Welcome to Population Health. Applying Health IT to Improve Population Health at the Community Level. This is lecture a, the objectives for this lecture are to describe the frameworks relevant to the concept of population health at the community level. By community, we mean just that, it could be a town, a city, or other geographic jurisdictions such as a state or even a nation. It's true that many of these concepts will focus not just on geographic communities, but also other groups of individuals, such as those enrolled in a health plan, or working for a specific organization. The second learning objective is to begin to examine other types of factors such as social factors and non-medical factors and discuss how they impact health and wellness. Very often, in this component and others that focus on health information technology, we tend to focus on the medical aspects, the biological aspects, which are very important. But as we'll see in a moment, they are not necessarily the key explanatory factors. There are many determinants of health drawing from the U.S department of health and human services, this is a simplistic representation of health. And again, as we'll explore in a moment, help goes beyond getting good medical care for diagnosed conditions. At the core of this graphic is the individual, acknowledging that there are both biologic factors as well as behaviors that lead to the person's health and well being. To the left of the individual, is the physical environment where a person lives. It could be the environment, for example, particulate matter in the air they breathe. It can also be factors that relate to how easy it is to get exercise. On the right-hand side is the socio-economic environment areas of poverty versus areas of wealth, for example. This graphic appropriately acknowledges the importance of access to quality healthcare on the bottom. Access to care is the code word in health policy discussions for whether or not people do or don't get healthcare. And obviously, health reform and getting a health insurance card are big factors in access to medical care. At the top, acknowledging the importance of government, be it local government or national government or policies and interventions, that's a key aspect of public health. The determinants of population health go well beyond medical care. There are many different graphics depicting them. This one is based on excellent work done at the University of Wisconsin that attempted to share with doctors and others, the important factors that population health should take into consideration. These percentages are estimates, and there's controversy concerning exactly what proportion each should be. But when one looks at the health of an entire population, there are the four factors to consider, including one, healthcare, two, healthy behaviors, three, the socioeconomic factors, and four, environmental or physical factors. Some research has shown that this percentages relate to a population being healthy or not healthy. Medical care or the access to good medical care is really a relatively small piece of what makes a person healthy, while healthy behaviors and socioeconomic factors compromise 70% of what makes a person healthy. These shows the importance of behavior, such as tobacco, exercise, alcohol, and safe sex. In terms of socioeconomic factors, study after study shows that people who are employed have more education, higher incomes, more social support, live in a safe community, and breathe clean air, are healthier. Now, can all of this be controlled by any government or any organization trying to improve health? Well, not necessarily. But it does suggest that when we look at the concept of health and population health, we have to go beyond medical care. We will continue to explore the implications of all these non-medical factors and how health information technology and other electronic digital information, can be used by various organizations or government agencies to monitor and ultimately improve the health of populations. This is a graphic developed by the team at the Johns Hopkins University Center for Population Health Information Technology, or C-P-H-I-T, or CPHIT as we say for short. We've reviewed a variety of other authors, relying heavily on Dr. David Kindig at the University of Wisconsin, who has done a lot of work in this domain. But we pulled together a graphic that we find helpful for understanding population health. We titled this quote, An Ecological Framework for Population Health, end quote, with key determinants. The levels and sectors of interventions and the different dimensions of outcomes. We use this to provide a framework for how one understands, potentially intercedes and uses a variety of digital health information technology to improve the health of populations. Starting at the left, if you think about the causal factor or the determinants. If one is trying to make a difference to try to improve the health of populations. These are the types of things that the government public health agency or another organization such as a Health Maintenance Organization, HMO, or Accountable Care Organization, ACO, might do to intercede. Obviously, we tend to focus on healthcare, doctors, nurses, public health, medical interventions. But we need to remember that for the population truly to achieve outcomes of health and wellness, we have to focus on behaviors. Again, not just for those patients who come into the office, but for the entire community. One needs to be very concerned about the socioeconomic factors. And yes, it's challenging for a public health agency and certainly for a medical care organization to impact socioeconomics, but they're key factors, and if we can intercede, that's great. And if not, we need to at least understand. A job is very important to a person's health. I think we can all appreciate that. And the environment, whether or not it's lead paint, whether or not it's lead in the water, whether or not it's secondary smoking, those are all important factors, too. Also, on the left-hand side we acknowledge that there are various determinants that are not amenable to intervention, at least not in the near term. Genetics comes to mind. Obviously, one needs to understand and take those into consideration and increasingly in the future. We might do that as part of genomic information on the patient, but we set that aside for now. Moving to the right, if one thinks about impacting and making an intervention, we find it useful to think about understanding population health and how it impacts really three levels of intervention. Intervention at the clinician level, that could be an individual doctor, nurse, or an outreach nurse. It could be a patient centered medical home, PCMH. It could be sort of the framework of a clinician. It could be the framework of an entire system, medical delivery system or health delivery system. Such as an ACO or an integrated system, IDS or Health Maintenance Organization or some government delivery system. Particularly relevant to this unit, it can be an entire community intervention. Most public health activities take place at the community level. Other types of social health activities almost always have to take place at the social level. The right side of this graphic reminds us that when one talks about health and well-being, one is not only talking about the mortality and morbidity. Yes, we want to live a long and healthy life, and that tends to be the focus of medical care. But also, there's function. Functional status, one can be not so healthy and function well, or one can be quite healthy and function poorly. Again, these are outcomes and different ways that we must increasingly understand how we impact a person's overall health and wellness. Not simply understanding their diagnosis code or how long they live. Clearly, part of health and wellness is the emotional and psychological aspect. One can be medically healthy, but unhealthy from an emotional, psychological perspective, and vice versa. And one cannot have good health and wellness. If one is not safe physically, and for example, does not have housing and food etc. This graphic takes the previous one a step further by providing a unified framework that talks about disease management. Some people call it chronic care population management, but it also talks about broader community population, health, and prevention. It tries to combine perspectives. Again, the three levels of intervention discussed at the clinical level, delivery system level and community level. This graphic provides sort of a framework for understanding, from the clinical perspective, stages of the disease. It shows the levels of population health interventions, the one's just expressed before. It describes the care management process and it talks about the prevention continuum. So, if an individual is potentially at risk for a disease or some health condition, let's just take the example of diabetes or hypertension. Some people do not yet have the disease, but they're at higher risk than others. That could be genetic, in which case we need to know about it. It could be environmental, not getting exercise or what they eat or stress. It could be a variety of other factors. The goal is using public health approaches, community health approaches to intervene and identify people who are at higher risk. So for example, let's say a person has diabetes or hypertension. They'll have early signs and symptoms. Their blood pressure is slightly elevated, or their blood sugar is slightly elevated. And then, they're diagnosed as having a disease. Clearly, the classic prevention suggests that you want to try to avoid that. The population medical case management risk pyramid that comes to play later in the process is often called care management or disease management. One of its key goals is to avoid negative medical outcomes. This is a common sort of clinical public health or clinical care management framework. On the bottom, we have added the perspective that is often taken. On the left is population risk assessment or mitigation. That is, trying to look at the entire population or a community or other denominator, assess risk, and intervene. You may have heard the term primary or secondary prevention. These are terms often used in public health and preventive medicine. Primary or secondary prevention would be preventing a disease from happening, or once it happens, trying to keep it from going to advanced stages that would be secondary prevention. And once it's too late to prevent the disease, we're moving more into clinical medicine. At the top, we provide the overview, from left to right although arguably, it isn't always from left to right, of things that are best handled at the community intervention. Things that are best handled at the clinical intervention and things that may be best handled at the delivery system intervention. As acknowledged here, all of those interventions can really happen at all levels. This is a graphic that provides a paradigm for the differences between clinical informatics and public health informatics, and the focus of this component, population health informatics. Clinical informatics can be considered the application of health information technology and other big data sources, primarily in support of the clinician. Be it doctor or a nurse for the care delivery process. Public health informatics focuses primarily on the application of health IT. In support of government programs that are targeted at geographic jurisdictions. The growing new field of population health informatics cuts across both the community and healthcare system to focus on populations of individuals and providers, who may or may not be defined based on geography. This slide presents a very interesting graphic developed by the Canadian Public Health Association, that tries to provide an integrating paradigm for linking medical care and public health at the community level. It touches on many of the same themes we have shared in previous paradigms. But I find it particularly useful and perhaps it will be useful to you. The core of the graphic represents the integration of clinical medicine, particularly primary care. That is entry-level medicine provided by general practitioners, nurse practitioners or general internal medicine or pediatricians. Chronic disease management, what is now frequently called population chronic care management. And population based prevention at the public health level or we would say possibly at other denominator levels. And for all of those to be pulled together, that would be considered integrated care. Following the public health approach, they remind us at the top that it's important to have common goals and values for the system. It's important to make sure there's a public health capacity and an infrastructure. Similarly, around the circle, one must have a community capacity infrastructure and primary care medical infrastructure. These are things that have to be done collaboratively both between government and the private sector. Off to the left is a reminder that all of this must focus on determinants of health. And off to the right, that we must have leadership and partnership and investment in all of these systems. When one talks about developing a system of population health or community health, one must not only talk about the intervention itself, but also whether or not it works and learning from that. That's science, that's evidence, these are the basic premises of the learning health system, or as we might say here a learning population healthcare system. The domain of population health informatics, population health information technology, HIT, really is a composite of various, sometimes independent disciplines. This would include classic public health, government public health, IT systems and systems of integrated delivery systems, IDS', such as, Health Maintenance Organization or ACOs. These concludes lecture a of population health, Applying Health IT to Improve Population Health at the Community Level. In summary, in this lecture you have learned that there are many determinants of health, including biological factors, the physical environment, socioeconomic environment, and human behavior. About the Johns Hopkins University Center for Population Health Information Technologies, C-P-H-I-T, quote ecological framework for population health, end quote. With key determinants, the levels and sectors of interventions, and the different dimensions of outcomes. About our unified framework concerning disease management or chronic care population management, that there is a paradigm for the differences between clinical informatics, and public health informatics, and population health informatics. About efforts to link medical care and public health at the community level.