From Data, to Knowledge to Action: Leveraging Clinical Analytics to Impact Patient Outcomes

Thomas Van Gilder
Thomas Van Gilder

Guest post by Thomas J. Van Gilder, MD, JD, MPH.

Electronic health record (EHR) technology has become truly transformative for the healthcare industry; prepared or not, healthcare teams are increasingly relying on new information technologies to improve the delivery and management of care. EHRs have enabled faster and easier access to patient information, and hold the promises of improved workflows, efficient sharing of information across communities and reduced costs for many physicians and hospitals.

But now that nearly 80 percent of physician practices in the U.S. today have EHR systems in place and the Centers for Medicare & Medicaid Services’ (CMS) meaningful use program is well underway, it is time to look to the next stage of health care technology and innovation. Health care teams must now move beyond the first step of digitizing patient records to transforming this valuable data into meaningful and actionable knowledge that will help care teams make more informed decisions at the point of care and ultimately, improve outcomes.

For this impact to take place at both the individual level and at the population level, care teams need to leverage clinical analytics that will provide visibility into important clinical trends across the entire population. For example, being able to review trends in diabetes care or readmission rates across a population represents an opportunity for specific, meaningful change to improve care delivery and outcomes.

For a practicing clinician, “population health management” means being able to see where an individual patient is within the clinician’s or clinic’s population (e.g., whether the individual’s chronic condition is above or below population benchmarks) and to take action at the point of care, as well as being able to refer to relevant population health metrics.

For a patient, clinical analytics presumes trust, not only in the competency and care of the physician, but also in the security of his or her information. Population health management and analytics tools must ensure that patient information can be gathered, stored, and used in a way that is demonstrably secure.

Care teams should consider four key elements when exploring clinical analytics tools for population health management:

Integration with interoperability capabilities – An interoperable environment where patient information can be aggregated from all care teams across a community and disparate EHR systems is crucial towards effectively managing the health of a population. By combining real-time clinical analytics with community wide information exchange, care teams can ensure that the right information is delivered to the right individual, at the right time, for improved care coordination and better outcomes.

The importance of integration and interoperability is evident based on care team complaints toward existing EHRs. The current workflow requires physicians and other care team members to access several systems, or even paper reports, to retrieve the healthcare data needed on a single patient or population. The ideal system collects information from disparate broader healthcare systems and even consumer systems and presents this information in a manner that is actionable and visually engaging.

Comprehensive, centralized patient information – Clinical data representing an organization’s patient population is often presented in a fragmented way that does not effectively provide clinicians and care teams with the intelligence they need to make informed decisions at the point of care. Patient information must be presented in a credible, comprehensive manner that provides care teams with actionable health intelligence. Having a 360-degree view of a patient’s medical profile in a single place would enable clinicians and care teams to effectively identify and analyze evidence-based gaps in care and drug safety concerns to avoid adverse drug events and unnecessary tests, improving clinical outcomes and reducing costs.

Personalized engagement – Clinical analytics can have the greatest impact when leveraged to engage individuals to help them manage their own health. For example, care teams can utilize customizable messaging templates to communicate intervention alerts and other important clinical information to patients and their care teams. This approach can help improve the likelihood of behavior modifications and adherence.

Mobile access – Accessibility to health information at the point of care, or whenever action can be taken, is crucial. Clinical analytics available via tablet and mobile applications can help improve care team collaboration and the overall physician-patient experience.  The patient experience literature and anecdotes are filled with concerns about EHR interaction supplanting physician-patient interaction. Therefore, mobile devices should allow care teams to better maintain eye contact with their patients and appropriate personal posture and distance, as well as facilitate information access and sharing.  Mobile devices in the exam room or on-the-go (e.g., after hours, when some clinical documentation takes place) will become a major force in healthcare in the near future.

Of course, these key elements require that data security, including patient privacy, confidentiality, consent and transparency, be actively and meticulously managed throughout the entire system. Without constant, careful attention to security, the power of analytics will not be realized.

As the healthcare industry grapples with the enormous amounts of clinical data available today and the need to find smart, innovative ways to make all of this data meaningful for clinicians, many are realizing the true potential of clinical analytics tools to transform patient data into real-time, actionable health intelligence that will truly improve outcomes.

Thomas Van Gilder, MD, JD, MPH, is the chief of medical services at Certify Data Systems, a wholly owned subsidiary of Humana Inc. For more information about Certify Data Systems, visit

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