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Leveraging Technology to Enhance Population Health Efforts

July 20, 2016
by Chet Stagnaro, Freed Associates
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How can you cost-effectively and efficiently harness technology to improve your population health efforts? It’s a common question, as technology is the enabler for population health initiatives, yet many providers appear to be stalled or stymied in their attempts.

For instance, according to a recent study, nearly two-thirds of hospitals and healthcare providers have adopted remote patient monitoring and analytics into their care processes. However, they are struggling to integrate this information into their clinical workflows and at the desired frequency to support clinical decision-making and identify population health outreach opportunities.

Chet Stagnaro

It’s certainly not for a lack of interest among healthcare providers, as population health ties directly into their desire to provide optimal care for their communities. The problem is that it’s incredibly challenging to consolidate the massive amounts of data needed to improve population health and simultaneously devise a nimble technology platform to support it. Use the following best practices to help guide you.


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Five Technology Best Practices

When leveraging existing data to get your population health program started, use technology solutions that keep patients at the center of your analysis and look for data enrichment opportunities within the following five technology best practices:

  1. Think “big picture” technology roadmap—Look for technology solutions that maximize your system’s electronic health record (EHR) and downstream clinical applications’ integration and leverage the EHR’s data model. However, you will also need to consider a “big picture” roadmap that delivers a population health technology platform capable of exploiting unstructured “big data” and structured data. This roadmap may include some or all of the following:

      Data Sources

      Social data

      Streaming device data

      SMS/text patient communications

      Genetic-based patient data

      Segmented market data, geographic information system (GIS) data

      Internet of Things (IoT) data, via telematics and 5G networks

      Patient-provided data such as wearable devices and external streaming device

      Home devices

      Physiological monitors

      Smart pumps

      Radio-frequency identification (RFID)


      Enterprise data warehouse

      Data lake

      Big data cloud strategy


      Data visualization

      Data mining

      Predictive and prescriptive analytics

      Business Intelligence

Considering the above list of emerging technologies and data sources and the drive to capture real-time data feedback, it is likely your population health platform will be a combination of technologies that address structured and unstructured data capture and storage wrapped into data governance processes. There is no one-platform technology that can encompass such diverse data management needs and objectives.

Therefore, exercise caution locking into single-vendor solutions, so that you can be flexible with strategic changes requiring new data capabilities. Remember to keep your specific population health problems and objectives in mind as you evaluate how technology will support your solutions. Leverage research and information available on websites, such as www.data.gov, and healthcare professional organizations, to assist with technology strategies that enable your organization to capture and share your data with other health care partners.

  1. Create a data management foundation with data governance and metadata standards—The “data lake” concept has become popular, in which data is captured but not run through an extract, transform and load (ETL) process. While a data lake offers architectural advantages—primarily a more nimble platform for data capture—it still requires a metadata strategy so that analysts will know how to find the data. Hence, what you need is a data governance process to support your metadata.
    The advantages of establishing a data management foundation include capturing the sources of many different kinds of data, and focusing on back-end analytical processes and tools to exploit this data. However, you may still require a metadata strategy beyond mere indexing in order to exploit data insights and to develop predictive and prescriptive analytics capabilities. The Data Management Association’s Body of Knowledge is a compilation of data management principles and best practices and an excellent data management framework to support this endeavor.
  2. Institute sufficient data profiling—Data profiling, also called data archeology, is the statistical analysis and assessment of data values within a data set for consistency, uniqueness and logic. Here is an opportunity to develop organizational data profiling capabilities, particularly based on these two realities:
  • Data variability and inconsistency—It would be wonderful if all healthcare data could be captured consistently and reliably, but we know better, as clinical data arrives in both structured and unstructured formats. Providers often document such data in ways that may fit their immediate clinical needs but, down the road, these habits often stymie attempts to aggregate and analyze this data in a consistent fashion. The technical solution will depend on effective organizational data management and tools to standardize data or prevent corrupt data from clouding analytical results. Data profiling can identify important business rules for data conformance.
  • Data collection variability—Data profiling can help evaluate the best sources for your data. Consider the variety of patient touchpoints in a typical clinical setting, ranging from ER to radiology to pharmacy, as well as variabilities in data source systems and formats. Data profiling supports ETL tools to organize and conform this disparate data into a single, central system to make it understandable and actionable.
  1. Evaluate technology needs and advances—Your health technology roadmap presents an ideal opportunity to consider your long-term technology needs. Now may be a wise time to consider using the services of an experienced health technology consultant who can advise you on ensuring that your organization has the tools it needs. Some leading questions:
  • Does your organization have the right set of technologies to generate the data your population health efforts require?
  • What potential technology-related barriers lie ahead, based on your systems and their interoperability, and how can you tell if there are any negative surprises ahead?
  • What’s ahead in integration technology? For example, consider the learnings available from the Fast Interoperability Health Resource (FHIR) from Health Level Seven International (HL7), which may become the new application programming interface (API) for healthcare.
  • What are your advanced analytics needs and capabilities? For example, these could include “suggestive analytics” for physicians.
  • How can data be more visual and meaningful? For example, there are now EHR “wrapper” applications that can draw out data more visually and meaningfully. Research shows there are approximately 100 most common order sets that physicians use in their EMR; is there an opportunity to develop “smart notices” about patients that focus on these?
  1. Ensure sufficient population health data storage—Consider using a data warehouse to manage population health data. There are population health management applications, and now major EHR vendors are stepping up with population health management applications. Consider a pilot approach to explore their capabilities and benefits. Bearing in mind the technology is emergent and quickly evolving, these solutions will provide a foundational data warehouse for population health. A data lake architecture may accommodate a data warehouse and unstructured big data sources. The strategy aspect of this architecture work typically requires consulting support from architecture solution experts for many healthcare provider and plan organizations.

Five People-Centric Best Practices

In addition to the technology-specific best practices listed above, you should also consider the following best practices related to the people who will be interacting with and using your technologies. Here are five people-centric best practices:

Tailor your initiative to your specific community needs—Rigorously determine your specific community’s most pressing health care needs and work backward from those information requirements. The data points required by one organization to meet its population health needs may be completely different than those which are most needed by your organization. Asking the right questions of your community will result in the best match for your technology solutions.

Align with patient engagement efforts—Assess how tools such as telemedicine and mobile device technologies can positively benefit your population health efforts and help drive patient engagement, as well as enrich your population health data with patient-provided data about their condition and satisfaction with the quality of care. Increasingly, tools that support patient participation with their health care are being found to beneficially influence patients’ behaviors. This implies a technology strategy that anticipates an ever-increasing need to coordinate the use of such devices within your care coordination systems framework, and correspondingly within your population health efforts.

Partner trained data management professionals—clinical, business and IT—with your physician leaders—Together, these professionals should identify your organization’s required data and population risk stratification scenarios. This approach will more likely generate the right types and amounts of data needed to provide the decision-making information necessary for your initiative.

Determine analytical roles & skills—Gauge the training investment needed with the complexity of the proposed health management technology. Technologies are only as good and as useful as the people who operate them. Consider the needs to get your clinical informaticists and business subject matter experts up to speed.

Consider using a population health vendor—Short term, you may wish to consider a strategic population health vendor partnership or another health system partner. Many healthcare organizations, particularly those serving rural communities, lack the IT infrastructure and staff needed to gather the required population health data and transform it into actionable information. Organizations with larger budgets to spend on leading-edge healthcare information technology, and the ability to gain economies of scale in their purchasing, will automatically have a head start on using technology to drive their population health needs.

Think Incrementally

Building a roadmap for your population health technology is complex. Given the emerging technologies, your roadmap will change course as you progress toward having the solid data management foundation you need. Revisit your roadmap to ensure you are:

  • Considering the most current technology
  • Following your data management strategy
  • Using well-trained resources
  • Asking the right questions about the population health needs in your communities

These guidelines will help you constantly improve your analytics capabilities and harness the ever-growing amount of data.

Chet Stagnaro joined Freed Associates in 2011. Chet has significant experience in PMO, program and project management. Prior to his position with Freed, Chet was a program manager with the University of California, San Francisco. He also has experience in IT PMO and portfolio management in healthcare IT.

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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.


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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”


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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.



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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

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