Case Study: One health system's population health journey

To consistently achieve high-quality, cost-effective care, healthcare organizations are shifting their attention away from acute, episodic-care delivery toward chronic-disease management through preventive medicine. This is no small feat, especially among those organizations providing the bulk of their services to uninsured and underserved populations.

Methodist Healthcare Ministries of South Texas, Inc. (MHM)-a private, faith-based not-for-profit organization and the half-owner of the Methodist Healthcare System-is pursuing a multifaceted approach to managing the health of a large population, relying on data to identify the most effective ways to proactively engage patients and leveraging technology to share information between facilities and programs.

MHM provides medical, dental, and health-related human services to low-income families and the uninsured through clinics it owns and operates, and it provides funding to other agencies that are successfully delivering healthcare and social services to this population in their respective communities throughout south Texas.

Leveraging Data to Understand Population Needs

To make meaningful improvements in population health, MHM first focuses on understanding its patient population and their diverse care needs, analyzing data to assess the landscape and drive interventions.

For example, before it determines where to provide services, build clinics or develop infrastructure, it commissions and studies detailed epidemiology reports which look at demographics and the types of conditions a population faces. The organization serves a substantial diabetes population as well as a large number of patients dealing with hypertension; so many of the interventions MHM supports address these particular conditions.

MHM also relies on data to reveal patients in need of proactive health management. Once an individual is identified as having a certain chronic condition like diabetes, there are many care interventions that can occur, depending on the patient's ability to comply with prescribed treatments. For instance, MHM has certified diabetes health educators that work with patients, educating them on how to keep their illness in check and make positive life choices.

Next: Technology Enables Robust Information Gathering

Technology Enables Robust Information Gathering

While data is the key to effective population health management, technology is the means by which MHM collects, analyzes, exchanges and responds to data.

MHM uses a single Electronic Health Record (EHR) across all of its programs so that it can easily analyze data and share information across the continuum, tracking quality measures, identifying trends and running “what if” scenarios to measure the potential impact of certain health management strategies.

MHM requires partner organizations that don’t use the same EHR to send quality reports that follow a specific format. This allows the organization to receive performance data from systems outside the immediate MHM family and incorporate that information into its ongoing studies, facilitating a more comprehensive data analysis effort.

MHM staff also leverages the EHR to communicate about patient care across practices. For instance, if during a dental examination a patient presents indicators that point to diabetes, the dentist will refer the patient to MHM's medical team, who will offer the patient a full medical workup. If a diagnosis of diabetes is confirmed, the patient is referred to a health educator who will provide targeted counseling and education. The patient may also be referred to MHM's Recreation & Enrichment Program to participate in a fitness class to support weight loss goals, or be referred to a social worker to assess the patient's ability to access other needed resources to manage her disease, such as a glucometer and testing strips.

Technology underpins this collaborative care because all the different providers use the same EHR, making it easy to communicate, exchange information and determine the best path forward for the patient.

Next: Technology Enables Information Sharing

Technology Enables Information Sharing

In addition to the EHR, MHM is actively involved in a public Health Information Exchange (HIE) known as Health Access San Antonio (HASA) which also includes the uninsured and underserved. HASA’s database comprises information from 29 hospitals in San Antonio/Bexar County and 21 surrounding counties in South Central Texas.

Creating HASA was relatively straightforward because there were few roadblocks ten years ago in terms of competition for the uninsured and underserved as there often are with other kinds of HIEs. No one wants to compete when it comes to serving the uninsured and underserved; it is something every organization strives to do efficiently and effectively, and sharing data is critical to achieving those goals.

Once the federal and state government stepped in to establish guidelines and funding for HIEs, a productive working relationship was established within the San Antonio healthcare community from years of working together focused on the uninsured and underserved.

While the HIE serves many purposes, it has become a critical tool to MHM’s healthcare providers, as it exposes whether patients have presented to area hospital emergency departments. This allows MHM to gather important facts about the conditions for which patients sought care, the treatment that was offered, and helps the system determine what course of action may be necessary to avoid future visits to the emergency room.

This is also of great interest to hospitals as the data the HIE collects can provide important insights into the factors that influence re-admissions.

Next: An Ongoing Focus

An Ongoing Focus

While managing the health of its diverse patient population is an evolving project, MHM has made a significant investment in the systems and technology that will complement its goal of improving the overall health of the population it serves, and creating access to care for the least served.

As trends in healthcare information systems and technologies further develop, MHM will continue to look for ways to better leverage data and technology to identify patients at risk, empowering them to make better life choices and transitioning them into proactive care.

Mark C. Holliday is the director of information technology and services for Methodist Healthcare Ministries of South Texas, Inc.