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 Orchestrating Value
Population Health in the Digital Age

Pam W. Arlotto, MBA, FHIMSS

Susan P. Irby, MSHS
CRC Press
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Library of Congress Cataloging‑in‑Publication Data

Names: Arlotto, Pam, author. | Irby, Susan P., author.

Title: Orchestrating value : population health in the digital age / Pam W.
Arlotto, Susan P. Irby.
Other titles: Rethinking return on investment.
Description: 2 edition. | Boca Raton, FL : CRC Press, Taylor & Francis
Group, 2020. | Preceded by Rethinking return on investment / Pam
Arlotto, editor ; with Susan Irby, associate editor. c2012. | Includes
bibliographical references and index.
Identifiers: LCCN 2019046127 (print) | LCCN 2019046128 (ebook) | ISBN
9781138367340 (paperback) | ISBN 9781138367913 (hardback) | ISBN
9780429429507 (ebook)
Subjects: MESH: Medical Informatics--economics | Investments--economics |
Health Information Management--economics | Population Health Management
Classification: LCC R858 (print) | LCC R858 (ebook) | NLM W 26.5 | DDC
610.285--dc23
LC record available at https://lccn.loc.gov/2019046127
LC ebook record available at https://lccn.loc.gov/2019046128

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Contents

List of Figures ..................................................................... xi

List of Tables ...................................................................... xv
Foreword ........................................................................... xvii
Preface................................................................................ xxi
Acknowledgments ..........................................................xxiii
About the Authors ........................................................... xxv

SeCtion i SettinG tHe StAGe

A New Cadence of Change ................................................ 1
Bonus Materials ................................................................... 2
Note ..................................................................................... 3
1 Orchestrating Value in the Digital Age ...................5
Purpose ............................................................................... 5
Introduction ......................................................................... 6
Defining Value .................................................................... 8
The Next-Generation Value Management Strategy ...........10
Conclusion ..........................................................................17
Notes...................................................................................17
2 The Journey to High-Value Healthcare:
A Framework .........................................................19
Purpose ..............................................................................19
The Transition from Volume to Value ..............................20
The Journey to High-Value Healthcare—A Framework ....21
1.0: Brick and Mortar Healthcare .............................23
v
vi ◾ Contents

2.0: Transition ............................................................25

3.0: Digital Health and Connected Health ...............30
Conclusion .........................................................................31
Notes ..................................................................................34
3 Digital Health and the Fourth Industrial
Revolution ..............................................................37
Purpose ..............................................................................37
The Coming Tsunami of Change ......................................38
Looking Back to Look Forward.........................................40
The First Industrial Revolution and the Growth of
the Hospital ....................................................................40
The Second Industrial Revolution and the
Industrialization of Healthcare ......................................42
The Third Industrial Revolution and the Electronic
Health Record .................................................................45
The Next Great Revolution—Healthcare Is Primed for
Disruption.......................................................................... 46
Enter Big Tech ................................................................49
Conclusion ..........................................................................50
Notes...................................................................................50

SeCtion ii LeADeRSHiP tHinKinG,

MinDSetS, AnD CULtURe
Change Is Not the Enemy, Rather the Only Path to
the Future ...........................................................................53
Notes...................................................................................55
4 The CEO and the Orchestra Conductor .................57
Purpose ..............................................................................57
The New Role of the CEO .................................................58
Orchestrating Leadership Thinking, Mindsets, and
Culture ................................................................................62
Mission and Future Purpose..............................................63
Change the Vision—Articulate the Value That Change
Will Bring and Invest Accordingly ................................... 64
Change the Leadership—Get the Right People
on the Bus ..........................................................................66
 Contents ◾ vii

Change Planning Methods—Cultivate a Culture of

Experimentation .................................................................67
Conclusion ..........................................................................69
Notes...................................................................................69
5 Healthcare Silos and the Leadership Pivot in
Decision Making ....................................................73
Purpose ..............................................................................73
The Leadership Pivot .........................................................74
The Impact of 1.0 Silos on Decision Making ....................75
Organization Charts and the Silo Mentality ......................76
The Pivot to Next-Generation Decision-Making
Models ................................................................................79
Conclusion ..........................................................................83
Notes.................................................................................. 84
6 Collaborate, Create, and Innovate: Platform
Thinking ................................................................85
Platform Thinking: A New Mental Model .........................85
Role of the Platform Players...............................................91
Platform Innovation and Design Techniques ....................94
Product Management .....................................................94
Design Thinking ............................................................94
Jobs-to-be-Done Framework ........................................ 96
Conclusion ..........................................................................97
Notes.................................................................................. 98

SeCtion iii tHe CARe MAnAGeMent PLAtFoRM

New Platforms, New Services .......................................... 101
Notes.................................................................................104
7 The Care Management Platform, Its Layers
and Hubs .............................................................. 105
Purpose ............................................................................105
Defining the Care Management Platform ........................106
The Hubs That Help Define the CMP ............................. 111
Care Team Hub ............................................................ 111
The Consumer and Patient Hub .................................. 113
viii ◾ Contents

The Hubs Combine to Create the

Next-Generation Platform ............................................ 116
Conclusion ........................................................................ 117
Notes................................................................................. 118
8 The Value of EHRs as Foundational Systems....... 119
Purpose ............................................................................ 119
The Clinical Information System and EHR Journey .......120
EHRs as the Foundation of the Care Management
Platform ............................................................................121
Value of the EHR .............................................................122
Challenges with Today’s Foundational Systems ..............125
The Next-Generation EHR ...............................................128
Conclusion ........................................................................129
Notes.................................................................................130
9 Interoperability and High-Performing
Networks..............................................................131
Purpose ............................................................................ 131
Definition of Interoperability ...........................................132
Interoperability—A Short History ....................................133
Standards for Interoperability ..........................................136
Key Components of the Interoperability Layer of the
CMP ..................................................................................138
Interoperability Challenges ..............................................140
Future of Interoperability ................................................142
Conclusion ........................................................................143
Notes.................................................................................144
10 Knowledge Management and Analytics ............... 147
Purpose ............................................................................ 147
Data and Analytics for Population Health ......................148
The Knowledge Management and Analytics Layer of
the CMP ............................................................................ 153
Challenges and Critical Success Factors .......................... 159
The Future of Analytics in Health and Healthcare ......... 162
Conclusion ........................................................................165
Notes.................................................................................166
 Contents ◾ ix

11 Advanced Care Management ................................ 167

Purpose ............................................................................ 167
Advanced Care Management Concepts and
Framework .......................................................................168
Key Components of the Advanced Care Management
Layer of the CMP ............................................................. 170
The Future of Advanced Care Management ................... 174
Conclusion ........................................................................ 174
Notes................................................................................. 175
12 Consumer and Patient Engagement ..................... 177
Purpose ............................................................................177
Consumer and Patient Engagement—Population
Health’s Missing Piece ...................................................... 178
The Consumer and Patient Engagement Layer
of the CMP .......................................................................181
The Future of Consumer and Patient Engagement.........186
Conclusion ........................................................................186
Notes.................................................................................187

SeCtion iV MAKinG VALUe ACtionABLe

Next Steps ........................................................................189
13 The Population Health Services Organization..... 191
Purpose ............................................................................ 191
The Population Health Services Organization ................ 192
Founded in the Tradition of the Management
Services Organization ......................................................194
A Case for Digital Health—Diabetes .............................. 200
Conclusion ........................................................................204
Notes.................................................................................204
14 Final Thoughts.....................................................207
Purpose ............................................................................207
Mindset Shift Redux .........................................................208
Moving the Needle While the Needle Moves .................208
Notes.................................................................................213

Index .......................................................................... 215

List of Figures

Figure 1.1 The Value Management Maturity Model ............13

Figure 1.2 Next-Generation Management Strategy..............16
Figure 2.1 The journey to high-value healthcare ................22
Figure 2.2 Percentage of ACOs dropping out of MSSP
(end of 2018) .......................................................29
Figure 3.1 Four industrial revolutions ..................................41
Figure 3.2 AI in healthcare.................................................. 48
Figure II.1 Culture is the most significant barrier to
digital effectiveness ............................................55
Figure 4.1 The CEO’s role ....................................................62
Figure 4.2 Value orchestration pillars ..................................63
Figure 4.3 Three PHM strategic scenarios .......................... 64
Figure 5.1 Healthcare silos ...................................................76
Figure 5.2 Hierarchical organization design ....................... 77
Figure 5.3 The network organization ..................................82
Figure 6.1 The innovation ecosystem ................................. 90
Figure 6.2 Platform players...................................................93
Figure 6.3 Design thinking.................................................. 96

xi
xii ◾ List of Figures

Figure III.1 Platform business and operating models .......103

Figure 7.1 The care management platform ......................108
Figure 7.2 The CMP stakeholders..................................... 110
Figure 7.3 JTBD for key CMP stakeholders ..................... 110
Figure 7.4 The care team hub .......................................... 111
Figure 7.5 The consumer and patient hub ....................... 114
Figure 8.1 The next-generation EHR................................129
Figure 9.1 Three types of interoperability .......................132
Figure 9.2 Organizational frameworks for data
exchange ..........................................................134
Figure 10.1 Florence Nightingale’s visualization of
mortality in the Crimean War .........................148
Figure 10.2 Enterprise data management system.............. 150
Figure 10.3 Insight-driven decision-making process ......... 152
Figure 10.4 The pivot from analysis to action ................... 153
Figure 10.5 Data maturity model ....................................... 157
Figure 10.6 Sources of data to support populations ......... 161
Figure 10.7 Expanding volume, sources, and types
of data..............................................................164
Figure 10.8 Continuous intelligence ..................................165
Figure 11.1 The advanced care management cycle ..........169
Figure 12.1 Investment in patient engagement
capabilities .......................................................180
Figure 12.2 Patients who give their providers an “A” .......181
Figure 13.1 Portfolio of people, programs and health
interventions .................................................... 193
Figure 13.2 Population segments and digital health
interventions ...................................................195
 List of Figures ◾ xiii

Figure 13.3 The PHSO operating model ........................... 196

Figure 13.4 The PHSO maturity model ............................. 198
Figure 13.5 The diabetes digital health ecosystem ...........201
Figure 13.6 Diabetic patient with multiple care
management issues .........................................203
Figure 14.1 Mindset shift—The role of technology ...........209
Figure 14.2 Internal ROI versus consumer value .............. 211
List of tables

Table 2.1 Phases of the Journey to High-Value

Healthcare ..............................................................33
Table 5.1 Leadership Pivots in Decision Making .................81
Table 6.1 Project Management versus Product
Management ..........................................................95
Table 7.1 The Care Team Hub Components ...................... 112
Table 7.2 Consumer and Patient Hub Components ........... 115

xv
Foreword

Many of today’s healthcare leaders came up through the ranks

during a time when their career goal was to become a hospital
chief executive officer. Our mentors taught us that the physi­
cian was the primary customer, and success would be gauged
by the number of patients in our hospital beds. Cost was all
but impossible to measure, but certainly controlled by the phy­
sician and his/her pen. Today these views have the potential
to make us quickly irrelevant.
Healthcare leaders must create a sense of urgency and
examine the following questions:

◾ How can we transform our healthcare system in an

increasingly digital world?
◾ Are we able to give ourselves permission to experiment
with new business and operating models?
◾ What is the role of population health within our
organizations?
◾ Do we fully understand what it takes to reinvent the con­
sumer experience?
◾ Are we willing to partner with others who bring some­
thing different to the table?

In Orchestrating Value: Population Health in the Digital Age,

Pam W. Arlotto and Susan P. Irby introduce the challenge of
transitioning from volume to value in a siloed, fragmented,

xvii
xviii ◾ Foreword

facility and provider centric health system. They pervasively

describe the pivot leaders must make to embrace the con­
sumer and to design disruptive business models and operating
platforms. They share cultural lessons learned from healthcare
leaders who have embraced the intersection of the digital age
and population health management.
At Froedtert Health and the Medical College of Wisconsin,
we created Inception Health as our innovation arm to solve
key health care problems, develop new ideas, and scale those
solutions across the health network. We collaborate with
innovators locally and across the country to combine a com­
mitment to “meet people where they are” with digital tech­
nologies to transform healthcare. Our efforts are resulting in
improvements that

◾ Empower people to stay healthy at home.

◾ Increase the reliability of care for the most complex cases.
◾ Engage consumers in understanding and using their per­
sonal health data.
◾ Expand access to mental health services and management
of chronic disease 24/7.
◾ Enhance the health care experience by helping people get
the right care at the right place at the right time.
◾ Reduce the cost and improve the efficiency of care.

Simultaneously, at Froedtert Health we are working to rein­

vent traditional healthcare delivery. Through initiatives such as
our micro-hospital strategy, we are partnering with others to
change traditional cultural views and deploy new care delivery
models. Our efforts at Inception Health and to reposition our
core business have generated important lessons about taking
risks, encouraging entrepreneurial and collaborative mindsets,
and challenging the status quo.
Orchestrating Value questions “business as usual” mindsets
including reliance on traditional revenue models, command
and control organization structures, and legacy information
 Foreword ◾ xix

technology infrastructures. Leaders are encouraged to reimag­

ine health and healthcare through the new combinations of
talent, digital technology, and information. Through multiple
frameworks and examples, Orchestrating Value describes an
evolving healthcare innovation ecosystem that focuses on solv­
ing old problems and creating new value. The book suggests
that the coming digital revolution will touch all that we do,
from the most simple patient encounter to the most complex
clinical intervention.
Last year, as Chairman of the American College of
Healthcare Executives, I had the opportunity to meet with
healthcare leaders across the country and around the world.
Through these conversations, it is clear, our greatest obstacle
is our past success. We must roll up our sleeves, change the
rules of engagement, and adapt innovative approaches. Digital
disruption will occur, either through our own leadership or
from outside the industry. Artificial intelligence, the Internet of
Things, genomics, and other digital platforms have the poten­
tial to change the very nature of work. Leaders across the
healthcare industry should consider their role in orchestrating
value.

David A. Olson, FACHE

Senior Vice President and Chief Strategy Officer
Froedtert Health and the Medical College of Wisconsin
Past Chairman, American College of Healthcare Executives
Preface

This book is about value, not about value realization and

return on investment (ROI) as in our previous books. A casual
conversation at a Healthcare Information and Management
Systems Society conference in 2002 led to a seventeen-year
journey exploring the increasingly complex effort required to
drive ROI from healthcare information technology (HIT). In
those books we focused on the operational change and incre­
mental performance required to manage the value from elec­
tronic health records, enterprise resource planning, revenue
management, and other information systems into reality. Over
the years, we have heard from many information technology,
informatics, operational, financial, and clinical leaders about
the insights gained from applying business principles to the
adoption and deployment of HIT. Yet, something was missing.
The promise of data and technology was not being realized
and many healthcare leaders struggle with the dollars spent,
the difficulty of use, and other challenges such as burn-out,
poor data quality, and lack of interoperability.
In our previous books, change management and culture
were always mentioned, but often as an afterthought. Across
the healthcare industry, information technology implementa­
tions were accompanied by change strategies and road maps.
After interviewing healthcare executives, completing research
on digital transformation across multiple industries, and advis­
ing health systems and solution companies on their journey to

xxi
xxii ◾ Preface

value-based care, our focus has shifted. Much like the lead­
ership pivot we describe in this book, our message became
less about the value of information technology and change
management, and more about building new capabilities and
operating models. We recognize that the fragmented, siloed
delivery system requires reinvention, transformation, and inno­
vation. While data and technology are core to future digital
health and connected care platforms, we must design new
competencies and cultures. Collaboration and partnership are
essential to our future success.
Orchestrating Value: Population Health in the Digital Age
starts a conversation. Based on an orchestra analogy, we dis­
cuss transitioning the industry from brick-and-mortar–based
care to consumer-centric, virtual care. While never intended
to replace all episodic visits or healthcare facilities, we hope
to challenge traditional leadership thinking. Our basic prem­
ise is that progress to population health and value-based care
stalls when tacked on to the traditional healthcare delivery
system as a program or project. To scale, digital strategies and
consumer centered design are needed. Rather than viewing
value as a payer contract for select populations, health system
incumbents, digital health start-ups, Big Tech, and other inno­
vators are partnering to create new value and new consumer
experiences for unique populations. Data and technology,
when combined with collaborative platform-based operating
models, will provide continuous intelligence, predictive and
prescriptive insights, and allow personalized medicine.
We look forward to advancing these conversations further
and receiving your feedback and insights.

Pam Arlotto
Atlanta, Georgia
November 2019
Acknowledgments

This book is dedicated to the many change agents driving

digital health innovation. For most of us, this is personal—
our own interactions with the healthcare system, or those of
a family member or a close friend, make change essential.
Thank you for sharing the vision of a healthcare system trans­
formed through the power of data, technology, and consumer-
centric value. Your hard work is inspirational. Appreciation is
extended to Heidi Davies and Jamie Lovett for their diligence
during the editing process. We are grateful to our family and
friends who have supported us during our careers and the
countless hours we have given to making this book possible.

xxiii