How Big Data, Analytics Drives Population Health, Closes Care Gaps

Patient hesitancy to seek care during the pandemic created the perfect storm for delayed care. But big data and analytics are driving population health at Southwestern Health Resources to close care gaps.

“There has been a dramatic decrease in willingness of people to seek healthcare, whether it’s for urgent, critical medical needs or routine screening,” Andrew Ziskind, MD, senior executive officer of Southwestern Health Resources told HealthITAnalytics. “Right now, there’s a public health crisis in the short term, but in the long term, there will be tens of thousands of new cancer cases because of a lack of screening.”

Four in ten adults reported avoiding care because of COVID-19, according to recent data from the Centers for Disease Control and Prevention. So closing care gaps required innovative thinking to manage populations. At the center of this strategy is actionable data.

“The first thing we can do for our existing members is to identify who has gaps,” Ziskind explained. “Our data is robust enough that we can see where the targets are geographically, age-wise, and so forth.”  

As a clinically integrated network, Southwestern Health Resources has access to claims data and clinical data to inform these decisions.

“Claims data is a lagging indicator,” Ziskind argued. “But clinical data is probably the most important advantage of being a provider-based clinically integrated network. All of our primary care physicians are connected to us through a common electronic medical record.”

This connectedness allows for easy data sharing.

At traditional health systems, patients with diabetes who might have seen an ophthalmologist and closed a care gap during that visit may have forgotten to inform their primary care provider. While the gap in care is technically closed, the provider is unaware.

But an integrated data network eliminates this problem as the primary care providers can have access to all of the patient’s records.

“Documentation around gap closure is often very challenging. The more we can mine the data and identify alternatives, the better,” continued Ziskind. “We’re using the breadth of data that we have access to for identifying where the gaps are. Once we know what they are, we can then use a gap-targeted approach for each specific one.”

Southwestern Health Resources took a multi-pronged approach to targeting patients and closing their gaps in care. The network began by calling each patient with unfilled gaps, but the call center team members saw very low response rates.  

“Patients are suspicious about phone calls. They sometimes are confused as to if the call is from the hospital or health system or insurance company,” highlighted Ziskind. “We found that the highest success rate is if the patient is contacted on behalf of their physician.”

Patients then had the option to seek care in person or have a provider come to their home. Patients who opted for in-office visits were given instructions on how to make an appointment and Southwestern Health facilitated services at home if the patient preferred.

“You have to customize at the level of the individual patient,” Ziskind emphasized. “We tried to get rid of any patient burden.”

Ensuring the information was culturally component was also critical. Not only does this include translating information into multiple languages, but it also means delivering messaging in a way that best suits patient need.

“There’s a component through local churches and community access. There’s traditional mail. There’s email. There’s social media,” Ziskind highlighted. “We’re really trying to take a multi-prong approach to enhancing awareness.”

These efforts began with data that allowed Southwestern Health Resources to identify gaps in care and thrived when data on individual patient preference was actionable. Customizing outreach improved gap closure and gave providers actionable information.

As gap closure efforts continue, Ziskind and team plan to focus on clinically relevant patient outcomes, including promoting preventive health screenings.

“More and more we’re trying to move upstream in the disease process. We’re focusing on risking risk as opposed to just the management of patients who have advanced, complex disease,” he concluded. “The earlier we can detect disease, the better the long-term outcome will be for the patient.”