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by Dr. Brian Jacobs
Published on January 3, 2018

Dr. Brian Jacobs is a critical care doctor by training. He’s been with Children's National for 12 years as CMIO and over the last six years as CIO. Over the past decade, Children’s National has transitioned into a highly digital environment with a focus on pediatric population health management and preventive care.

I want to keep kids healthy.

That’s my goal as a physician in a pediatric hospital. I believe that it’s also my responsibility, and the responsibility of my organization, to do whatever it takes to make sure kids stay healthy – and if they do need to come to the hospital, that they have a safe, high-quality experience with excellent outcomes.

That line of thinking is critical as the industry moves toward a value-based care system. Moreover, it’s the best way to think about changing the health outcomes of a community for the better.

At Children’s National, our earliest venture into population health started in 2007 when we established a pediatric health information exchange (HIE) called the Children's IQ Network. When we first started, the goal was to try to help community pediatric practices move off paper documentation and onto the electronic health record (EHR). There were a lot of barriers to that back then, including high cost and unfamiliar technology. We helped practices transition to EHRs by subsidizing their cost in exchange for their agreement to share data with Children's National. That was the beginning of us aggregating health data from children around the region – including D.C., Maryland and Virginia – and looking at ways to improve the health of the pediatric population.

Fast forward to the last few years: We've adopted a cloud-based enterprise strategy, aggregating data from a variety of different sources, including acute and critical care units, the emergency department (ED), our primary care clinic and the community independent practices. All this information is housed in a cloud-based enterprise data warehouse. We've established pediatric-specific population health registries for six different conditions so far: asthma, diabetes, inflammatory bowel disease, epilepsy, cardiomyopathy and sickle cell disease.

Actionable population health data

Our health information exchange captures information from over 850,000 encounters per year, representing about 300,000 unique children in our region. This gives us essential health data including lab results, immunizations, clinician notes, X-rays, allergies and medication information, which empowers us to holistically understand our patient population.

For example, if we look at our asthma population, we're looking at a registry that has over 30,000 children in it. If we assess how those children stratify across the population of asthmatics, we see a spectrum: There are those with mild asthma and occasional flare-ups who are on the right medicines with an asthma action plan, and they're staying out of the emergency room and the hospital. At the other end of the spectrum, we have very sick children who are in and out of the ED and hospital. These children are having issues with medication compliance and are not following their action plan. Additionally, they may have socioeconomic and environmental issues where they live – particularly if they're around smokers or are continually exposed to mold, dust and pollen. These children might not be going to their primary care visits and they may not take advantage of preventative actions like getting a flu shot every year.

In other words, with those 30,000 asthmatic children, we have a full spectrum from the very sick to the healthy. For the first time, this gives us the opportunity to look at asthmatic children in a region from a population basis as opposed to an individual encounter basis.

Our business model – that is, the business of being a care delivery system – is very much reliant on the encounter in the clinic, ED or inpatient environment. Our business, in other words, is taking care of kids when they present to the clinician that they're not feeling well and need assistance with their underlying condition.

Our population health registries have provided us a new way of looking at things. It's not just thinking about the child who presents as sick – rather, it’s thinking about the 30,000 children out there with the diagnosis of asthma. How can we keep them from being admitted to the hospital for something that could be easily prevented? How can we keep them out of the ED and in school, where they should be? How can we keep them healthy?

Strategies for pediatric population health management

1. Getting organizational buy-in and community support

When I consider strategies for keeping kids healthy, there are many different dimensions. I believe it starts with organizational leadership and buy-in around the concept of population health management. It’s saying, from the top-down, that we do care about the broader population, and we're going to spend time keeping children healthy in addition to taking care of them when they're sick. That's a big, transformational move for a lot of organizations that, for many years, have survived on only caring for kids that are ill.

At Children’s National, we've escalated that concept to a corporate goal. It’s our first population health goal, and it's focused around those six conditions – asthma, diabetes, inflammatory bowel disease, epilepsy, cardiomyopathy and sickle cell disease. The goal is to move the health of the children to a better place within one year. We've established baseline metrics and target metrics of where and how we want to improve the health of children with those six different conditions.

That may seem like a lofty and novel goal for an organization like ours. We know that the time that we care for children represents only a small portion of their lives, and that when they’re not with us, they're at school or day care or home. This means that improving children’s health becomes everybody's job. It involves the parents, the patients, the school system and other support systems that go along with a staying healthy strategy. We know that if we’re going to be successful with this corporate goal, we must work with our community doctors, families and school systems to think about ways to keep kids healthy and out of the hospital.

2. Documenting care and collecting data

A lot of the success in the work with population health starts with the data and the source systems that provide that data. This is often challenging work because it requires clinicians and care team members to not only deliver good care, but also to document the delivery of that care. I may be the greatest doctor in the world doing all the things that I need to do to keep my diabetic patients healthy, but if I'm not documenting it in the EHR so that the data can be aggregated and placed in the data warehouse and become part of the population health registry, my work isn’t being optimized for the good of the broader population.

To that end, we've worked with our EHR vendors, our clinical informatics specialists and our clinicians to ensure that when they do things like create an asthma action plan, carry out tobacco cessation counseling or administer a flu shot, those are well-documented in the EHR. That way, we can then capture that data and use it to manage the health of the population.

This is important, because ultimately, when we look at the population of children with these different conditions, we want to devote the most resources, time and energy to the children who are most likely to benefit. For example, if we have a set of children who haven’t had a flu shot, are around smokers and don’t have an asthma action plan, then focusing on that group will have a greater payoff in terms of their health outcomes and their consumption of health care resources versus focusing on the healthier and more compliant population.

3. Analyzing data and taking action

The operational engine of population health is turning all that data into useful, actionable information, and being able to disseminate that information to clinicians, patients and families so that they can take steps to improve those things that require attention to stay healthy.

The last component is the actual tailoring of resources to ensure that those patients who are in most need of support are the highest priority. That's where work with multiple groups – patients, parents, care coordinators, case managers, primary care physicians and the school system – is critical, so that the children who need the most assistance get the care they deserve.

Coordinating between these groups doesn’t have to be complicated. For example, every child with asthma should have an asthma action plan. This is a straightforward, one-page document that outlines the preventative actions a patient should take and reactive steps should the condition escalate. The plan generally produced in the inpatient setting, is documented and lives in the EHR and it's made available to the patient and any caretakers. For a young child, that might include the parents, grandparents or the school system, and it ensures that everyone is on the same page about what needs to be done if the child has increased difficulty in breathing.

Making population health management our business

It’s easy to rely on the buzz-phrasing of population health management without instituting actual organizational changes. My goal, which I hope is shared with health care industry leaders, is to make population health management the new business model.

The data we’ve collected has granted us a new lens on health care for children. We’re prioritizing pediatric population health management because it's the right thing to do, and we believe in keeping kids healthy and improving the overall health of the populations that we take care of. It is also important that we move to a financially sustainable model to support that effort – because we can’t continually rely solely on sick care reimbursement as a viable business model in health care. The industry is evolving beyond that, to a future where high-quality care is measured on both individual outcomes and the health of the community.

Join the conversation on pediatric population health at the 2018 Population Strategies for Children's Health Summit from Feb. 19-20 in Washington, D.C. Learn how population health management strategies can improve care quality for an entire pediatric population in a way that supports your health system's bottom line. Register here.

At Cerner, we’re focused on connecting traditional venues, the health continuum and advanced information about a person’s lifestyle to empower individuals in their health and care. Learn more about our cloud-based enterprise population health management platform.