Katya Samardina

Achieving Integrated Care as the Foundation of Population Health Management: The Drivers for Change, Part 3


When I was practicing as a registered nurse, I used to get so frustrated not knowing everything I needed to know about my patient. One day, an elderly woman arrived in the ER. She’d fallen and hit her head. She was disoriented and understandably afraid. When asked, she couldn’t remember where she lived, the phone number of her next-of-kin, or who her PCP was. All she knew was her name. 


I searched the hospital records but couldn’t find anything. I didn’t know if she was on blood-thinning medication that might interact with certain pain relief; I didn’t know if she had a history of hypertension or stroke; I didn’t know anything more than what she presented that day. I can tell you that that’s a scary situation to be in when you’re triaging numerous cases in a busy emergency department. The chances of making a mistake are high.


That experience, and many other similar ones, was part of the reason why I wanted to move into healthcare IT—to work toward ameliorating what I believe to be a bad situation for healthcare professionals: the siloed nature of healthcare information.


This is what integrated care endeavors to change. It aims to bring together all parties involved in delivering healthcare to coordinate their services through the sharing of information and transform healthcare into a seamless experience for the patient. This means moving care away from emergency department visits and lengthy hospital stays to more accessible and less costly settings—home, school, and work. It’s the idea of “connected health,” and technology adoption is critical to deliver this.


In a 2013 article, Michael E. Porter and Thomas H. Lee expounded on the six critical elements for delivering coordinated care: organize into Integrated Practice Units (IPUs); measure outcomes and costs for every patient; move to bundled payments for care cycles; integrate care delivery systems; expand geographic reach; and build an enabling information technology platform.


If you haven’t read it already, the article is well worth your time. While all six points warrant further discussion, it is the sixth point that I’m going to examine more closely: build an enabling information technology platform. In fact, it is only through a robust IT solution that Porter and Lee’s previous five elements can work.


Despite being published in 2013, Porter and Lee’s theory holds true today. Healthcare systems globally are at different stages of maturity, but all need to follow a similar path to achieve the holy grail of population health management—where integrated care includes analysis and patient engagement such that everyone has an actionable patient record, improving both clinical and financial outcomes across the population.


Porter and Lee identify that a value-enhancing IT platform has six essential elements:

  • It is centered on patients
  • It uses common data definitions
  • It encompasses all types of patient data
  • The medical record is accessible to all parties involved in care
  • The system includes templates and expert systems for each medical condition
  • The system architecture makes it easy to extract information


The Porter and Lee strategy is on point with how we at Rhapsody organize our technology to support the journey to integrated care as the building blocks for population health management. We call it the 7 A’s, and it involves seven key non-linear steps to building out technology infrastructure:


  1. Acquisition: Acquiring Data From Disparate Information Systems and Care Locations. Multiple EHRs and other clinical systems format, store, and share data in many different ways. To get the complete picture of an individual’s health; protect the privacy and security of patient information; ensure secure exchange and information transport; and enable accurate, reliable interoperability with a wide array of systems, an IT system needs to support effective data acquisition and feature integration-engine technology. 
  2. Aggregation: Secure Storage of Structured, Normalized, and Identified Data. Each of the systems contributing data to a healthcare network has its characteristics and conventions for formatting and sharing data. Even common EHR and other healthcare information system (HIS) platforms can alter their data formats from version to version of the software. The data that needs to be aggregated includes clinical information—clinicians’ and nurses’ notes, medical images (X-rays and scans), lab tests, and discharge summaries, and additional types of data, such as health insurance claims (to reconcile interventions with payments made), medication adherence, social determinants of health, and genetics. It also needs to include systems for identity management and terminology services to ensure normalization of data across multiple systems.
  3. Analytics: Tools for Risk Identification, Management, and Quality Improvement. Mining data for views into population health, finding the actionable insights that can drive improvements to quality and efficiency, and keeping up with the ongoing and ever-increasing regulatory reporting requirements—these issues and many more drive the need for analytics as a fundamental component of a successful integrated health network. Leveraging data-driven intelligence to improve care delivery is also something that a well-constructed IT infrastructure is uniquely able to do. With solid data acquisition and aggregation come the ability to learn from and act on data in very powerful ways.
  4. Access: Fast, Easy, and Convenient Access to Information for the Entire Circle of Care. Several different types of stakeholders will need secure access to various aspects of a healthcare network’s data, such as clinicians, administrators, health information management (HIM) professionals, patients, family members, health insurers, and many others. Each constituency has its own unique set of priorities, permissions, and levels of technical and clinical sophistication to consider. But for all of them, the access to data must be as frictionless as possible to support initial and ongoing adoption. Healthcare providers will typically be best served by gaining access to information within the EHR itself, whereas patients and family members in their circle of care will need a web-accessible secure patient portal.
  5. Action: Turning Information and Insights Into Interventions and Outcomes. Coordination workflow tools are a key technology requirement that enable care managers to turn this data into actionable assets enabling them to deploy consistent care pathways based on patient and population data, and to document and communicate progress with the healthcare providers and patients they support. 
  6. Adapt: Creating a Big-Picture View of Medical Decision-Making. Once the population has been stratified and cohorts of interest have been identified via analytics, customized action plans can be put in place for each patient and care can be coordinated across facility lines accordingly. 
  7. Adoption: User Engagement and Adoption of Technology. Adoption is as much an issue of technical prowess—making the data seamlessly easy to get to and impeccably accurate—as an issue of emotions and behaviors, and these issues are inextricably linked. If clinicians and care coordinators fail to adopt, key information will not be used for decision-making and outcomes will suffer. Both effects are potentially devastating to the success of any integrated care delivery system.


Achieving integrated care requires more than just technology. We must be clear on our objectives and empower the people involved through the right processes. We must have a clear goal to unify disparate organizations and put the patient at the center of the health system. Only then will individuals and communities have a better experience of care—and improved support—by enduring less inequality and achieving better outcomes.

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