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Today on Insights. We go back to a conversation Host Bill Russell had with Dr. Jamie Reedy, Chief of Population Health for Summit Health. The topic of discussion was Foundational Data Capabilities Needed In The Infrastructure of Healthcare. It’s important to move beyond the limited clinical data in EHRs. And to develop enhanced and predictive analytics. How do you even begin to lay a foundation that will allow staff to use data to drive powerful efficient workflows? 


Hello and welcome to another episode of Insights. My name is Bill Russell. I'm a former CIO for a 16 hospital system ???? and creator of This Weekin Health IT. A channel dedicated to keeping health IT staff current and engaged. Our hope is that these episodes serve as a resource for the advancement of your career and the continued success of your team. Now onto the ???? show.

Today on insights. We go back to a conversation host Bill Russell had with Dr. Jamie Reedy, Chief of Population Health for Summit Health. The topic of discussion was foundational data capabilities needed in the infrastructure of healthcare. It's important to move beyond the limited clinical data in EHRs and to develop enhanced and predictive analytics. But how do you even begin to lay a foundation that will allow staff to use data to drive powerful, efficient workflows?

Let's talk about the information infrastructure a little bit. What's the foundation of the ACO analytics?

Sure. So I can take that one. So in order to be successful in an ACO or any value-based program, we've learned that you need to have access to lots of data and you need to make that data work for you.

As we set out to assess a couple of years ago, our analytics options and potential vendor partners. We quickly learned that we needed to seek certain foundational capabilities. First, we needed to create an expansive dataset as our foundation, which allowed for integration of many disparate data sets. As we took on all these new BBC contracts and new populations. We wanted to move beyond the limited clinical data that was in our EHR and incorporate medical and pharmacy claims data from our health plan partners, as well as clinical alerts of encounters that were incurring outside of our four walls by adding in ADT notifications. Secondly we wanted really our workflows in the clinics to be data driven So we prioritized the use cases where we wanted data to drive workflows. For example, active management of patient attribution is critical for success and accountable care. And this includes knowing who your patients are, where they are, how sick they are and what services they need to achieve optimal outcomes. So as we invested in FTEs to support coding and quality and overall patient management, we were focused on ensuring that those staff were using the data to drive their daily workflows in those areas. And the third foundation was we really wanted our analytics teams to have direct access, to normalize sets, allowing them to calculate performance on all critical components of value-based care success.

And develop enhanced and predictive analytics that would grow in sophistication and impactability as our care teams were growing in their ability to use the data, to inform their workflows. And we also needed our analytics teams to generate scorecards from these data sets that our providers and care teams could use to know that their workflows were making a difference in improving health outcomes.

So those are a few of the foundational capabilities that we felt were really needed, where we needed data to support.

That's fascinating. So you have foundational dataset, you have workflow support, and then you have enhanced analytics is the foundation. So, talk to me about where the data comes from. We heard some of it's coming from the EHR. Some of it's coming from claims. Are there other sources of the data?

There are. Data can come from many sources across the healthcare ecosystem. As we explored our foundational analytics needs and as we've become more sophisticated in our ability to use data, we've learned so much about the various available data sources and we continue to explore additional sources that we plan to integrate.

In the early days, we integrated all the common data sources, such as health plan eligibility and health plan claims data, the clinical EHR data and practice management data. Data from our core facility partners. So hospital admission and discharges and various reference files that were very unique to our value based care contracts But there are other data sources that facilitate connectivity to an extended network of data that's highly valuable for patient care. For instance, as we progress deeper into our risk journey, adding data related to risk adjustment, and coding gaps became critical. And in this age of virtual care, telehealth and remote physiologic monitoring data is critical for coordinated and comprehensive patient care.

And now there are more and more sources of socio-demographic data as well that help us understand the potential social needs of our patients, which are incredibly important influencers of health outcomes. So that the data sources we integrate are really driven by our business needs and prioritized by considering technical challenges for accessing the data. With each of these data sources there's just constant trade-offs between getting the most or the best data and leveraging what's easily available and easy to integrate, to match to our current data sources. So we really can create that full clinical picture for each of our patients.

On the show, we've talked about a whole patient profile. Building a whole patient profile, and it sounds like you guys are getting pretty, pretty close to that.

Can you, can you touch on the social determinants data real quick. Where are we getting that? Are we getting that from surveys and that kind of thing? Are we actually connecting into I don't know, some partners who are bringing that data into us?

Sure. So we've just begun our journey to figure out the best way to collect that data directly from our patients. And we've started to do it through sort of preregistration processes and we'll eventually use our newly launched patient app to do some of that We're also working on selecting a social needs vendor who will be able to help us with social needs referrals into the community and the whole closed loop referral process, which will include a full social needs assessment template that patients can complete.

But in the meantime, our analytics vendor has incorporated into their platform a census track data. And the US census data that it's collected actually annually, I believe it's called the American community survey is integrated right into our platform. And so that data at the zip code level helps to inform some of the risk stratification of our patients within our analytics work.

Talk a little bit about the value and the role of the claims data.

Absolutely. In our experience, obtaining medical and pharmacy claims data from all of our health plan partners has been really critical for mutual success, managing financial risk in an ACO or in any sort of incentive arrangement requires insights about patients, patterns of care and utilization outside of our own organization.

And so complete claims data provide us that full visibility. In the early days of our value based care journey, our health plans were actually reluctant to provide this level of data, but we're finding now that most health plans are open to providing the data limited only by regulatory and privacy concerns.

When we first started working with our health plans to receive claims data, we found ourselves in a position of having to explain and justify what we would do with the data to find actionable insights and then implement work. So for instance, we explained to them how we use pharmacy claims data to calculate our providers, generic prescribing rates at a therapeutic category level, and then hold the providers accountable in our incentive program to using cost-effective generic alternatives.

We also use claims data to assess where our patients receive care such as ambulatory procedures and infusions. And this data allows us to better educate our physicians about the cost differentials between different sites of care and allows us to develop patient facing message about the value of outpatient non-hospital sites of care in order to avoid the claims data gaps, or lags and receipt.

We have developed standard data provision language that we include in our value-based care contracts That outlines our expectations upfront. And if the health plan does not provide the data that we need to manage risk, then there are consequences for the overall contract reconciliation because this data is so incredibly important to mutual success.

Wow, thanks for tuning in another great episode. If you have feedback for us regarding this content and materials, or if you would like to help us to amplify great thinking to propel healthcare forward, which is our ???? mission, please send us a note at [email protected] Thanks for listening. That's all for now. ????

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