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Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
POPULATION HEALTH ANALYTICSANALYTICALLY-DRIVEN INSIGHTS FOR POPULATION HEALTH
LAURIE ROSE, PRINCIPAL CONSULTANTHEALTH CARE GLOBAL PRACTICE
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
DISCUSSION TOPICS
Technology for Population Health
Analytics
Population Health Analytics in Action
Population Health: What & Why Now?
Genomics
Electronic Health
Records
Disease Registries
Demographics
Labs
Public Health
Claims
Patient Reported
Rx
AnalyticsSocio-
Economic
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
POPULATION HEALTH WHAT IS IT?
• A program to address health needs at all points along the continuum of health and well-being 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.
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
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.
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
EMPOWERED CONSUMERS:Proliferation of Digital Data
EXPLOSION OF DATA:Big Data – EHR, ‘Omics, Claims, Devices
ACTIVATED CARE TEAMS:Data Enabled , Analytically –Driven Decision Support
BIG DATA IS SHAPING THE LANDSCAPE OF HEALTHCARE
experience data
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
VALUE-BASED HEALTHCARE WHY NOW? TRANSFORMATION IS UNDERWAY
Risk Shift
Pop Health Focus
Data & System Integration
Care & Cost Variance Episode Analysis
Government Driven Programs
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MOVEMENT TO VALUE
Fee-for-Service Value-Based Payment
Provider ACO
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ANALYZING AN EPISODE OF CARE
EXAMPLE: KNEE REPLACEMENT EPISODE
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HOW MODELS ARE CHANGING
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WHY NOW? MULTIPLE OPPORTUNITIES FOR INTERVENTION
Inpatient Care Transition PCP Specialist
Care Team Related Causes
Severity Comorbidity Cognition Environment
Patient Related Causes
Motivation Ability
CommunicationStratificationIntervention
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
POPULATION HEALTH ANALYTICS
Integrate and Prepare Data
Assess and ReportPerformance Across Continuum
Define CohortsAnd Identify Gaps in Care
Assess Risks and Profile Patients
Design Interventions and Programs
Engage Patients and Deliver Care
ImproveCare Delivery
Performance
OptimizeCare
POPULATION HEALTH
ANALYTICS
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
PatientsAnalysts
Clinicians
Campaigns
POPULATION HEALTH ANALYTICS FRAMEWORK
SO
UR
CE
DA
TA
Ambulatory
Pharmacy
Economic
Social
Hospitals
Claims
Biometric
INTEGRATED DATA STORE
ACTION AND RULES
PREDICTIVE ANALYTICS
PATIENT PROFILE
RISK MODULES
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
Support Index
ActivationLevel
Dx Conditions
Readmission Risk Score
Rx Prescriptions
Segment ID
Propensity to Engagein home monitoring
SocialDemographics
PATIENT PROFILE
INTEGRATED DATA STORE
ACTION AND RULES
PREDICTIVE ANALYTICS
PATIENT PROFILE
RISK MODULES
PATIENT PROFILE
Patient Experience Dimensions
Descriptive Dimensions
PsychosocialDimensions
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
Valu
e
Time
Support Index
CognitiveImpairment
Score
Dx Conditions
Readmission Risk Score
Rx Prescriptions
Segment ID
Propensity to Engagein home monitoring
SocialDemographics
Increasing complexity and sophistication of understanding
STRATEGIC ASSET
Support Index
CognitiveImpairment
Score
Dx Conditions
Readmission Risk Score
Rx Prescriptions
Segment ID
Propensity to Engagein home monitoring
SocialDemographics
Support Index
CognitiveImpairment
Score
Dx Conditions
Readmission Risk Score
Rx Prescriptions
Segment ID
Propensity to Engagein home monitoring
SocialDemographics
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SEGMENTATION TO CREATE INSIGHT
Population
Un-diagnosed At RiskDiagnosed Healthy• Reduce Costs• Quality of Life• Promote self-
management
• 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
Segmentation Process
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Self-management
Cos
t / U
tiliz
atio
n / S
ever
ity
Time
Educate
EOL Strategy
Diagnosis
Diagnosis
Onset
Healthy
SEGMENTATION BENEFITS
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POPULATION STRATIFICATION FROM SEGMENTS TO INDIVIDUALS
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ADVANCED ANALYTICS USING MULTIPLE METHODS
Rules
Rules to surface known issues
Examples:
• Relevant diagnosis code recorded
• Prescription not filled
For known patterns
Anomaly Detection
Algorithms to surface unusual (out-of-band) behaviors
Examples:
• New symptom presents
• # patients with event exceeds expected
For unknown patterns
Predictive Models
Identify patterns and event relationships to indicate potential future events
Examples:
• Patterns of patient behavior for known issues
• Drivers for high cost buckets
For complex patterns
Text Mining
Leverage unstructured data elements in analytics
Examples:
• Static data elements (e.g., address) used for linking regional behavior
• Integration of rich case file information
For unstructured data For optimizing
Hybrid ApproachProactively applies combination of all approaches at entity and network levels
Simulation & Optimization
Simulate scenarios of care models, financial and other constraints; optimize actions
Examples:
• Compare various interventions for target populations
• Measure simulated responses
• Optimize interventions
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
MODELS AT WORK DECISION TREES
N: 31,438PMPM: $51
Diabetes with Complication
No< >Yes
N: 27,164PMPM: $43
Anti-diabetic Agents, InsulinsNo< >Yes
N: 4,274PMPM: $103
Chronic Ulcer of Skin
No< >Yes
N: 22,511PMPM: $36
Diabetic Retinopathy
No< >Yes
N: 3,520PMPM: $90
Chronic Renal Failure
No< >Yes
N: 4,653PMPM: $76
N: 754PMPM: $164
N: 2,470PMPM: $57
N: 20,041PMPM: $33
N: 3,345PMPM: $85
N: 175PMPM: $188
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
PatientsAnalysts
Clinicians
Campaigns
EXAMPLE PATIENT RISK, CHANNEL PREFERENCE AND BEHAVIOR
SO
UR
CE
DA
TA
Ambulatory
Pharmacy
Economic
Social
Hospitals
Claims
Biometric
INTEGRATED DATA STORE
ACTION AND RULES
PREDICTIVE ANALYTICS
PATIENT PROFILE
RISK MODULES
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
Treat
Coordinate Engage
Predict Risk Score
Inform Clinical Decisions
IdentifyCare Gaps
PersonalizeCare Plan
Execute Outreach Campaigns
Track, AdaptOptimize
ProfilePatients
Prevent
Reward & Sustain
MEET THE PATIENT
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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
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Predict
EngageMeasure
Learn
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?
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
POPULATION HEALTH ANALYTICS
Integrate and Prepare Data
Assess and ReportPerformance Across Continuum
Define CohortsAnd Identify Gaps in Care
Assess Risks and Profile Patients
Design Interventions and Programs
Engage Patients and Deliver Care
Improve Care Delivery
Performance
OptimizeCare
Support Index
ActivationLevel
Dx Conditions
Readmission Risk Score
Rx Prescriptions
Segment ID
Propensity to Engagein home monitoring
SocialDemographics
POPULATION HEALTH
ANALYTICS
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
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
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
SEPSIS BIO SURVEILLANCE WITH DIGNITY HEALTH INSIGHTS
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
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.”
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
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
• Helps identify and care for patients and populations in accountable care organizations (ACOs)
=OR
?
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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
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
“One big data fabric”
Physiological
Biometric
Psychographic
Clinical
Administrative
Claims
• 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
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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
Copyr igh t © 2015, SAS Ins t i tu te Inc . A l l r igh ts reserved.
SustainWellness
Lessen Chronic Disease
Target Appropriate
Care
Reduce Avoidable Costs
Copyr igh t © 2013, SAS Ins t i tu te Inc . A l l r igh ts reserved.
InternalProcesses
andProcedures
InternalProcesses
andProcedures
ImprovePopulation
Health
ImprovePopulation
Health
POPULATION HEALTH ANALYTICS