How EHR Vendor Population Health Tools Support Care Coordination

A population health tool from EHR vendor athenahealth has helped accountable care organizations (ACOs) boost care coordination for higher quality care delivery and cost savings.  

In the 2020 Medicare Shared Savings Program (MSSP), ACOs that used the population health tool earned a total savings of $143 million.

Paul Brient, chief product officer at athenahealth, told EHRIntelligence in an interview that the reason the tool has seen such success is because of its ability to support care coordination through a two-pronged approach.

“It's an analytic solution in the sense that we go find people who aren't getting the care that they need and it's a workflow solution to help healthcare managers coordinate care,” he said.

Brient explained that the tool first gathers as much information about the ACO’s patient population as it can. This includes payer data, athenahealth EHR data, and data from other EHR vendors. 

After that, the population health management tool runs data analytics to understand which patients in the population are experiencing care gaps.

For example, the tool can cohort all the diabetic patients and show which are not receiving any care, or which patients have not had an eye or foot exam.

Then, the tool sends that information to a healthcare provider.

Brient noted that typically, a group of analysts determine what care patients need based on the population health information. Care managers, who are often nurses, usually conduct patient outreach for the well visits.

Upon patient arrival at the practice, the physician has access to the results of this analysis to inform the visit.

Brient added that if patients come in on their own accord for something unrelated to care gaps, such as a cold or a COVID-19 test, the tool still exposes those care gaps in the care plan.

“Even if they're here for some acute episode, we'll still try to resolve those care gaps during that visit,” Brient said.

He noted that while most population health systems are separate from the EHR, athenahealth has been working on integrating the tool into the EHR to support usability.

“Over the last two years we've been integrating it into athenahealth so that if you're a provider and you have the population health tool, you see the results of those things in your normal workflow in an extra couple lines on a screen,” he explained.

Brient said that fully integrating the population health tool into the EHR will help clinicians deliver higher quality care.

“It makes it so much easier to do the right thing,” he said. “It doesn't mean that you can't do the right thing without it being easy, but if things are easy, they get done.”

Brient explained that athenahealth has integrated the population health tool at a level where it takes one click to satisfy issues.

For instance, if a patient needs an ophthalmology exam, there's one button to order the eye exam and choose a doctor.

Brient emphasized that the process of integrating the population health tool into the EHR has been a journey.

“It's challenging,” he said. “There's a reason why people don't do it that much.”

He noted that overall, athenahealth is 75 to 80 percent complete with the integration.