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Health systems shifting to value-based care are using analytics to reshape care delivery and improve the lives of high-risk patients.

Aurora Health Care is one of them. Sylvia Meltzer, chief medical officer of population health and risk, is sharing what she’s learned.

1. Tell me about Aurora, and some of the goals and initiatives that lead to purchasing an analytics platform.

Aurora is one of the largest multispecialty and integrated delivery networks in the United States, with 15 acute care hospitals, about 2,000 employee providers, and about 172 clinics mainly in Wisconsin and northern Illinois.

We also have about 80 pharmacies, a visiting nurse association — it’s a very widely integrated network of providers and caregivers.

We started work on analytics several years ago with a lot of goals in mind. Our mission statement is “Helping Patients Live Well” and we wanted to do that with populations rather than one patient at a time.

We also wanted to look at populations in different ways to help drive organizational efficiency and to better prepare us for the shift that’s coming from volume to value.

2. How has the analytic platform helped you reach your goals?

We’ve used it in some key clinical uses, most recently in some high-risk heart failure and COPD patients, with an operational planner on the predictive analytic model. We’ve been able to decrease our heart failure patients in our pilot.

We’ve also been able to decrease admissions by 65 percent in that patient cohort while driving patients to a lower risk category.

We’ve embedded it in primary care redesign, our current project. There are about 700 primary care physicians in our organization and we’re redesigning how they deliver primary care, shifting to a team-based model.

It involves more population health, where the analytic tool is key.

We’re applying it to high-risk populations: COPD, heart failure and pediatric asthma. We’re using different care team members like health coaches, pharmacists and home health care, to affect patients’ lives for the better.

3. With such an extensive organization, how do you distribute data?

We disseminate patient lists. The platform stratifies patients into different risk categories and then we can choose which ones we want to work on — for example, 80 percent or higher risk for immediate need hospitalization in the next six months.

We want to operate as a program for those patients, and the platform helps us identify them so we can develop a program around them.

4. Has the data surprised you?

There haven’t been many huge surprises, but it helps us to focus our efforts. The platform allows us to benchmark with ourselves and with different regions across the country.

When we looked, we saw where we were not performing as well as other systems. We found that we have a very large cohort of heart failure patients in Wisconsin. It really helped us focus where we wanted to work.

5. How has the analytics software platform changed your business?

I think having an analytics platform has helped us begin the shift to value-based care. We’ve been able to use the data to make a business case for the new model and sell it to our providers.

The providers are very data driven, and we can show them that (a) the data is accurate and (b) what you can do with it. It has propelled us along the road to value-based care.

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