Using Data Analytics and the EHR to Improve Population Health

Managing population health is impossible without two things: good data and good analytics. Novant Health has both of these. As a result, the not-for-profit, integrated system that spans communities in the Carolinas, Virginia, and Georgia is making significant strides in an era of value-based payments and population health management.

Keith Griffin, MD, chief medical information officer, and Ryan Neaves, MHA, director of IT applications, shared their data-driven strategy at Medical Group Management Association’s (MGMA) annual conference held in Boston Sept. 30-Oct 3. In particular, they provided these five tips:

1. Create Dashboards

Novant Health created dashboards that allow physicians to view their own population health metrics, said Neaves. Physicians use these dashboards to focus on specific patients who ‘fall out’ of the measures (e.g., those who haven’t yet had a breast cancer screening). They can send a letter or email from within the dashboard directly to these patients to engage them. “We try to make it interactive so providers can reach out to these populations,” he added. Novant Health also created cost and utilization dashboards that use claims data to measure contract performance. These provider-specific dashboards include metrics such as-as attributed lives, cost per member per month, admissions per thousand, readmission rate, ED visits per thousand, outpatient visits per thousand, out-of-network spending, and more. “Claims data is a mountain of information and really confusing. This report rolls it up into something we can use,” Griffin said. The health system also developed high-level dashboards that measure three important prongs of MIPS for each practice within the system: Quality, improvement activities (using Press Ganey survey results), and cost (using risk-adjusted cost data from claims).

2. Use Registries in all Services Lines

Novant Health uses more than 75 active registries to segregate patients into groups so they can target interventions, Neaves said. “If you can’t identify populations, you can’t measure performance,” he added. Some registry examples include: asthma, care gaps, chronic kidney disease, congestive heart failure, general high risk, HIV, hypertension, obesity, osteoporosis, pre-diabetes, and tobacco.

3. Assign Risk Scores to Each Patient

Novant Health uses an algorithm that assigns one or more of 22 different risk scores that predict re-admissions. A patient outreach group reviews these scores to prioritize care coordination following a discharge. The outreach group also reminds patients of preventive health services for which they’re due (e.g., diabetic eye exam or A1C monitoring).

4. Use Best Practice Advisories (BPA)

BPAs are alerts that allow clinicians to easily see when patients are due for certain tests or services that are directly related to various quality measures. Novant Health has more than 90 BPAs in its EHR. To create these BPAs, Neaves said he reached out to service line leaders for the input—specifically to determine workflow and timing. He said it’s a continuous work in progress to ensure all BPAs remain up-to-date and are in line with governing agencies. Novant Health has had a lot of success with its BPAs. Griffin cited the administration of Tdap vaccines that almost doubled immediately after the related BPA was initiated. He also cited hepatitis C screenings that increased shortly after the related BPA was launched.

5. Focus on Patient Engagement

Novant Health went live with its patient portal in 2011, and approximately 875,000 patients have signed up. Neaves shared these other current statistics:

• 85% of lab/test results are released to portal users
• 6,800 patient history questionnaires are entered monthly
• More than 26,000 patient-initiated updates occur monthly

The health system uses the portal to manage population health by sending annual health reminder letters that Neaves said inspire patients to call for preventive health appointments. These letters begin by stating the following:

In addition to providing remarkable care to help you feel better when you are sick, we also want to prevent illness and injury from occurring in the first place. With that in mind, our system indicates that you have may be due for the following:

“We want to make our patients actively participate in their healthcare. We don’t just want to dictate to them,” said Neaves. “Our patient portal program is part of our DNA. We want to make sure everyone knows about it.”