Population health starts and ends with individuals. Carol Cain, director of clinical integration for the Permanente Federation and Kaiser Permanente’s Care Management Institute plans to illustrate that point using her audience as an example.

“We’re starting to collect exercise data on every visit,” she says, referring to the millions of members that Kaiser serves. “We can tell folks who don’t have any medical conditions that, based on our data, they are likely to get a medical condition in three to five years if they don’t exercise. We can look at their needs for staying active, and then think about a care delivery program that would respond to those. If you have two jobs and two kids at home, that’s the universe you live in and we won’t get anywhere pretending that you’re going to go running.”  She plans to end her session by getting the audience to analyze the individual and collective needs of the group “people who attend conferences.”

Cain will use her time to identify novel uses for data from electronic health records, outline how to create proactive population health programs, and describe barriers to the kind of information integration necessary to establish such programs. She’ll explain how Kaiser is integrating and using “big data” to do both qualitative and quantitative research.

“We need to wrestle with how to get knowledge from data,” she says. “We won’t be able to interpret every last piece. “ However, an integrated system like Kaiser has enough data to deduce a lot about its patients. For example, it can track the percentage of medication prescriptions that are actually picked up in the pharmacy, and use that data to create a model of medication adherence. At that point, a pharmacy manager can call the patient and find out what’s going on:  are they feeling better? Are they taking too many pills to keep track of? Are side effects bothering them?  If the patient is only willing or able to take five medications, which five will have the most positive impact?

Kaiser can also use its patient data for public health initiatives that have nothing to do with direct clinical care. For example, it can look at the geographic distribution of its patients and decide to make an investment in recreational facilities in neighborhoods with a high concentration of Kaiser members, increasing the odds that they’ll be able to get the exercise they need.

“We have a more comprehensive view and incentives to do population management,” because of Kaiser’s dual role as provider and payer, Cain says. “But with the rise of accountable care organizations, prevention will become more important for all providers.”

Educational session #98, “What Big Data Means for Care Delivery Transformation,” is scheduled for March 5 at 2:15 pm.

 

 

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