Guest Column | October 3, 2019

Leveraging The Right Ruler For Measuring Clinical Outcomes

By Amy Amick, SPH Analytics


Knowing how to properly measure outcomes is as important as having the right clinical resources in place.

If you’re not measuring your efforts against industry benchmarks, how do you know you’re making progress?

This was the question that The Consortium for Southeastern Hypertension Control (COSEHC), an organization based in Winston-Salem, N.C., sought to answer in 2015 as it embarked on a high-stakes, longitudinal program designed to improve outcomes for high-risk patients while lowering care-delivery costs.

The problem wasn’t that COSEHC lacked knowledge about how to improve health for patients who live in the region with one of the highest rates of hypertension in the country (at most recent count, nine of the 10 states with the highest rates of hypertension are in the South). COSEHC understood best practices, as well as the unique challenges of its demographic, such as the social inequalities that are a barrier for eliminating known risk factors.

The main problem was that COSEHC’s thousands of clinicians, which serve more than 2 million patients at hundreds of locations, lacked a mechanism to analyze the care gaps in their total population to drive change. In other words, providers possessed the skills they needed – they just lacked the right ruler to measure and demonstrate quality across the healthcare system.

But all of that would change when COSEHC engaged these practices by providing technical and educational services across the nine-state region in the Southeast.

COSEHC established goals and benchmarks by which to measure progress. This process proved more challenging than expected, because COSEHC’s 700+ practice sites served varying demographics. Getting everyone on the same page would be difficult – especially rural practices with few providers and limited resources. Patient data was abundant but existed in at least 30 unconnected EHRs. The lack of cohesion, collaboration and organization meant COSEHC had a tall order to fulfill.

Getting Started

For this program, COSEHC built on its earlier successes in the Southeast, including its partnership with a large health system in Louisiana, to successfully implement a primary-care transformation initiative. That experience demonstrated that timely, in-depth data — normalized across systems and participants — could help facilitate transformation and improve outcomes.

To move forward, COSEHC sought a technology partner that could support the “Triple Aim”: 1.) help organizations improve population health; 2.) reduce the overall cost of care; and 3.) improve the patient experience.

It became clear quickly that COSEHC would need some way of unifying its disparate data, so the organization selected a population health data-aggregation tool that would analyze and synthesize information from provider group EHRs. The analytics solution provided key insights into patient metrics — both at the provider level and the system level. The tool, which sits on top of providers’ existing technology stack, leverages advanced algorithms to extract quality data codes, other codified data and structured texts fields — and present them in a single dashboard format.

By culling information from multiple, disparate sources, the system helped providers to quickly and easily identify care gaps and prioritize them based on risk of the patient. By pulling all of the data into one pipeline, the analytics tool catalyzed care decisions.

For example, the data-aggregation tool helped providers to isolate high-risk patterns and trends among specific demographics: e.g., patients experiencing acute exacerbations of their hypertension who also had diabetes and needed ancillary services such as nutrition counseling or dietary consultations on an ongoing basis. It also helped providers flag patients at a high risk for hospital readmission, so physicians could intervene at more frequent intervals — such as when patient blood-sugar readings exceeded the safe threshold.

Over time, providers mastered the dashboard, and began to truly see the effectiveness of their care protocols and interventions (e.g., the correlation between medication reminders and disease flare-ups). This gave them the opportunity to offer new insights to each other, so everyone could benefit.

Better Measurements = Better Results

COSEHC empowers providers to better share, adapt, and further develop comprehensive quality improvement (QI) strategies, aligning with the healthcare industry’s criteria for innovative models.

Four years since the program began, providers have seen positive results on high-impact, high-risk measures, such as hypertension and diabetes management, as well as system-wide improvements in patient and family engagement and clinical quality.   

As of March 2019, COSEHC has achieved multiple financial and clinical benchmarks for the four-year program. The vast majority of COSEHC patients have achieved optimal blood pressure control rates in many of the enrolled practices. As a result, the group expects to see continual reductions in hospital admissions.   

Through analytics, the implementation of evidence-based clinical processes and a continued focus on high-risk patient groups, COSEHC has exceeded its own goals, proving that transformation is possible across multiple settings and demographics.

Best of all, each provider group knows where it stands at all times in achieving clinical measures, and how it fares, both with peers and to nationally recognized evidence-based target goals. Measuring the success of interventions on a continual basis helps everyone — especially the highest-needs patients. And that’s a win for all stakeholders.

This publication is supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.