The move toward population health and alternative payment models has seen providers embracing innovative approaches to care delivery, including significant investments in health information technology, according to the spring 2016 Economic Outlook survey from Premier.

The study – which polled health system chief executive officers, chief financial officers and chief operating officers – found the requirements of the Affordable Care Act and the demands of population health management leading to big changes in care processes.

Most notably, Premier found that the expansion and integration of post-acute care networks is a major priority, cited by 95 percent of C-suite respondents as a key area of focus over the next three years.

At the same time, almost as many execs said that project is the biggest challenge their health systems will face in the coming years.

"As healthcare continues to transition from an acute-care hospital focus toward an integrated system of providers, the creation of high-value post-acute care networks is essential for success within alternative payment models, such as bundled payment programs and accountable care organizations," Premier COO Michael Alkire said in a statement.

Health IT, of course, is an essential enabler to this task, and 84 percent of respondents indicated that technology continues to represent a place for significant capital outlay.

Still, challenges remain. More than two-thirds (68 percent) of respondents said their health systems are successfully accessing data from the ambulatory EHRs of their employed physicians. But barely one-third (38 percent) said that they're successfully accessing data from affiliated or non-employed physician networks.

"Many affiliated practices lack the proper incentives to invest in high-cost data sharing agreements and interoperable interfaces. We urgently need public policies that require health IT interoperability standards so that providers can access data from any system," said Alkire.

Interestingly, one area that's often overlooked with regard to pop health is one that's also ripe for innovation, according to Premier: the supply chain.

Many providers are running disparate software systems to track procurement, accounting and contract management, according to the report – leading to "system-wide blind spots" that can hamper efficiency efforts.

The expansion of affiliated practices have only complicated matters, according to more than half of poll respondents.

"By marrying all the functions associated with purchasing across the continuum on a single IT platform, materials managers can close gaps and generate the significant savings needed to succeed in the new world of payment reform and cost cuts," said Alkire.

Dana Alexander, RN, kicks off the Opening Keynote session at HIMSS16 with poignant remarks about the state of the healthcare industry and how advancements in health IT have driven fundamental change - but there is still work to be done.

LEARNING CENTER: Purchase the HIMSS16 Education Session Recordings

Care coordination, quality measurement, patient engagement and population health management strategies are routinely used by physicians with electronic health records who participate in accountable care organizations or patient-centered medical homes, according to a new study published in the American Journal of Managed Care.

Aiming to find out whether doctors using health IT and working within new reimbursement models were actually employing improved care processes, researchers Jennifer King, Vaishali Patel, Eric Jamoom and Catherine DesRoches examined cross-sectional data on office-based physicians from the 2012 National Ambulatory Medical Care Survey Physician Workflow Survey.

"Early indicators suggest strong physician participation in initiatives to support health IT adoption and to reform healthcare payment and delivery," they said. "However, evidence on whether provider participation in these initiatives has translated to better care delivery is just beginning to emerge.

"Although studies prior to HITECH and the ACA found health IT and external reporting or payment incentives to be associated with a higher likelihood of performing these care processes," they added, "they are performed at low rates even when these factors are in place."

[Also: 4 surprising benefits of PCMH]

King et al. examined how ACO and PCMH docs used their EHRs for 14 specific processes in four categories: population management, quality measurement, patient communication and care coordination.

They found that those factors were independently associated with better processes: "Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes."

Indeed, those docs "were between 6 and 22 percentage points more likely to routinely perform the care processes than physicians with EHRs alone."

While fewer than half (44 percent) reported routinely doing quality measurement, substantial majorities of docs said they routinely engage in care coordination (89 percent), patient communication (69 percent), and population management (67 percent).

"Given the cross-sectional nature of this study, these results do not establish a causal relationship between payment reform, EHR use, and these care processes," researchers said. "Nonetheless, this finding is consistent with other research that shows that healthcare providers are most likely to perform these care processes when practicing in a payment environment that incentivizes and supports such care."

Moreover, many U.S. physicians are still "not performing these processes routinely," researchers said. "Our analysis highlights several specific areas – including population management processes that require the aggregation and analysis of individual patient data and communication with patients and other care team members – where additional technology and policy supports may be important to facilitate wider adoption of these activities."

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New York's Mount Sinai Health System is joining other high-profile health systems across the nation in embracing OpenNotes, an initiative that gives patients access to their care provider's notes in their medical records.

The notes are available for the first time in the health system's online electronic health record portal, called MyMountSinaiChart. Users can now read details of their office visit from the convenience of their personal computer, tablet or smartphone.

MyMountSinaiChart, launched in 2012, also enables patients to communicate with their doctor, access test results, request prescription refills and manage appointments.

The goal of OpenNotes is to improve transparency, communication and trust between patients and physicians – and it's working, Mount Sinai officials say.

[Also: OpenNotes: 'This is not a software package, this is a movement']

"When patients can access their physicians' notes, they can better understand their medical issues and treatment plan as active partners in their care," said Sandra Myerson, chief patient experience officer at the Joseph F. Cullman, Jr. Institute for Patient Experience at Mount Sinai.

"This can ultimately lead to improved patient engagement, patient empowerment, and communication between patient and physician."

"Patients expect and deserve to have full access to their medical records and the Mount Sinai Health System is committed to meeting this expectation," Jeremy Boal, MD, chief medical officer at Mount Sinai Health Systems, said in a statement.

Four Mount Sinai physicians in various clinical practices conducted the initial OpenNotes pilot beginning in December 2015.

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More widespread implementation of gaps in care programs is essential to realizing the value of population health management, according to a new report from the Workgroup for Electronic Data Interchange.

In its study, "Closing Gaps in Care through Health Data Exchange," WEDI defines those gaps as the discrepancy between evidence-based best practices and the care that's actually delivered to the patient.

At too many providers, that chasm is still too wide, according to the report. Better IT infrastructure – enabling more robust exchange health data, automating identification of information gaps and streamlining care coordination – is needed to bridge it.

Toward that end, WEDI offers five key takeaways:

1. Education and communication are essential to making providers aware of the value of identifying and closing gaps in care."Providers appear to lag behind health plans in implementing gaps in care programs," according to the report. "Challenges include the lack of sufficient resources or education about how to maximize workflow changes and effectively close gaps in care."

2. Gaps in care can adversely affect provider performance."Surveyed providers are significantly more concerned than health plans that gaps in care pose a threat to their organization by affecting clinical performance, financial performance and the ability to retain patients," according to WEDI.

3. Programs to address gaps in care offer a high return on investment."Improvements were observed in quality outcomes such as access to behavioral healthcare, pediatric and adolescent check-ups and medication adherence," according to the report. "Reductions in utilization of ambulatory care, hospital admission and hospital readmission were also observed."

4. Better consensus is needed to develop and standardize quality measures and methodologies for data exchange among payers, providers and patients."The terminology, standardization and scope of gaps in care measures need more clear definition and alignment between health plans and providers before actionable data harmonization can occur," WEDI researchers say. "Best practices need to be disseminated that illustrate stakeholder roles, automation of workflow and quality improvement.

The report also points to other barriers such as the "provenance, quality, completeness, timeliness, transparency and accuracy of data." More widespread use of open API and element - based exchange could help address these

5. Fixing care gaps will only grow in importance as value-based models evolve and access to care and coverage expands."As newly eligible consumers continue to enter the health insurance marketplace and access healthcare, it will be essential for stakeholders to develop effective healthcare communication, prevention and education and intervention strategies to improve the quality of patient-centered care," the report says.

"As we increasingly grow fee-for-value arrangements in our nation, it is critical that we look to methods  automate gaps-in-care – to not only ensure that data moves seamlessly between clinical systems and payment systems but that the information is useful and actionable for clinicians and patients," WEDI founder and former HHS Secretary Louis W. Sullivan, MD, said in a statement.

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Greenway Health CEO Tee Green revealed on Wednesday that he is handing the chief executive role at the EHR company he co-founded over to Scott Zimmerman.

Green will continue full-time as executive chairman, according to the company, including a focus on innovation as the company is working to transform itself from an electronic health record and practice management vendor into a population health and revenue cycle specialist.

Before taking the helm of Greenway, Zimmerman was president of Televox, which provides patient engagement communications tools.

Zimmerman also has worked at Boston Scientific, GE Healthcare and Merck during his career.

“It’s a privilege to be working alongside the Greenway Health team to support caregivers in this time of change,” Zimmerman said in a statement. “It’s exciting to be a part of an organization working to deliver the technology, people and processes that can impact the clinical excellence and financial success of our customers. I am looking forward to doing everything I can to help further that mission.”

Zimmerman’s appointment marks the second C-level announcement in recent months. In December 2015, Greenway named Robert Ellis as its new chief financial officer. Ellis came from Vista Equity Partners, where he was a managing director.

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IBM Watson and ODH Inc., a behavioral health analytics company, have launched a population health management platform specifically for behavioral health organizations, the companies announced today.

The platform, dubbed Mentrics, will gather and combine behavioral and physical medical services and prescription claims data from Watson Health Cloud. The new tool is designed to create a more accurate profile of behavioral health patients, the vendors said.

“One of the biggest gaps in our health system today is behavioral healthcare,” Lauren O’Donnell, vice president, life sciences, at IBM Watson Health, said in a statement.

“Our goal with Mentrics is to make it easier for managed care organizations to achieve clinical and business goals in population health management while optimizing provider network performance so patients don’t fall through the cracks,” she added.

Providers can also use the broader data from Watson to improve data insights, such as similarity analytics and risk stratification, the vendors said. The platform can be deployed in the software-as-a-service model on the Watson Cloud and integrated with existing infrastructure and storage capacity.

Mentrics has been designed to target three behavioral health areas: population management, provider network performance and patient care coordination. Providers can customize the platform to target specific populations and trends to address any gaps in care, while assessing the effectiveness and risk-adjusted performance of providers, the vendors explained.

"New analytics tools are needed as behavioral health benefits are integrated into managed care plans,” said Arthur Webb, founder and group leader at the Arthur Webb Group, in a statement. Mentrics will become "an invaluable asset to managed care organizations responsible for behavioral health populations."

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Centra Health announced on Thursday that it will deploy Cerner Millennium on both the clinical and business sides, including revenue cycle and patient health management. Centra will also implement HealtheIntent, Cerner’s population health management platform.

In addition, Cerner will support Centra’s growing health plan, which covers more than 45,000 individuals. With five hospitals and 50 ambulatory and long-term facilities, the Centra is one of the largest healthcare systems in central Virginia.  

[Also: How satisfied are you with your EHR? Satisfaction Survey results]

“As one of the leading care providers in our area of the country, it is essential that Centra continues to influence the health of not only our patients, but also our community as a whole,”

Centra intends to “influence the health of not only our patients but the community as a whole,” CEO E.W. Tibbs Jr., said in a statement.

Financial terms of the deal were not revealed.

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Intermountain, Stanford forge clinical genomics and precision medicine partnership
Researchers aim to develop new technologies to solve pressing issues in healthcare.

Intermountain Healthcare and the Stanford Genome Technology Center will work together on research aimed at developing advances in precision health.

Comprising the team of researchers, clinicians and other experts are members of the Stanford Genome Technology Center based in Palo Alto, California, and Intermountain's Precision Genomics Core Laboratory, based in St. George, Utah.
 
Together, they will focus on identifying novel biomarkers using an advanced array of technologies developed at SGTC, and with an emphasis on solving clinical issues for patients.

One of the key objectives in the collaboration is to determine the clinical benefits associated with applying molecular analysis to patient care.

As Lincoln Nadauld, MD, executive director of precision medicine and precision genomics at Intermountain, sees it, the initiative will lead to the development of new technology to address critical medical questions, offering the chance to "conduct clinical population-based studies that will accelerate adoption of precision health."

The collaboration is part of a partnership announced earlier this year between Intermountain Healthcare and Stanford Medicine to support revolutionary projects in research, patient care and medical education.

"This research partnership has the potential for a direct and very positive impact on our ability to extend the lives and improve the quality of life for patients with advanced cancer among other health issues," Terri Kane, vice president of Intermountain Healthcare's Southwest Region, said in a news release.

"Conducting our studies in collaboration with Intermountain Healthcare will enable our joint team to address more ambitious clinical research questions on a much broader scale," added Hanlee Ji, MD, senior associate director of SGTC and an associate professor at the Stanford School of Medicine's Division of Oncology.

When the Centers for Medicare and Medicaid Services revealed that it would start paying, under CPT code 99490, for "non face-to-face care coordination services," one might have expected providers to rush en masse to cash in on what appears to be reasonably easy revenue. In certain instances, 99490 affords healthcare organizations to bill CMS for services they were already providing essentially for free.

That did not exactly happen in the chronic care management program's first year. One reason, of course, is that CMS only gave the industry about 4 months notice that 99490 would kick in on January 1, 2015 – and even then it was essentially, if perhaps accidentally, advertised as a new telehealth code.

Whereas mHealth, telehealth, even POTS (Plain Old Telephone Service) products are key pieces in a chronic care management program, they're really just technological underpinnings enabling an initiative with much, much bigger potential.

What 'big' might one day mean
One way to calculate the potential total is to take the 36 million Medicare patients with two or more chronic conditions and multiply that by the approximately $40 dollars (rounding down from for simplicity's sake) per month CMS will pay for 20-minute consults and then multiply that by 12 months to arrive at: $17.2 billion. Every year.

That whopping total, however, requires that every single one of those 36 million patients enlist in a chronic care management program, then be treated via non-face-face means monthly, and the provider has to track each session and bill accordingly.

[Also: Innovation Pulse: Meet the new CMS code worth $17 billion annually] 

At the risk of calculating overzealously, that $17.2 billion figure represents only the opportunity afforded by treating Medicare patients. When private payers follow CMS' lead and start paying for 99490, the market could effectively triple to some $51 billion annually.

But let's not get ahead of ourselves just yet.

Meaningful use: A CCM precursor?
Whether you consider meaningful use an abysmal failure or a veritable roadmap for digitizing a $2.7 trillion industry in seven years, one aspect of it is undeniable: the program succeeded in pushing a lot of taxpayer money into the hands of hospitals and, in turn, EHR makers. CMS, in fact, has disbursed more than $30 billion to date.

Indeed, just as incentivizing hospitals to spend hundreds of thousands if not double-digit millions on EHRs opened doors for those vendors, care management and population health software purveyors are eyeing a similar opportunity around CCM.

Chronic care management, as a technology product and healthcare services market, is nascent. Despite the already widespread appreciation of CCM's potential benefits, and evidence that hospitals' interest in CCM is on the rise, the reality is that only 13 percent of participants in a recent study have actually filed a 99490 claim and been paid, according to research conducted by Enli Health Intelligence and the consultancy Pershing, Yoakley and Associates.

Here's what has to happen
The math about CCM's potential growth, while simple, is currently rooted more in the hypothetical than the concrete.

Yes, the market could expand somewhere close to the vicinity of $51 billion, but both CMS and providers face obstacles.

CMS, for its part, will have to clarify a number of facts, including the billing to lessen the paperwork burden, tweak what can and cannot be counted as part of the 20-minute monthly consult, waive or reduce the necessary co-insurance for participating, and perhaps most important better outline the value of CCM for patients and their families to make it easier for hospitals to enlist prospects with two or more chronic conditions.

On the caregiver side, providers need to automate the process of identifying and notifying qualified candidates and then manage the care team workflow effectively to ensure both proper follow-up and billing CMS for the work.

[Also: Chronic care management a boon for one practice's population health strategy — and its bottom line]

That right there is the technology heavy lifting necessary to institute a chronic care management plan and the reason why population health management platform vendors are moving toward CCM.

And the fact that if 30 percent of those eligible to participate actually do so, the CCM market will surpass $5 billion annually.  

Inevitable growth
Even if the first year of CCM was arguably slow in terms of consumers and providers getting on board, there's one other factor to consider: the so-called silver tsunami.

CMS statistics suggest that Medicare covered 55.3 million people as of 2015 – approximately 69 percent of whom have two or more chronic conditions, that being the qualifying criteria to enroll in CCM – and CMS is projecting that number of total beneficiaries to skyrocket close to 80 million by 2030.  

The pool is growing and, along with it, the number of qualified CCM participants and the amount CMS will pay out every year.  And that will drive innovations as chronic care management vendors compete to differentiate themselves and other technology titans step into this realm, too.

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In the first major overhaul of Medicaid managed care requirements in more than a decade, the Centers for Medicare and Medicaid Services published new rules on April 25 that affect how Medicaid works for the nearly two-thirds of beneficiaries who get their coverage through private managed care plans.

It aligns key rules and practices with those of marketplace and Medicare Advantage, including the addition of reporting medical loss ratio to Medicaid to ensure managed care plans focus on delivering care, not profits, CMS said.

The rule finalizes a medical loss ratio at 85 percent. Insurers must spend at least 85 percent of their Medicaid revenue on medical care to improve quality. The remaining 15 percent may be spent for administrative reasons such as salaries and marketing, CMS said.

Health plans that don't meet the goal will face future penalties in having their state rates lowered.

On the health information technology front, the rules encourage – but don't require – commitment to the principles of health information exchange

"Health information technology and the electronic exchange of health information are important tools for achieving the care coordination objectives proposed," according to the final rule.

HHS "supports the principle that all individuals, their families, their healthcare and social service providers, and payers should have consistent and timely access to health information in a standardized format that can be securely exchanged among the patient, providers, and others involved in the individual’s care," it states.
 
"Further, the Department is committed to accelerating health information exchange through the use of health IT across the broader care continuum and across payers. Health IT that facilitates the secure, efficient and effective sharing and use of health-related information when and where it is needed is an important contributor to improving health outcomes, improving health care quality and lowering health care costs."

Specifically, the rule points to ONC's Nationwide Interoperability Roadmap and 2016 Interoperability Standards Advisory as containing the "best available standards and implementation specifications to enable priority HIE functions." Providers, payers, and vendors are encouraged to take them into account "as they implement interoperable HIE across the continuum of care, including care settings such as behavioral health, long-term and post-acute care, and community service providers."

CMS also sets the conditions for broader applications of telehealth, specifically as a way to bolster network adequacy standards.

"Several commenters recommended that CMS add elements (to the rule) to include triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions," officials write.

"We agree with commenters that such services and technological solutions could impact the needs of enrollees in a particular area and could change the manner and extent to which other network providers are needed and utilized. We encourage states to consider how current and future technological solutions could impact their network adequacy standards."

An estimated 72 million Americans currently rely on Medicaid as their source of health insurance coverage, 14 million more than in 2013, CMS said. This is largely due to the Affordable Care Act's coverage expansion.

The improvements modernize the way managed care health plans operate so that Medicaid and CHIP continue to provide cost-effective, high quality care to consumers, according to Monday's announcement by Andy Slavitt, CMS acting administrator and Vikki Wachino, CMS deputy administrator and director for the Center for Medicaid and CHIP Services.

The rule strengthens states' efforts to support delivery system reform and authorizes the first-ever Medicaid and CHIP quality rating system so that states can publicly report plan quality information, and people can use that information to select plans, CMS said.

The rule also addresses quality of care standards, as well as focusing on improved communications, such as electronic notices to beneficiaries and creating online provider directories.

"States are making gains in using population based payments, episodes of care and quality-based payments," write Slavitt and Wachino in a blog post. "In addition, states operate 30 health home programs that focus on coordinating care for people with chronic conditions like obesity, diabetes and mental health conditions. Over the last several years, sates have undertaken significant efforts through State Innovation Models, integrated care models, and delivery system reform incentive programs to create alignment with physicians and hospitals to provide the highest quality of care. And we have proven that when we and states dedicate ourselves to changing the delivery of care, we get results."

Read the final rule here.

CloudMedx, a big data health analytics company, has acquired Gyrus Labs to extend its CloudMedx Analytics Platform, which is designed to help improve patient care through data insights. CloudMedx acquired the Gyrus Labs team along with the company's IP and data rights, and already has integrated the Gyrus Labs technology into the CloudMedx platform.

"CloudMedx resolves two major paint points for healthcare organizations: achieving quality and dealing with revenue pressure," said Tashfeen Suleman, co-founder and CEO of CloudMedx. "Healthcare is moving toward value-based care, and payment models are becoming more performance-driven. As this is happening, healthcare needs something more than retrospective analytics that is just based on claims data, which is a few weeks to months old, and by that time patients have gone in and out of health systems multiple times."

The solution to this problem, Suleman said, is prospective and predictive analytics that studies historical trends and predicts future patterns to optimize physician performance and improve an organization's bottom line.

"This requires data from multiple points including electronic health records, claims, patient-reported outcomes, lab systems and pharmacy systems," Suleman said. "CloudMedx taps into these traditional sources but goes a step further, providing the ability to peek inside doctors' notes that are hidden in IT workflows such as clinical summaries, discharge summaries, SOAP notes and more, through its natural language processing engine. The CloudMedx engine reads and understands these notes and predicts trends and outcomes."

On the clinical side, organizations and clinicians can identify currently sick patients and patients who are at risk of illness and plan accordingly; and on the executive side, leadership can identify its high-performing physicians and units, and boost population health efforts, Suleman said.

"At present, a lot of population health programs are providing retrospective analysis that is reactive and based on claims data that is months old, which introduces gaps in care, avoidable readmissions, misdiagnosis, and unnecessarily high utilization and low performance of doctors," Suleman said. "There is a ton of healthcare data that is locked inside health systems and medical records. That data is hard to get and is not being utilized properly. It's a goldmine when it comes to early intervention and reducing clinical risk for patients."

Also with the acquisition of Gyrus Labs comes Dongyang Zhang, MD, a Gyrus cofounder who previously was one of the early researchers on the core team that created IBM Watson for health. He was the original medical scientist who helped the team adapt Watson to healthcare. He has assumed the role of CloudMedx senior medical scientist.

Geisinger Health System has enlisted 100,000 people for its genomic study and did so more quickly than expected. Attracting so many volunteers over two years has prompted program executives to raise the bar to 250,000 or more participants.

The study called MyCode Community Health Initiative launched in January 2014 in collaboration with the Regeneron Genetics Center. It is the largest study in the United States with electronic health records linked to large-scale DNA sequencing data.  

Health system officials credit the success to Geisinger patients' "stability" in the region.

"The families in our core markets are multi-generational and the population is incredibly stable, meaning they don't move away from the area, Geisinger President and CEO David T. Feinberg, MD, said in a statement. 'When we ask to look into their genome, they tell us 'yes' based on trust and respect."

[Also: Geisinger CEO David Feinberg, MD, on patient satisfaction, population health, genomics and more]

The information gleaned from the MyCode study will contribute to a broad range of research aimed at understanding, preventing or improving treatments for disease.

"Our ultimate goal is to help improve healthcare by finding ways to diagnose medical conditions earlier or before they appear and also find new treatments or medications to manage these diseases," said Geisinger Chief Scientific Officer David H. Ledbetter.

"MyCode is not only one of the world's largest genomic studies, it's also the most comprehensive with medical record data going back to 1996. Combining DNA sequence data with 20 years' worth of medical records is groundbreaking," Ledbetter explained.

Geisinger is returning results to patients who are at risk for 27 conditions, for example Lynch syndrome, which can result in a higher than normal chance of developing colorectal cancer, endometrial cancer, and various other types of aggressive cancers at a young age, or familial hypercholesterolemia, which can cause heart attack and death at an early age.

By and large, population health measurement efforts are poorly developed and uncoordinated – and without effective measurement, success will remain elusive.

Without population health measurement, in other words, there can be no population health management.

Part of the problem is different people mean different things when they say "population health," said Michael A. Stoto, professor of health systems administration and population health at Georgetown University.

"For some, population health is using predictive analytics to identify groups of people who need intensive care, and thus measures are required to see how their care is being managed," he explained.

"For others, population health is hospitals and ACOs identifying groups of beneficiaries and members whose care you are trying to manage, and that's a related but somewhat different set of measures," he added. "And for still others, population health means the population in a geographic area. All of these legitimately are called population health, and they all need measures that in some ways overlap but in other ways need to be distinguished."

Learn more at the upcoming HIMSS and Healthcare IT News Pop Health Forum 2016, May 19-20, 2016 in Boston. Register here 

So healthcare and related organizations undertaking population health must agree on what population health is, harmonizing on goals and measures, Stoto said.

"Imagine a hospital and a community both decide reducing obesity is a priority," Stoto said. "What are they going to do about it? Hospitals can offer weight loss clinics, physicians and other providers at the hospital can counsel patients about physical activities and diet, the community can do work through its parks and recreation department, and so on. Then you need performance measures to see whether the hospital, providers and the community are doing these things. All of these things can be measured."

The hospital, the local health department and other organizations share responsibility for the obesity problem. Measures indicate how well the group is doing meeting population health goals; organizations harmonize in the way they define and work on obesity and measure progress, Stoto said.

"There are standard measures for obesity, physical activity and diet, for example, available from organizations such as the CDC, and hospitals and other providers can use these same measures for their population health programs," Stoto said. "So if those are the problems we are trying to address, what are we doing about it? This is where you need process measures. For example, how many people are using the programs a hospital provides? Track the use of these things. Track physical activities of kids in school."

The key is to study through a "driver diagram," Stoto added.

"What are the outcomes we want to achieve?" he asked. "What are the steps needed to achieve those outcomes? Who is going to do these things? And how do we measure what they are doing?"

Marking a "new chapter as a company," Nokia Technologies announced Tuesday that it plans to acquire French connected health device maker Withings for $191 million.

Withings' smartphone-connected scales, blood pressure cuffs, activity trackers and, recently, thermometers can enable remote patient monitoring and population health management programs.

Nokia has been searching for a new focus area since it sold its mobile phone business to Microsoft. In March, Nokia Technology President Ramzi Haidamus suggested that future could lie with healthcare. 

"We’re also looking at another area where we have not launched any products – digital health," he told Fortune last month. "Digital health is something that comes very natural to Nokia... A lot of research is happening right now in the field of digital health."

With the Withings announcement, Haidamus has continued to speak of digital health as a major new direction for Nokia.

"We’re now starting a new chapter as a company, this one focused on connecting you to better health through technology," he wrote in a statement.

"We aim to help you lead a happier, healthier life through the kind of beautifully designed products that you expect from Nokia," he added. "To help us do this as fast as possible, we will be welcoming Withings into the Nokia family. A leader in digital health products and apps designed to improve everyday well-being and long term health, Withings will combine perfectly with Nokia’s heritage of mobility and connectivity."

Withings CEO Cedric Hutchings also shared his thoughts in a blog post.

"We started Withings in 2008 to explore the possibilities provided by the Internet of Things,” he wrote. "Today we can proudly say we are leading the connected health revolution, inventing smart, beautiful things to give people the knowledge they need to live happier, healthier lives. When we were approached by Nokia, it was inspiring to discover how perfectly aligned our visions are. Together, we believe we can truly transform the world."

Hutchings also assured Withings users that the acquisition won’t lead to any change in the experience of using Withings products or apps. 

"We’ve been impressed with the plans the Nokia team has shared with us both for Preventive Health and Patient Care," he wrote. "As soon as we close the deal, we can start working together to determine our way forward as one team with a broad but focused portfolio of incredible products and innovations."

A version of this story was originally posted by Healthcare IT News' sister site, MobiHealthNews.

A lack of real-time data hinders the ability to provide accurate and effective care. And as a manager, it's a time-consuming challenge to assess the patients currently in the hospital – and to predict those with the greatest risk for readmittance once they're out.

"The analytics platform helps me to identify patients still in the hospital and create a tailored discharge plan long before they head out the door," said Jessica Taylor, RN care manager and clinical lead at St. Joseph Healthcare in Bangor, Maine.

And since the information is updated every evening, she can reach out to those patients to provide the greatest amount of support to reduce the risk for readmission.

The analytics software used by the staff at St. Joseph sits on top of Maine's statewide health information exchange, HealthInfoNet, which allows providers to access real-time data from all hospitals connected to the HIE – not just data collected from Medicaid, said William Wood, vice president, medical affairs, St. Joseph.

Wood handles the specificity of the analytics portion, while Taylor focuses on the population health package. She's able to input parameters to check risks and specific categories, such as disease and performance limitations.

"The frequent flyers and high-risk patients, we know who they are," Taylor said. "They're right in the forefront of our tool. We can be proactive instead of reactive with care, when before we were waiting for these patients to come to us."

[Also: Maine's HIE launches analytics business]

"Most of the folks she manages, she can figure out their needs without the tool," said Wood. "But it's that middle group that hides without analytics.

"Your ability to leverage valuable care management resources is really dependent on how good the data is and what you can do with that data," he added, noting that it's about filling in the gaps and meeting those patients typically lost in the shuffle to support population health.

One of the biggest uses of the analytics software for St. Joseph has been to reduce readmissions, Wood said, which have dropped below 10 percent - about 5 percent below the state average. That includes a 15 percent drop in emergency department readmissions in a six-month period.

St. Joseph became the first healthcare institution in the state to use analytics across the state's health information exchange for its daily operations, in January 2015. HealthInfoNet, was established in 2006 and launched its analytics business in partnership with Palo-Alto, California-based HBI Solutions in early 2015.

Maine was also one of the first states to achieve full-interoperability between all statewide hospitals. HealthInfoNet connects nearly all of the state's 1.3 million residents, collecting clinical information from 32 of the 36 state's acute care hospitals and 376 ambulatory provider sites.

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Population health IT developer Caradigm named its new CEO on Thursday, promoting its chief technology officer Neal Singh to the executive role.

Singh will take over for Michael Simpson, who has led the company since it was founded as a joint venture by Microsoft and GE four years ago.

Earlier this month, Caradigm became a wholly owned affiliate of GE Healthcare.

After spending more than a decade as general manager of Microsoft Dynamics, Singh joined Caradigm as CTO, leading the companies business strategy, product management and engineering.

"This is an extraordinary time to be in healthcare and I am thrilled that Caradigm has the ability to innovate – hand-in-hand with our customers – to bring new ideas and solutions to the forefront, as the industry shifts to value-based care," said Singh in a statement.

"GE Healthcare is fully committed to supporting Neal and the Caradigm leadership team as they continue to raise the bar for exceeding provider expectations and outcomes in population health," said GE Healthcare Chief Digital Officer Charles Koontz.

St. Joseph Health announced that it will deploy a real-time analytics platform from Clearsense.

The analytics suite is expected to provide the health system with real-time views of patient conditions and condition changes to enable early detection and prevention. For example, streaming data from monitors, ventilators and other biomedical devices can allow clinicians to stay one step ahead of sepsis and other serious conditions.

Clearsense’s platform is also expected to enable clinicians to better monitor quality measures, collect data from at-home devices and alert clinicians to health issues, making it possible clinicians to intervene earlier and reduce readmissions.

[Also: Population health management demands an effective set of measures]

St. Joseph CIO Bill Russell said that implementing analytics will enable the Irvine, California-based not-for-profit 16-hospital integrated healthcare system to ultimately improve care quality while reducing both cost and risk.  

"St. Joseph Health recognizes that our communities’ healthcare needs are changing, which prompted us to look at ways to stay ahead of these needs by harnessing the power of data,” Russell, who is also on Clearsense’s advisory board, said in a statement.

To that end, the health system will pilot Clearsense Surveillance technology beginning this fall.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

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