POPULATION HEALTH ANALYTICS

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1 POPULATION HEALTH ANALYTICS ANALYTICALLY-DRIVEN INSIGHTS FOR POPULATION HEALTH LAURIE ROSE, PRINCIPAL CONSULTANT HEALTH CARE GLOBAL PRACTICE

2 DISCUSSION TOPICS Population Health: What & Why Now? Population Health Analytics in Action Public Health Disease Registries Socio- Economic Electronic Health Records Analytics Rx Patient Reported Claims Labs Demographics Genomics Technology for Population Health Analytics

3 POPULATION HEALTH WHAT IS IT? A program to address health needs at all points along the continuum of health and wellbeing through participation of, engagement with and targeted interventions for the population. GOAL: Maintain or improve the physical and psychosocial well-being of individuals through cost-effective and tailored health solutions.

4 POPULATION HEALTH ANALYTICS WHAT IS IT? Applying advanced analytics to healthcare and related data of individuals and larger populations to yield insights that drive improved health outcomes and reduced cost of care.

5 BIG DATA IS SHAPING THE LANDSCAPE OF HEALTHCARE EMPOWERED CONSUMERS: Proliferation of Digital Data EXPLOSION OF DATA: Big Data EHR, Omics, Claims, Devices ACTIVATED CARE TEAMS: Data Enabled, Analytically Driven Decision Support experience data

6 VALUE-BASED HEALTHCARE WHY NOW? TRANSFORMATION IS UNDERWAY Risk Shift Pop Health Focus Data & System Integration Care & Cost Variance Episode Analysis Government Driven Programs

7 MOVEMENT TO VALUE Provider ACO Fee-for-Service Value-Based Payment

8 ANALYZING AN EPISODE OF CARE EXAMPLE: KNEE REPLACEMENT EPISODE

9 HOW MODELS ARE CHANGING

10 WHY NOW? MULTIPLE OPPORTUNITIES FOR INTERVENTION Care Team Related Causes Inpatient Care Transition PCP Specialist Communication Stratification Intervention Severity Comorbidity Cognition Environment Patient Related Causes Motivation Ability

11 POPULATION HEALTH ANALYTICS Optimize Care Improve Care Delivery Performance Integrate and Prepare Data Engage Patients and Deliver Care POPULATION HEALTH ANALYTICS Assess and Report Performance Across Continuum Design Interventions and Programs Define Cohorts And Identify Gaps in Care Assess Risks and Profile Patients

12 POPULATION HEALTH ANALYTICS FRAMEWORK Social Campaigns SOURCE DATA Biometric Economic Hospitals RISK MODULES ACTION AND RULES PATIENT PROFILE PREDICTIVE ANALYTICS Patients Analysts Claims INTEGRATED DATA STORE Clinicians Pharmacy Ambulatory

13 PATIENT PROFILE Descriptive Dimensions Psychosocial Dimensions RISK MODULES Demographics Segment ID Social ACTION AND RULES PATIENT PATIENT PROFILE PROFILE Activation Level Dx Conditions Rx Prescriptions PREDICTIVE ANALYTICS Readmission Risk Score Propensity to Engage in home monitoring Support Index INTEGRATED DATA STORE Patient Experience Dimensions

14 STRATEGIC ASSET Increasing complexity and sophistication of understanding Demographics Segment ID Social Value Demographics Segment ID Social Cognitive Impairment Score Demographics Dx Conditions Segment ID Social Rx Prescriptions Cognitive Impairment Score Dx Conditions Rx Prescriptions Cognitive Impairment Score Readmission Risk Score Dx Conditions Propensity to Engage in home monitoring Rx Prescriptions Support Index Readmission Risk Score Propensity to Engage in home monitoring Support Index Readmission Risk Score Propensity to Engage in home monitoring Support Index Time

15 SEGMENTATION TO CREATE INSIGHT Population Segmentation Process Diagnosed Un-diagnosed At Risk Healthy Reduce Costs Quality of Life Promote selfmanagement Identify earlier Limit progression Quality of Life Reduce Costs Prevent or delay disease Eliminate or reduce future cost Quality of Life Maintain wellness Maintain cost

16 SEGMENTATION BENEFITS Cost / Utilization / Severity Educate Diagnosis Diagnosis Onset Self-management EOL Strategy Healthy Time

17 POPULATION STRATIFICATION FROM SEGMENTS TO INDIVIDUALS

18 ADVANCED ANALYTICS USING MULTIPLE METHODS For known patterns For unknown patterns For complex patterns For unstructured data For optimizing Rules Rules to surface known issues Anomaly Detection Algorithms to surface unusual (out-of-band) behaviors Predictive Models Identify patterns and event relationships to indicate potential future events Text Mining Leverage unstructured data elements in analytics Simulation & Optimization Simulate scenarios of care models, financial and other constraints; optimize actions Examples: Relevant diagnosis code recorded Prescription not filled Examples: New symptom presents # patients with event exceeds expected Examples: Patterns of patient behavior for known issues Drivers for high cost buckets Examples: Static data elements (e.g., address) used for linking regional behavior Integration of rich case file information Examples: Compare various interventions for target populations Measure simulated responses Optimize interventions Hybrid Approach Proactively applies combination of all approaches at entity and network levels

19 MODELS AT WORK DECISION TREES N: 31,438 PMPM: $51 Diabetes with Complication No< >Yes N: 27,164 PMPM: $43 Anti-diabetic Agents, Insulins No< >Yes N: 4,274 PMPM: $103 Chronic Ulcer of Skin No< >Yes N: 22,511 PMPM: $36 N: 4,653 PMPM: $76 N: 3,520 PMPM: $90 N: 754 PMPM: $164 Diabetic Retinopathy No< >Yes Chronic Renal Failure No< >Yes N: 20,041 PMPM: $33 N: 2,470 PMPM: $57 N: 3,345 PMPM: $85 N: 175 PMPM: $188

20 EXAMPLE PATIENT RISK, CHANNEL PREFERENCE AND BEHAVIOR Social Campaigns SOURCE DATA Biometric Economic Hospitals RISK MODULES ACTION AND RULES PATIENT PROFILE PREDICTIVE ANALYTICS Patients Analysts Claims INTEGRATED DATA STORE Clinicians Pharmacy Ambulatory

21 MEET THE PATIENT Profile Patients Predict Risk Score Inform Clinical Decisions Prevent Treat Identify Care Gaps Personalize Care Plan Execute Outreach Campaigns Track, Adapt Optimize Coordinate Engage Reward & Sustain

22 INSIGHTFUL ENGAGEMENT Develop campaigns and optimize selection Identify population with highest probability of responding to a beneficial intervention Approach using the most appropriate channel Ensure program compliance

23 ENGAGE CLOSING THE LOOP Was the model effective? Did the patient respond? Did the patient engage? Did the patient change behavior? Did cost decrease? Is the patient happy? Learn Measure Predict Engage

24 POPULATION HEALTH ANALYTICS Optimize Care Improve Care Delivery Performance Integrate and Prepare Data Engage Patients and Deliver Care POPULATION HEALTH ANALYTICS Assess and Report Performance Across Continuum Design Interventions and Programs Define Cohorts And Identify Gaps in Care Demographics Segment ID Social Assess Risks and Profile Patients Activation Level Readmission Risk Score Dx Conditions Propensity to Engage in home monitoring Rx Prescriptions Support Index

25 DIGNITY HEALTH INSIGHTS OPPORTUNITIES Plan care for individuals and populations, including predictive disease management. Define and apply best practices to reduce readmission rates. Predict the risk of sepsis or kidney failure, and intervene early to reduce negative outcomes. Better manage pharmacy costs and outcomes. Create tools to improve each patient s experience. 39 Hospitals > 9000 Providers

26 SEPSIS BIO SURVEILLANCE WITH DIGNITY HEALTH INSIGHTS

27 DIGNITY HEALTH INSIGHTS Lloyd Dean CEO of Dignity Health Forbes 5/17/2015 At Dignity Health, we want to set an example in lifting the walls on data. We believe that sharing information and technology among doctors, hospitals, and health care providers will lead to a more positive patient experience, higher quality, and reduced health care costs.

28 GENEIA Goal: Make meaningful decisions about using wearable devices to monitor health and timely intervention for patients at risk of serious illness = Technology: Developed a SAS-based platform, Theon Brings together all available data sources Uses advanced analytical models OR Helps identify and care for patients and populations in accountable care organizations (ACOs)?

29 GENEIA One ACO client found A targeted list of patients discharged who would benefit from home monitoring to avoid future ER visits and potential readmission One patient currently in the hospital who had 13 prior admissions as well as more than 200 specialty visits and 150 prescriptions Ten patients with > $100,000 in medical costs who had not been seen by their primary care physician in > 12 months Two physician practices with significantly higher prescription costs than their peers and information to remedy the situation Copyright 2012, SAS Institute Inc. All rights reserved.

30 One big data fabric Claims Administrative Clinical Psychographic Biometric Physiological See episodes of care for each patient Identify gaps in care Learn better care at home Help aging population remain active Show them their own biometric info

31 FUTURE ROADMAP More data air quality Devices with accelerometer Less exposure to viruses and disease New technology, machine learning Use big data, relationships, find precursors to early onset of disease Be more productive earlier, stave off onset of illness

32 POPULATION HEALTH ANALYTICS Reduce Avoidable Costs Sustain Wellness Internal Processes and Procedures Improve Population Health Target Appropriate Care Lessen Chronic Disease Copyright 2015, 2013, SAS Institute Inc. All rights reserved.

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