Population Health Management A look at Cerner’s Population Health Management Offering
Cerner Population Health Management The Challenge Healthcare systems are becoming unsustainable the world over, struggling to keep up with the rising demand from the chronic disease burden, patient expectations and the costs which come with advancement of medical care. Most current strategies are focused on doing more for less, by leveraging tactics such as freezing top line growth in spending and/or reducing provider payments. To address this challenge, many developed countries are establishing new models of care aimed to movie away from activity-based payment models to health maintenance and wellness models, based on outcomes. This change is facilitated and made possible by underlying technology as patient data is coded and digitised and the processes of care are automated across the health and care continuum. For health information technology, it is no longer enough to correctly report what has happened. Success in the new environment requires tangible improvements in outcomes – utilising automated data from different venues to impact care in the moment and for the future. With these changes, health care organisations need new solutions, roles, and processes to succeed. Cerner understands these changes and is prepared for the future state of health care.
Cerner Population Health Management What is Population Health Management? “Population health management tightly integrates the best available diagnostic, clinical and IT tools with the available care delivery and reimbursement processes to deliver the best possible clinical result for individual patients with the most efficient economic outcome for a defined group of consumers.� JAAG Research Sept 2013
Population Health Management, as the name suggests, is targeted at managing the health and care of a population. However, to do this well and to do it right, Cerner is focusing on the patient or the individual, not solely on patient cohorts at aggregate level. Managing the health and wellbeing of individuals goes beyond automating health systems. It is a complete transformation in health care delivery, focusing on the person whilst assuring health outcomes and responsibility for care management. A healthier overall population will not only maximise patient satisfaction but will also serve to minimise costly resource consumption. Achieving this goal will require a complete view of all patient data and being able to meaningfully use that data to engage individuals at all times, exchange information between providers and ultimately drive better outcomes. It is a massive shift in perspective that will shape the future of health care – one driven by accountability, transparency and value. Cerner believes the best way to manage the health of a population is one person at a time. To make this transformational shift toward proactively managing a population, our solutions allow organisations to:
Know what is happening and predict what will happen Engage people they can help Manage health and improve care
Cerner Population Health Management Patient at the Centre Cerner has created a cloud-based population health management platform, called HealtheIntent™ that organises data around the individual, rather than the visit or activity. Organisations which take on the population health management challenge by managing risk will need to rethink the role the hospital and the individual play in overall care. In the future, fewer patients will be cared for and managed within the four walls of a hospital. Cerner has developed the ability to create a managed health network that supports the integrated care management of patients ensuring clinical outcomes are delivered through closing care gaps using our integrated HealtheIntent platform. This platform enables evidence-based care and decision support to be provided in the location that is most suitable for the patient, even within their own home. The patient is truly at the heart of their own care. In the below visual, Virginia’s care team have access to all her information through population health management solutions enabled by the HealtheIntent platform.
Cerner Population Health Management How does it work? The HealtheIntent platform enables the inclusion of data from disparate, external sources in an effective way – to build population-level views, and to programme a network of resources to manage the health of the individual. Data is pulled from any electronic source, in any available format, at any time. This data is then transformed and normalised to be available when needed. Core capabilities of this platform support the ability to know your population, engage your members and manage your outcomes by:
Aggregating, linking and sharing clinical and administrative information at patient level across the health economy, from disparate systems, in real time, so as to best know and understand the individual and how to care for them
Attributing the responsibility of care for a patient to the correct care service provider
Enabling the management of patients and cohorts to defined quality measures across the health economy, helping clinicians to identify and close out gaps in patient care
Leveraging the power of big data and analytics to not only predict patients at risk but to allow providers to take action from within the electronic health record (EHR) workflow in real time for individual patients
Supporting performance management across provider networks to deliver integrated care provision whilst balancing supply and demand
Providing these aspects in a programmable or customisable fashion so as to meet the unique needs of a given population, region, or community
Cerner Population Health Management Cerner’s vision for the HealtheIntent platform includes the following major capabilities: Consumer engagement: services which the consumer (patients/ social care clients/ citizens) can utilise in order to take an active role in managing their own health and wellbeing. These services include access to and the ability to contribute to health records, the ability to support health and wellbeing education programmes, and active participation in care management and coordination programmes. Care management and coordination: services that enable the design and execution of coordinated care programmes for cohorts of patients across a population. These services are required to enable delivery of care driven by and measured against best practice quality metrics, allowing prioritisation and best use of provider resources to have the greatest impact on improving patients’ health outcomes. Provider performance management: services that enable the design of provider incentive programmes and manage their contribution to patient outcomes across a network of providers. These services enable the ability to monitor and act on provider performance across a population against clinical and financial outcomes, to analyse and predict population wide issues requiring attention, and to guide the continual development of how services are delivered. Data acquisition: the underlying capability to deliver a real-time architecture to share and aggregate clinical and administrative data conformant to patient information governance controls. These services will standardise and normalise data from disparate systems creating a true longitudinal patient record. This aggregated data will allow real-time population health management programmes tailored to patient cohorts and orchestrated across health and social care providers.
Cerner Population Health Management The journey to population health management Health Information Exchange at Barts Health NHS Trust
Health Information Exchange
“I don’t know how we didn’t have this ten years ago” is a common response from staff at the Royal London Hospital when asked about the new Health Information Exchange.
Taking the first step towards population health management starts with connecting
Clinicians say that just one month into the project, being able to view a ‘community record’ is already helping them to make better clinical decisions and reducing the amount of time they spend chasing information or ordering repeat tests.
with the UK primary care GP system network; with one click, hospital staff are able to
A&E staff are particularly enthusiastic users of the new system. Working in a paper-free department, they are always using computers to enter information and now have a community record just a click away. The Exchange Factor, E-Health Insider
and sharing information across the care continuum. Cerner’s Health Information Exchange (HIE) is a common platform to integrate patient-related data from external systems and manage the wide variety of clinical records and document types prevalent in today’s health and care system. HIE supports real-time data exchange check the real time information about the patient: illness, injuries, test results , immunisations, and medicines they are taking or have taken. Organisations using Cerner’s HIE have been able to recognise improved quality and safety, including a significant reduction in unnecessary tests and clinical errors. This is an effective and transformational step on the journey towards full population health management.
Connecting the individual through Patient Portal The Cerner Patient Portal allows your organisation to provide patients and their families/carers with a view of their clinical information from their Cerner Millennium electronic health record. The portal also enables you to share educational material, helping to keep consumers informed and engaged with their own health. The portal is customisable, allowing you to choose a subset of information for members to view, including allergies, lab results, immunisations, and more.
For more information on population health management, please email us at CernerUK@cerner.com
Cerner Population Health Management Too Important to Stay the Same For more than 30 years, Cerner has transformed health care by eliminating error, variance and waste for providers and consumers around the world. Our solutions optimise processes for organisations ranging from single-doctor practices to entire countries, for the pharmaceutical and medical device industries, and for the field as a whole. As we enter our fourth decade, we remain focused on developing innovations that will improve our entire system. Health care is too important to stay the same, so we’re changing the way people:
Use and share information
Improve clinical care
Think about health
Join us as we work to make health care all that it should be
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