February 20, 2017 | Written by: Virginia Opipare and Joe Reilly
Categorized: Watson Health
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Doctors and hospitals often do tremendous work when health problems are immediate, acute and episodic – think of the heart attack or the broken leg – but getting patients with more long-term, chronic problems to get and stay healthy is an enormous challenge. This difficulty is why chronic conditions like diabetes and hypertension make up as much as 75 percent of our nation’s healthcare costs.
Often at the core of that challenge is managing the myriad of data sources from electronic health record systems, health information exchanges and even the information from non-health social service providers in the community. Recent years have brought a tremendous effort in what is known as population health – managing information about the whole of a patient, breaking down the siloes that so often exist in healthcare.
But by employing the power of cognitive, the Central New York Care Collaborative (CNYCC) – www.cnycares.org – is taking on this task. Working together with IBM Watson Health – and leveraging CNYCC’s connectivity to 2,000 care providers across six counties in the Empire State – we are building a population health management platform. Integrated with Watson Care Manager and broader Watson Health offerings, the platform will be designed to harness cognitive capabilities to optimize chronic care management for some of the most complex conditions and patient populations that exist today.
At CNYCC, we’re dedicated to increasing patient access to needed services and reducing avoidable hospital stays by 25 percent. Our main efforts are with the region’s population of patients on Medicaid, the federal-state health care program for those with lower incomes. Often these patients connect into healthcare through other social service offerings and can be difficult to track as they access care in less-coordinated ways. They are also more likely be have chronic diseases – 83 percent of Medicaid costs nationally are because of chronic conditions.
It’s well-documented that early intervention leads to better outcomes. The new platform will help caregivers find and communicate with those patients early – working with patients before disease progresses, and eventually helping providers figure out what type of outreach works best for communicating with a particular patient. Cognitive systems will help enable proactive care, not just for Medicaid patients, but every patient population will benefit from the platform.
Across the U.S. healthcare system, patient data often resides in multiple siloes, making it difficult for physicians to understand the full spectrum of health issues and risk factors that could impact a patient’s care. For example, an endocrinologist may not know that her diabetes patient also suffers from depression, which significantly raises the risk of a patient failing to take medication that will improve health.(2)
By collaborating with IBM Watson Health, CNYCC will be able to integrate data from a variety of care settings — primary care, post-acute, behavioral health, community and acute care – including more than 75 electronic health record systems, health information exchanges, and other data sources.
Additionally, our cognitive health platform will help providers learn more about what works best to help people get and stay healthy. Our goal is to learn which social and behavioral determinants in health play a much bigger role than we previously thought. Armed with this insight, we should be able to help community leaders coordinate a more thorough, scaled response to issues that impede healthcare access, such as lack of transportation and homelessness.
Driving the demand for this invigorated population health management is the changing nature of the way the U.S. pays for care. Payers from Medicare to Medicaid all the way to private insurance plans are moving toward value-based care, with reimbursements tied to patient outcomes. These shifts necessitate taking a proactive approach, with cognitive solutions giving us a new lens through which to make key decisions about optimal care management.
In a value-driven world, we have a shared incentive to prevent the onset of disease. By properly tracking the sickest and riskiest patient populations — and helping them avoid the worst outcomes — we are able to improve care, decrease costs and ensure success in a value-based system. Employing cognitive solutions to improve population health management is not only the optimal way forward for patients, payers and providers, we think it’s the only way forward in an increasingly quality-rooted system.
(2) Gonzales, J.S., et al. (2008). Depression and Diabetes Treatment Nonadherence: A Meta-Analysis. Diabetes Care (12). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19033420.