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Population health management

We believe that the best way to manage the health of a population is one person at a time. By turning data into knowledge, people and their care providers can work more efficiently and effectively together, cultivating a mindset of proactive health, rather than reactive care. Cerner’s strategy with clients for population health management is to know your population in order to focus attention, to find and engage citizens to take an active role, and to actively manage each individual to improve their health and wellbeing.

In order to address their future sustainability, care systems – that are currently focused on improving the patient experience of care – need to also focus on improving the health of populations and being a good steward of the per capita cost of care – this is the IHI Triple Aim for healthcare. The UK, with its publicly funded care systems, has a significant opportunity to lead the world in establishing place-based care.

Population health management is about taking responsibility for managing the overall health and wellbeing of a defined population and being accountable for the health outcomes of that community. The goal of population health is to improve the quality of care and outcomes whilst managing costs for a defined group of people. Population health should be viewed as part of a wider health and wellbeing strategy that includes wider determinants of health, such as housing, the environment and employment.

Against the Five Year Forward View strategy, NHS England is encouraging the development of new care models and learning from others on the same journey, like the move to accountable care in the USA. Guided by sustainability and transformation partnerships, networks across the country are forming into accountable care systems to establish new ways of working and take on new population health responsibilities. Compare this to today’s care models: they aren’t centred on the citizen, aren’t anticipatory or preventative, duplicate effort, hand-off patients between care settings in a way that causes them to falls between gaps, and cannot assure clinical standards across the system. The reasons to change are obvious.

Informatics has a fundamental role to play. Cerner is leading the world in its vision and execution through our investments in developing a new population health management platform, called HealtheIntent®. Layered over any existing information systems in a care network, in near real-time it normalises data into single source of truth population records for a patient, and provides the new tools that are required to manage the health and wellbeing of the population. Care gaps, surveillance alerts or actions to drive evidence-based programmes of care are provided directly back into clinicians’ own information systems.

FAQs

Is working across health economies new for Cerner in the UK?

Whilst HealtheIntent is new to the UK market, Cerner is already well known in the country for supporting health and care integration and has for many years provided Health Information Exchange to enable interoperability of EHRs and ensure the right information is available to the right care professionals.

A key requirement of the GDEs to achieve global exemplar status is that they demonstrate how they have improved the operation of the whole care system and not just the hospital in isolation. They are required to be population health ready. Cerner is working with six of the GDE Trusts to establish HealtheIntent to support their own operations, population health management with their health and care partner organisations, and for one Trust, their expansion as a hospital chain.

Our value-driven, community-wide population health management approach supports clinical, financial and operational needs for NHS providers, health organisations, local authorities and social care, communities, employers, and other venues of health.

The UK is on a journey towards establishing integrated care arrangements to take on accountability for populations, with various organisational forms and partnership approaches. Cerner is working with Global Digital Exemplars in England tasked with population health readiness, emergent accountable care systems, and health and care provider networks to establish population health management approaches. We are also engaging with smaller clinical hubs to integrate primary care and GP provider federations or integrated practice units.

Cerner’s population health clients in the USA are performing well against cost and quality in accountable care organisations. Memorial Hermann is the top MSSP in terms of total saved at $89m, while Advocate Physician Partners is number one in terms of size, with savings of $77m. On the clinical side, Advocate has seen a reduction in oncology testing, a 39 percent decrease in serious safety events and 45 percent fall in the need for high-risk medication. Read more in Advocate’s value report.

In general, clients are quickly identifying unmet needs through surfacing more complete joined up records, and improving standardisation on population quality metrics through proactively driving out gaps in care. Clients make good sustained progress on their approaches, including how care model redesign, citizen engagement and iterative focus on the things that matter are impacting on reducing inappropriate utilisation of services and optimising appropriate use of services, with overall financial savings.

The foundation of Cerner’s population health management approach is the HealtheIntent platform. HealtheIntent is a multi-purpose, programmable platform designed to scale at a population level while facilitating health and care at a person and provider level. Solutions built on the platform can be securely accessed anywhere, anytime. The platform:

  • Collects data from multiple, disparate sources in near real-time, including any electronic health record (EHR), existing IT system or other data sources
  • Enables organisations to not only aggregate, but also transform and reconcile data across the health and care system, establishing a longitudinal record for each person within a population
  • Identifies and stratifies populations to pinpoint gaps in care, enabling organisations to act on information and match the right care programs to the right people

No, organisations do not have to be using Cerner’s EHR to benefit from our suite of population health management solutions and services – our platform normalises and aggregates data from any known source. We realise that organisations need a system-agnostic platform that establishes a longitudinal record across multiple disparate systems, while leveraging your existing infrastructure, and the ability to get new insights at population level back into the workflow of care professionals in the EHRs they use every day.

Yes, HealtheIntent enables the development of applications and extensions that work seamlessly with other solutions and outside vendors. The platform promotes the extension and integration of HealtheIntent solution capabilities into existing, day-to-day applications, regardless of the transactional system being used. Discover more in our Open and interoperable section.

Offerings you may be interested in

Analytics

By leveraging aggregated and normalised data across the community, we can provide healthcare facilities with a comprehensive suite of real-time in-workflow data-driven decision support capabilities. These, alongside our near real-time analytical solutions, enable you to perform advanced analysis that is tailored to your organisation or health and care economy’s needs and goals.

Care management

Care management and coordination is a key strategy for proactively supporting and managing the health of citizens in many countries, but is not yet a key strategy in the UK market. In the past the market has evaluated telehealth programmes with care management support but it has been hard for these programmes and support structures to integrate into the mainstream of care provision. Arguably, the drivers and strategy for moving the whole health and care system to population health management have not been there. Nonetheless, some UK integrated primary care teams are establishing new care coordination roles, as they recognise that the community holds a wide range of assets that can holistically support individual citizens, often with complex needs, to address the wider determinants of their health and wellbeing.

Citizen engagement

We’re all patients at some point, and as we work towards a health and care model that’s focused on keeping us well and out of hospital, we need to turn our attention to engaging everyone to take an active role in improving and maintaining health and wellness. The explosion of self-management apps and personal monitoring devices can help us to create a single source of truth as we look to move from reactive care to proactive, coordinated health.

Health Information Exchange

Our Health Information Exchange (HIE) is enabling care professionals to exchange and view patient data, whether it’s based on our EHR or another care provider’s system. When the care professional needs it, the Cerner HIE brings together patient data across the health and care system in a secure manner, embedding a single aggregated longitudinal view of the patient natively in each EHR system. This is joined-up, safe and effective healthcare across organisational and system boundaries.

Registries and scorecards

Establish care programmes for cohorts of your population, proactively identify gaps in care and drive remediation to improve patient outcomes as well as care provider performance with Cerner’s registries and scorecards solution. They enable organisations and accountable care systems to identify, attribute, measure and monitor people and providers at an individual or population level.