Eliminating essential gaps in care starts with data

It took 27 weeks for physician visits to return to pre-pandemic levels after COVID-19 emerged, and some specialties, such as gastroenterology, nephrology and urology, have been slower to rebound than others, an MGMA analysis found. This raises the risk that outcomes for complex conditions could worsen due to delayed care, especially among populations that struggled to access care before the pandemic.

Now, leading practices are exploring the use of data to detect complex conditions sooner, identify treatment options faster and empower patients to be more engaged in their care.

How can healthcare organizations lean on data to eliminate essential gaps in care and improve health outcomes for vulnerable populations? Here are four approaches to consider.

No. 1: Look for trends among missed and canceled appointments. For example, the MGMA analysis revealed that seniors were likely to cancel preventive screenings due to fears of contracting the COVID-19 virus in a healthcare setting. A deeper dive into the data showed that missed screenings were especially prevalent for chronic kidney disease and prostate cancer. With data such as this in hand, physician practices and health systems can devise creative ways to encourage individuals to get caught up on recommended screenings, such as through mobile or pop-up clinics, early detection kits sent by mail, or in-home laboratory services or clinician visits. Data-driven efforts to support early detection of disease can make a profound impact on health outcomes. Prostate cancer, for example, has an extremely high one-year survival rate—around 100%—when it is detected in stages 1, 2 or 3, but the survival rate falls to 87.6% when it is detected in stage 4. This is an instance where early detection can lead to longer survival.

No. 2: Make it easy for medical assistants to ask questions that inform discussions at the point of care. An American Medical Association expert estimates physicians could reduce administrative tasks by up to three hours a day by more effectively leveraging medical assistants. One urology practice in San Diego, Genesis Healthcare Partners, uses innovative technologies that prompt medical assistants to ask relevant, specific questions that help identify risk for disease or—for patients with a history of disease or chronic illness—ascertain where patients are in their care journey. This safely delegates data gathering to non-providers. It also gives physicians a comprehensive view of the patient’s medical history at a glance, supporting deeper, more nuanced conversations that inform medical decision-making and in-office follow-up. With this approach, the practice identified new treatment options for 45 patients with prostate cancer.

No. 3: Automate clinical workflows for more timely data capture and proactive follow-up. When physicians do not have the data they need at the point of care, such as lab test results or imaging scans, this diminishes patient trust at a time when some individuals already are fearful of in-office care. It also increases operating expense for specialty practices, which must engage in extra work following the appointment to track down missing information and reengage patients. By using automated tools to detect information gaps and prompt clinicians and assistants to obtain this data prior to the visit, specialty practices can eliminate “wasted visits.” Further, artificial intelligence-based solutions can prompt patient navigators—health professionals who help facilitate access to care, including for individuals with complex care needs—to proactively check in with patients who have delayed screenings or follow-up visits during the pandemic. It’s an approach that supports earlier detection of disease and better health outcomes. At Genesis Healthcare Partners, when the practice used AI to prompt proactive follow-up with patients based on risk factors such as delayed screenings and diagnostics, 20% of the patients who responded were found to have progression of their prostate cancer.

No. 4: Explore data-driven care coordination. Studies have shown that the use of patient navigators to assist patients with chronic conditions reduces costs and improves outcomes. When patient navigation support is paired with data-driven navigational workflows, navigators receive automatic nudges to close gaps in data, such as by scheduling lab tests or imaging scans, uploading results and ensuring that physicians receive the information. For Genesis Healthcare Partners, use of data-driven workflows for care navigators has improved symptoms of disease among prostate cancer patients and reduced side effects while enhancing patient satisfaction. It has also strengthened the practice’s bottom line, increasing Chronic Care Management (CCM) revenue by $12,000 per month.

A Data-Smart Approach to Post-COVID Specialty Care

At a time when two out of three individuals are not receiving recommended cancer screenings and more than half are skipping or delaying routine care, patients’ risk for serious health issues, including disease progression, is rising—and specialty practices need to be prepared. By taking a data-driven approach to detecting chronic or complex conditions, identifying treatment options and engaging individuals in their care, specialty practices can enhance patient outcomes. They can also help avoid bottlenecks in care while strengthening revenue. It’s a data-smart approach that ensures the right resources are used in the right way, creating a better experience for patients as well as physicians.

Shirley H. Lee, CRNP-FNP, MPH, is Vice President of Clinical Strategy for Preveta, a care coordination platform for specialty care. She is also the director of a patient navigation program and a nurse practitioner for the Greater Los Angeles Division of Genesis Healthcare Partners, PC. Lee is a graduate of the Johns Hopkins School of Nursing and Johns Hopkins Bloomberg School of Public Health.