applying data - for population health
TRANSCRIPT
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1
Population Health Ask the Experts Town Hall Series
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 2
Applying DataTrigger Early Warnings for Population Health
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.”
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Data Tsunami
Healthcare data is increasing in volume by 48% per year
1
1. IDC Research
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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
Rachel West Exchange
Post-discharge follow up
Rachel follows up with PCP PulmonologistPCP
Referral
Jan 2014
Feb 2014
Mar 2014
CAU ERRachel West
Longitudinal Member Journal
A03
837p
A01/A03
837i
A03
837
837p CCD
834 A03
837
CCD
ORU
ER ER+ IPEnrollment(Exchange) ER
PCP +Referral
278 Req/Rep
NCPDP B1
SpouseParent
Parent
Anthony’s Hypertension management
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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^APT10B^ANYTOWN^AL^35244|| (205)555-1212| (205)681-2000 X999||M||a12345|999999999PD1|||HEALTHCENTRE^^|123456789^DARTH^VADER^A^^^MD^^^^^^^PV1|1|R|||||ANAKIN^SKYWALKER|LEA^SKYWALKER||||||||||||||||||||||||||||||||||||20110221
OBX|1|ST|^^^1010.1^Smoking Cessation^ASTM||Yes|||||||||20110221DG1|1||401.9^HYPERTENSION, NOSDG1|2|I9|786.59|CHEST PAIN|20110106095819-0800|FDG1|3|I9|794.31|ABNORMAL EKG|20110106095819-0800|F
AgeSmoking HistoryIndicative symptom of dyspneaOutpatient
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
InterventionGateway
Establish KPIs / Incentives
Assemble Integrated Patient Records (IPRs)
Set Up Early Warning System
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Next Steps
WatchRecorded webinar
Population Health