For Charles Macias, M.D., young Jenny Jones was the last straw in tolerating a fragmented care delivery system.

The emergency physician had seen the child with severe asthma three times previously and here she was again after visiting one primary care physician, two hospitals and three ERs within the past six months. Macias, now chief clinical systems integration officer at Texas Children’s Hospital, asked Jenny’s mother if she was doing everything on the asthma action plan previously given to her. “She had six different action plans from us in her folder,” he recalled at Health Data Management’s Healthcare Analytics Symposium in Chicago. “She laid them on the table and said, ‘You tell me which plan to follow.’”

The plans, each created in a silo, conflicted with the others, Macias said. No plans coordinated with others and none provided quality care. It became clear to him that the organization needed to minimize care variation. To do that, Texas Children’s Hospital created a foundation to improve outcomes that included EHRs with evidence-based practice guidelines, team-based care with processes to improve quality and data analytics to assess where quality stood and where it needed to go. “To this day, we don’t have physician scorecards; it’s all about team performance,” Macias said.

The analytics platform gives insight in near real-time, such as population health management status updates every 24 hours with improved accuracy by using the same definitions of the severity of conditions, such as asthma, on the same populations. Permanent teams of clinicians, technicians and quality improvement experts drive adoption of evidence-based medicine. So far, Macias said, these teams have developed nearly 100 evidence-based summaries to guide care of specific conditions based on severity and other factors.

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