Applying data - for population health
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This presentation, shares methods for using data and risk thresholds for “early” warning and early detection – the keys to effective population management and proactive care coordination.
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Applying data - for population health
- 1. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1 Population Health Ask the Experts Town Hall Series
- 2. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 2 Applying Data Trigger Early Warnings for Population Health
- 3. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 3 Evolution of Population Health “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”
- 4. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 4 Data Tsunami Healthcare data is increasing in volume by 48% per year1 1. IDC Research
- 5. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 5 Demonstration Scenarios Continuously collate and track digital data in a Member Journal Assemble member “digital footprint” Rachel’s life events Rachel visits ER – elevated COPD condition Rachel enrolls in P health plan through FFM RachelWest Exchange Post-discharge follow up Rachel follows up with PCP PulmonologistPCP Referral Jan 2014 Feb 2014 Mar 2014 CAU ERRachelWest Longitudinal Member Journal A03 837p A01/A03 837i A03 837 837p CCD 834 A03 837 CCD ORU ER ER+ IP Enrollment (Exchange) ER PCP + Referral 278 Req/Rep NCPDP B1 Parent Anthony’s Hypertension management
- 6. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 6 Early Warning System Design If Patient AGE > 40 and Patient has SMOKING HISTORY or indicative symptom of DYSPNEA then Patient at-risk for COPD, alert Care-coordinator PID|0|PFX123456789|MRN12345||TEST^WEST^E||19811012||F|100 MAIN ST^APT 10B^ANYTOWN^AL^35244|| (205)555-1212| (205)681-2000 X999||M||a12345|999999999 PD1|||HEALTHCENTRE^^|123456789^DARTH^VADER^A^^^MD^^^^^^^ PV1|1|R|||||ANAKIN^SKYWALKER|LEA^SKYWALKER||||||||||||||||||||||||||||||||||||20110221 OBX|1|ST|^^^1010.1^Smoking Cessation^ASTM||Yes|||||||||20110221 DG1|1||401.9^HYPERTENSION, NOS DG1|2|I9|786.59|CHEST PAIN|20110106095819-0800|F DG1|3|I9|794.31|ABNORMAL EKG|20110106095819-0800|F Age Smoking History Indicative symptom of dyspnea Outpatient Initiate guideline-based interventions for members at risk of COPD within 7 days of detection INGEST INBOUND DATA DEFINE CLINICAL INTERVENTION RULE PARTNERSHIP CARE MANAGEMENT GOAL LINK BITS OF DATA TO CONCEPTS Intervention Gateway Establish KPIs / Incentives Assemble Integrated Patient Records (IPRs) Set Up Early Warning System
- 7. Pathways to Partnerships | Bridging Connections For Value edifecs confidential 7 Next Steps Watch Recorded webinar Population Health Questions? alison.south@edifecs.com
Editor's Notes
- Let’s set the stage by defining what we mean by Population Health Population health was defined by Kindig and Stoddart (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Berwick and colleagues (2008) identify “improving the health of populations” as one element in the Institute for Healthcare Improvement’s (IHI) Triple Aim for improving the U.S. health care system (the other two elements call for improving the individual experience of care and reducing the per capita costs of care for populations). OR The Triple Aim defines 3 inter-dependent aspects of population health - Improving the health of a population - Improving the patients experience of care - Reducing the per capita costs of care for populations Health outcomes are measured for a defined group that is at-risk (based on agreement to metrics and measures of health) How does that translate into practicing, actually implementing Population Health Management Programs at Oschner? What you see her on this slide are the essential components of our Population Health program. If you take the 3 components at the lower left part of the circle, EMR, HIE and Analytics, these are the fundamentals of data access, integration, analysis and reporting that are essential for identifying your chronic conditions and patients at risk, stratifying them into groupings or cohorts that are then tied to interventions and programs, including targeted disease management, education and self-management training. On the upper part of the circle, Expanded PC access and developing a PCMH infrastructure is critical for holistic and team-based patient management, navigation and engagement. Post acute alignment is essential for addressing what happens to patients when they transition from the hospital to other settings. Aligning the post acute stakeholders is one way to prevent unnecessary readmissions. Finally, patient activation and engagement is important. Having implemented and scaled a diabetes population health management program, we know that diabetes self-management is critical for success.
- Big Data is expanding on three fronts: Volume – 48% per year as projected/estimated by IDC Velocity – rate of change is increasing exponentially driven by MU, ACA, consumer-created data, HIEs, etc. Variety – introduction of new data (consumer devices, mhealth apps, telehealth, genomics) 41% of health executives say the volume of data their organization manages has grown more than 50% in the last year alone.
- Demo of Rachael West’s integrated patient record with all encounter and clinical data history. Family view reveals that Rachael is related to Anthony, a hypertension patient.
- Assembles Integrated Patient Record (IPR) by combining: Discrete clinical elements from the Longitudinal Patient Journal, and enhance to normalize vocabulary to reduce duplication across data sources, Risk Scores, Gaps in Care and Care Plan details from health plan systems, and Value-Based Network awareness, healthcare team and contract KPIs Enables transparency within the ACO – single patient view across the care continuum Healthcare Data As a Service (hDaaS): Services-based access to IPR Learn more: www.edifecs.com
- Connect: alison.south@edifecs.com