Putting healthcare data and analytics in the hands of the community

Health and healthcare are local. From the family doctor who treats our kids, to the neighborhood grocery store, or the recreation center that offers free yoga classes, each community has its own health footprint. Because of this, community is core to health and is critical to achieving population health goals.

Recently I attended the Jefferson Population Health Colloquium in Philadelphia and had the opportunity to hear Humana present on their Bold Goal program – an incredibly ambitious national initiative to help make the communities they serve 20 percent healthier by 2020. Anyone who knows me, knows how passionate I am about the power of community. So I was really excited by Humana’s program because everyone at the conference was talking about engaging communities to improve population health – but Humana is actually doing it.

Their vision is to create a powerful network of locally-based associates and community partners – powered by data and analytics – to create measurable change. To learn more, I spoke with Vipin Gopal, Ph.D., Humana’s Enterprise Vice President of Clinical Analytics, and Saradhi Balla, MS, Analytics Consultant, about lessons their team learned from a data analytics perspective as they tackled this formidable task. They outlined four key things:

#1: See the big picture for a population’s “whole-health”
When a cross-functional group of leaders at Humana sat down to plan the initiative that would later become the Bold Goal, they were keenly aware of the challenges of changing ingrained social behaviors. “We started out by thinking creatively about what information we could use to deeply understand and influence population health,” said Vipin. To do this, the key was to capture a comprehensive view of health and health drivers in any given community in the U.S., prompting the development of robust, community-focused analytics and visualizations.

Vipin’s analytics team, in partnership with the broader Humana Bold Goal initiative, initially looked at financial and utilization-driven metrics like costs and number of hospital admissions per year. They then examined clinical condition information, such as prevalence and severity of chronic conditions, and how they differed by region. Finally, they brought in external data on social determinants such as income, education, access to healthy foods and more, from sources including the Robert Wood Johnson Foundation, U.S. Centers for Disease Control and Prevention, and the U.S. Census Bureau. Recognizing that healthcare service utilization is only one indicating factor of overall health, they used this combination of data to understand communities from not just clinical, but from a broader social perspective as well.

#2: Present the data so users can draw actionable insights
With the project’s large size and ambitious goals, Vipin’s organization was faced with an enormous amount of complex and varied data that needed to be analyzed and presented clearly and quickly. This led to their collaboration with Qlik. “Our teams have been working together in one way or another since 2013,” said Vipin. “We knew we could rely on their powerful visualization tools to help us move the needle for this ambitious project.”

A cross-functional project team from various parts of Humana created the requirements, with significant attention given to how best the data would be visualized. Following development and extensive testing and validation, the resulting dashboard offers users real-time, on-demand data access with the ability to drill down to community-specific information based on geography, clinical conditions or other parameters.

“We frequently hear from users how easy it is to digest the data and drill down to the information they need to focus on,” said Saradhi, who was the technical lead on the project. “Prior to the dashboard, users would have to make an ad hoc request for a report that needed manual work and took time. Now, they’re able to pull what they need on the go, right in the meeting.”

The dashboard makes it easier to identify the top morbidities, as well as the trends, in each community, and displays well-organized metrics in a meaningful fashion. “Putting a bunch of data in a spreadsheet doesn't create a meaningful discussion,” said Vipin. “What matters are insights that are actionable. Qlik, provides, for example, a visual of chronic conditions that gets to the insights in the data. We can look at 50 conditions and then zoom into two that really matter for a particular community. That’s an incredibly powerful thing.”

#3 Put the data in the hands of the users
Improving population health is not easy. When Humana embarked on the Bold Goal journey, they were faced with the question, “How do we logistically do this?”

“This is not an effort that we can execute solely from corporate headquarters. We engaged associates all over the country to make a difference in this work,” said Vipin. “The sheer volume of data that needs to be analyzed is so enormous that we knew we needed to manage it at the community level. Health and healthcare are local, so if we wanted to affect change, we should put the right information in the hands of our associates and community partners. That’s when we started to think creatively about what kinds of data we could use and how”

The dashboard highlights where to focus improvements for meaningful gains by providing a comprehensive view of each community. Data becomes information for discussion about the combination of actions, programs, and partnerships needed to achieve goals. Understanding each community’s social determinants for driving healthy outcomes gives associates the ability to identify and engage the best local partners, whether that’s a pharmacy, a grocery chain or the neighborhood YMCA.

#4: Partner with like-minded community organizations
The Bold Goal program works by creating Health Advisory Boards – teams of nonprofit and community leaders, healthcare professionals and Humana associates – who together identify key findings on the top barriers to health for that population. These insights lead to partnerships and real change, with early results showing that the program is working.

In San Antonio, Texas, Humana associates are addressing community diabetes and behavioral health issues in partnership with H-E-B grocery stores and the San Antonio Food bank; members have shown a 23 percent increase in completion of health risk assessments. In Louisville, Kentucky – a community with a high prevalence of diabetes and respiratory conditions – diabetic members have increased statin therapy by 15 percent, and a pilot program focused on asthma that leverages the Internet of Things, provides inhalers that transmit information about air quality, temperature, and spikes in either to members. “If we help members manage their health better, they’re going to the ER or inpatient hospital less, catching things before it’s too late,” said Saradhi. “The bottom line is the improvement and analytics plays a big role.”

“It is an aspirational goal and many things need to come together to move the needle,” added Vipin. “Data and analytics are critical components, without which we couldn't identify the key drivers and bring the insights to the forefront easily.”

Putting the ability to analyze data into the hands of people on-the-ground has been essential to the Bold Goal program’s success, empowering each community to drive health changes from within. The vast amount of data involved required a data visualization solution capable of pulling from multiple, disparate sources, providing drill-down capabilities and displaying trends. It’s this deep, local understanding of the health landscape that is critical, as it has allowed Humana’s associates to identify each community’s unique pain points and make the case for specific areas of change intervention. For any population health program to be successful, data must be accessible by everyone involved, understandable, and result in actionable insights.

About the Author
With nearly a decade of healthcare analytics experience, Joe Warbington has helped some of the most complex healthcare organizations in the U.S. gain insight into the massive amounts of data captured in their medical and back office systems. Prior to joining the Qlik Healthcare team, Joe led the customer-facing clinical intelligence and data analytics team at Epic. He has helped organizations reach HIMSS Stage7, attest for millions of dollars in Meaningful Use bonuses, and advance care with actionable population health analytics for patients with various chronic diseases. Joe is based in Madison, Wisconsin USA - home to cheese, beer, and healthcare software.

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