Goal: Use Data to Enable Investment and Policy Decisions
The information required for data-informed delivery and management is produced in a learning cycle where care delivery provides data that is in turn used for population-wide analysis. Data becomes a tool to support action, whether focused on creation of public policy or investments in resources or programs.
Ben’s Story
Ben is a data scientist that works for a large, networked health care organization. He spends his days pulling together information about how Vermonters’ are cared for, their health outcomes, and how health care is paid for, so that he can understand trends in the health care system. For instance, recently Ben looked at a care management program his organization instituted which identifies people with poorly managed chronic diseases, like diabetes, and links them with a care manager who helps them get to appointments, manage nutrition and prescriptions, and learn how to incorporate exercise into their lives. Using information from electronic health record systems, health care surveys, claims management software, and the care managers’ care coordination tool, he learned that patients who receive home visits are more likely to see positive impacts on their health. Ben provides this information to his organization, and the care managers agree that home visits are best for patients, as they can meet them where they eat, exercise, and manage their medications - at home. Over time, Ben continues to measure the impact of investing in more home visits and he continues to see the positive trend. Fortunately, healthier patients, also means less of a strain on the health care system.
Since Ben works for such a large organization, sometimes he notices trends that are likely impacting a large portion of Vermonters. For instance, earlier this year, Ben began to notice a vaping trend in patients 18-24 and an associated increase in pneumonia cases. Ben’s organization relayed this information to Vermont’s Department of Health (VDH), who operates the Vermont Tobacco Control Program. VDH staff used this data to enhance their public outreach around tobacco cessation. VDH could also convey the trends to the Vermont legislature to consider which public health campaigns may be most impactful to Vermonters at a point in time.
Today, Ben is constrained by lack of standards across different types of data and systems and the fact that electronic health record systems are not designed to track information that is not directly related to care. If systems and standards improve, Ben will be better able to analyze data in real time, ultimately improving his organization’s ability to quickly respond to patient’s needs.