Data and Analytics for the Right Care to the Right Patients at the Right Time

by Mark Schippits, M.D.

Data and analytics are the operative words in healthcare. The challenge is no longer getting information but, rather, figuring out what to do with it.

Arizona Care Network has found a way to harness Big Data to help its nearly 6,000 physician partners prioritize care for patients who need them the most. ACN developed a proprietary algorithm to stratify patients according to their health status — from Healthy to Risking Risk and from Chronic Conditions to High Risk and Catastrophic Acute Need — and then working with providers to coordinate care through an innovative program called N Compass.

The goal is to deliver the right care to the right patients at the right time.

Consider the “Rising Risk” patient recently diagnosed with diabetes. As part of ACN’s population health strategy, this individual can learn how to proactively manage his condition, get reminders for screenings and receive periodic check-in calls to ensure his disease is in under control.

“High Risk” patients may receive special attention in select situations as well.  For example, when a patient faces physical limitations to visit the physician’s office after a complex transitions event, ACN providers can make house calls or arrange a face-to-face visit with a registered nurse care coordinator or a social worker to alleviate access-to-care barriers.

The program empowers patients to play an active role in their health, arms physicians with an information-rich summary on their patients’ conditions that they would not otherwise have, and is designed to positively impact clinical outcomes while reducing overall cost of care.

Accountable care organizations like ACN were created expressly for this purpose — to help busy physicians and health systems coordinate care for patients as a means of delivering the best possible care and limiting unnecessary healthcare spending. A thoughtful strategy that looks at the larger population while delivering care one patient at a time, delivers on this promise.

Mark Schippits, M.D., is chief medical informatics officer at Arizona Care Network, a physician-led and -governed accountable care organization owned by Dignity Health and Abrazo Community Health Network that improves clinical outcomes and reduces costs by actively managing care for its 310,000 member patients.

Photo by Marek Levák on Unsplash 


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