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    Leveraging data integration to manage chronic conditions


    Preventive care yields financial benefits

    This model of leveraging PGHD to scale resources and focus efforts on sick patients, while also monitoring healthy patients presents tremendous potential for the future of patient care. However, adequate prevention-based financial incentives for health systems and individual practices for these types of programs is not yet a reality.

    Brockton Hospital, part of the Signature Health System in Massachusetts, in partnership with iGetBetter, appears to be overcoming that challenge. The health system is leveraging PGHD to reduce readmissions for patients with heart failure and chronic obstructive pulmonary disorder. These efforts have led to remarkably improved patient care and outcomes, but more relevant, Brockton has witnessed a substantial cost savings. A pilot involving 31 heart failure patients conducted in 2014 aimed to reduce readmissions utilizing connected blood pressure monitors and weight scales. Data from the devices fed directly into iGetBetter’s care management portal.

    Without this intervention strategy, Brockton typically experienced a 28% readmission rate, which would have meant eight of the 31 patients in the pilot at a cost of $27,000 per readmission. In this study, zero patients were readmitted, leading to an immediate savings of $216,000. Programs like this demonstrate the immediate value of PGHD and provide a useful incentive for helping clinicians and IT staff begin to understand how to effectively capture and utilize patient data generated outside of the clinical setting.

    Opportunities for provider organizations of all sizes

    Much of the talk about leveraging PGHD is centered on work being done by large health systems in major metropolitan areas. Individual and regional practices can take advantage of contributed data without these institutions’ large IT budgets by utilizing the Centers for Medicare and Medicaid Services (CMS) reimbursement codes that incentivize disease prevention, remotely monitoring patients with multiple comorbidities, and remote collection and analysis of patient data. Outsourcing care management to third-party companies is also becoming an option. In exchange for a monthly fee, these companies will coordinate care for patients, monitor treatment protocol adherence and even offer around-the-clock nursing access to patients by phone or mobile app.

    Engaging with patients in preventive care measures, whether through mobile or other means, and obtaining access to in-time status data, is essential to improving clinical outcomes and controlling costs amidst the impending physician shortage. By capturing and integrating reliable PGHD with other EHR data to guide clinical interventions and care decisions, health systems will have an advantage that will pay off in care quality and financial returns.


    Drew Schiller is the co-founder and chief technology officer of Validic, a digital health platform provider.


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