CareSkore Population Health Management Blog

Bridging the Gap: Why Providers Must Marry Clinical and External Data

Clinical data has and will continue to set the foundation for care quality improvements. The data, however, that informs patient-specific risk assessments—readmission, attendance and likelihood of payment—is nowhere to be found within the confines of a hospital. Integrating external data now becomes essential but obtaining this data can be challenging. It’s high time providers be able to understand patients beyond looking at clinical encounters. By tapping into this underutilized source, the path to improving outcomes become more evident.

Cue Clinical Data

Clinical data, sometimes referred to as internal data, is fundamental to improving the health of your patients. This includes data from:

  • Your EHR(s)
  • Labs and pharmacy feeds
  • Health assessments
  • Registrations and claims 

As it provides background on conditions and risks relative to a patient, it’s the only source of information for many. In most cases, providers can only leverage data recorded within the hospital’s ecosystem. But this information alone doesn’t tell the whole story.


Meet External Data

In order to improve outcomes, you need to introduce external data into the care continuum which includes:

Geographic data

How close does your patient live from the hospital or nursing facility? Location and proximity data influence whether your patients will attend, cancel, or fail to show up to appointments.

Economic data

Does your patient have a job?  Can she pay her bill?  What’s her claims history and credit score?  Each factor can help inform likelihood of patient bill payment, and help you account for that likelihood in your financial model.

Social data

Does your patient live alone or is there someone to assist her in understanding instructions for care, to make sure she takes the medications you’ve prescribed? Is a professional caregiver checking on the patient periodically?  Is she being cared for between appointments?


Where Clinical and Environmental Meet

One universal challenge for most hospitals is systematically identifying at-risk patients during an initial hospitalization, a key condition for modifying a patient’s post-discharge risk of readmission. For that you need to understand the many factors involved. Marrying together clinical and external data permits you to:

  • Predict and Risk-Stratify

A cohesive system-of-record and engagement combines risk predictions, chronic disease criteria, or utilization thresholds with patient-to-provider referrals or assessments for a complete picture. This shifts onto ongoing predictions in real time, based on combination of clinical, labs, demographic and behavioral data that identifies patient populations at-risk for poor outcomes or unnecessary intervention—which EHRs alone aren’t able to support. Ultimately, doctors, nurses, and care teams know what patients to focus on the most at a time of need and opportunity for impact.

  • Engage Patients

You can respond to changes in your patients’ conditions and uncover issues and factors that, if addressed using effective interventions, will improve care and reduce the need for expensive services—particularly ER visits and hospitalizations. Personalization—in tandem with automation that does not demand the need to increase nurse headcount—creates an individualized experience for patients whether it’s disease specific workflows and care plans. As a result, you can actively manage risk factors such as readmission, mortality, length-of-stay, compliance, and adherence risk and ultimately improve your patients’ health.


Choosing the Right Technology

Providers need to adapt to the changing healthcare landscape. The first step to doing so? Integrating clinical, social and economic data from multiple sources: your data warehouse, EHR, claims records and external. By applying technology, you can focus on the data that is meaningful to a particular patient at a given moment and predict whether patients adhere to medications, are most likely to readmitted, or pay their bill. In this new era of value-based care, having a complete 360-degree view becomes table stakes. A population management platform that enables this by not only aggregating actionable data from multiple sources, but empowers the entire care continuum is becoming a must-have.




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