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Most Health Organizations Now Integrating SDOH Into Pop Health Management Programs

Posted on February 20, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new survey has found that healthcare organizations have begun to actively integrate social determinants of health into the population health management strategies.

The research, conducted by Change Healthcare and the HealthCare Executive Group, found that 80% of organizations had begun to track and use data on social determinants. This is a huge step up from just a few years ago, when discussions around SDOH and their use in population health management were more speculative than practical.

Perhaps the most interesting technique organizations are using is enlisting doctors in this effort. About 21% are training doctors to identify social determinants, a step which, in my opinion, is long overdue. Given how taxing this might be for physicians at first, it’s good to see that just a hair under 21% have also rolled out point-of-care checklists designed to help clinicians identify potential social determinants.

Other strategies respondents are using to leverage SDOH info include integrating community programs and resources into their population health management programs (42%), integrating medical data with financial, census and geographic data (34%), offering social assessment tools with health risk assessments (33%), incorporating social determinants into the clinical workflow (27 percent) and using third-party software, data and/or services (19%).

On a side note, the research data also suggests that another set of tools in PHM — mobile and digital health technologies — haven’t found their footing. When asked what’s limiting widespread consumer adoption of these tools, top reasons respondents cited included security and privacy concerns (49%), limited functionality (35%), a duplicative, redundant and confusing app environment (34%), problems with system interoperability (33%), a lack of healthcare literacy (33%) and poor user interface design (32%).

The latter data pointing to low mobile/digital health adoption came as a surprise to me. I like to think I can see through health IT industry hype, but maybe I’ve been fooled somehow. The data I’ve seen to date (some of it, admittedly, collected by vendors) has suggested for years that mobile healthcare adoption was climbing dramatically and that more recently, other digital health tools have begun to follow suit. I guess I missed something.

Given this lag, I’m glad to see that healthcare organizations are enlisting physicians, point-of-care checklists, clinical integration and other tactics to make use of SDOH data. We all know on a gut level that if the patient can’t get to the doctor, lacks social support or lives in a “food desert” where finding unprocessed foods and healthy produce may be quite difficult, preaching at them about their health concerns isn’t going to help. It’s high time we help physicians collect this information and find ways to close some of these gaps.

KPMG: Population Health Taking Hold

Posted on January 31, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new KPMG survey has concluded that population health management approaches are becoming popular – and for nearly half of respondents, are already working.

According to the consulting firm, which reached out to 86 respondents working for a payer or healthcare provider, 44% said that they have a population health platform in place which is being used “efficiently and effectively.” Twenty-four percent of respondents said that they were in the process of implementing a pop health program within the next three years, while 10% said they had no plans to use such a platform. (Another 21% said that their organization didn’t need one.)

Thirty percent of respondents said that the biggest individual obstacle to implementing a population health strategy was aggregating and standardizing information from multiple sources. Meanwhile, 10% cited stakeholder adoption as a barrier, and 10% named integrating with clinical work flows as a key issues. Meanwhile, another 34% cited “all of the above” as a significant barrier, along with enabling patient engagement, funding investments and choosing the right vendors.

Along the way, KPMG asked respondents where they stood with value-based payments. Thirty-six percent said “some of our revenue is generated by value-based payments,” and 14% said that the majority of their revenue came from value-based payments.  As for those that weren’t there yet, 26% said they were planning to enter into value-based contracts within one to three years, while just 7% said they were not planning to do so. (The remaining 17% said they don’t require value-based payments.)

All that being said, though, there’s a problem here. And that problem is that while everyone seems to think they mean the same thing when they discuss population health management, I’d submit that in many cases they aren’t on the same page. In fact, I’d argue that until we get that straight, studies like these don’t tell us a lot.

Yes, I think we all have the same broad idea in mind when the topic of PHM comes up, which is to say that we envision a system in which a health system, ACO or health insurer sets broad goals for key health metrics across a population.  And as most readers probably know, the health insurance industry has been managing a population-wide set of standards known as HEDIS (the Healthcare Effectiveness Data and Information Set) for decades. HEDIS is designed to make apples-to-apples comparisons of health plan performance possible by providing very carefully defined criteria.

On the other hand, the number of technologies, approaches and philosophies being implemented by health organizations for population health management do no such thing. While there’s probably many areas of broad consensus on what should be measured – particularly when it comes to chronic, costly conditions like diabetes and heart disease — we don’t have any shared performance standard.

So before we look at pop health stats, it might be a good idea to clarify what that means to those answering surveys like this. Otherwise, it’s GIGO.

Population Health Polls

Posted on August 11, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was thinking about population health today. It’s become a hot topic of discussion now that a lot more healthcare data is available for population health management thanks to EHR adoption. Although, in many ways, the various value based reimbursement and ACO programs are a form of population health. I guess, for me I classify all of these efforts to improve the health of a population as population health.

I just wonder how many organizations are really working on these types of solutions and how much of the population health is just talk. Let’s find out in the poll below.

I’ll be interested to hear how organizations are approaching population health. Also, let’s do another poll to see how much people will be working on population health in the future.

I’d love to hear more details to your responses in the comments. If you are working on population health, what programs are you doing and what IT solutions are you using to support it?

Partners Integrates Mobile Data With EMR

Posted on June 25, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In a move that could realize much of the promise of wireless remote monitoring, Partners HealthCare system has made it possible for providers to view remotely-collected patient health data in its EMR.  The program was launched by Partners division The Center for Connected Health, which focuses on delivering new forms of patient care outside of standard medical settings.

For years, Partners has been running programs which collect patient data through a combination of remote-monitoring technology, sensors and Web-based tools. Their focus has included management of chronic diseases such as diabetes and high blood pressure, medication adherence and improved pregnancy outcomes and cardiac care outcomes. The Center’s remote monitoring database now stores over 1.2 million  patient vital signs.

Now, Partners has linked The Center’s proprietary remote monitoring database to its EMR, a step which moves the system in the direction of offering continuous chronic disease management. If a patient is participating in a remote monitoring program, Partners physicians can can now see a patient’s day-to-day vital signs, blood glucose levels, weight and other key health indicators directly within their records in the EMR.

The ultimate notion, according to the press release at least, is to  “put the patient at the center of their care while maintaining a close watch on their condition when they are not in the hospital or doctor’s office.”

While Partners didn’t say how many patients are involved in The Center’s programs, it’s doubtless a small fraction of overall Partners patient population. So despite the general coolness of what they’re trying to do, this is still more on the order of an experiment than a population health management program via remote monitoring.

Still, what Partners is doing is a large step in the right direction, and will doubtless realize some of the long anticipated benefits of remote monitoring for patients who are involved. Good show, folks.

HFMA ANI Las Vegas: That’s a Wrap

Posted on June 28, 2012 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

Though it was only my second time attending the annual HFMA ANI show, I think it’s fast proving to be my favorite when compared to HIMSS – at least when both are held in Las Vegas. The shorter exhibit hall hours; a smaller, more manageable venue; and a general feeling of being less rushed to accomplish every task I set myself was a welcome contrast to the breakneck speed at which we all seem to attend HIMSS.

Though the ANI show had a more laid back vibe, it was by no means any less meaningful to its attendees and exhibitors. Some of the exhibitors I spoke to noted that while booth traffic wasn’t as brisk as they’d have liked, they were having deeper, more meaningful conversations with the folks that did stop by. Others told me that it didn’t seem like many members of the hospital C-suite were in attendance, and decided to send their seconds-in-command instead. (Perhaps they were too busy back home attending to projects related to any of the following healthcare IT acronyms – EMR, HIE, ACO, CPOE, ICD-10, SCOTUS.)

I didn’t get a chance to attend any educational sessions, but from the tweets that I saw, most folks really enjoyed keynotes from Olympian Carl Lewis and renowned pilot Sully Sullenberger. Speaking of tweets, the volume of chatter on Twitter was pretty dismal. There were a few devoted tweets around the #ANI2012 hashtag of course, but for the most part, Twitter (and social media in general) was non-existent.

I walked the show floor Tuesday to see if I could spot any technologies tied into EMRs, and didn’t find much to choose from – at least not as many as I came across last year. I did have some interesting conversations with the folks at Nuance about new solutions being sold under the Dragon Medical umbrella.

Population health management was a phrase I heard (or saw) a number of times, as was predictive analytics and the ubiquitous “Big Data” – all three of which tie together in the world of hospital CFOs. In my mind, it seems that it will be necessary from a financial standpoint for hospitals to get a firm grasp of what “Big Data” means to their organization, and then how to use predictive analytics to derive meaning from that data in their population health management programs, especially if they plan on successfully participating in any sort of coordinated or accountable care program. MedAssets is doing some interesting work around this concept that I hope to learn more about once I get back home and settled.

I’d be interested to hear your thoughts about the show, especially if you were an attendee. How did it compare to last year? Did you think, like me, that many folks were seduced by the lure of the pools at Mandalay Bay to the detriment of folks working the exhibit booths? Gather your thoughts while you peruse a few pictures I took on the show floor:

I stopped by the MedAssets booth to talk population health management with Carol Romashko, Director of Marketing.

AfterHours UR intrigued me with its pleasant logo and hospital utilization review service founded by nurses.

The folks at Executive Health Resources had a catchy come-by gimmick with a caricaturist creating portraits on etch-a-sketches.


EnableComp definitely had kid-friendly schwag. I'm still kicking myself for not going by there during the last hour of the show.

Emdeon's Cash Stacker games seemed to be a big hit on the show floor.

HumanArc knows that creativity really does pay off, at least when it comes to attracting passers by with Lego-inspired logos.

It was interesting to me, being an Atlanta native, to note how many Georgia-based revenue cycle management clients MediRevv has.

My favorite part of the Nuance booth was the tag line "Use it for Good."

Objective Health, formerly known as McKinsey Hospital Institute, had a very inviting booth. It was nice chatting with their CEO, Dr. Russ Richmond.

I didn't see any "whack a mole" type attractions, but this game from PNC definitely grabbed attendees' attention.

I didn't get a chance to stop by the Premier booth, unfortunately, but it was certainly eye-catching.I heard several interesting customer success stories from the Protiviti team, which I hope to cover in greater detail in the near future.

The VisiQuate booth impressed me with its high-tech feel.

It certainly wasn't all work and no play. I enjoyed Dell's evening event at the Shark Reef Aquarium with Stephen Outten, Content Marketing and Social Media Strategist at Dell, and Amanda Woodhead, Manager of Corporate Communications at Emdeon.