7 Components of Population Health Compilation


One by one, we’ve taken a look at how MEDITECH directly satisfies Bill Spooner’s 7 IT components for population health. Now, we’ve gathered all 7 entries together for a complete breakdown of how we’re helping care organizations to successfully manage their population health initiatives.

1. Patient Registry

Bill Spooner: Population health organizations must have a tool to record and maintain the list of patients under their care. This can be a component of a master patient index, a separate database or a subset of an HIE or data warehouse. Absent a common patient identifier, the tool must possess strong patient record matching capabilities.

MEDITECH: A crucial part of managing populations is grouping patients and managing chronic diseases efficiently, with the goal of providing high quality, low cost care and reducing high cost inpatient and emergency department visits. Our Patient Registries, housed within our Web Ambulatory solution, are worklists that update in real time with information from across the continuum, allowing providers to examine different patient populations (Diabetes, Hypertension, Asthma, Wellness). From the Registry, users can access the patient’s singular health record, make orders, document, send messages to the patient’s portal, and much more.

2. Electronic Health Records System

Bill Spooner: EHRs serve as a key tool for gathering patient health information during encounters with the healthcare system. You need a robust and powerful health record to have patient information on hand to manage population health.

MEDITECH: Our clinically-integrated, single platform system provides clinicians with immediate access to data, evidence-based guidance, and notification features to keep them up-to-date on patients as they move through various care settings. Our solutions span the entire Healthcare Ecosystem (Inpatient, Emergency Department, Ambulatory, Long Term Care, Home Care) under a single problem list, single allergy and medication file, and single analytics engine. MEDITECH provides standard content throughout the system and employs a ‘single query theory’ where information that is captured once seamlessly flows to other care areas, allowing the care team to operate with more efficiency and measure quality.

3. Robust Analytics Capabilities

Bill Spooner: Health organizations must have the capacity to take in, hold and organize vast amounts of clinical information. In addition to containing data, they have the essential information needed to identify how care can be improved. Having the patient information on hand is a start, but a variety of analytics tools are needed. Such applications handle tasks from the esoteric to the mundane, such as compiling information to report outcomes indicators to Medicare and other payers.

MEDITECH: Our Business and Clinical Analytics (BCA) solution is a web-based business intelligence dashboard solution that enables organizations to visualize and use data to drive operational efficiency, maximize financial performance, and improve patient outcomes. As a senior-management driven tool, BCA emphasizes actionable business and clinical performance drivers. Dashboard views feature the ability to explore supporting levels of detail to understand root causes of issues. Users can use a variety of selectors to slice data by different time periods, providers, payers, patient populations, clinical conditions, etc.

4. Health Information Exchange Interface Capabilities

Bill Spooner: Population health management will involve a variety of diverse providers, and they’re likely to store information on different systems. An organization must have an approach to find patient information and merge it to get a total picture of the patient. This can be done through point-to-point interfaces or with a full-blown HIE.

MEDITECH: Providers using the MEDITECH EHR can safely and securely exchange patient information with everyone involved in a patient's care, meaning organizations are empowered to connect across their local HIE exchange, spanning states, regions, and communities. Our EHR can easily exchange CCDs with non-MEDITECH systems, as well as Record Locator Services. We also support Direct Messaging with any HISP for secure communication. Our customers are empowered to contribute data to their community’s centralized HIE, or form their own with our full-fledged HIE solution. Even our physician consultants are leading the way in HIE — and healthcare organizations are taking notice:

“MEDITECH is foundational to the work that we’re doing with Health Information Exchange. That HIE is critical to optimize care and service delivery entirely across the continuum of care, whether it’s for public health services, all the way through to behavioral health, emergency care, trauma care, and acute care services.”
                -Philip Barker, VP of Information Management at Fraser Health

5. Patient Portal

Bill Spooner: Patient portals have received a lot of attention as a requirement for achieving meaningful use of electronic health records. Portals can help bind patients to providers, since under accountable care, they can seek care outside of a provider’s network. Portals can help prove that a provider’s organization is the best game in town. If you make it convenient for them as possible, the portal creates that stickiness.

MEDITECH: We believe empowerment is the key to healthier, more satisfied patients. Patients tend to agree - according to an EMR Impact Study, 82 percent of patients who use patient portals believe they receive better care. That’s why MEDITECH customers can provide patients with the tools they need to take charge of their care with our intuitive, easy-to-use Patient and Consumer Health Portal. 

With the Patient and Consumer Health Portal, patients can access visit history information from across the health system, schedule appointments, request prescription refills, and conveniently communicate with their provider, all on their own terms, from home or any location where they can use a web-enabled device. 

6. Care Management System

Bill Spooner: These systems layer on top of electronic health records systems and help to coordinate care across multiple providers. These applications are crucial to tracking everything that’s happening with a patient and to managing handoffs from one provider to another. A lot of these are coming on the market.

MEDITECH: MEDITECH's Case Manager system empowers case managers to work with patients both in the hospital and post-discharge, ensuring a smooth transition of care and reducing the risk of costly readmissions. Following a discharge, the Case Manager follows up with the patient several times a week to identify any potential risks for readmission in an effort to manage any changes in condition in a lower cost setting. 

Patients can also be sent home with a mobile kit, such as a bluetooth-enabled scale and a bluetooth-enabled blood pressure cuff for CHF Patients. When the patient records a measurement, an app on the patient's phone is automatically updated, and through an interface with Validic, this information flows through the MEDITECH system to the Case Manager, allowing case managers to quickly identify changes in condition and potential risks for readmissions.

7. Revenue Cycle Solutions

Bill Spooner: While healthcare organizations have used revenue cycle applications for years, they’ll need systems that can handle more complexity, particularly in managing bundled payments, reconciliations, and write-offs.

MEDITECH: Our solutions automate the Revenue Cycle Management process, ensuring that the appropriate information is captured on the front end, copays and deductibles are collected at the point of service, charges are automatically captured, claims are accurate upon submission, and collection streams are automated. And it’s all part of the bigger billing picture. 

“MEDITECH’s RCM is designed to be centered around the patient/consumer — and the provider,” says Melissa Swanfeldt, MEDITECH AVP. “Today, we still see different entities with varied contracts and regulatory requirements that drive billing. We centralize all of the processing for those different entities by providing one statement and one worklist for billers and coders that crosses the continuum. As healthcare moves away from fee for service and into value-based reimbursement, this is the foundation our customers need.”


Looking to learn even more about how MEDITECH is making population health a reality? Click here.