Using data analytics to help manage chronic care, high-cost patients: 3 experts weigh in

Data analytics gives hospitals and health systems the insight to support optimum decision-making and identify areas in need of improvement. 

How to use data analytics to help manage chronic care and high-cost patients was among the topics a panel of health experts discussed during a session at the Becker’s Health IT + Revenue Cycle Virtual Event on Oct. 9.

Presenters were:

  • Isaiah Nathaniel, CIO of Delaware Valley Community Health in Philadelphia
  • Kimberly Scaccia, vice president of revenue cycle at Mercyhealth, Wisconsin and Illinois
  • Tinu Tadese, MD, vice president of clinical informatics at Lake Health System in Concord Township, Ohio

Here is an excerpt from the conversation, lightly edited for clarity. To view the full session on-demand, click here.  

Question: How can providers use data analytics to help manage chronic care and high-cost patients?

Kimberly Scaccia: As I’ve gotten through all the different physician practices in the hospitals that we serve, it has been a real challenge. We have a fabulous, very well-known electronic health record, and the data and analytics that are not available for these kinds of things are astounding.

We don’t do a good job at providing any of this really important information back to our providers for chronic care management or those high-cost patients. It’s just disheartening. With the tremendous amount of data that we have available, this should be something we are able to do. I don’t know how we do this, but we’re working on building it here so that we can provide information back. 

I would love to get some artificial intelligence inside of our system. It’s definitely something we’re exploring, but this would be a place where I could see it could really have a major impact, especially on those chronic care patients.

Dr. Tinu Tadese: Healthcare is behind, but it’s not that behind in that we actually have made steps in the last three, four years in the AI section of informatics and IT. With the right systems in place, we can follow those patients. The question is, though, the cost of it, because these are all newly developed analytics, and it’s not just analytics. Usually you just don’t get the analytic tool. You’re getting a whole robust population health platform.

For many health systems, that’s like maybe not at this time, because we’re not really in the value-based care reimbursement the way we want to be. The kind of data, the platforms that can really give us some of this analytics and that has artificial intelligence built in, it is really very expensive. Many CFOs are weighing it. Is it worth it? Maybe I have 500 chronic care patients, and I’m looking at the cost.

Maybe it’s a million dollars, and I’m looking at per member, per cost, and I’m thinking, ‘This doesn’t really make sense.’ It’s not that those things are not there, but it’s like, everyone is very slow to embrace it because they’re pretty costly. People feel they can’t get the bang for their buck yet. They’re there. The work has been done. We just don’t have them where we need them yet.

Isaiah Nathaniel: Our job at community health primary care institutions is to relieve that pressure off of hospitals from their ER rates, their high-cost patients. That’s our job. When we talk about population health and we talk about the hierarchical condition category coding, because we are in a revenue cycle panel, we have that data. When I say we have 50,000 patients, we’re seeing the entire family.

For years, and I mean decades, we’ve had population health as a part of our care opportunity. We know what’s going on with these patients, and we try to deal with it up front. When we’re looking at all of these families, we’re not just seeing the mom, we’re not just seeing the dad. We’re seeing the mom, the dad, the grandmom, the grandpop, the kids. Everything. We have all that data in our population health management tool. Then another thing about Delaware Valley Community Health is that we are a patient- centered medical home.

What does that mean? That means we are reimbursed for the value that we provide to those 50,000 lives. It is our job to manage that cost structure. There is a collaborative nature that we need to have both from the hospital perspective and traditional primary care. This pandemic has shown it very, very vividly and rapidly that primary care is a part of the solution, not on the outskirts.


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