Healthcare organizations are taking a deep dive into healthcare data to personalize care for underserved patients.
Data analytics may seem like a cold, heartless concept, but healthcare organizations are learning how to use data to deliver more compassionate care.
For Robert Paeglow, MD, founder, president, and medical director of Koikonia Primary Care in Albany, New York, compassionate analytics involves using patient information to build a complete healthcare model, identifying and addressing gaps in care. That's especially important to underserved populations such as dual-eligible patients, who might be getting a fraction of the care they need because they only visit a doctor for an immediate health concern.
"You have to be able to understand all that the patient has to deal with in order to be effective," he says. "We can all read a medical textbook, but what good is it if you don’t understand what the patient is going through?"
Paeglow has been practicing medicine for more than 20 years, growing up around and serving some of the poorer neighborhoods around New York's capital city. And while he says he's "not a computer guy," his practice has used an EHR for more than a decade.
Like many care providers, there's a challenge not only in gathering data through the EHR, but it's also putting it to use. And with the spotlight now on health equity and addressing social determinants of health, the emphasis is on finding the right data to impact patient care.
Paeglow's medical practice gets some of its guidance from Belong Health, a digital health company that works with hospitals and health plans to improve what it calls patient-centered care. Belong Health is one of several companies focused on extracting and analyzing data to improve Medicare Advantage and dual-eligible programs.
Mac Davis, the company's vice president of analytics and growth, says providers often need help pulling together information for complex populations.
"It's really our job to make numbers work for people rather than making people work for numbers," he says. "Numbers tend to make healthcare faceless and dehumanize the patient. [Healthcare providers] need analytics that understand value and humanize that process."
But what does that mean? To Davis, it means understanding where and why complex-care patients aren't getting the care they need. Coordinating care with different providers, such as specialists, may be too complicated, or there may be barriers to accessing care, such as work, family or transportation. That's where the gaps occur, and where patients become disenfranchised with the healthcare system.
To coordinate and manage care for those patients, Davis says, providers need to integrate care into daily life and make it easy to access. That means staying close to home.
"Healthcare is very local for these populations," Davis says. "It has to be."
Paeglow, known to his staff, colleagues, and many of his patients as "Doctor Bob," is that connection. He's the first and often only healthcare contact for his patients, and a trusted resource. And Koikonia Primary Care was founded to be that resource for poor and marginalized populations.
"You kind of want to be like Cheers, where everybody knows your name," he says.
But with that name comes a responsibility.
"We're providing healthcare on a shoestring budget," Paeglow points out. "So it's important that we make it as efficient as possible. But how do we do that and still have that personal touch? We have to make sure the resources we have matter to them."
Paeglow says he and his colleagues hold weekly staff meetings to go over the information, identifying trends and predictors that they can address with their patients. They look for specific data points that they can translate into actionable information, targeting issues like diet and exercise, medication adherence, blood pressure, and blood sugar.
"We need [that information] to refine our programs so that they can be more effective," he says.
That includes mental health. Being the primary care provider for underserved populations means identifying and addressing those concerns, Paeglow says.
"These people can't go to a psychiatrist if they don’t have access," he points out.
At Belong Health, Davis says they look not only at patient engagement, but specific interactions over longer periods of time. They develop risk stratification models based on those interactions, and the likelihood that someone will react positively to this advice or that suggestion.
"It's how you use them and how you’re adding to these things that makes a difference," he says. "The ultimate goal of medicine is that people can live their lives outside of medicine … so you’re looking for [interventions that make an impact.]"
Davis says compassionate care is a journey. Built into that strategy is the idea that providers and patients are collaborating on that journey. Patients will stay engaged if the information they get from their care providers is meaningful and effective. Conversely, if the information doesn't mean much, or doesn't produce results, they'll tune out the doctor or nurse, ignore advice, and skip scheduled appointments.
"This compassionate analytics approach is really about building trust," he says.
"We're like the linchpin that holds everything together," he says. "At the end of the day, it's all about the data you have and can use. And I can't imagine working now without this."
“You have to be able to understand all that the patient has to deal with in order to be effective. We can all read a medical textbook, but what good is it if you don’t understand what the patient is going through?”
— Robert Paeglow, MD, founder, president, and medical director, Koikonia Primary Care.
Eric Wicklund is the Innovation and Technology Editor for HealthLeaders.
Healthcare providers and health plans are using data analytics—or partnering with digital health companies—to improve care management and coordination.
By identifying specific care gaps and trends, providers can personalize their interactions with patients, especially those with complex care needs.
These strategies are allowing providers to put compassion back into healthcare and improve the doctor-patient relationship.