Improving Population Health: Data-Driven Approach to Identifying and Engaging Patients with High Risk of Mortality from COVID-19

THE CHALLENGE

MemorialCare为ACO和HMO人群提供了大量的患者级医疗保健数据，这些数据可以轻松访问，因为大多数MemorialCare都使用了EMR系统。我们面临的挑战是了解MemorialCare如何以有意义的方式尽快组织这些数据，以应对COVID-19疫情。MemorialCare和Health Catalyst之间的合作为应对这一挑战提世界杯葡萄牙vs加纳即时走地供了合作机会。

THE PROJECT

Leveraging the Health Catalyst^®Data Operating System (DOS™) platform and the ACO Risk Stratification Dashboard, MemorialCare developed and implemented an algorithm to identify and risk-stratify members at the highest risk of mortality from COVID-19. Members are stratified into two categories:

Extremely high-risk:Patients with complex health problems that place them at even higher risk of severe illness from coronavirus based on recommendations from the WHO and CDC. These health problems include, but are not limited to, patients with organ transplant, active cancer with chemotherapy, leukemia, lymphoma, and cystic fibrosis.

High-risk:这一类别又进一步分为三个不同的子类。

• All patients over the age of 70 years, regardless of any medical condition.
• Patients under the age of 70 years who have an underlying health condition. These conditions include, but are not limited to, asthma, COPD, heart failure, chronic kidney disease, and diabetes.
• 孕妇。

Care managers can visualize at-risk members and the specific factors contributing to the increased risk in the ACO Risk Stratification Dashboard, enabling them to quickly prioritize member lists for outreach.

THE RESULT

MemorialCare正在使用DOS来确定其成员因COVID-19死亡风险最高的成员，成功地开展了患者外展活动，并提供针对成员的干预措施，以改善人群健康和降低死亡率。

• Developed and deployed the algorithm for COVID-19 risk for mortality within four days. The algorithm was applied and visualized on MemorialCare’s entire ACO population.
• Within one week, the algorithm was expanded to include MemorialCare’s entire HMO population.
• 在MemorialCare的ACO人群中，有66%的极度高危人群参与了护理管理。