Under all value-based care arrangements, getting patients the right service at the right time is key, and doing this correctly involves the appropriate use of data to drive clinical activity. Whether the timing of that activity is less precise (e.g., colonoscopies for patients 50 and over) or tightly time-bound (e.g., transitions of care after Inpatient Stays or ED Visits), having easily consumable information in the hands of care teams is critical to success.
CDMS worked with a Medicaid ACO in Iowa to enable the member healthcare organizations—community health centers—to utilize these data for more consistent transitions of care. As depicted in the figure below, the solution connects to the statewide HIE every morning, extracts the previous day’s Admit, Discharge, and Transfer (ADT) data involving ACO-attributed patients parses these data to identify the Iowa Medicaid members whose care has been attributed to one of the health centers participating in the ACO. With these data identified for each center, the program then connects to the electronic medical record system at each of the member centers and extracts current data related to each patient so that when the care management team receives their morning ADT report they have localized information that will make the report more actionable (e.g., the patient’s primary care provider, the date of their last clinic visit, contact information, etc.). These data are then compiled into a report for each center and their care coordination team receives the report via encrypted email moments after the data are extracted from the HIE.
This is just one example of the how our Analytics as a Service offerings can overcome what was, previously, an insurmountable problem for healthcare organizations operating in an increasingly data-driven healthcare environment.
If you would like to learn more about how CDMS can bring targeted solutions to bear on your analytics and informatics problems, please contact us.