Managing population health takes on a new look

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Dr. Belperio

But until the warehouse came along, there was no good way nationally to look at a particular patient population at higher risk for HCV that had not yet been tested. “The CDW provided a way for us to look for the 1945 to 1965 birth cohort, a group recommended by the CDC to have HCV testing, and see who in that cohort had not been tested.” The data warehouse also made it easier to generate a list and automate the letter mailing.

Automated letters are not new, but in the past they were used to notify people of test results or appointments. The difference here lay in contacting a certain group of veterans to say, “You’re at risk for this disease. We need you to come in and get tested for it,” Dr. Belperio says. “We have the tests already ordered. You just need to come into your local lab with this letter, you don’t have to see the provider, and we’ll notify you of the results.”

“That’s really important for the patient, because it’s one less appointment they need to come in for. I’m not aware of other programs that have been so impressive in identifying people who are at a very high risk for a particular disease, notifying them to get tested, having orders in place for the testing to occur, and then notifying them of the results.”

The VA has seen the highest testing rates for HCV in that birth cohort of any large health care system in the U.S. by far, she says. “We’re at about 75 percent of that birth cohort being tested, and nothing that I’ve seen in the literature is over 50 percent.”

But the approach is not limited to HCV. “Any other disease state where there might be a need to reach out to people who are unaware they have the disease, this approach could be used for.” For example, Dr. Belperio is involved in a pre-exposure prophylaxis program for HIV that will administer medication to people who are at a high risk of developing HIV.

Having new medications that sharply improved HCV treatment gave impetus to this population health project. “That was the thing that transformed HCV, because we had these new medications available and we wanted to get as many people in and cured as we could,” Dr. Belperio says. “If there were some new diabetic medication that would be life-changing for patients meeting specific criteria, you could use the [data warehouse] to identify the markers of patients who would gain the greatest benefit from the new treatment. Several transforming medications are on the horizon and expected to be quite life-changing compared to what we’ve had, so we’re expecting that in the future, that will affect the VA’s choice of other population health projects.”

Unlike breast cancer, lung cancer, and cervical cancer, “liver cancer is rising and the main reason is HCV. It’s also the leading cause for liver transplants,” Dr. Schifman says. So he thinks of the VA’s HCV testing notification program as not just a screening program to help prevent and cure HCV and chronic liver disease, but also as a cancer prevention screening program.

Dr. Schifman

“This is one example of where pathologists can get involved with patient care with regard to population health,” Dr. Schifman says. Traditionally, utilization management has focused on reducing unnecessary tests or removing obsolete testing. “But a widely quoted study has shown that it’s more common to omit testing that needs to be done than to over-test. So in terms of outcomes, that’s where we’re trying to go.”

Dr. Schifman cites three areas of laboratory testing where pathologists can contribute to population health approaches. “One is screening high-risk populations. Another is chronic disease monitoring such as HbA1c for patients with diabetes. Those are patients who might fall through the cracks but should be getting monitoring.” High-risk medications present a third area: “This would include patients on oral anticoagulants, or high-risk medications like amiodarone that require thyroid testing because of the risk of side effects.”

One of the strategies is to try to improve awareness of clinicians or help them use decision support techniques that are built into the ordering process, he notes. “So there will be a pop-up, for example, that will remind the clinician it is time for the patient’s HbA1c test because they are in a population that requires screening.” As decision support systems, however, pop-up menus have two problems, Dr. Schifman cautions. “One is that clinicians are being inundated by alerts.”

“The second issue is the doctor doesn’t necessarily get an alert if they’re not interacting with the patient’s medical record. So if there hasn’t been a patient encounter, then there may not be an opportunity to get the alert, order the test, or make a decision about that patient’s screening or monitoring.”

If the pathologist has access to a patient registry, and it could include HCV, oral anticoagulation, or other similar patient populations that require lab monitoring, then that pathologist could use that information to determine whether the testing has been done. “If it has been done, then that’s fine—move on to the next patient. But if it hasn’t been done, then develop some type of intervention in partnership with the patient’s provider to provide easier access to needed testing.”

An approach similar to the VA’s HCV program would involve taking a registry of patients with diabetes, “to remind them in a primary care clinic of their HbA1c screening, so we can check on patients who have not had their testing performed within the specified period.”

The pharmacist is an important partner, says Dr. Schifman. He or she might have the most knowledge about what testing might be needed for specific medications. “And then you can tie that list into your LIS to see if the patients have had their testing done for potential drug side effects.”

The VA is poised to launch a new population health screening that addresses patients’ opioid use. “There’s a lot of attention, particularly in the VA system, to making sure that pain management is optimized, and one part of that program for patients receiving pain medication is that they get periodic urine drug screening to check for compliance,” Dr. Schifman says.

Ensuring that this occurs will require taking a registry of all patients undergoing pain management, checking to see if they’ve had their periodic urine screen performed, and then sending the same type of letter used for HCV screening, to remind the patients and to provide them with a ready-made requisition for the testing. “So population health goes beyond just screening for chronic disease; it includes compliance with health management programs as well.”

Before the birth-cohort HCV screening program was launched, Tucson had slightly below average compliance on HCV screening. “There was an option in the electronic health care system to remind clinicians about patients who needed HCV testing, and our facility had the auto-alert turned off.” This may have played a role in lowering the compliance level.

The current 75 percent compliance with HCV screening throughout the VA is about twice the national average. In September 2016, a VA database study showed that new drug regimens for HCV have resulted in high cure rates among patients within the VA’s national health care system. Among patients with the most common strain of HCV, 93 percent of veterans receiving treatment were cured.

The VA’s HCV program shows how pathologists can add value to health care by making sure patients have the testing they need, Dr. Schifman believes. “In this particular case, we identified that HCV was a problem, and so we went to GI and our medical staff and said, ‘Here’s a solution that will let us increase our screening by identifying this population that needs screening.’ So this was a pathology-driven process.”

Population health will continue to influence health care systems’ approaches to improving patient care, Dr. Donaldson believes, for two reasons. “No. 1, the complexity of the data within an EHR or patient medical record at this point exceeds the intellectual and analytic capacity of any one person. No. 2, applying that data to determine resource allocation is even more difficult. So when you’re trying to make decisions based on complex data that have an impact on people’s lives, and also reflect a wise use of resources, you’re really out of your depth. You need decision support. Getting people to understand these two points is what population health management is all about.”
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Anne Paxton is a writer and attorney in Seattle.