The Data Challenge in Community Healthcare
For Dr. Jay W. Lee, medical director at Integrated Health Partners of Southern California, the fundamental challenge as a family physician practicing at a community health center has always been demonstrating the impact of clinical care across a fragmented healthcare network.
“Every day, patients are being cared for at dozens of clinical sites across our network,” he explained of the clinically integrated network and independent physician association. “Many of our health centers operate on different electronic health record systems. The critical question becomes: how do we ensure the hard work of delivering outstanding primary care is being captured in a unified way that represents care gaps being closed?”
The complexity of managing population health across multiple sites with disparate systems creates significant barriers to identifying patients who need additional support. “How do we systematically identify patients that need extra support to achieve their health goals?” Lee continued. “Having an analytics technology platform allows us to do this at scale, transforming how we approach patient care coordination and quality improvement.”
Implementing a Centralized Analytics Solution
Integrated Health Partners selected the analytics platform from healthcare technology vendor Arcadia to address these persistent data integration challenges. The primary objective was to integrate disparate data systems from clinical sites throughout the healthcare organization and build a comprehensive centralized data asset for performance monitoring and utilization management.
“This data repository would fundamentally enhance the organization’s population health management capabilities,” explained Sarah Cho, vice president of population health management at Integrated Health Partners. “Our goal was to share and integrate best practice workflows across the entire network, support enhanced care management capabilities, and leverage the reporting and analytic capabilities of the platform to identify actionable insights for our value-based care initiatives.”
Centralized Data Integration and Visibility
Using the vendor’s population health platform, the organization’s health centers have achieved enhanced visibility into the longitudinal health records of patients. This comprehensive view enables caregivers to act decisively on known care gaps and identify special patient cohorts who require additional care and attention.
“Without this platform, we would otherwise be making educated guesses at who needs that targeted outreach,” Cho noted. “One of the foundational building blocks of high-performing primary care is data-driven improvement. With this platform, we are able to drive meaningful changes in clinical performance informed by real-time data and analytics.”
Building a Longitudinal Master Patient Index
Integrated Health Partners collaborated extensively with the vendor to build nearly 20 sophisticated data connectors that aggregate and normalize information, producing a longitudinal master patient index across the entire care continuum. These data feeds integrate multiple critical information sources including clinical data from nine separate health center electronic health records, health plan eligibility files, claims data and care gap reports, admission-discharge-transfer alerts from the health information exchange, comprehensive immunization records, and laboratory data.
The healthcare organization continues working with internal and external stakeholders to implement additional data connectors and expand platform functionalities based on emerging organizational initiatives. These ongoing enhancements support new payer contracts, health center EHR migrations, social determinants of health data integration strategies, and federal grant opportunities, according to Cho.
Achieving Measurable Clinical Outcomes
“Partnering closely with our population health IT team, we developed customized dashboards for our health centers that provide real-time visibility into which care gaps remain open over time,” Lee explained. “This data is reviewed regularly with each health center leadership team and among the organization’s clinical leaders. We like to say this transparency creates a spirit of ‘co-opetition’ wherein we are competing with the clear intent to enhance everyone’s performance and ultimately improve patient outcomes.”
Record-Breaking Performance Results
The Arcadia platform served as the source for organization-wide supplemental data extracts that led to the closure of more than 40,000 care gaps for one contracted payer in a single year, Cho reported. This exceptional performance contributed directly to Integrated Health Partners earning recognition as the top-performing independent physician association in California for this health plan based on results in the quality incentive program.
Sustained Excellence Across Multiple Metrics
“As far as standard leadership work for a clinically integrated network, our HEDIS performance continues to be exceptional, earning us the prestigious designation of top performer for three of our contracted health plans,” Lee said. “Special population health projects have included reducing urgent care eligible emergency department visits by nearly 3%, decreasing readmissions within 30 days by 7%, and reducing overall spend on high-cost injectable medications by strategically pivoting infusions closer to a patient’s home ZIP code – including at-home administration when clinically appropriate – versus requiring visits to tertiary hospitals.”
The analytics technology empowered the organization to identify patients for innovative clinical interventions that extend beyond the traditional four walls of health centers and into the communities where patients actually live and work.
Strategic Guidance for Healthcare Leaders
Aligning Stakeholders and Setting Expectations
For peer organizations considering similar population health technology investments, Cho advised working collaboratively with all stakeholders to carefully define the scope of data needs and ensure there is clear understanding of what the analytics tool will and will not accomplish.
“Set realistic expectations with stakeholders regarding the inherent limitations of different data types and analytic platforms,” she emphasized. “Partner with vendors who can accommodate the unique data sources, workflows, and analytic requirements specific to your organization’s structure and strategic priorities.”
Strategic Planning and Vendor Selection
Lee recommended that healthcare organization executives “know who you are now and who you want to become in the near future – think strategically about your organizational trajectory.”
“Knowing this going into the vendor selection process will allow you to think clearly about what capabilities you actually need versus what features you are being sold,” he continued. “Also, trust your intuitive ‘Spidey senses’ when it comes to building a long-term relationship with a technology vendor.”
“Listen carefully to what your implementation team is sharing with you and understand how a potential vendor fits with your current organizational culture and capabilities,” he concluded. “Imagine realistically how they may grow and evolve with you over time. Nothing will be perfect out of the box, but you need to feel confident your vendor will be there with you as a true partner and genuinely care when you inevitably encounter headwinds after the initial honeymoon phase of implementation is behind you.”
