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  • April 18 2012

    Moving beyond episodic care: Managing the health of populations

    Earlier today, we announced a collaboration with Advocate Health Care, the Midwest's largest health system and one of the top health systems in the country, based on clinical performance. Working with Advocate, we'll develop models that help predict adverse outcomes before they occur – leading to earlier interventions and helping to improve the health of Advocate's patient population across the continuum of care.

    We had a chance to speak with Advocate's Dr. Rishi Sikka, vice president, clinical transformation, and Tina Esposito, director, Center for Health Information Services, about population health and why it's an important topic in health care right now, the goals of this partnership and the impact it will have on their community.

    Why focus this partnership on population health? Why is this topic important right now?

    Dr. Rishi Sikka: Traditionally the American health care sector has focused on episodes of care. As we move into delivering better value, which means delivering exceptional quality and an exceptional experience as efficiently as possible while managing our costs, we no longer can manage by episodes. We have to manage across the continuum of a patient's experience, not just the experience in a hospital and focus on a patient's health throughout their lifetime. Managing population health is central to solving some of the fundamental issues the health system in our country is facing.

    Tina Esposito: In terms of best supporting our patients, you have to look at care more holistically, ensuring that we're following our patients across care settings and improving their outcomes regardless of where we see them.

    What are the goals of this partnership?

    TE: Our goals are to best leverage the information we have to enhance our patient outcomes. There will be a key focus around predictive analytics so we can make interventions early and ultimately improve health outcomes.

    RS: The goals are patient-centric. It's about improving the care we deliver our patients throughout the continuum.

    How do we move beyond simply capturing health data in the EHR? How does this project represent the next step in utilizing health data to drive improvements in health and care?

    TE: The goal is to make the data more meaningful. We're capturing all this data, but now what we are trying to do is leverage it to help improve outcomes.

    How important is system interoperability to the success of this project?

    TE: Interoperability is foundational. If the data is not integrated, you are not able to gain the insight we are in search of, such as understanding the care across the care continuum. It's a cornerstone to support modeling and analytics.

    Why is it important to capture information across the entire continuum of care (ambulatory, acute and post-acute)?

    RS: For us to really manage a population's health, we need to know what's going on through the lifetime of the care experience. The only way to understand this is to take away the focus on episodic care and construct a whole picture of what that patient is going through. You have to consider their experiences in the hospital, in an ambulatory care setting and in a post-acute setting. You have to break down those silos that exist and bring the information together into one place. Once the data is all in one place, we can work on the analytics and modeling that will drive improvements in a patient's care.

    What benefits will accurate predictive models provide in health care?

    RS: We hope we can develop models that predict events before they occur, and that's really powerful. To be able to predict a patient who might fall and intervene before they do, to intervene on a patient who would be readmitted before they are, to predict what complication a patient might develop from a chronic disease and focus on that and prevent it from happening, those are all very powerful examples. It allows a more proactive approach when caring for a patient.

    How will this project change the culture of how you deliver care?

    TE: This will help us work better together to ensure we are addressing population health issues. It's about integrating all the venues of care, whether that is the hospital, doctor's office or home care.

    RS: Patients will see that we have a dedication to keeping them healthy, and we will have resources and tools geared towards that ultimate goal.

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