Population Health: Five Important Questions to Ask When Integrating Your Data

Guest post by Thomas J. Van Gilder, MD, JD, MPH, chief medical officer and vice president of informatics and analytics, Transcend Insights.

Thomas Van Gilder
Thomas Van Gilder

Population health has become a puzzle of processes and technologies to improve health outcomes, enhance the physician-patient experience, and reduce costs. Although the healthcare industry is making great strides toward achieving these goals, a necessary step—the integration of clinical, claims and wellness data—has just begun.

Today, many medical business decisions are based on claims data; yet, robust insights into clinical quality require clinical data. Furthermore, information that is not typically found in healthcare information systems, such as that from wearable devices, and from those who may have little to no contact with the health care system, needs to be incorporated into population health management systems.

Accessibility to clinical, claims and wellness data can provide physicians and care teams with a more complete view of the care delivery system journey and an integrated view of a patient’s data as he or she has engaged the healthcare system. With a broader view of a population’s health and various opportunities to proactively address an individual’s care, a physician or care team can help prevent adverse events or future disease to ultimately improve the health and well-being of the individuals they serve.

As we embark on this journey to complete the population health puzzle, it is important that healthcare systems, physicians and care teams optimize the value of integrating clinical, claims and wellness data by considering the five questions I have outlined below.

  1. Do you have a reliable, complete and manageable way to access clinical, claims and wellness data?

Clinical data, in its current state, requires an “interoperable platform” to be able to present a single, comprehensive view of a patient’s or population’s health data at the point of care. An interoperable platform connects disparate electronic health record (EHR) systems across a community to collect and provide access to information in a secure and confidential way.

Claims data, traditionally aggregated from health insurers, and now from Accountable Care Organizations, needs to be integrated as well to create a more complete picture of an individual’s or population’s health. Not only does claims data yield rich insights that may not be present in clinical information alone—for example, completed pharmacy transactions—but it can also display health-related activity that occurs outside of any given health system. This could pertain to the use of a non-network urgent care facility or activity that might not be captured in an EHR, such as retail pharmacy vaccinations.

Wellness data generated from things such as immunization campaigns, wellness fairs or wearable health technologies, which seem to be on the rise, can help provide a broader record of an individual’s health so that a physician or care team does not have to rely only on sick encounters. Wellness data can help physicians and care teams identify opportunities in the course of an individual’s health, to intervene earlier and try to prevent some of the complications, or even some of the illnesses, from occurring in the first place.

Therefore, ensuring all of this valuable health information is accounted for to generate a more complete picture of a given patient’s or population’s health, requires accessibility to the data, achieved through community-wide interoperability, and a thoughtful plan for using the data to drive quality improvement, care experience enhancements, and reduced health care costs and utilization—the “Triple Aim.”

  1. Do you have a way to normalize your data and corroborate your inferences?

Transitioning from data access to achieving the Triple Aim requires that clinical, claims and wellness data make sense together, across various systems and coding schema. In other words, the data must be normalized, duplicate and time-decayed information removed, and data gaps filled in by interpretation or clinical corroboration with other information.

Normalization requires a platform and an approach that first recognizes that clinical, claims and wellness data may conflict or overlap, and provides a systematic way to address these issues. This all requires solid quality assurance activities, software, and staff with sufficient data science skills to be able to bring clinical, claims, and wellness data together and use the integrated data set to provide actionable health intelligence.

Additionally, as standards are becoming more broadly adopted and health systems are becoming more sophisticated in their use of information technology, data normalization will become more seamless. Until then, I believe it will remain a critical issue.

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Health IT Thought Leader Highlight: David Caldwell, Transcend Insights

David Caldwell
David Caldwell

David Caldwell is the vice president of sales and marketing at Transcend Insights, a wholly owned subsidiary of Humana Inc., dedicated to simplifying population health. Transcend Insights helps manage the complexities of population health through community-wide interoperability, real-time healthcare analytics and intuitive care tools. The company’s HealthLogix platform provides healthcare systems, physicians and care teams with valuable clinical insights that enable more informed decisions at the point of care, enhance the patient experience and reduce costs.

Here, Caldwell discusses how the firm serves its clients; the benefits of analytics and its impact on ACOs; population health initiatives; and the future of the company.

Tell us a bit about your product offerings and the role that they play in the health care technology space.

Transcend Insights is a population health management company that provides health care systems, physicians and care teams with advanced community-wide interoperability, real-time health care analytics and intuitive care tools designed to simplify the complexities of population health. The new company represents the merging of three leading health care technology businesses—Certify Data Systems, Anvita Health and nliven systems. We integrated Anvita’s health care analytics into Certify’s HealthLogix™ platform to provide physicians and care teams with the real-time insights necessary to improve health outcomes and reduce costs. In addition, we made these insights accessible at the fingertips of physicians and care teams through a mobile point of care solution, a technology we gained from nliven.

Today, Transcend Insights works with more than 130 health systems, serving at least 600 hospitals and over 20,000 physicians. Through community-wide interoperability, we help large health care systems gain access to both acute care and ambulatory data that reside in various silos across the care continuum.

We analyze 2.3 billion clinical data points on 10.8 million patients every day. Our analytics engine offers more than 33,000 evidence-based clinical rules and last year identified over 36 million opportunities to improve care and helped our clients close 4.3 million gaps in care.

Lastly, we leveraged nliven’s expertise in mobile health technology to develop a mobile point of care solution that allows physicians and care teams to not only visualize data but also gather and assimilate patient data in real-time.

Who are your customers and what level of clinician typically accesses your product on a day-to-day basis?

The vast majority of our customers are multi-hospital, integrated health care delivery networks that have purchased our product to help them move from a fee-for-service to a value-based care delivery model. Our customers utilize the HealthLogix platform to reach both contracted and affiliated physicians, and to piece together disparate electronic health record (EHR) system data across the care continuum.

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