptance of social determinants as a key part of healthcare.

How will the entry of non-traditional players (e.g., Walmart, CVS, Amazon, others) into the value-based and direct-to-consumer healthcare markets impact new care models?

University of California, Davis, Team

• These players will offer more affordable, accessible care by leveraging their excellent customer experience design, logistics and partnerships.
• The COVID-19 pandemic highlighted the critical need for nursing staff; post-pandemic, we are seeing the impact of the massive staffing shortage on healthcare.
• Non-traditional players will fill the shortage of primary care physicians in healthcare markets.
• As care moves to the home-virtual setting and medical information becomes more democratized, then players like Walmart will jump in to eat up a good part of that emerging market.

Dr. James Lin, Hawaii, Pacific Health

There is an opportunity to improve general population healthcare more accessible. Healthcare systems will benefit from the convenient locations these retailers already service. The decentralization of care makes interoperability and data exchange even more important to providers and patients. Without it, ongoing care will neither be accurate nor equitable.

Dr. Katherine Behan, FACP, Jefferson Health

These players already operate at a scale that positions them to deliver care less expensively than more traditional providers. That gives them a significant advantage. Quality and effectiveness in managing large populations will ultimately determine if they have a lasting impact on care models. Will they be able to deliver high value, cost-effective care at such a scale?

What role and impact does digital health have in redesigning current care models?

University of California, Davis, Team

• It eliminates distance and paperwork as barriers.
• The COVID-19 pandemic was a real-world test of digital tools. Healthcare went from in-person care to using digital health tools almost overnight. The trend to use digital health tools will become more pervasive as we continue to transition away from brick-and-mortar hospital care.
• As time goes on, medical knowledge will be widely available to diagnose as will treatment options for severe illnesses.

Dr. James Lin, Hawaii Pacific Health

Digital health should always be an enhancement to the patient-physician relationship. Does the digital health tool provide access to care not otherwise available? Does the digital health tool provide digestible and actionable information for patient and provider choice? Is it convenient and usable, especially when a healthcare decision or diagnosis can be a life-changing event? If the answer to these questions is “yes,” then digital health can have a huge impact, like telehealth did during the pandemic. If not, it will be an added distraction to the complicated world of healthcare delivery.

Dr. Katherine Behan, FACP, Jefferson Health

Very significant impact, especially with younger healthcare consumers, and many older, who are used to engaging with digital technology in all other areas of their lives. If done well, digital health can significantly improve healthcare access for underserved populations as well as others. It also offers a significant opportunity for teams to expand their capacities to reach more patients, without adding additional resources.

What tools, technologies, and innovations do you see having the most impact, and how? 

University of California, Davis, Team

• Mobile apps, real-time and big data, and artificial intelligence would allow care to be administered faster.
• Disease-specific monitoring tools will continue to mature over time.
• Things that make medical knowledge widely available and simpler to understand and implement; standardized repositories of information that offer a baseline of care options given certain symptoms; and the increasing use of physician assistants and other less formally trained care providers to perform the bulk of medical diagnosis.

Dr. James Lin, Hawaii Pacific Health

Telehealth has the most impact now, but it is still in its infancy and will continue to expand. Home monitoring with automated feeds to augment video, audio, or patient portal interactions will improve access and reduce utilization costs. Data-driven decision support at the point of care with either normalized or de-identified data will also have an impact. To mitigate physician burnout, voice activated documentation and navigation tools will be a breakthrough when it becomes affordable and reliable. For payors, integration or enhanced access to healthcare system, electronic health records (EHRs)  data will reduce administrative burdens, will speed the right care and the right time, and reduce denials and approvals needed.

Dr. Katherine Behan, FACP, Jefferson Health

Simple technology that engages patients, and just as importantly, is easy for physicians and providers to implement and use will have the most impact in the future. Integration with EHRs is important. 

What clinical scenarios are primed for transformation using digital health (e.g., population health, chronic care, acute care, hospital at home, etc.)?

University of California, Davis, Team

• Any clinical scenario that doesn’t require hands-on care.
• In-person care will become more specialized as non-traditional players enter the market.
• In-person care may eventually mostly become a thing of the past. Many medical devices may become consumer grade electronics, enabling virtual care to a greater degree.

Dr. James Lin, Hawaii Pacific Health

Population health is primed now that most healthcare is digitized. How can healthcare organizations, or developers of healthcare, use this information to push limited resources in care delivery in a data driven direction?

Dr. Katherine Behan, FACP, Jefferson Health

Post-discharge services for acute patients when they are in a vulnerable time, and at a higher risk for a worse outcome, are primed for a digital health transformation. Digital health can enable closer monitoring and access to services for return visits back to the emergency department and readmissions. Digital health programs that engage patients with chronic diseases could also have a significant impact by helping them to better manage these conditions.

I don’t think digital technology is in place to accelerate hospital in the home right now. The bigger barrier for home care is creating a care delivery infrastructure in the home and finding a way to pay for it.