One-on-one care in the Age of Population Health Management

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Dody Fisher, MD, MGH, Chief Clinical Officer, Forward Health Group

Not long ago I heard “The Times They Are a-Changin’,” on satellite radio, that old Bob Dylan tune from all those years ago. Made me think about Frieda.

Frieda is a veteran physician and an outstanding clinician with her heart in the right place – always looking out for her patients. However, she was upset and stressed out; Frieda was not a happy doctor. After meeting for coffee one day and discussing the usual frustrations of life as a physician, the world of electronic health records (EHRs) came up. Frieda noted how physicians have their noses “buried in their laptops” and how no one is talking. It’s simply point, click, cut, paste. Frieda felt as though we’ve lost something.

As we talked further, Frieda conceded that things were improving for her as a physician, and the new world of the “digital doc” had great promise. Our conversation reminded me of Robert Wachter’s valuable book from 2015, The Digital Doctor, discussing the dawn of medicine’s computer age. Yes, we have problems, but there is hope.

However Frieda voiced another concern. She worried new strategies such as Population Health Management (PHM) were outside her range of expertise – that she attended medical school to learn how to take care of patients one-on-one. Frieda discussed how she learned to develop relationships with her patients, gain their trust, and forge a collaborative approach to meet their healthcare needs. She worried programs such as PHM were just one more thing to add in her already busy day.

Gaining a new perspective: PHM on the individual level

It’s critical for providers to understand that PHM can be translated into a one-on-one relationship. For the patient who’s floating out there, figuratively, and needs that relationship with a physician who doesn’t know the patient even exists – PHM enables a way to identify that patient, contact him or her, and bring him or her into a one-on-one relationship with the physician.

Take for example Rhonda, a long-time “non-compliant” diabetes patient with a long list of recommended screenings that need to be scheduled. Rhonda is like many others – she’s going at full speed, caring for her chronically ill mother, raising her family and working full time. She has little time for herself, let alone her own health. She was “invisible” until her primary care team identified her as needing a follow-up. After a care manager engaged with her, Rhonda began properly managing her diabetes and received the tests she needed.

Simply put, PHM is not just managing a population. It’s a way to identify “invisible” patients who need one-on-one care — those who are not on physicians’ radar screens.

The need for powerful data and smart PHM

Physicians need clean, accurate data to leverage for critical decisions, and in turn, a technology platform that effectively supports it. Without this, physicians are working in the dark, with little insight into who needs help the most and how to prioritize resources and best manage workflows. Data must be available in an actionable and easy-to-understand format so care teams can leverage a physician’s expertise and allow him or her to practice at the top of their license and do what they were trained to do – care for their patients.

Smart PHM arms clinicians and care teams with a bit of breathing room. For Frieda, the nagging notion that some of her patients are falling through the cracks comes often. Waking up in the middle of the night, Frieda wonders about the last time she saw certain patients, how they’re doing, and if she needs to get them into the office. As a physician, I think we all know that feeling.

With accurate data and the right PHM tools, care teams can automatically keep track of this information. Patient navigators and patient outreach specialists are armed with the latest information about the most at-risk patients, granting physicians’ a bit of peace of mind knowing their data is working and it’s trustworthy. And, they don’t have to remember everything. Smart PHM helps bring patients in and enables physicians to do what they do best.

PHM is the art and science of caring for patient populations while still allowing primary care physicians to do their job – care and prescribe individual treatments for patients. The times may be a-changin’, but by effectively leveraging data, and with smart PHM, we can truly impact patient outcomes – one on one.

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Comments (1)

  • One-on-One Care in the Age of Population Health Management | Forward Health Group

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    […] Frieda is a veteran physician and an outstanding clinician with her heart in the right place – always looking out for her patients. However, she was upset and stressed out; Frieda was not a happy doctor. After meeting for coffee one day and discussing the usual frustrations of life as a physician, the world of electronic health records (EHRs) came up. Frieda noted how physicians have their noses “buried in their laptops” and how no one is talking. It’s simply point, click, cut, paste. Frieda felt as though we’ve lost something.” Read the full article. […]

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