eClinicalWorks Blog Details

  • 10 February 2022
  • Blog

All the Ingredients for Population Health Management



Book-Utensils A complex topic will yield to a systematic approach

In last month’s opening blog in this series, we defined the field of Population Health as including “health outcomes, patterns of health determinants, and policies and interventions that link these two.”

That sounds complicated, and the truth is that Population Health isn’t simple. Because it draws together every aspect of medical practice — and often takes providers and staff outside familiar routines — it can be hard to grasp and harder still to execute.

But the flip side of that reality is that Population Health efforts can pay enormous dividends in improved patient outcomes, higher satisfaction, and cost savings.

The further good news is that if practices focus on Population Health in a systematic way — while retaining flexibility — success is likely. It’s like great cooking: You need the right ingredients, and you can’t stray too far from the recipe, but a dash of creativity and intuition are vital for achieving great results.

Bowl-Spoon- Don’t omit ingredients from the recipe 

In an April 2019 blog post for Health IT TODAY, “The Complexity of Population Health,” author John Lynn notes that most people underestimate how hard it is to succeed with Population Health.

It is an area that requires both technical and clinical skills, he notes. Many practices try to shortcut complex processes, omit key elements, and wind up with ineffective results.

Lynn cites an example from Orion Health in which providers trying to treat a patient may have clinical, claims, and medication data, but their efforts fall short. Why? Because they lack information on the patient’s Social Determinants of Health, the many non-medical factors — such as employment, language barriers, housing situation, and family supports — that can have a profound impact on physical and mental health.

Pot-Clock eClinicalWorks takes a comprehensive approach

At eClinicalWorks®, we understand that an industry-leading EHR and Practice Management solution is only the basis for great healthcare and must be supplemented with fully integrated tools for understanding and engaging patients. 

Our Population Health Bundle includes these powerful tools for analysis and planning:

  • Hierarchical Condition Category (HCC) coding calculates risk acuity, identifies gaps in coding, and predicts expenditures for individuals and populations.
  • HEDIS® Analytics helps evaluate access to care, identify high-risk patients, measure compliance, and evaluate both provider performance and patient satisfaction.
  • Cost & Utilization Explorer enables providers to access Medicare claims data and derive the insights they need to meet the challenges of value-based care.
  • ACO Clinical Quality Measures provide an up-to-date and interactive view of performance across group practices, with analysis by providers and locations.
  • Population Care Planning establishes a holistic view of each patient’s overall health and wellness, from lifestyle and activities of daily living to home and community supports.
  • Patient-Centered Medical Home (PCMH) Analytics helps practices earn recognition for taking a patient-centric approach that improves outcomes and lowers costs.
  • Disease Explorer offers better visibility and sharper insight into patient populations by enabling practices to group patients into cohorts based on common needs.

Cup-Bowl Additional solutions to deepen understanding

In addition to our bundle solutions, eClinicalWorks offers products to help guide care for chronically ill and at-risk patients.

  • Our Chronic Care Management (CCM) module can help your practice deliver evidence-based care and achieve the goals of CMS’ Chronic Care Management program.
  • Our Transition Care Management (TCM) module helps care for patients moving among care settings while meeting CMS’ regulatory and compliance requirements.
  • Remote Patient Monitoring (RPM) gathers data from patients’ wearable devices and trackers to give providers insight into health trends and capture time-based activities.
  • The Care Plan Oversight (CPO) module helps manage patients’ post-acute care and helps providers supervise home health services.
  • eClinicalWorks helps Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) manage chronic conditions, understand risk, control costs, and more.

For more information on our Population Health products, click the button below.

Click here

Next month, our Population Health blog series looks at Patient-Centered Medical Home (PCMH), a self-guided operational excellence program that serves as an excellent starting point for practices exploring better healthcare through Population Health Management.

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