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The 12-Criteria of Population Health Management By Dale Sanders. Contact Information. Dale Sanders, Senior VP, Strategy, Health Catalyst @ drsanders Carrie Ivers , The Advisory Board, Crimson Product Line

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The 12-Criteria of Population Health Management By Dale Sanders

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contact information
Contact Information
  • Dale Sanders, Senior VP, Strategy, Health Catalyst
  • @drsanders
  • Carrie Ivers, The Advisory Board, Crimson Product Line
  • 512-681-2383
  • Dale Sanders: 35 minutes
    • Description of the 12 Criteria for Population Health Data Management
  • Carrie Ivers: 25 minutes
    • Description of Crimson’s capabilities and strategy related to the 12 Criteria
  • Q&A
    • We will stay online as long as it takes to answer all the questions
the supporting white paper
The Supporting White Paper
  • Google: “12-Point Review of Population Health Management Companies”
  • Evaluate healthcare IT vendors and their PHM offerings
  • Develop internal strategies and roadmaps for Accountable Care Organizations (ACO)
  • Not the processes of PHM, per se
  • Not on activity based costing and fixed-price (bundled pricing) contract management– that’s a separate webinar
poll question
Poll Question
  • On a scale of 1-5 where do you feel your organization is in its Population Health maturity?
  • 5 – Very high maturity
  • 4
  • 3
  • 2
  • 1 – Little or no maturity
today s key takeaways
Today’s Key Takeaways
  • The ROI of Population Health Management (PHM) is still in debate
    • Investment is costly, returns are challenging
    • 40% of healthcare is patient lifestyle related
    • Focus on the highest ROI areas of PHM for now
  • Stratifying population risk makes no sense without a strategy for intervention
    • And focusing on the highest risk patients might have the lowest ROI
  • No single vendor meets all PHM needs
    • You’ll need a patchwork of solutions to fill the gaps
    • “So you offer PHM, eh? OK, which parts?”
true population health management
True Population HealthManagement

Requires a collaborative strategy between leaders in healthcare, politics, charity, education, and business

Robert Wood Johnson Foundation, 2014

population health management
Population Health Management

The Ordered Checklist for Your 3-5 Year Journey

  • Registries: Evidence-based definitions of patients to include in the PHM registries
  • Attribution & Assignment: Clinician-patient attribution algorithms
  • 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
  • Clinical & Cost Metrics: Monitoring clinical effectiveness and total cost of care (to the system and the patient)
  • Basic Protocols: Evidence based triage and clinical protocols for single disease states
  • Risk Outreach:Stratified work queues that feed care management teams and processes for outreach to patients
  • External Data: Access to test results and medication compliance data outside the core healthcare delivery organization
  • Communication: Patient engagement and communication system about their care, including coordination of benefits
  • Education: Patient education material and a distribution system, tailored to their status and protocol
  • Complex Protocols: Evidence based triage and clinical protocols for comorbid patients
  • Coordination: Inter-physician/clinician communication system about overlapping patients
  • Outcomes: Patient reported outcomes measurement system, tailored to their status and protocol
precise patient registries
Precise Patient Registries
  • Evidence-based definitions of patients to include in population health registries
  • 1

Must go beyond ICD codes, which are likely to miss 30-40% of the population

patient provider attribution
Patient-Provider Attribution
  • Strategies and algorithms to assign patients to accountable physicians or clinicians
  • 2

Generally accepted options for assigning attribution

precise numerators in registries
Precise Numerators in Registries
  • Discrete, evidence-based methods for flagging the patients in the registries that are difficult to manage or should be excluded from PHM, altogether
  • 3
clinical and cost metrics
Clinical and Cost Metrics
  • Monitoring clinical effectiveness and cost of care to the system and patient
  • 4
basic clinical practice guidelines
Basic Clinical Practice Guidelines
  • Evidence-based triage and clinical protocols for single disease states
  • 5

( )

( )

High Opportunity =

Number of patients

In the population

The Average Total Medical

Expenditure (TME) per Capita


risk management outreach
Risk Management Outreach
  • Stratified work queues that feed care management teams and processes
  • 6

Risk stratification enables an organization to analyze and minimize the progression of a disease and the development of comorbidities

be careful what you ask for
Be Careful What You Ask For


Patients with the highest satisfaction scores =>

Higher rate of hospital admissions

Prescribed more medications

Unpublished, internal data analysis; Northwestern University Medicine Enterprise Data Warehouse, 2008

We were not the first or only organization to see this trend

strategies for phm intervention
Strategies for PHM Intervention
  • Disease management — Example: Diabetes management programs
  • Catastrophic care management — Example: Programs to reduce risk for individuals with a high risk of developing conditions that lead to catastrophic healthcare costs (e.g., cancer, brain injury)
  • Demand management — Example: Nurse call lines
  • Disability management — Example: Employer-sponsored programs to reduce disability days and costs
  • Lifestyle management — Example: Seat belt compliance campaigns, smoking cessation programs, weight management programs
  • Integrated care management — Example: Programs that integrate other types of interventions (e.g., catastrophic care management,disease management and demand management for cancer patients) with shared outcomes and monitoring over time

From Becker’s Hospital Review. Connie Evashwick and Ann Scheck McAlearney, at the American College of Healthcare Executives' 57th Congress on Healthcare Leadership.

caution of paradox
Caution of Paradox
  • “…population strategies which focus on reducing the risk of those already at low or moderate risk will often be more effective than strategies which focus on high risk individuals at improving population health in the long run.”

Gordon Norman

Chief Medical Officer, xG Health Solutions

Recommended reading: Geoffrey Rose, “Sick Individuals and Sick Populations”, International Journal of Epidemiology 1985;14:32–38.

acquiring external data
Acquiring External Data
  • Access to clinical encounter data, cost data, laboratory test results, and pharmacy data outside the core healthcare delivery organization
  • 7

Contrary to current national strategy and focus, acquiring external data should be a secondary focus in today’s market

communication with patients
Communication with Patients
  • Engaging patients and establishing a communication system about their care
  • 8

Current solutions are fragmented and immature but will improve dramatically in the next 3 years

educating and engaging patients
Educating and Engaging Patients
  • Patient education material and distribution system, tailored to the patient’s status and protocol
  • 9

Our current patient education system is hampered by the lack of highly personalized materials and an effective distribution system

  • 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
aco vs acp accountable care patient
ACO vs. ACP: Accountable Care Patient

From Eric Topol’s Twitter feed, @EricTopol


Obesity Rates by Occupation

American Journal of Preventive Medicine

Volume 46, Issue 3 , Pages 237-248, March 2014

Graph from The Atlantic, March, 2014

complex clinical practice guidelines
Complex Clinical Practice Guidelines
  • Evidence-based triage and clinical protocols for comorbid patients
  • 10

Establishing protocols for comorbid patients is complicated

care team coordination
Care Team Coordination
  • Inter-clinician communication and project coordination
  • 11

We need to treat every patient as if they are at the center of a project plan

tracking specific outcomes
Tracking Specific Outcomes
  • Patient-reported outcomes measurement system, tailored to the patient’s status and protocol
  • 12

Patient-reported outcomes data is one of the most important pieces of data missing from our ecosystem today

vendor evaluation and scoring
Vendor Evaluation and Scoring

No single vendor today offers an integrated and fully functional population health management solution that meets all 12 criteria

How did I come up with these scores?

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

vendor evaluation and scoring1
Vendor Evaluation and Scoring

First tier evaluation scores

vendor evaluation and scoring2
Vendor Evaluation and Scoring

Second tier evaluation scores

asset allocation and timing
Asset Allocation and Timing

Recommended asset allocation as the market and organization evolve and mature in population health management

asset allocation and timing1
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
poll question1
Poll question
  • Who do you think will be the most capable to meet the data management requirements of Population Health Management?
  • EMR vendors
  • Analytic Specialists
  • A combination of both
  • 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
  • NQF has a new PHM initiative… keep an eye on that
  • 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
other population health resources
Other Population Health Resources

Click to read additional information at

  • The Evolution of Care Management to Population Health Management
  • This covers the evolution of the care management market to the population health management, the data needs for effective population health management, and population health business models
  • Why the Solution to Population Health Management Woes Isn’t an EMR
  • Healthcare systems are struggling to figure out how to shift to a value-based model and remain competitive. This will require hospitals to identify and reduce waste in three categories: the variation in 1) the care that is ordered, 2) how efficiently that care is delivered, 3) in care delivery that causes preventable complications .Clearly, EHRs aren’t the answer.
  • The Best Way to Prioritize Your Population Health Management Efforts
  • Effective population health management starts with clearly defining a subset or cohort of patients and determining on which clinical processes to focus improvement efforts. The Health Catalyst Key Process Analysis (KPA) application determines the highest variation and highest resource consumption by integrating and analyzing clinical and financial data.
other population health resources1
Other Population Health Resources

Click to read additional information at

  • Case Study: Using Data and Reporting in Population Health Efforts
  • How a healthcare system went from manually pulling together reports with varying data to having near real-time data that one executive says, "enables our care coordinators to drive preventive care and ultimately lower our population health costs"
  • Case Study: Using Advanced Analytics to Manage Primary Care Population Health Population health management is largely being driven by the 5 percent of the population accounts for 50 percent of healthcare costs. Being able to identify these patients, provide high-quality care and reduce their utilization is a pressing goal for many of today’s primary care providers (PCPs). Learn how one organization used health care analytics to meet this challenge.
  • Implementing a Successful Population Health Management Strategy
  • A White Paper by Dr. David Burton
  • Based on 25 years of experience, first as a senior executive at Intermountain Healthcare and later as the Chairman of the Board of Health Catalyst, Dr. Burton shares his in-depth learnings about how to systematically implement population health management in a long-term, sustainable way.
In Pursuit of Value

Combining Precise Population Risk Analytics with Robust Care Management Support

CrimsonPopulation Health

transition to value based care
The Advisory Board Helps YouTransition to Value-Based Care
  • Build the Provider Network
    • Achieve clinical integration
    • Deliver targeted outreach to high-value physicians
    • Reduce referral leakage
  • Optimize Network Performance
    • Engage physicians in performance improvement
    • Reduce cost and care variation
    • Improve quality


accountable care projects across 45 states


Clinical Integration programs developed

Crimson Population Health

Analytics and workflow technology enabling health systems to manage the clinical and financial outcomes of defined populations.


lives in population health benchmark database


  • Manage Financial Outcomes
    • Develop strategy for payment transformation
    • Negotiate risk-based contracts
    • Manage contract performance
  • Transform Care Delivery
    • Prioritize at-risk patients
    • Surface care gaps and intervene
    • Coordinate care across the continuum

Consulting &

Talent Development


NCQA PCMH recognition for 50+ members


the business case for change
Diverse Motivations for Population Health

Source: Health Care Advisory Board interviews and analysis.

The Business Case for Change

Strategic Benefits of Transformation

Clinical Advantage

Financial Advantage

Market Advantage

Align financial incentives with mission

Move away from faltering fee-for-service economics

Attract market share of lives

Support investments in better health

Capture greater share of premium dollar

Secure attractive purchaser contracts

two plausible transition paths
Enabling Financial Success from Population Health Management

Source: Health Care Advisory Board interviews and analysis.

Two Plausible Transition Paths

Migrating to a Value-Based Business Model

  • Leading with Care Transformation
  • Invest quickly
  • Prove concept
  • Obtain value-based payment

Care Transformation

  • Leading with Value-Based Contracts
  • Meet payer demands for risk
  • Secure share
  • Adapt care model

Payment Transformation

extremely challenging to execute successfully
Four Critical Success Factors, Many Hurdles Along the WayExtremely Challenging to Execute Successfully
  • Achieve Data Transparency to Manage Utilization
  • Hard to arm physicians with information due to limited transparency provided by payers
  • Difficult to link and reconcile disparate data sets using data warehouse solutions
  • Internal clinical and financial systems constrains visibility to utilization inside organization
  • Focus Interventions on Highest Prioritized Opportunities
  • Lack of integration between analytical and workflow tools prevents effective execution
  • Difficult to quickly identify and engage the appropriate resources for each intervention
  • Limited ability to bring together timely clinical and financial risk data for clinicians at the point of care







  • Measure Impact of Interventions and Continuously Improve
  • Difficulty linking cost and utilization data hinders ability to track and trend PMPM costs
  • Data complexity prevents routine analyses with frequency required for course correction and continuous improvement
  • Difficulty connecting productivity of care managers to outcomes and return on investment
  • Prioritize Patients at Highest
  • Risk of Poor Cost and Quality Outcomes
  • Predictive analytics required to forecast outcomes with accuracy not a core competency of EMR, financial system vendors, or providers
  • Lack of robust benchmarks prevents identification of actionable opportunities based upon gap to benchmark
  • Limited visibility into psycho social factors
managing three distinct populations essential to profitability
Third-Party Information Valuable But Should Not be Sole Determinant in Segmentation StrategyManaging Three Distinct Populations Essential to Profitability


5%; complex

Financial Analysis Indicates Necessity of Managing Rising-Risk Patients


Low-Risk Patients

60-80%; any conditions minor, easily managed

5 Year Margin Projection by Risk Management Level


Rising-Risk Patients

15-35%; may have conditions not under control

Managing high-risk only

Managing high-risk and rising-risk patients




Source: Health Care Advisory Board interviews and analysis.

hardwiring a critical feedback loop
The Crimson Population Health Solution

New Insights Achieved by Marrying Clinical Data with Total Cost and Utilization

Hardwiring a Critical Feedback Loop

PopulationRisk Management

+ Care Management Workflow + Care Gap Analysis

Functionalities Achieved

through Platform Integration

  • Who are my highest-risk patients?
  • Which diagnoses are contributing most to avoidable utilization?

Prioritize Population-level Improvement Opportunities

Linking clinical values with claims data

Enables multivariate analysis of utilization, claims and clinical values for superior population health management

  • Are these patients receiving recommended care?
  • What interventions would decrease avoidable utilization?
  • Did these interventions reduce avoidable utilization?
  • Were our medical homes successful in decreasing PMPM costs?

Population analytics at the point of care

Integrates population-level risk analytics with point-of-care clinical workflow tools, enabling prioritization of high-risk patients for targeted interventions

Proactively Manage Individual Patient Health

Evaluate Effectiveness of Interventions

tailored data acquisition approach
Tailored Data Acquisition Approach

Population Risk Management

Network Management



Real-Time Risk Identification

insights to


  • Medical home support
  • Patient compliance tracking
  • Patient outreach and engagement
  • Instant patient risk assessment
  • Inpatient and ambulatory clinical risk surveillance
  • Intervention impact tracking
  • Risk-based contract performance management
  • Avoidable utilization identification
  • Population risk stratification
  • Physician relationship analytics
  • Network leakage analytics
  • Cross-continuum physician performance management
  • Risk contract modeling
  • Population utilization benchmarking
  • Predictive risk algorithms
  • Severity-adjusted physician performance benchmarks
  • Charge normalization
  • Total market referral analysis
  • Multi-source evidence-based care guidelines
  • Point-of-care workflow tools
  • Customizable measure sets
  • Real-time clinical predictive analytics
  • Natural language processing
  • Automated chart review


Data analytics

Advisory board company data extract

Hospital Data Warehouse




Accounting System


Clinical System

Practice Management



Clinical System


Claims Processor


Lab System

common data approaches failing to deliver a complete solution
Common Data Approaches Failing to Deliver a Complete Solution



Hallmarks of a Best-Practice Population Health Management Solution







  • Cross-continuum data
  • Total market data
  • All payer data
  • Clinical and financial data
  • Clinical and financial predictive analytics
  • Customizable performance benchmarks
  • Continuous measurement
  • Analytics embedded in point-of-care work routines
  • Designed to engage providers
  • Accessible across care sites
data driven insights enable proactive and comprehensive care
The Crimson AdvantageData-Driven Insights Enable Proactive and Comprehensive Care

Analytics Fueled by

Research and Insight

Consolidated Data

From Multiple Sources

Unparalleled Care

Transformation Support

Manage Total Cost and

Quality of Key Populations

Identify areas of inappropriate utilization, low compliance to manage network performance

Risk stratification algorithms to identify high priority patients requiring timely intervention

Measure, manage interventions

  • Payer and Employer Data
  • Medical Claims
  • Prescription Drug Claims
  • Eligibility Files
  • HRA and Biometric Data
  • 25+ years of experience researching best practices and identifying areas of opportunity for providers
  • Provider-centric user interface
  • Consolidated view of financial and , clinical performance; robust and customizable benchmarks
  • Extensive cohort services

Improve Individual Patient Health

Address all levels of patient risk through automated alerts, triggers and care plan development

Standardize care manager activities regardless of payer contract or care model to improve overall patient outcomes

Increase patient panel size through robust prioritization and automated assignment of tasks across entire care team

  • Hospital Data
  • ADT messages
  • Physician Practice Data
  • Office-Based PMIS
  • CPT2 Codes
  • Office-based EMR
  • Lab Systems
  • E-Prescribing Systems
  • Direct Entry
  • Leading provider of utilization / cost benchmarks and actuarial analytics to the health care industry
  • Benchmarks customizable by geography, plan design, demographics; powered by a database of 45M lives, 2.5B claims
  • Proprietary clinical and financial modeling tools

Hardwire Physician Intervention

Point-of-care workflow tools to maximize efficiency, effectiveness of patient encounters

Proactively identify care gaps using multi-source guidelines, customizable rules engine





Lives in utilization benchmark database

Potential savings across 1,000 lives

Evidence-based care guidelines and prompts

Lives contracted for care management

providing extensive support to ensure member success
Beyond the Technology

Unparalleled Services and Resources for Crimson Members

Providing Extensive Support to Ensure Member Success

Additional Services for Crimson Members

Hands-On Support

Dedicated Advisors

Serve as educator, analyst and counsel identifying care variation, advising on goals and tactics to drive results.

Business Analysts

Dedicated technical talent who works closely with IT staff, testing data files and formats to ensure seamless site launch and maintenance.

Crimson Executive Partners

Our most respected executive talent will partner with your leadership team to ensure that our support continually serves your organizational strategy. The EPs bring clinical training, consulting experience, and proven industry depth.

  • CXO Affinity Groups
  • Leaders from across The Advisory Board gather with members in our offices or via webinar to problem-solve addressing market and regulatory forces and overcoming implementation challenges as providers migrate toward accountable care.
  • Patient-Centered Medical Homes
  • Bundled Payments
  • Shared Savings
  • Clinical Integration

Progressive Peer Network

Annual Performance Summit

Seminal event gathers the entire Crimson cohort to celebrate achievements, share best practices, and highlight successful member case studies.

National Webinars

Educational intensives focused on current research topics or member case studies including live discussion with Crimson experts and peers.

Clinical Consultants and Coaches

Our Medical Directors and Nurse coaches provide insight on how best to improve clinical workflow and leverage data transparency across the collaborative care team

Clinical Advantage Product Advisory Council

Participation throughout the year in exclusive meetings with Crimson leaders of product management. These sessions provide an opportunity to preview planned enhancements ahead of Crimson peers, as well as contribute to the near-term product roadmap, and next-generation product capabilities.

30+ Years of Best-Practice Research

  • The industry leader for health systems in search of research and insights on the implications of value-based payments and accountable care. Current library includes:
  • Medicare Shared Savings Program Rulebook
  • Succeeding Under Bundled Payments
  • Playbook for Clinical Integration - Building the Performance-Focused Physician Network
  • Blue Print for the Medical Home

Program Managers

Our proven project managers serve as a single point of contact managing your technical deployment and ensuring continual implementation progress.

a proven record supporting population health management
A Proven Record Supporting Population Health Management

Depth and Breadth of Expertise

A Sampling of Population Health Management Partners

  • About Memorial Hermann Physician Network:
  • Clinically integrated network of Memorial Hermann, a 9 hospital system in Houston, Texas
  • Over 2000+ physicians and 850 independent practices
  • At risk for 60K employee, commercial, Medicare lives


At-risk populations supported

by Crimson

Number of lives managed

using Crimson

Lives in population health benchmarking database

Cost and quality profiles for

over 500K physicians

Payers sending data to Crimson

Payer types supported: Medicare, Medicaid, Medicare Advantage, Commercial, Self-Insured


Medicare Shared Savings Participants


About MissionPoint Health Partners:

  • Clinically integrated network of St. Thomas Health of Acension Health in Nashville, Tennessee
  • Four major hospitals, over 100 outpatient locations and 1200 physicians participating in network
  • At risk for 40K Medicare and local employer lives



5 of 5

About Covenant Health Partners:

  • Clinical integration program of Covenant Health System in Lubbock, Texas
  • Network of 150 employed. 150 independent physicians
  • Hospital Efficiency Contract for 30K admissions to Covenant Health System, fully at risk for 9K+ lives

Groundbreaking Technology Capabilities and Assets

  • Cross-continuum analytics that provide insight into opportunities for improvement by physician, patient and population
  • Risk stratification algorithms with proven predictive superiority
  • Seamless link between population-level analytics and care management work flow to support direct management of high-risk patients
  • Exclusive access to Milliman MedInsight’s customizable benchmarking database of over 2.5B claims and 45M lives
  • Evidence-based guidelines and measures proactively identify gaps in care to facilitate physician and care team workflow
  • Supports tracking for all 33 Medicare ACO metrics and Group Practice Reporting Option submission for identified patients
  • Continuous innovation: member-driven changes , 10 new technology releases per year

For Additional Information, Infographics and Research visit the following link:

You can also email

thank you
Thank You

Next Educational Webinar

  • The Path to Shared Savings With Population Health Management Applications
  • Laser Focused on Finding Waste, Defining and Monitoring Populations, Accountable Care Organizations and Health Systems Alike Will Learn About The Success of One System Who Reduced Heart Failure ReadmissionsDate: Wednesday, April 9th
  • Time: 1:00-2:00 PM ET
  • Presenter: Eric Just, VP, Technology; Kathleen Merkley, VP, Clinical Engagement
  • By Failing to Prepare, You Are Preparing to Fail
  • Laying the Foundation for Sustainable Change and SuccessDate: Wednesday, April 16th
  • Time: 1:00-2:00 PM ET
  • Presenter: John Haughom, MD, Senior Advisor, Health Catalyst
  • Register at