Problem
The Harris Health System (HHS) is the largest health system in the nation’s third most populous county, Harris County, and it contains a wealth of data representing Houstonians. In the recent past, the sharing and application of such information, from PHI to resource utilization patterns to metrics regarding the engagement of patients with agencies within HHS, has been limited in use.
For example, if a patient within HHS initially receives care from Ben Taub General Hospital (BTGH), their renowned Level 1 trauma center, then later goes to Lyndon B. Johnson Hospital, HHS’ largest acute care center, the only information that is tracked between the two entities is the PHI, thereby inadvertently neglecting the bigger picture: the need to find a comprehensive solution to the patient’s health story rather than just addressing temporary, immediate needs.
Furthermore, with the understanding that each patient has a different level of need, HHS has no way of stratifying patients in their system based on their needs and offering supplementary services to those who fit the description of a high-needs, high-cost individual (HNHC). Using data to understand the who, what, when, where, why, and how of HNHC individuals would allow HHS to target specific patient demographics, in terms of condition and geography, for additional care, mobilize resources to entities within the system according to their capacity, and form strategic partnerships to meet logistic and care-based needs identified.
The existing lack of intra-system communication has perpetuated the siloed nature of care prevalent in health systems across the country. Without a meaningful use for these data, it is difficult to improve upon the existing system in terms of providing individualized care, improving health outcomes for patients, and reducing the cost of care per capita.
Solution
Since 2015, our team has incrementally increased involvement with HHS’s population health team to facilitate a regular data “dump” schedule to path/discovery, in which data from HHS can be analyzed to answer the following questions: Which patients within the system are considered High-Needs, High-Cost (HNHC)? What are the specific needs for certain patient cohorts, and how can the path to delivering such treatments be expedited? On what frequency basis do certain patient cohorts visit ERs or any other type of agency within the system? What are the reasons behind visiting the ER for those who frequent it?
By addressing these questions, the holes in the current care model can be identified and remedied to overcome the issues previously present: generalized and sometimes ineffective care, stagnant community health outcomes, and exorbitant cost per patient.
Since the beginning of the partnership in 2015, the width of data transferred, in terms of the type of demographic information conveyed, has expanded greatly, giving our data analysts the ability to construct highly specific data dashboards that visualize resource maps around the city, maps to identify areas particularly affected negatively by Social Determinants of Health (SDoH), and utilization patterns within the system, among other metrics for use by HHS. This increasing data load for an already expansive system demonstrates the scalability of such a platform to other health systems.
HHS’ team of navigators, individuals tasked with coordinating supplementary services for patients, can use these dashboards to understand the imminent needs of patients in their system on an individual and community level, particularly for those who are frequent users of their main ERs, at LBJ and BTGH.
Moreover, by working with our team to develop data-driven inclusion and exclusion criteria, HHS can now identify their cohort of HNHC patients, otherwise known as their “MVP” patients, and use the tools integrated into the path/bridge and path/net modules to communicate with and refer their MVP patients to external agencies capable of providing care, in real-time.
Additionally, our account managers have played a consulting role for HHS’s care navigators by providing assistance to enroll patients into the system, training care providers on the Values-Based Model of care and advising on best practices for patient interaction.
