The Constitution of the World Health Organization (WHO) states, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” There has been some disagreement about this as the definition of health, but there is general acceptance of the core idea that health is more than just the absence of disease. That is, the goal for achieving personal health is not just being healthy; it is the capacity to live everyday life. WHO states in the Health Impact Assessment that the determinants of personal health are subject to a range of intrinsic and extrinsic factors. In fact, the root cause of many health problems exists outside the traditional disease treatment model of healthcare delivery.
For the healthcare sector to move beyond the disease management model and into true population health, it has to exist in the communities where people live their lives, not just in the brick-and-mortar hospitals and clinics. It has to be integrated into other efforts that are driving to deliver the key ingredients for health outside of healthcare. According to Institute for Healthcare Improvement (IHI), healthcare systems of the future have to simultaneously deliver better care to the customer, improve the health of the population, and do it so at a lower cost. Addressing personal health, with all of its varied determinants, is a challenge all by itself. To also improve population health at a lower cost for each individual is an even larger undertaking, one that will require innovative approaches. One such approach is ImagineCare. This customer-focused health service uses a model of knowledge-based intervention to move care from the hospital or clinic into the community. As initially reported at that time, this is a cloud-based solution built on Cortana Analytics Suite and Microsoft Dynamics CRM, the ImagineCare program includes the deployment of remote medical sensors and a round-the-clock, nurse-led clinic. Incoming data from wearable and home sensors, such as Microsoft Band and blood pressure cuffs, is enriched with contextual data in the Cortana Analytics Suite and used by the nurses to deliver personalized care.
All of the data exists in the highly secure and HIPAA-compliant Microsoft Azure cloud with pre-loaded evidence-based care pathways created by a team of experts at Knowledge Map and ImagineCare nurses. Initially this will be used for care delivery and decision support. However, the power of Azure with machine learning and predictive analytics will provide new tools and approaches for achieving population health, beyond the disease management model and better personalized care.
ImagineCare’s richness lies in its combination of technology, clinical expertise, and the human touch to effectively move health toward better outcomes, lower costs, and a great patient experience. The program provides benefits to all involved. For customers, ImagineCare provides a convenient, proactive, and highly coordinated healthcare experience. For nurses, there is the opportunity to work to the full extent of their training, or top of their license, to meet complex health needs in a manner that is in line with the nursing philosophy of holistic care. For clinical teams, the solution delivers proactive data that enhances their care management process, improves performance in accountable care organizations and shared risk type contracts, and helps them do right by their patients.
Justin Montgomery, APRN, Director of Clinical Integration, ImagineCare