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June 20, 2016 Readers Write 2 Comments

Mapping Out a Big-Picture Strategy to Drive Smarter Healthcare Decisions
By Nancy Ham


Analytics are like a GPS navigation system for healthcare. With a full view of your route, they give you step-by-step directions for exactly where you need to go. By aggregating data from electronic medical records (EMRs), claims, health risk assessments, admission / discharge / transfer (ADT) systems, and other sources, analytics can create 360-degree views of individual patients and entire populations. This holistic approach drives smarter decisions and better outcomes.

When providers can see which patients are not following treatment guidelines, visiting out-of-network specialists, or are at risk for readmission, they can deliver more impactful interventions, close gaps in care, and improve quality. In a recent survey, 82 percent of healthcare decision makers say analytics have helped to improve patient care at their hospital or health system and 63 percent say analytics helped to reduce readmission rates.

With the right technology and strategies in place, health systems can drive change and shift value-based care initiatives into high gear.

Strategy #1: Keep patients in-network

When patient care falls outside of a health system’s network, it can lead to gaps in care, administrative referral headaches, and lost revenue opportunities. However, keeping patients in-network is a challenge, especially in today’s competitive healthcare market. Having the right data to even know who is going out of network and why compounds the problem.

Yet studies estimate that only 35-45 percent of adult inpatient care stays in network. For one accountable care organization with 27,000 lives, out-of-network services resulted in lost data, missed care coordination opportunities, and increased costs. Patients seeking treatment for hip/knee replacements saw a:

  • 10 percent increase in radiology services
  • 32 percent increase in emergency and medical visits
  • 25 percent increase in physical therapy sessions

Advanced analytics with drill-down capabilities can help. It allows users to tap into claims and clinical data so they can identify out-of-network drivers by service line and provider. These systems even allow users to see how much they are losing by diagnosis code.

From there, health systems can find ways to close gaps in services and create a strategy to keep patients in-network. For example, health systems may find opportunities to improve retention by expanding their cancer service line or adding a new service such as electrophysiology. As a result, out-of-network referrals are reduced, in-network retention improves, and the health system finds new revenue opportunities.

With this detailed level of insight, it’s also possible for health systems to pinpoint network leakage down to the provider level and use this information to educate providers about their referral patterns. When doctors and other caregivers see the impact of their referral processes on overall network performance, it’s easier to have collaborative conversations and work towards improving retention.

Strategy #2: Coordinate care to reduce readmissions

Patient data resides in a number of different sources across the continuum of care, including ambulatory EMRs, community health records, and hospital information systems. By aggregating and analyzing this data and applying predictive algorithms, it’s possible to create readmission risk scores for admitted patients so they can be proactively flagged for intervention or special consideration upon discharge.

Capabilities like these are critical for improving outcomes, particularly when it comes to managing the five percent of patients who drive more than 40 percent of our healthcare costs. When this type of information is presented as part of the clinical workflow, providers can review discharge data, anticipate potential roadblocks, take action quickly and efficiently, and reduce readmission rates.

Strategy #3: Leverage actionable intelligence and analytics

Data and analytics can help providers to gain a clearer picture of all of the populations they serve. With data from multiple sources in one central location, it’s possible to layer and visualize this information in new ways. Much like how a GPS presents directions differently based on whether you are walking, driving, or taking public transit, these tools offer users flexibility on how to view and analyze data.

By looking at clinical and claims data in a new light, providers can better understand a patient’s complete profile, including lab tests, self-reported data, health conditions, co-morbidities, lifestyle risk factors, and gaps in care. As a result, it’s possible to better stratify risk, match patients to the right interventions, and address high-risk conditions before they lead to costly treatment. Providers can then prioritize the appropriate interventions and determine a complete care plan that includes support, such as personalized patient education and coaching.

Having a comprehensive, 360-degree view of a patient or population—much like the one a GPS navigational system would provide—can ensure your journey is a successful one. With this perspective, you can reach your destination of high-quality, cost-effective care by following these key takeaways:

  • Concentrate on keeping patients in-network to improve quality care, capture vital performance metrics, and retain service revenue
  • Strengthen care coordination to reduce readmissions
  • Visualize data in new and different ways through enhanced analytic capabilities to promote better clinical and financial performance

Providers need a full picture of their patients and populations to deliver high-quality, impactful care. By harnessing a wide range of data and actionable insights, healthcare organizations can make smarter decisions that better engage patients and clinicians, reduce duplicative services, mitigate risk, and improve quality.

Nancy Ham is CEO of Medicity and VP of Healthagen Population Health Solutions, an Aetna company.

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Currently there are "2 comments" on this Article:

  1. This is exactly the problem that I have with today’s healthcare regulations, health systems, vendors, and EMR systems. While keeping the patient “in-network” has benefits for the health system, it doesn’t necessarily benefit the patient. Who is to say that my health system has the best or even most competent specialists/clinicians in all areas of care in “their” network? If patients do their homework ( as I generally do), their research may lead them to choosing a physician/clinician for services that are not in the health system’s network. But this choice should not hinder the patient’s coordination among all services among all of their providers. Yet Ms. Ham’s solution is to keep all of the patient’s services “in network” to facilitate care coordination and cost reductions. The bottom line is that if we are encouraging patients to take an active part in their own healthcare, their choices should not be restricted to staying “in network” simply for the purpose of ensuring better care coordination and reducing costs; these objectives should still be able to be achieved without eliminating patient choice.

  2. NOT IMPRESSED may have the skills to identify a provider with above average skills who can reliably and regularly deliver better outcomes and a better experience at an optimal cost. But most patients don’t. MS. HAM argues that the informational integrity benefits arising from a narrow network are provider-agnostic. But this ideal is not consistent with the reality that the organic machine that delivers health care suffers from material execution variance.

    The win is to take MS HAM’s integrated data model and NOT IMPRESSED “Dr. Great” vision and use advanced technology to improve physician decision-making and then also improve the quality of execution and the quality of the decision maker.

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