Improving population health outcomes: top tips for care team collaboration

April 20, 2015

When taking on population health management, laboratories and care teams enjoy great opportunities—but face equally great challenges. In many labs, the lack of access to real-time actionable health intelligence can lead to unnecessary lab orders, workflow inefficiencies, and increased operating costs. However, there are ways to advance the quality and coordination of care, increase efficiency, and reduce costs to improve population health outcomes. These include establishing a more complete and comprehensive view of an individual’s medical profile at the point of care by: connecting diverse electronic health record (EHR) systems; identifying and analyzing opportunities for health improvement; managing laboratory results; and engaging individuals and care teams with a more personalized approach.

Connecting diverse EHR systems

As the healthcare industry continues to transition from a fee-for-service to a value-based system, care teams need to evolve to improve the quality and coordination of care—while reducing costs. Improving care team collaboration requires community-wide interoperability and clinical analytics to connect EHR systems across the community for actionable health intelligence. A true 360-degree-view of an individual’s medical profile allows laboratory professionals and care teams to view and share data from across the healthcare continuum in real time. According to, “Incomplete or misplaced test results make efficient, safe, and effective clinical decision-making difficult. Having lab and test results in the patient’s record allows for ease of access and reference when and where it is needed. The availability of structured lab results within the EHR contributes to office efficiencies while also assisting providers in the ability to make real time decisions about the patient’s care.”1

A health information exchange (HIE) platform should enable the bi-directional semantic interoperability between EHR systems to ensure healthcare organizations (HCOs), physicians, lab professionals and care teams can: share real-time clinical information; review compliance with the latest national quality measures and clinical guidelines; ensure patient data security and integrity;  provide value and personalized engagement; and seamlessly integrate within established clinical workflows.

To ensure the exchange of essential health information in real time, a network approach can be leveraged within existing workflows that support cloud-based options and numerous system configurations. This ensures an interoperable environment that allows care teams to more efficiently and effectively coordinate an individual’s care. Through implementing these initiatives, HCOs, laboratories, physicians, and care teams can achieve new interoperable priorities and prepare for the continuously evolving requirements of the future healthcare landscape.

Identifying and analyzing opportunities for health improvement

Population health tools that enable community-wide interoperability, real-time information sharing, and analysis can provide care teams with a single, “full picture” view of an individual’s medical profile by normalizing and clinically corroborating his or her disparate healthcare data. This process can involve identifying drug safety concerns, irreversible procedures and diagnoses, as well as removing implausible and time-decayed diagnoses and duplicate information. In addition, clinical analytics with a robust, evidence-based, clinical rules library can help ensure compliance with the most up-to-date clinical protocols and national quality measures, including: Healthcare Effectiveness Data and Information Set (HEDIS) rules; Meaningful Use (MU) Clinical Quality Measures (CQM); The National Committee for Quality Assurance (NCQA) specifications for medical records; and preventive services screenings.

As a result, care teams can refer to meaningful and actionable insights to avoid adverse drug events and unnecessary tests to improve clinical outcomes and reduce costs, while also ensuring compliance with clinical guidelines and national quality measures. According to an estimate from IMS Institute for Healthcare Informatics, “Healthcare costs caused by improper and unnecessary use of medicines exceeded $200 billion in 2012.”2 Interoperability and clinical analytics can help reduce healthcare costs, while improving the quality and coordination of care by enabling informed decisions at the most teachable moment.

Managing laboratory results and interventions

Measuring and reporting on the success of interventions and laboratory results is an important step toward demonstrating reduced costs and improved clinical outcomes. According to the California Healthcare Foundation, “Laboratory test results are a critically important source of information for medical decision making and an integral data component of EHRs and electronic HIE. Both state and nationally convened groups have recognized that laws governing electronic laboratory results use and exchange must be reviewedand made compatible in order to facilitate the benefits of HIT and HIE.”3

To improve health outcomes, clinical analytics can provide laboratories and care teams with the insights needed to ensure the effective and efficient management of care alert interventions and results. Clinical analytics can help care teams reduce risk and costs by providing a complete view of an entire population, and compare benchmarks against an individual’s health status to best inform care interventions.

Engaging patients and care teams with a personalized approach

According to a Health System Change Research Brief, “people actively engaged in their health are more likely to stay healthy and manage their conditions, follow treatment plans, eat right, exercise, and receive health screenings and immunizations.”4 A personalized approach to healthcare can help improve the overall healthcare experience.

Customizable messaging templates utilized to communicate care alerts to individuals and care teams can help increase the likelihood of an individual’s medication adherence and gap closure. Alert messages can typically be customized by alert type, severity level, audience, format, and language to ensure specific requirements are met and that communication (and ultimately an individual’s care) is addressed and enhanced to optimize their health status.   

By enabling a more personalized approach to care with greater transparency, mobile point-of-care devices can also help strengthen individuals’ relationship with their physician and the overall healthcare experience. According to the Robert Wood Johnson Foundation, “programs that encourage collaboration among patients can help them learn to better manage their own health.”5

Connect, analyze, manage, engage

As laboratories gain access to real-time actionable health intelligence, they can advance the quality and coordination of care, increase efficiency, and reduce costs to improve population health outcomes. Improving care team collaboration and the health status of individuals across a population requires a population health platform capable of connecting diverse EHR systems, analyzing lab data in real-time, managing lab results and interventions, and providing the tools necessary for personalized engagement.


  1. Found at: Accessed March 7, 2015.
  2. Aitken M. and Valkova S., et al. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. IMS Institute for Healthcare Informatics. June 2013. (pg. 1, par. 2). Accessed March 7, 2015.
  3. Purington, K. and Alfreds S., et al. Electronic Release of Clinical Laboratory Results: A Review of State and Federal Policy. California Healthcare Foundation.  (pg. 14, par. 1). Accessed March 7, 2015.
  4. Hibbard J. and Cunningham P., How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter. Center for Studying Health System Change. October 2008. Accessed March 7, 2015.
  5. What We’re Learning: Engaging Patients Improves Health and Health Care. Robert Wood Johnson Foundation Issue Brief Number 3. March 2014 (pg. 2, par. 1). Accessed March 7, 2015.