Population health management has become an important competency for hospitals and health systems. But the road to implementing effective pop health strategies is laden with challenges: monitoring chronic illness rates and preventing community transmission, triaging emergencies over routine health care circumstances, and executing preventive services all require providers to alter their traditional fee-for-service workflow.

Advanced healthcare platforms, such as digital front doors, are emerging as an answer to some of these challenges. Digital front doors can help process large amounts of demographic data related to community health and population wellness.

Healthcare IT News sat down with Keith Algozzine, CEO of UCM Digital Health, a vendor of digital front door technology, to get a handle on the aforementioned challenges; how digital front doors can help with population health; how digital front doors work behind the scenes to accomplish goals; and how digital front doors work with enhanced health benefits such as in-home care and treatment, virtual primary care, and therapeutics to empower a population to take control of their health for the better.

Q. What are some of the challenges facing successful population health management programs today?

A. More and more organizations are looking for ways to improve the health of the populations they serve. They understand that "health" is more than just "healthcare" and are looking to make a positive impact on health status.

Implementing population health initiatives does come with challenges. It takes expertise and experience, which is why many organizations are looking for third-party partners to help them implement health improvement initiatives. These initiatives are often outside the realm of direct care and fall into the sphere of social determinants of health.

Once a population health initiative is defined, the challenge becomes identifying the right individuals for outreach and personalizing the approach to meet unique patient needs. Overall health depends on ensuring that patients get timely, medically appropriate preventive care and that patients with chronic conditions are proactively followed to prevent future complications.

There is no question that engaging patients and getting them involved in their care is critical to improving health. For instance, many patients know that there are things they can do to improve or maintain health, but don't do them due to non-health barriers.

It is not enough to urge someone to see a primary care provider; we have to be certain they have transportation to get to the appointment and that their work schedule or other responsibilities and circumstances do not interfere, making it difficult or impossible to attend an in-person medical appointment.

After an initiative is defined and implemented, patient adherence, compliance and tracking of outcomes are keys to ongoing success. Because data isn't always integrated seamlessly across various points along a patient's healthcare journey, providers and other organizations don't always get a full picture of patient compliance and tracking of outcomes.

A robust data platform can be effective in bridging this gap. It allows different organizations to have visibility of each other's data and information, enabling a more complete understanding of that patient's health.

Q. You suggest digital front doors can help healthcare provider organizations overcome some of these challenges. How?

A. Digital front doors can be effective in removing barriers while ensuring that patients get continuity of care specifically designed around their individual needs. Provider organizations often cannot reach the patients that would benefit the most from population health programs.

Digital health and digital front doors can be an effective means of providing any patient with access to a medical or mental health care provider, removing barriers by allowing patients to connect via phone, chat, video or even asynchronously. Care can start digitally but can extend into the home with a combination of hands-on support from medical professionals working alongside telemedicine providers virtually.

Programs can be created for proactive identification and outreach to the right populations to conduct wellness visits, close gaps in care and address social determinants of health by connecting to community resources, as examples.

Moving a healthcare encounter to a virtual visit can break down a host of barriers and enable success in population health initiatives. For example, with digital-first care, the patient doesn't have to worry about traveling and transportation to get to the appointment. Time and money spent on commuting are saved.

Productivity is gained at work and at the home. Stepping away from work or household responsibilities for a few minutes for a virtual visit may be more feasible for many people than missing several hours for roundtrip travel to and from an in-person appointment. A virtual provider can even tour a home by video to identify hazards or other social determinants of health and assist the patient with the next steps to get them addressed.

You can't act if you don't know. In a traditional healthcare setting, information is fragmented. Collecting information about health and non-health allows you to determine actions that can be taken to improve a patient's health. An effective data platform can facilitate data sharing and integration, providing providers and other organizations with full visibility of the patient's health information, including the ability to track population health program compliance and outcomes.

An effective data platform can solve data interoperability issues, further enabling population health initiatives. For instance, platforms can have the ability to understand and translate different code sets across organizations so they can come to a common understanding of the patient's data and information, ultimately improving health outcomes.

Q. How do digital front doors work behind the scenes to accomplish these goals?

A. Patients want convenience, and a digital front door can give it to them. Digital front doors can be open 24/7/365, giving patients access when they are truly in need, with wait times that are often non-existent or minimal.

Quality of care is equal to, if not greater than, the care provided in a traditional brick-and-mortar setting. Providers are often able to spend more time with patients and provide dedicated one-to-one, personalized attention and care. For the patient, no time is lost in the doctor's office waiting room, where the patient also risks being exposed to other illnesses.

Patient compliance is also higher in the digital space, with data emerging from the National Library of Medicine showing patients are less likely to miss a telemedicine appointment. And with care available on demand, no appointment is necessary.

A common data platform can be effective in connecting patient data across organizations to get a full picture of the patient, enabling whole-person care, and looking at the patient holistically instead of in discreet, siloed medical encounters.

It can be effective in bringing together multiple platform partners that can enable optimal care for the patient. For instance, connecting a partner who delivers in-home labs, along with a telehealth provider and a brick-and-mortar primary care physician, to enable data sharing and collaboration with the patient's health, the appropriate level of care and best outcomes in mind as the objectives.

Q. How can digital front doors work with enhanced health benefits, such as in-home care and treatment, virtual primary care and therapeutics to empower a population to take control of their health for the better?

A. This is really the future of care. Digital front doors can provide one single entry point and experience for the patient. They provide patients with access to enhanced benefits because they offer access to a range of patient services across a variety of care settings: virtual emergent and urgent care, virtual mental health care, virtual primary care, in-home care and more.

Patients can initiate care digitally, get complete care virtually, or can continue it in-home, if and when needed. Patients get their choice and are empowered to choose how and when they interact with the healthcare system.

We are entering a digital landscape where physicians and paramedics can work together to deliver care in the home as an alternative to an ambulance ride to the hospital emergency room.

We are seeing 911 systems that can now connect a caller to a nurse navigator or to a telemedicine physician to address health needs without an hours-long wait in an emergency room, making care more accessible, affordable and safer. And is wisely using scarce healthcare resources, for example, by allowing paramedics and 911 centers to focus on true emergencies.

Digital front doors can make up for many things that our healthcare system should do but isn't doing. How much better off would a patient be if the healthcare provider checked back in with them three days after a virtual visit to make sure treatment and recovery were going according to plan?

How much more would that digital engagement and followup increase compliance with population health programs, along with patient satisfaction and overall health? A digital presence clearly is the future of care, enabling providers to make meaningful connections with the patient and other organizations and engaging the patient in their health.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.