By LeRoy E. Jones
There is a natural tension between managing the health of an individual patient and managing the health of a population of individuals. For years, the clarion call in health care and HIT has been to increase “patient centeredness,” resulting in broad industry concepts such as Blue Button and Patient-Centered Medical Homes (PCMH), among others. As the industry pendulum now swings back toward population health, there may be unintended consequences for the principle of patient-centered care.
For the last 10 years, the concept of patient centeredness has prevailed in the HIT marketplace. This doctrine espoused that the patient should be the hub of his or her own care and inspired functionality around ensuring patient access to data, patient consent directives for caregivers, patient engagement in care processes, and the like. Further, care delivery programs such as PCMH began to incorporate patients broadly as actors in networks that have historically been provider oriented. Consequently, information systems like those for EHRs began to incorporate this paradigm into their feature sets. A core tenet of this philosophy is that the patient is paramount, and a tacit corollary is that care delivery optimizes outcomes for each patient because each patient is empowered (eg, via information and inclusion) to spur the health care system toward this end.
The rise of population health management (PHM) and attendant collaborative care approaches has sounded a different rallying cry. The principles of patient-centered care, which ensure that patient values guide all clinical decisions, are being compromised by group-focused goals in PHM. Striving for measurable improvement across entire population segments has inadvertently shifted patient-centered care to a provider-focused model that cultivates and enables collaboration among caregivers as a first principle. Further, and maybe more importantly, has been the shift to optimizing care for the entire population rather than for the individual patient. For example, PHM often calls for patient health to be categorized by a “red, yellow, and green” severity scale, which serves as the de facto population-based diagnostic definitions determined on a relative—not absolute—scale for each patient.
Care providers are being tasked with deciding between taking a patient’s health from red through green or managing a patient’s care more intensely until it reaches yellow—at which point the care team would focus its efforts back to those in red in an attempt to reduce the severity of aggregate health issues within the population. Contrary to the principle of patient centeredness, especially in the early days of PHM, provider organizations are choosing to focus on patients in red zones.
The premise is that those in yellow are managed within the normal patient-centered care system. While this model attempts to reduce the costs of care in high-risk populations, it de-emphasizes the potential health benefits that a given patient could garner from intensive treatment that spans red to yellow to green.
This focus on population stratification in the rationing of resources and attention raises concerns as to whether certain organizations are hyper-focused on PHM at the expense of reducing patient-centered health activity. This concern is compounded when it is noted that PHM populations tend to already be only a segment of the total patients cared for, such as those among safety-net populations, suffering from multiple chronic diseases, or having an illness such as diabetes or hypertension that is associated with federal incentive programs. Every patient is not equal, and thus not every patient is at the center of care decision-making considerations.
As PHM centralizes its focus on the collaboration of care teams, broad initiatives such as Blue Button and PCMH could feel the effects. For example, while the Blue Button initiative, which enables patients to view and download personal health information, is not supplanted by the principles of population health, some tenets are undermined. Whereas Blue Button tries to empower patients through the provision and control of their medical records, PHM may be enabling a category of information not captured in the record, namely the patient’s reckoning within the subpopulation he or she belongs to, and the consequent impact that has on his or her care.
All is not lost, however. Next-generation PHM systems support the delivery of whole-person care, a major pillar that integrates medical care, behavioral health services, and social and human support services across the full continuum of care. This functionality helps manage high-cost, high-risk patients and offers infrastructure tools to improve transitions in care, avoid rehospitalizations, and manage population health. Providing data analytics and reporting capabilities to measure and predict patient and program outcomes enhances the care providers’ ability to engage patients with only the most relevant information. This helps patients digest information related to their clinical decisions and values, thus bringing the principles of patient centeredness to the forefront of the PHM care model. The onus is on care teams to ensure patients understand and are appropriately engaged in these new dimensions of care delivery.
As health care ultimately shifts from episodic to value-based care, provider organizations will be challenged to bridge gaps in contrasting care models. The cornerstone to revitalizing clinically integrated care models with patient values and engagement will be contingent upon PHM adoption that prioritizes the balance of long-term patient centeredness with the improved health of entire patient populations.
— LeRoy E. Jones is CEO of GSI Health, LLC.