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For This Health System, Population Health is Personal

April 23, 2014
by Gabriel Perna
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At Christiana Care Health System, population health management is achieved at a personalized level.

As the largest health system in Delaware, however, getting data down to that personalized level is easier said than done. Christiana Care is comprised of two hospitals with more than 1,100 patient beds, a home health care service, preventive medicine, rehabilitation services, a network of primary care physicians, and a range of outpatient services.

Even so, leaders at the Wilmington-based health system are embarking on an ambitious initiative, drilling down multiple sources of data, both in and outside the health system, and using analytics to spur proactive care plans for ischemic heart disease patients.  “The right way to do care management is to personalize care plans based on the patients’ own data,” explains Terri Steinberg, M.D., CMIO at Christiana Care.

Doing this kind of extensive population health management has always been a goal at Christiana Care. However, the technology that enables care management at this kind of level isn’t exactly a cheap investment. After failing to getting enough money for it in the system’s budget, project leaders at Christiana Care applied for and received a population health grant from the Centers for Medicare and Medicaid Services (CMS) Innovation Grant. Using the grant money and internal funds, they were able to get going on the project.

That was a year-and-a-half ago. Today, a multidisciplinary care management group uses a care management platform (from the Wayne, Pa.-based Medecision) with an analytics database from Coldlight Systems (Wayne, Pa.). The database grabs patient data (some of this integration is ongoing) from the Delaware statewide health information exchange (HIE), Christiana Care’s internal systems, the visiting nurse systems, and from the American College of Cardiology (ACC) clinical database, which is their ambulatory registry database. The latter allows Christiana Care’s cardiologists to benchmark for individual patients and for a patient population.

“We get all of the data we could get our hands on for a patient and we run analytics to score a patient for what they need. Patients who score high need more services than patients who don’t score high. We then enroll everyone with ischemic heart disease in the program, and they get scored and rescored regularly. The magic is it’s not static. Every time a new piece of data comes in, we rescore,” says Steinberg.

Care managers are able to create a smarter database by working with clinicians to determine which triggers are not necessary. Steinberg says the analytics technology will learn and adapt to create even more rigorous, accurate predictive data.

Terri Steinberg, M.D., CMIO at Christiana Care.

Using a Payer System

The care management platform has typically been used by payers in the past. This didn’t dissuade the health system from investing in the system. It offered a patient safety element that was necessary for this initiative, which other systems couldn’t deliver. Plus, Steinberg notes that population health management is achieved in conjunction with payers that are at risk for a subset of insured lived.

Christiana Care still needed to do a fair amount of configuring to get it usable on the provider side. Now that that’s done, there are multiple possibilities for its potential when it’s used with the analytics warehouse. The warehouse is closer to a big data system that sifts through unstructured data, she says. 

“Over time, we hope to learn more about our data as a result of the analytics that are in the database. For now, we’ve written algorithms in terms of scoring, readmissions, and things we wanted to know about the patients, but we do have the ability to look in the database and understand if there are associations,” Steinberg says.

Indeed, there are a lot of questions to be answered. Overall, effectiveness of the technology has yet to be determined. The initiative is also only being used only for the ischemic heart disease patient population. While there are plans to expand to other chronic disease populations, funding has to get in order before that happens.

The grant system, Steinberg says, provides a lot of challenges because its three-year time limit forced Christiana Care to stand up the program and implement the technology at the same time. This is expounded once you factor in the reality that care management, at any level and of any form, is incredibly difficult to undertake. Different sides of the operation that have to speak the same language, she says.

For those looking to try their hand at care management, Steinberg says it’s best to keep it small and keep simple. “Don’t let the technology overwhelm the process. At the end of the day, care management is about people working with patients. The technology can help you see who is sicker and who needs something before humans can appreciate it, but can’t let it overwhelm,” she says.