What causes two patients of the same age and with the same disease but from different regions to respond differently to a certain treatment? Even if these two patients appeared similar on paper, their lifestyles are very likely to differ — socioeconomic status, gender, race, ethnicity, family structure and education.
Is SDOH a promise for a better future, or is it just another hype?
Success in the value-based care environment cannot be achieved based solely on clinical insights. According to one study, clinical care accounts for only 20 percent of the health outcomes of patients, while health behaviors, social and economic factors, and physical environment combined add up to in?uence the remaining 80 percent of health outcomes.
Social determinants matter because they can affect the health of the population residing in a particular region for better or for worse. Trying to improve population health armed with only clinical data and not the non-clinical factors, is like investing in a project which cannot generate positive returns.
Although multiple pieces of research demonstrate that social determinants may substantially contribute to a person’s health status and well-being, the major problems are these:
How do we address these complex challenges?
Who is the best-positioned stakeholder to do so in a clinical environment?
What is the right way to address these social determinants?
The Centers for Disease Control and Prevention (CDC) has defined an algorithm to estimate the Social Vulnerability Index (SVI) for every census-tract in the US. However, this algorithm is based on a simple summation of the percentile ranks for all SDOHs, which results in an over-estimation of social vulnerability in cases of high positive correlation between multiple SDOHs.
Working with SDOH data requires a more drilled-down approach and the use of predictive analytics to accurately measure the at-risk population and to advance preventive care methods in an ecosystem.
The right approach is to start from a state-level analysis and drill down to the zip code-level. The effects of social determinants vary in accordance with a very small region. There is a high possibility that all the zip codes in a county will have different susceptibility to a particular social determinant.
What new ways can a revolutionary approach to SDOH open for healthcare?
Every social determinant affects the region in its own way and corresponding preventive actions need to be taken in order to overcome the adverse health outcomes of the citizens of that region. For instance, community resources and data needs to be integrated into the care coordination processes to make proper interventions. When providers are able to completely understand the effects of non-clinical factors, they can provide much better care to their patients.
The analysis of social determinants can be applied for multiple use cases such as:
Identifying the role of behavioral health, social workers and health coaches
Increasing the efficiency of the care coordination team
Forging better partnerships with community resources and social improvement funding agencies, and many more.
The road ahead
Though providers have recognized that social factors significantly influence their patients’ health, they are often unaware of their patients’ social vulnerabilities and are unable to accept responsibility for managing these issues or providing support to their patients outside of the clinical realm. We are stepping into the age of predicting and preventing diseases instead of curing them. That was the traditional approach. With non-clinical data and resources such as SDOH, we can change the future of US healthcare. All we need is the will to right these wrongs.
By Abhinav Shashank, CEO and co-founder, Innovaccer.
Once while I was scrolling through the news feed on my phone, there was one specific line that really made me wonder: “There’s a 40 percent chance of gusty and blustery winds today.” Statements such as this one strongly influence people’s behavior, as they are based on evidence or data findings from years of surveying, studying, and analyzing past trends and occurrences. However, my question is “Why are we not able to make such claims in healthcare- even today?”
Can we predict the vulnerabilities a patient might face in the future or the current health risks a population segment faces?
Is risk scoring the answer we have been looking for?
Almost all kinds of care organizations have some risk scoring methodology to target care interventions. With quality, costs, and patient experience taking the center stage in healthcare, care organizations need to stratify patients based on their need for immediate intervention.
The need of the hour is to address high-risk issues that impact large groups of patients and ensure that these needs are met in a timely fashion. Often, frequent fliers among high-risk patients come into the emergency department as if it’s their second home.
What if we take the method of risk scoring to a whole new level?
Traditionally, providers and health systems have relied on claims-based risk models, such as CMS-HCC, ACG and DxCG, which were built to forecast the risk of populations/sub-populations but not for individual patients. Hence, these models give an accurate prediction of the average risk of the population but exhibit very poor accuracy if used to predict risk for individual patients.
Although risk scoring has turned out to be a key factor in addressing the needs of the patient population, this method cannot provide all the important insights that are needed to drive necessary interventions. Since healthcare already has the right data from sources such as EHRs, claims, labs, pharmacy, social determinants of health (SDoH) and others, can we predict the future cost of care instead of just stating the risk score of the patient?
The right machine learning-driven approach to predict the future cost of care for patients
It all starts with the right data. The first step is to integrate the data from multiple sources- whether it is clinical or non-clinical data, such as SDoH. The data from these sources can allow us to use the comprehensive patient’s data for multiple predictive models to predict future health cost with greater accuracy.
By Abhinav Shashank, CEO and co-founder, Innovaccer.
Articles on social media channels that carry a sense of apprehension regarding the future of our healthcare system sadden me. However, I learned a long time ago that you never win by arguing with the referee, and that the most logical way to react to apprehensions is to prove them wrong based on concrete evidence.
Building a sustainable model for care delivery is not a tough nut to crack as long as organizations have the right approach. If healthcare leaders can adapt to the constantly changing needs of providers and payers alike, they can steer their organizations towards a better future.
What if we already know all the answers?
Patient outcomes depend on a number of factors. I know cities with poor air quality have a higher percentage of patients with lung-related diseases than the green countryside. Similarly, patients who follow-up with their doctors more often usually take less time to recover from a problem as compared to less engaged patients.
Care management is one area I genuinely believe is an answer to a plethora of problems that surround our healthcare system. However, enabling a culture of managed care is easier said than done. To begin with, it is quintessential to make providers and patients believe in its very significance. This can be achieved by promoting patient engagement, streamlining referrals, increasing annual wellness visits, and regular follow-up meetings, among others.
Creating pathways for automated care management procedures
Baby boomers, millennials, middle-aged people, and kids? everyone has different needs and expectations. However, every patient longs for comfortable, connected, and cost-effective care.
Continuity of care is the key here. Care delivery is an end-to-end process. Care coordination and its various domains? transitional, chronic, and post-acute, among others? holds the potential to improve care and cost outcomes drastically. The more providers know about their patients, the easier it gets to impart care in a much more personalized and evidence-based manner.
Making things easier for patients shouldn’t come at the cost of frustrated providers. Provider and patient satisfaction are, in fact, interdependent. For instance, organizations should ensure that there are little or no skipped appointments and at the same time, calling patients to remind them of their scheduled meetings should be the least of providers’ concerns.
Non-clinical factors can account for up to 80 percent of the health outcomes for patients. Such factors, including socioeconomic conditions, healthy behaviors, and physical environment, may vary drastically for each patient and can significantly impact health outcomes such as poor medication adherence, frequent visits to the ED, and more. Thus, it is essential to consider these factors while creating care plans to ensure that the specific needs of patients are addressed.
Additionally, healthcare’s transition to value-based care is pushing organizations to lead more efficient population health management programs that address every clinical and social need of the population in which they serve. The challenge, however, is that organizations don’t usually have the means to capture the social needs of the patients or address them beyond the four walls of a hospital to ensure that no care gaps remain unplugged.
Innovaccer offers to assist healthcare organizations in a stepwise approach, starting with surveys for patients to complete in order to evaluate their social needs, such as access to food, housing situations, or economic conditions. Additionally, Innovaccer’s solution allows care teams to send as many surveys as needed with multiple language support. Based on the answers received from the survey, the solution helps care teams find suitable community resources to assign to the patient from a pre-built national database.
The solution’s AI-assisted closed-loop referral process to community resources enables care teams to ensure patient-centric care, even after an encounter is over. This closed-loop referral process gives physicians and social workers complete visibility into the social needs of their patients, which allows them to refer their patients to the most relevant community resources. In fact, patients are also kept in the loop in such a way that they can track their referrals, give feedback, and coordinate with their providers at any time, all through a single mobile application.
Innovaccer’s primary aim with this solution is to empower physicians and care teams with visibility into the social needs of their patients, right in the moment of care. The solution also triggers automated and real-time alerts to care teams if a patient’s needs are found to be urgent, such as high social risk or missed follow up. Additionally, the insights from the survey are available to the physicians right at the point of care within their EHR workflows, ensuring that they have a holistic picture of their patients.
“For organizations under value-based contracts, establishing a culture of wellness is a priority to keep their business model financially viable. Social determinants of health are a gamechanger in this regard and organizations who leverage them put themselves in the driver’s seat,” said Abhinav Shashank, CEO at Innovaccer. “We hope that our solution is instrumental to healthcare organizations as they tie their efforts to address social determinants of health and create similar strategies to maximize care and cost outcomes.”
Only recently, Innovaccer also launched its first-ever in-house research authored by Dr. David Nace, CMO at Innovaccer, around the social vulnerabilities of the population across the US. The research paper named “From Myth to Reality- Revolutionizing Healthcare with Augmented Intelligence and Social Determinants of Health” discusses a revolutionary way of leveraging advanced algorithms to determine the social vulnerability of the zip code-level population.
To learn more about Innovaccer’s SDOH Management solution, click here.
By Abhinav Shashank, co-founder and CEO, Innovaccer.
U.S. healthcare is nowhere near what technology made us dream of a decade back. Healthcare technology was meant to act as a means of reducing costs, eliminating burnout, and making care delivery patient-centric. Cut to today, where a broken leg can cost a patient as much as $7,500, seven out of 10 physicians do not recommend their profession to anyone, and we rank poorly among other developed countries in terms of the number of preventable deaths.
Why did technology fail?
While disruptive technology solutions did flood healthcare in the last couple of decades, many of them required physicians to go the extra mile to comprehend those sophisticated systems. Today, physicians are still crunching large data files day in and day out, nurses are doubling up as technical executives, and patients are perplexed by the fact that their providers hardly have time for them.
It’s time for technology to care
If a technology solution is not assisting organizations in improving care quality, reducing costs, and optimizing utilization levels, then its very relevancy is questionable. Healthcare organizations need technologies that can help them actuate their data, realize their strategic goals, and bring patients closer to their providers.
Health IT solutions should make the lives of providers easier. Any health IT solution that puts an additional burden on providers is unjustified and unacceptable. Providers are not data analysts, and expecting them to train tirelessly to understand an IT system and spend a couple of hours each day navigating through complex interfaces can drastically reduce physician-provider time and pave the way for physician burnout.
In with ultimate integration. We need to bring together EHRs, PHMs, payer claims and HIEs and put it all in the palm of the providers’ hands. Whether it’s quality management or data management, it should be simple.
In with relevant insights right at the point of care. Providers are tired of wading through complicated EHRs and excel sheets. What we need now is to seize the nanosecond and realize truly automated care delivery that helps boost the clinical outcomes.
In with 100 percent transparency and bi-directional interoperability. Healthcare providers are often forced to access bits and pieces of electronic healthcare analytics and referrals on disparate applications. Physicians need to capture real-time care gaps, coding opportunities, patient education opportunities, and more; the only problem is that they don’t know how exactly to accomplish this. Providers should be able to capture the gaps in patient care right when they need to and enhance the patient experience of care.
In with true patient-centric care. Healthcare is not just providing episodic care to patients, it is about building relationships with them. In a world where the quality of care directly influences the financial success of an organization, providers should look forward to aligning the needs of their patients to their treatment procedures.
Healthcare of the 2020s needs reliable data activation platforms
“If you can’t explain it simply, you don’t understand it well enough.” — Albert Einstein
Buzzwords like innovation, intelligence, and analytics make sense in today’s time; however, unless the user experience is seamless, the charisma of back-end development does little good for healthcare professionals.
We’re moving into an age of intelligence, and in this age, successful organizations do one thing right- they know the worth of their data. This is the same thing that we need to do in healthcare. Organizations have to switch from a makeshift approach to engage patients and find a concrete strategy that is suited to their advantage, but this needs to be done with the support of data.
By Abhinav Shashank, CEO and co-founder, Innovaccer.
What makes Super Bowls, banking transactions, and online search results altogether more special?
As an ardent supporter, concerned customer, and curious observer, I keep witnessing all three of them in real time. I want the best experience every time that I am the end user, and so does everyone else. In this day and age, it shouldn’t be an unrealistic dream anyway. We should be able to know the score in real time and in the same way, our credit card transactions as and when they happen.
Why doesn’t my healthcare data show the complete picture?
Ironically, for healthcare organizations, real-time updates are not always available while making decisions that can potentially impact patients throughout their lives. Traditionally, many solutions were not even made to optimize the time that providers spend with their patients. Rather, they were only built to ingest data in electronic formats, evaluate macro-level performance trends, and in the best case scenario, provide top stakeholders with financial trends in a concise manner.
Though most organizations today have business intelligence (BI) infrastructures in place, most of the insights generated through them are only good for analyzing things in retrospect and do not really assist providers in the moment of care.
Activated data is the backbone of healthcare technology
It’s one thing to know what is wrong, it is another to have a way of addressing it. For instance, notes from the last appointment with a patient can only provide care teams with half of the story. Unless care providers have a holistic pool of information regarding the patient’s whereabouts, they cannot initiate personalized care plans or impart evidence-based care.
Healthcare leadership should look for activating data from different facilities in their bid to maximize the knowledge base of their providers. Once they have all the data points, they can begin to run customized analytics to support clinical decision-making.
Jane Smith, a 53-year-old diabetic patient, goes to her kitchen to grab a glass of water when she suddenly feels dizzy. She grabs her portable, battery-operated blood glucose monitor to check her blood sugar level and finds it is higher than usual. The HbA1c level from the device is immediately sent to her care team, who are connected with her via a common digital platform.
Her care coordinator calls and advises her to take an insulin shot at the earliest. Within a few minutes, she is visited by a nurse who assists in giving her the insulin received from the pharmacy. Jane is also asked to see her PCP as soon as possible. A week later when she consults her PCP, he is already aware of her medical condition and the medication dosage she received the other day. He looks at her profile on his EHR and marks the care gap that was created as closed.
Now, Jane, her care team, the PCP, the hospital, and the pharmacy can look into her medical records and manage her care with a few clicks on this online platform; and Jane herself has enough clinical insights to make an informed decision about her care.
Does all of this seem like a far-fetched dream?
Healthcare technology has birthed many dreams and turned them into a reality. And yet, it lacks the capability to share clinical data efficiently at the exact moment of care.
What do we want from 100 percent interoperability?
When we talk about technology, the first thing that pops into our heads is Google. It’s an absolute comfort when we get a notification on our calendars that we might be late for an upcoming meeting. This is not rocket science, just two different products interacting on the same layer of a platform to make our lives simpler.
What do the best care teams in healthcare have in common? They don’t just take care of the sick — they help them get better. They engage and empower their patients to play a central role in their care and become healthy. The RWJ Foundation suggests that compared to highly engaged patients, patients without the skills and confidence to manage their own health end up incurring up to a 21 percent higher cost of care. It’s time we brought patients on to the center stage for the healthcare transformation.
While consumer engagement always plays an important role when delivering any kind of service, patient engagement is an important cog in the wheel of value-based healthcare; this much has always been clear. Whether or not we are capable of meeting these needs — or if meeting them is easy — is up for debate.
Patient engagement: The ‘quarterback’ of healthcare’s transition to value
As Dr. Geeta Nayyar, chief healthcare and innovation officer at Femwell Group, expressed in an interview this HIMSS19, “Patient engagement is the quarterback to get us from fee-for-service to fee-for-value,” and one cannot agree more.
Leading health systems recognize that patient engagement is a high priority. At face value, the term may seem pretty straightforward, but there is a lot more nuance to defining a truly engaged patient. It may start with giving them the tools they need to understand what makes them sick, enabling access to a portal where they can look at their information, and motivating them to take care of themselves with help from friends and family.
The well-being of a patient — broadly, the entire population — is an important measure of the quality of care and its effectiveness in a particular network. And that’s what providers need to realize. The healthier and happier their patients are, the better their network would be.
By Abhinav Shashank, co-founder and president, Innovaccer.
Consider a situation where healthcare is not just an industry term — a situation where EHRs are not an integral part of physicians schedule but just a support to providing care. All considered, imagine a situation where patient-centric care actually involves the patient, and patient engagement is not just a buzzword but a reality. Unfortunately, all these imaginations were supposed to be a reality, but still, healthcare managers and organizations are struggling with the problems such as the lack of patients’ adherence to medication, varying trends in the population health, and a lot more. Patient population, nowadays, expect the same on-demand delivery convenience from the healthcare organizations as they get from the other companies, like Netflix.
Why is Patient Engagement the Core of Providing Patient-centric Care?
To understand the value of the patient in the entire care continuum, let us take an example. Consider a patient, Marcus, who works at an IT firm and is affiliated to a Commercial ACO in his county. Marcus is a 65-year-old male suffering from comorbidities like Type 1 Diabetes, and diabetic retinopathy. He is at constant risk of sporadic elevated blood pressure.
In the year 2016, Marcus visited the ED approximately five times. Considering the situation, his primary care physician referred him to a specialist and prepared a schedule comprising at least two monthly visits.
The year 2017 started with a lot of workload for him at his firm, and he was unable to keep up with the prescribed schedule. Because of improper communication between his PCP and him, his physician was not able to keep track of Marcus’s health. As a result, the ED utilization rate for Marcus increased from five times to nine times. Because of enhanced stress and improper quality of care, the sporadic episodes of elevated blood pressure turned into a constant problem of hypertension. Also, the overall cost of care for Marcus increased drastically.
Challenges in Achieving True Patient Engagement
Patient engagement, in itself, is not as simple as ABC. It is not just bringing patients in the cycle of care continuum but enhancing the patient’s skills, ability, knowledge, and most importantly, willingness to participate in the task of managing his own care. The concept of providing care with “engaged patients” sounds great theoretically, but it is not that smooth sailing. According to a survey, nearly 87 percent of the patient population believes that communication with their doctor apart from their scheduled appointments is really important.
The major flaw is the lack of awareness among the patients regarding their care procedures. Many patients are ignorant of the clinical processes which a physician follows, and they might miss out on major health details. With no actual knowledge of the disease symptoms, patients might not report to their physicians which might lead to reduced patient engagement, not to mention the increased risk of developing a chronic disease.
Care teams play a vital role in engaging the patients through regular follow-ups. Irregular and fragmented workflows of care managers and lack of personalization might lead to the generation of ineffective care plans for the patients. Reduction in patient engagement could also be the result of under utilization of technologies to analyze the massive amount of patient data that care managers have at their disposal. Through building more personalized care plans, patients can be engaged at a more grass-roots level.
Driving Effective Engagements through Value-based Care
Predictive population health analytics is the answer to nearly every problem linked with patient engagement. Advanced predictive analytics tools will help in dealing with the problems of disparate data systems and can pinpoint the exact area on which healthcare organizations can focus. Leveraging the insights obtained by data analytics, care teams can prepare the statistical models to prioritize each patient and can take necessary measures to engage patients in the process of decision-making. Understanding the patients’ habits by the care teams increases the chances of preparing personalized care plans for them and enhancing the level of patient satisfaction.
In January 2015, the Department of Health and Human Services set a goal to tie 50 percent of the Medicare payments to value or quality by 2018. This transition has put physicians on the frontlines of healthcare, as they play a major role in the value-based roadmap of an organization.
However, on the downside, this shift is causing substantial physician burnout — PCPs are spending more than 50 percent of their workday in the EHR doing documentation, order entry, billing, and coding, instead of spending time with their patients. There is a need to reduce physician’s IT usage by giving them easy and quick access to actionable information such as care-, and coding- gaps, thereby allowing physicians to focus on things that matter most – delivery and improvement of care.
Regardless of how many patients physicians see per day, they have to put in an equal, if not more number of hours in front of the EHRs for logging in every single detail. Physicians are likely very interested in quality care and making the care processes efficient; it is important to understand the implications that would be created on their reimbursements with a solution that mitigates IT usage burnout. Physicians should automatically be updated instead of having to inquire about information they need at any given moment as it might be disengaging. It is possible to engage physicians so that they can take forward the quality improvement efforts.
Alternative Physician engagement methodologies and their adoption
Making improvements to the healthcare system are the top of the agenda but how does the current scenario of physician engagement compare to this? Addressing the problem of physician burnout, several methods for engaging physicians have surfaced over the past few years:
Print / Fax PVP
Push data back in EMR
Medium in young physicians
Low in older physicians
Another Web Portal
All of these methods are sub-optimal – either they are labor-intensive, or costly to implement, or require physicians to leave the EHR and go to another portal, thus decreasing the physician adoption rates. It is critical to engage physicians in a timely and effective manner to bring information transparency across the network and allow for prompt identification of low-quality care outcomes and unnecessarily high-cost events.
The solution: Engaging physicians with point of support for smarter and holistic care
Addressing above limitations, there is a dire need for a smart point-of-care support for physicians that is automated, easy to implement, and user-friendly. A support system that operates right besides EHR, pinpoints and surfaces only relevant insights, including care gaps and risk factors, which will help physicians right at the point of care without being overloaded with too much information.
Providing precise insights
Physicians require a solution that pops up just the precise insights like care gaps and risk factors to assist them in working with the patient within the EHR at the point of care. Moreover, creating a holistic picture of patients remains highly essential for physicians, however, it is still a challenge because of siloed data storage platforms in healthcare. This lack of a 360-degree view for every patient is a major barrier to collaborative and coordinated care efforts. These challenges can be addressed by integrating various patient-specific datasets, including clinical and claims and surfacing key insights on the physician’s screen in nearly real-time.
Personalizing patient interactions
Almost 80 percent of healthcare data is unstructured, and thus, to create impact at scale, physicians need pioneering analytic capabilities. For example, if a patient has visited the ED three times in the past two months, he needs to be tagged as a ‘frequent ED visitor.’ Giving physicians access to this information will guide them to revisit and optimize their care-programs for this patient such that the patient’s ED visits go down, which would further translate into decreased overall spend for the network.