In this blog series on the six stages to successful population health management, we have explored Acquisition, AggregationAccess and Adoption. This blog post discusses how Analytics allow health care providers to harness the transformative power of data. 

Population data analytics give us the insights we need to transform the way we deliver patient care. They enable us to prioritize at-risk groups of patients, predict outcomes, increase efficiency and coordination in care delivery and get ahead of ever-increasing regulatory requirements. To achieve all the potential benefits, analytics solutions are best established on the high quality, connected infrastructure that we have been discussing in this blog series.

To uncover actionable insights into our population’s health,  the technology infrastructure needs to effectively aggregate, normalize and store data in a central repository that also ensures very high quality privacy and security controls. This data should be compiled as close to real-time as possible so that insights garnered have the greatest value when accessed by care providers.

Organizations should evaluate available data sources  from multiple perspectives before including them in their central repositories. In particular, does the new data source contain comprehensive, high quality data that will contribute to enhanced understanding of the population, calculation of risk levels and point to where there are gaps in current care delivery?

Alberta Embraces the Power of Data

Alberta is home to Orion Health’s largest HIE implementation in North America, known as Netcare. Netcare integrates data from over 120 high quality data sources housed across the province. In fact, it’s frequently used as a best case example to other healthcare organizations across the globe seeking to integrate clinical information systems. Alberta’s Netcare system was created to address the initial situation where siloed clinical information systems sequestered clinical data into disparate systems, including multiple EMRs, documentation, lab and pharmacy systems. The system is used intensively across the province by a large majority of clinicians and providers in Alberta.

Building on the very strong Netcare foundation, Alberta created a seamless bi-directional information exchange with appropriate access to a range of chronic disease management programs for providers interested in improving their care of patients with chronic diseases. The enhanced exchange enables providers to send and receive updates and tasks for their patients on a range of chronic disease management programs.  

Additionally, providers are able to access analytics dashboards that display their panel of patients sorted according to each patient’s level of disease or risk severity.  This approach successfully lowered population risk by enabling the evidence-derived targeting of patients most likely to benefit from interventions, combined with tracking and resolution of gaps in care across the population.

Scottsdale Health Partners Uses Analytics to Improve Quality and Manage Cost

As part of the Obamacare initiatives in the USA, a large number of Accountable Care Organizations  (ACOs) were established, contracted with the Center For Medicare and Medicaid Services (CMS.) The contracts required clinical providers within the ACO to reduce their total spending on health care while demonstrating that quality of care was at least maintained and hopefully improved. The approach to improving quality was first to capture the quality related data which, at the time, was found in multiple data stores across the region, and store it in a central data repository (CDR). Analytics could then be applied to the data to identify (1) Current quality scores for a number of quality measures (2) determine the overall score for the ACO based on CMS determined algorithms (3) identify patients that are subject to gaps in care such as patients who are eligible for flu vaccination but have not had the vaccine (4) navigate from the quality measure to the individual patient record and (5) take action to address the patient’s care gaps.

The system has been in use since January 2016 providing reports on data gathered across the region since January 1st, 2015. The analytic measures will change each year as CMS identifies better quality measures, so it’s important that the software can easily be configured to handle the new quality reports as required. Because it’s reporting on a real time basis, patient gaps in care can be identified as early as possible, enabling the clinical teams to more efficiently and effectively target patients who need specific interventions. By the time the end of the year comes around, quality measures are much higher and the ACO can be very confident not only that it has done a great job throughout the year, but also that it has the data needed to prove the point.