Big data for health

In my first post, I outlined five features of the patient-focused integrated health care system that I envisioned. The third feature is a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.  This post focuses on part of this feature: the value of big data in health care performance.

Today, physicians, therapists, nurses and other clinical experts each use different tools to assess patients’ needs and record pertinent information to manage their care. The clinical expert learns about each patient, their past, current conditions and needs but once a patient  moves from one setting, like a family physician’s office, to another, like a hospital, the process usually repeats. Time is lost to redundant questions and similar assessments, while some details remain a mystery, known only to one setting’s care providers.

In the home and community care sector, we securely share our assessments, plus other data, within and across our CCACs to uncover evidence-based insights that inform and manage our patient care decisions. And when a hospital discharges a patient to a CCAC, which coordinates care with their service provider, the patient’s information follows them. But these scenarios are the exceptions. CCAC also coordinates care with other organizations in the patient’s neighborhood but the ability to appropriately  share that information in real time is currently not a standard.

For patients like Yasmin, a frail senior admitted to the emergency department with a broken leg, the clock ticks while her frantic husband recalls her medical history. Tests are run to assess her bone density, anesthetic threshold and other details her family physician already has on file. Meanwhile the backlog of aging patients with urgent needs builds.

To meet the needs of a rapidly growing older population with multiple or complex care requirements, there’s a rising imperative for more integrated systems. We need to access data from clinical experts across the continuum of care to see a complete picture of each patient, learn about the broader population’s needs and identify system opportunities to improve people’s experiences.

Organizations are working to eliminate redundancies by creating one electronic health record (EHR) for each patient, which is shared and understood across the continuum of care, but much needs to be done.

At the Canadian Home Care Association’s 2015 summit, I heard about Belgium’s work as one of the first countries to share a single assessment record per patient between multidisciplinary clinical experts and across various care settings. Dr. Anja Declercqu outlined how BelRAI, its evidence-based assessment solution, enables home care organizations, hospitals and long-term care homes to securely exchange patient data with each other. She also cited challenges, as health partners were still learning to trust each other’s assessments, but their progress was impressive.

If Yasmin lived in Belgium, all clinical experts would quickly know her history and conditions, as she moved between care settings to have her fracture set and safely return home to heal – faster and at less cost.

With a more integrated system, we will be able collaborate and coordinate our patients’ care with other members of their care team. Working together, will also deepen everybody’s understanding about the unique contributions each sector brings to the continuum of care and foster conversations about what needs to improve.

We are moving closer to this ideal in Ontario and can increasingly use big data to:

1. Address each patient’s needs –

Care coordination begins with thoroughly assessing each CCAC patient’s health care and social needs, as well as learning about their goals. Our care coordinators combine this assessment data with their clinical expertise to inform decisions around a care plan that will best meet their patients’ needs. Ontario’s CCACs are gradually adopting InterRAI, an international version of Belgium’s BelRAI assessment solution, recognized worldwide for supporting best practice patient care. It will empower our frontline teams to develop more personalized evidence-based care plans, centred on each patient’s experiences and goals.  And in a patient-focused, integrated system, a patient’s single, electronic health record will follow them, as they move between care settings, versus multiple records across the continuum of care.

2. Understand neighbourhood level needs –

Data also helps us understand the patient populations our organizations serve. It shows us people often live near those who are like them and may think, work and even approach their health care in similar ways.  Through our Community Capacity Plan study, we learned that a community care organization delivers better patient outcomes if they are familiar with the neighbourhoods where their patients live and receive their care. Our Care Coordinators need to know their local supports to an in-depth degree so they can develop a sustainable care plan aligned with their patient’s neighbourhood.

Knowing this, we developed Socioeconomic and Cultural (SEC) tools to help us understand a population or neighbourhood through data, such as income levels, average persons per dwelling and the percentage of dwellings owned, versus rented. For example, this data shows us that patients in a neighbourhood with a high SEC, are 40 per cent more likely to visit the emergency department, than those in other areas with a low SEC.

Viewed together with other population health information, these data points build a picture of a neighbourhood’s needs. These insights inform current home and community care services, including those to address a patient’s social determinants of health, as well as their clinical needs.

This data helps identify areas where services are inequitably distributed and is invaluable to long-term health system planning. When we plan neighbourhood clusters or community service hubs of services, there’s no need to arbitrarily put a pharmacy here or a chiropractor there. We can drive these decisions by evidence-based patient population needs, which we know, right down to the postal code level.

3. Coordinate care across the province –

I wonder if many realize that CCACs have an electronic health record for every patient they serve.  Our Ontario-wide Client Health and Related Information System (CHRIS) was developed by our provincial organization and CCACs. We rely on this web-based system to manage all aspects of each patient’s care, along with reporting and finances.

eHealth Ontario used CHRIS as a core part of its ConnectingGTA solution for CCACs and hospitals across the megacity to securely share electronic health information about its residents.

We’re now looking for ways to extend CHRIS access to other partners in the system. Then, it could take us beyond neighbourhoods to uncover regional trends and identify barriers that may be limiting patient outcomes.

4. Monitor and optimize resources –

Data doesn’t just inform patient care decisions, it can also manage ongoing performance. To help our teams decipher the data they need to manage all aspects of each patient’s care in real time, we developed ‘Insights.’ 

On a personal level, this interactive dashboard enables care coordinators to measure their own performance against consistent guidelines for exceptional care.

From a broader organizational perspective, clinical managers can use this tool to track resource use, patient outcomes and performance to identify issues or best practices. But why stop here? Insights can be adapted and its scope expanded to oversee performance in other care settings for an integrated people-focused system.

Our community capacity plan showed us one of our biggest opportunities lies in leveraging our current resources to build capacity, including the people, technology and processes that define how we use data.

In 2013, we looked at data across all care settings to build a comprehensive picture of our community’s needs in the next 10 to 20 years, particularly within the borders of our Health Link neighbourhoods. We saw how hospital, long-term care, community support services and CCACs currently use resources and we identified opportunities for improvement. And we used modeling to project what optimizing those resources would look like, if we had no new money to where we should invest to create the best outcomes for our patients, when resources are available.

If our health partners effectively leverage our assets, we have a shot at reaching Belgium’s ideal and optimizing our ability to care for people across Ontario.

With its Patients First legislation, the Ontario Ministry of Health and Long-term Care intends to establish sub-regions (LHIN sub-regions) within local health systems to plan performance improvement and more equitably integrate services at a community level.

Our CCAC has been moving in this direction for some time, re-aligning our care coordinators and contracted service providers around neighbourhoods that are similar to LHIN sub-regions. This model offers several benefits. Among others, these include addressing socioeconomic impacts and inequities, which I’ll discuss in my next post.

What do you think? Are there other ways we can leverage big data to improve patient outcomes and experiences?