Mass General exec on applying population health tactics without changing clinician workflow

The hospital's multidisciplinary care teams track patients in real-time and can mount interventions to correct lagging performance. And Mass General’s clinical director of population informatics Adrian Zai, MD, said that doctors like the program.
By Bill Siwicki
08:15 AM
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Mass General population health

Mass General's Adrian Zai said that among the population health challenges is coordinating care and making sure all the right pieces are in place. 

Population health is all about taking care of large groups of people, so it should come as no surprise that it takes a group of people to head up this care.

A team-based strategy is needed to tackle the challenges of population health management, said Adrian Zai, MD, clinical director of population informatics at Massachusetts General Hospital.

“Let’s focus and talk just about a team that drives one population health intervention: Initiatives that identify high-risk diabetic patients that are not well-controlled and potentially require insulin,” Zai said. “A team that takes care of that typically consists of a diabetologist, a nutritionist, a social worker and a clinic secretary, and the team is concerned with how all these people work together to drive the care of a patient population of high-risk diabetics. That is where the multidisciplinary care team comes together using the IT tools to drive the care of these populations.” 


 Learn more at the Pop Health Forum in Boston, April 3-4, 2017. Register here.​


The challenge, however, is care coordination – how do all of these people work together?

“Parsing the right path to the right role to drive the care of these patients; all of these roles work synergistically to drive the outcome performance of a patient population,” Zai explained. “People often think about population health simply as analytics – you identify who those patients are. But once you get to that point, how do you act on those patients to get to the outcomes you are trying to get? It is essentially by building that multidisciplinary care team to work together via population health IT tools. The care coordination piece of it is the team that drives the intervention.”

As part of the team-based approach, Massachusetts General Hospital has what it calls population health managers who track the performance of the health system’s entire primary care network.

“Every practice is tracked in near real time; the managers check the outcomes data on who is getting what done, and step in if they realize a dip in any of the practices,” Zai explained. “For example, the population health managers realize there is a sudden dip in hemoglobin A1C value tests being done at Practice A, what they will do is mount an intervention immediately and make sure that gets rectified quickly and centrally. That is an approach that we have taken as an institution to act on these practices or physicians who are starting to show a lag in performance, and we’re able to rectify that very easily.”

Trend lines occasionally dip a little bit, and then an observer can tell an intervention has been mounted when the trend line goes back up because population health managers have helped that practice ensure patients are notified to get tests done, Zai said.

“It’s not so much changing the physician workflow,” he said. “There is no change in physician workflow. It’s supporting them from the back office perspective. This is something physicians typically enjoy a lot because it doesn’t require them to be part of the intervention. Say there is a lack of cancer screenings, then the organization mounts the intervention and drives those cancer screenings upward again. They monitor and enhance performance through trend analytics across the board.”

Zai will be discussing population health issues at the HIMSS and Healthcare IT News Pop Health Forum, April 3-4, 2017, at the Westin Copley Place in Boston, Massachusetts, during an educational session entitled “Keynote: Driving Outcomes Through a Workflow: Technology Interface.” Register here.​


 Related articles ahead of the Pop Health Forum: 
⇒ Pop Health Forum to address value-based care, executive leadership, innovation
⇒ Partners Healthcare uncovers twist, and savings, in population health data
⇒ Palmetto exec on overcoming telehealth funding and physician reimbursement challenges


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