it hasn’t been very helpful. We’ve had Epic in place for 15 years, and we’ve done a lot of work in improving data entry and capture and quality. And so as we start to try to answer questions, we need to figure out how to contextu- alize the data—why do we use certain codes, etc. So we had to learn how to understand the data at a very granu- lar level, why data might be missing, before we can successfully analyze it.” Importantly, Drozda emphasizes, the connections among data collection, data analysis, and continuous clinical performance improvement, are vital to pursue. “So there’s a lot of work involved in coming up with conclu- sions in our analyses. A lot of people in the past have tried to just gather up raw data from EHRs, and it’s not really usable for meaningful analyses. That’s been a major learning for us.” And, he adds, what has become evident is that “We need to be getting patients in to see cardiologists sooner rather than later. It’s been a very worthwhile exer- cise; we still haven’t answered all the questions yet, but we’re raising them.”

The unique landscape of pediat- ric healthcare At Nemours Children’s Health, a mul- tidisciplinary team has been sifting through immense amounts of digital data, and turning it into actionable alerts and prompts for clinicians. As Alex Koster, director of analytics and technology at the VBSO (Value-Based Services Organization) at Nemours explains it, “from an architecture per- spective, Nemours has started to build out HealthyPlanet platform from Epic; we’re on a single instance of Epic. We have the ability to look at data across all our markets for our primary care population: 112,000 patients across Delaware Valley, and 170,000 alto- gether, including Florida. We’re able to look at different data sources—payer files, rosters, gap in care reports, not yet adjudicated claims, but we have the capacity to do that. And we have the capacity to do more advanced analyt- ics, like composite clinical risk scores, to stratify our populations, and for that, we use 3M’s CRG—Clinical Risk Groups.”

And what are the team members learning? “As you look through dif- ferent lenses—for example, when you look at who your high utilizers are for ED services, or readmissions, and then add another filter, such as their clini- cal risk score, you can see opportunity with regard to historical utilization and clinical complexity,” Koster says. “You also find contradictions, where

a patient isn’t clinically complex, but presents with high utilization.” “We have limited resources, and we [can’t] do everything, so we’re leverag- ing our data to identify resources” that can really change patient outcomes, says Jamie Clarke, executive director of the VBSO. And what that translates to, says Lisa Adkins, R.N., senior director of the VBSO’s medical management team, is that “We have care coordina- tors embedded in all the primary care practices: so how can we impact both the high-acuity high utilizers and the low-acuity high utilizers? We’re roll- ing out a medical management care management program where we’re building disease management models. So with the data analytics crew under Alex, we’re able to focus on either the highest-utilizing, sickest kids, who need help with their care as well as social determinants of health (SDOH) issues like housing, language, food insecurity; or middle-level patients where the care coordinators can help pull the patients into the patient-cen- tered medical home; to our lowest-risk kids, who mostly need reminders and health education.”

data, Adkins adds, “The embedded care coordinators

“By using data we are able to assist in forging these connections so care can be connected to the different care providers an individual may see, giving a total picture of the person. We’re looking at provider collaboration and care optimization as key areas where we can focus and make an impact.” -- Antonio Linares, M.D.

their care, to follow up on specialty care appointments, to deal with SDOH issues, to follow up around emergency care and inpatient use, and to share opportunities for telehealth appoint- ments, utilizing our Kids Health on Call—a nursing phone service—to let kids and their families know that we have their backs and they can contact a nurse 24/7. They work very hard with families who have a lot of needs

Leveraging the insights from that really work with

the families to help them coordinate

and don’t have a lot of resources, so they connect them with resources around food insecurity, transportation, even housing and clothing needs. But they’ve focused so much on build- ing registries, with Alex’s group, to help them develop registries. We’ve developed an asthma registry, so we’re able to help families understand their asthma action plan, and that they need to see their PCP at least twice a year, and they may need to see a pulmonolo- gist or someone else,” says Adkins.

Addressing avoidable readmis- sions

Meanwhile, at Advocate Aurora in Illinois and Wisconsin, Tina Esposito, system vice president and chief health information officer, reports that she has been helping to lead a multidisciplinary team that’s been addressing avoidable readmissions, creating a readmissions probability model. “What’s been dif- ferent about it,” Esposito notes, “is that we’ve embedded it into the workflow and into the EHR. And it recalculates a patient’s risk of future readmission throughout the inpatient stay. It’s fed by a number of variables, including lab results, medications, and length of stay.” And, extremely importantly, “The total use of the model has reduced readmissions by 30 percent. And a model is only as good as the consump- tion of it. You need to make sure that it’s relevant to care.” Of course, ultimately, policy and payment concerns are driving all of this work. With overall annual U.S. health- care system expenditures expected to explode from $3.3 trillion a year now to around $6 trillion by 2027, clinical transformation will become a necessity. Moving forward, Blair Childs, senior vice president for public policy at the Charlotte-based Premier Inc., urges provider and health plan leaders to be willing to rethink care delivery. “How do you engage and keep patients? How do you manage your population more proactively and effectively? There are facility strategies, there are clinician strategies, and there are population health strategies.” Data analytics, he agrees, will be an absolutely critical element in moving forward to trans- form the healthcare system overall. Fortunately, the leaders at all of these healthcare organizations—both pro- viders and health plans—are cracking the code, and providing case studies in success in leveraging data and analyt- ics to fuel the transformation of care delivery and care management that needs to happen in the next decade of U.S. healthcare. HI


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