1.
© 2013 Health Catalyst
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The 12-Criteria of
Population Health Management
By Dale Sanders
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
© 2013 Health Catalyst
www.healthcatalyst.com Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.

2.
Overview
Focus is on the data management of
Population Health Management
• Not necessarily the processes of PHM
Purpose
• Evaluate healthcare IT vendors and their PHM offerings
• Develop internal strategies and roadmaps for Accountable Care
Organizations (ACO)
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3.
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CRITERIA
Precise Patient Registries
1
Evidence-based definitions of patients to include in population health registries
Beyond ICD-9 billing codes, which are likely to miss 30-40% of the population

4.
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CRITERIA
Patient-Provider Attribution
2
Strategies and algorithms to assign patients to accountable physicians or clinicians
Generally accepted high-level options for assigning attribution
Patient selection of
physician during
open enrollment
“Most frequently
visited” physician
over the past two
years
Random assignment
of patients to primary
care physicians in
the same geographic
area
Random assignment
of patients in an
employer group to
primary care
physicians in the
PPO or HMO

5.
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CRITERIA
Precise Numerators in Registries
3
Discrete, evidence-based methods for flagging the patients in the registries
that are difficult to manage or should be excluded
Reasons why a patient may not be able to fully comply with clinical protocols
Language barriers
Cognitive inability to participate in a care protocol
Physical inability to participate in a care protocol
Economic inability to participate in a care protocol
Willing and informed refusal to participate in a care protocol, e.g. religious reasons
Medication contraindications to participating in a care protocol
Geographic inability to participate in a care protocol
Mortality (it can be surprisingly difficult to identify these patients)

6.
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CRITERIA
Clinical and Cost Metrics
4
Monitoring clinical effectiveness and cost of care to the system and patient
Measure practice of medicine against these protocols
Measure the variability in care
Build dashboards around specific patients and population of patients
Must track the total cost of care for specific patients and a per-capital basis across the population
Provide quality, outcome, and cost variance feedback to physicians, risk adjusted, at the point of care
Ultimately this prepares an organization for fixed-fee contracting in a true value-based system

7.
Measure practice of medicine against these protocols
Current evidence-based medicine lacks applicability outside the specific clinical trial
In the future, clinical trials’ “evidence” will be displaced by derived evidence from the analysis
of local data sourced by the EDW
In the meantime, the industry must make-do with existing evidence and guidelines
Many external commercial sources and commercial vendors
Health systems need to establish a “Clinical Practice Guidelines” governance body and select
their source(s) and processes
Start by defining clinical practice guidelines for patient cohorts and process families that offer
the highest opportunity for improvement and cost savings
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CRITERIA
Basic Clinical Practice Guidelines
5
Evidence-based triage and clinical protocols for single disease states
Number of patients
In the population
The Average Total Medical
( ) X ( E xp e n d it u re ( T M E ) p e r C a p it a)

8.
Risk stratification enables an organization to analyze and minimize the
progression of a disease and the development of comorbidities
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CRITERIA
Risk Management Outreach
6
Stratified work queues that feed care management teams and processes
First need to stratify and monitor the registry
patients
Then develop strategies to identify and intervene
with high-risk trajectory patients
Ultimately need to profile and proactively treat
patients before becoming members of the registry

9.
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CRITERIA
Acquiring External Data
7
Access to clinical encounter data, cost data, laboratory test results, and
pharmacy data outside the core healthcare delivery organization
Contrary to current national strategy and focus, acquiring external data should
be a secondary focus in today’s market
It is geometrically more complicated to manage a patient
population beyond the core healthcare delivery organization
Start with in-house process and data quality first
Then, carefully and deliberately expand the data ecosystem
HIEs are the most visible technology associated with ACO
external data exchanges, but only address a small portion of
the data puzzles required for PHM
The “A” in M&A will shift from bricks-and-mortar acquisition to
data acquisition

10.
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CRITERIA
Communication with Patients
8
Engaging patients and establishing a communication system about their care
Current solutions are fragmented and immature but will improve dramatically in
the next 3 years
Today’s typical patient engagement solution is through a
personal health record (PHR) tightly associated with a
healthcare delivery organization EMR
The future patient engagement solution will be completely
patient owned, decoupled from an EMR or single
healthcare organization
The PHR will evolve into a personal project management
system, with a combination of project management,
knowledge management and social support.
Take advantage of current PHRs, but be prepared to
jettison current PHRs for something more informative,
customized, collaborative and functionally rich

11.
• Low-income, preteen girl with type 1 diabetes
likely to receive same education material as a
middle-aged executive man
• Materials are not tailored to blend comorbid
conditions together
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CRITERIA
Educating and Engaging Patients
9
Patient education material and distribution system, tailored to the patient’s
status and protocol
Our current patient education system is hampered by the lack of highly
personalized materials and an effective distribution system
Often, today’s patients receive no education material about their condition
PHRs tend to present generic education information
No certified, widely available method of evaluating material quality
Widely used vehicles like Twitter, Facebook, Zite, and Amazon have yet to be fully embraced

12.
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CRITERIA
Complex Clinical Practice Guidelines
10
Evidence-based triage and clinical protocols for comorbid patients
Establishing protocols for comorbid patients is complicated
Few industry sources for clinical protocols for
comorbid patients
Physicians often left to build their own guidelines,
or chain individual disease treatment protocols
together
Medicare patients on average affected by at least
chronic diseases at the same time
Organizations that optimize comorbid care will be
in a strong position to differentiate themselves in
the market, both financially and clinically

13.
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CRITERIA
Care Team Coordination
11
Inter-clinician communication and project coordination
We need to treat every patient as if they are at the center of a project plan
All members of a patient’s care
management team should be able to quickly
and easily see the patient’s overall project
plan, next milestones, and responsibilities
Acute encounters should show recovery
milestones and assigned people
Chronic diseases should show a lifetime
project plan for health
The ideal system would function like a
project management tool (like Basecamp)

14.
This is also the most culturally and
technically difficult criteria to implement
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CRITERIA
Tracking Specific Outcomes
12
Patient-reported outcomes measurement system, tailored to the patient’s
status and protocol
Patient-reported outcomes data is one of the most important pieces of data
missing from our ecosystem today
Our best efforts today is assessing patient
satisfaction, but that data falls short as an
aid for measuring actual clinical outcomes
Currently, no reasonable options exist in our
industry
A future patient-reported outcomes system
must have a closed-loop data relationship
with the EMR, and then exported to the
EDW for analytic purposes

15.
Vendor Evaluation and Scoring
No single vendor today offers an integrated and fully functional
population health management solution that meets all 12 criteria
Vendor scoring criteria
Personal experience as a customer of the vendors’ products
Personal experience as an executive in the company (i.e. Health Catalyst)
Conversations and interviews with current and past customers of the vendors’ products
Market reports from, and conversations with, industry analysts at KLAS, Chilmark, IDC,
Gartner, and the Advisory Board
Publically available information on the vendors, including their own case studies, white
papers, on-line product demos, and product information
Conversations with current and past employees of the vendors
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16.
Vendor Evaluation and Scoring
Two patterns emerge from the scores
1: The vendor market is very inconsistent
in its approach to population health
management
2: Not all criteria equally important now
The first six to eight
criteria are the most
important now
They should be
weighted heavier in
the decision making
and deployment
planning process
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17.
Vendor Evaluation and Scoring
First tier evaluation scores
Crimson Explorys
Health
Catalyst
Lumeris
Optum
Humedica
Phytel Premier
Average
Score
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Criteria #01:
Precise
Patient Registries
5 5 9 3 3 3 3 4.4
Criteria #02:
Precise
Patient Attribution
5 5 8 5 6 5 5 5.6
Criteria #03:
Precise Numerators
in the Patient Registries
0 0 5 0 0 0 0 .7
Criteria #04:
Clinical and
Cost Metrics
7 7 9 6 5 4 5 6.1
Criteria #05:
Basic Clinical
Practice Guidelines
0 0 0 3 5 5 0 1.9
Criteria #06:
Risk Management
Outreach
1 0 0 5 7 5 0 2.6
Sub-Total 18 17 31 22 26 22 13

18.
Vendor Evaluation and Scoring
Second tier evaluation scores
Crimson Explorys
Health
Catalyst
Lumeris
Optum
Humedica
Phytel Premier
Average
Score
© 2013 Health Catalyst
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Criteria #07:
Acquiring
External Data
0 5 6 0 4 2 7 3.4
Criteria #08:
Communication with
Patients
0 0 0 4 5 6 0 2.1
Criteria #09:
Educating and
Engaging Patients
0 0 0 2 3 4 0 1.3
Criteria #10:
Clinical and
Cost Metrics
0 0 0 0 0 0 0 0.0
Criteria #11:
Complex Clinical
Practice Guidelines
0 0 0 0 0 2 0 0.3
Criteria #12:
Tracking Specific
Outcomes
0 0 0 0 0 0 0 0.0

19.
Asset Allocation and Timing
Recommended asset allocation as the market and organization
evolve and mature in population health management
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20.
Asset Allocation and Timing
Recommendations
Build a population health
management roadmap
Start as soon as possible with the
first six criteria while the latter six
develop in the market
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21.
Conclusion
Key points to remember
Follow the lead of the IDNs which have been
practicing PHM for years
Reference this presentation and the CCHIT
framework when developing an organizational
strategy and evaluating vendors for PHM
There is no single vendor that can provide a
complete PHM solution today
Sequencing is important. Focus on the first six
criteria over the next three years while the
context evolves
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22.
Population Health Management
The Ordered Checklist for Your 3-5 Year Journey
1. Registries: Evidence-based definitions
of patients to include in the PHM
registries
2. Attribution & Assignment: Clinician-patient
attribution algorithms
3. Precise Numerators: Discrete,
evidence based methods for flagging
patients in the registries that are
difficult to manage in the protocol, or
should be excluded from the registry,
altogether
4. Clinical & Cost Metrics: Monitoring
clinical effectiveness and total cost of
care (to the system and the patient)
5. Basic Protocols: Evidence based
triage and clinical protocols for single
disease states
6. Risk Outreach: Stratified work queues
that feed care management teams and
processes for outreach to patients
7. External Data: Access to test results
and medication compliance data
outside the core healthcare delivery
organization
8. Communication: Patient engagement
and communication system about their
care, including coordination of benefits
9. Education: Patient education material
and a distribution system, tailored to
their status and protocol
10. Complex Protocols: Evidence based
triage and clinical protocols for
comorbid patients
11. Coordination: Inter-physician/clinician
communication system about
overlapping patients
12. Outcomes: Patient reported outcomes
measurement system, tailored to their
status and protocol
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23.
Link to original article for a more in-depth discussion.
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© 2013 Health Catalyst
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