Jack’s Story

By Marc Malloy

Summarized Transcript of Speech Delivered To World Congress 2nd Annual ACO Population Health Conference

A few weeks ago, a patient of ours – let’s call him Jack to protect his privacy – was discharged from Mission’s Memorial Hospital after fighting a serious battle with sepsis.  He received great care at Mission, which has a highly effective care process model in place, but that’s just the end of the story.

Jack arrived at Mission in the Ford Escape vehicle that is used by our Community Paramedics. Our CaraMedic (that’s what we call them) was there to visit Jack in his home and upon checking vitals quickly, concluded that Jack needed to be in the hospital right away. Sepsis, as you may know is serious infection of the blood and untreated in short order, it is often fatal – minutes and hours matter. Jack was placed in the Mission badged car and driven straight to the ER, where notified clinicians were standing by to begin the immediate treatment of IV’s and antibiotics to save Jack’s life, and yet that’s not all.

The CaraMedic was in the home because Mary, a nurse in our care management team, had been working with Jack telephonically helping to ensure that he got the right care at the right time and place. On this particular day, Jack reported no new signs or symptoms, and yet Mary sensed that something just wasn’t right.  Now, you can call it intuition or a gut feeling, but I prefer to think of it as a qualitative analysis. Based on that, Mary called the team and asked for a visit that day.

Mary, of course, only knew of Jack because he emerged from our data analytics as a patient with chronic disease and a patient activation score that indicated that he needed much more guidance and help than other similarly situated patients. Of course, the analytics would not have been possible without data architects, database developers, and systems engineers. Much as we call all employees in the hospital system ‘caregivers’, all the people in our population health efforts are ‘care coordinators’.

So why did I tell you this story? First and foremost, it’s a real patient experience that highlights what we do and why we do it.  I presume that all of us have those days of endless meetings, inboxes full of noise and distractions that have little to nothing to do with our mission to improve our population health strategies.

Why tell you the story in reverse? We have developed all that we have by following Covey’s advice – beginning with the end in mind.  We wanted a model that would hit the major aspects of improved clinical outcomes, low costs, and an excellent patient experience. Jack’s story illustrates that we seem to be delivering on that front.

I also wanted you to see that the end result was the continuation of work that started with data that had been transformed into actionable information.  Actionable information is the currency of effective population health; it’s pure and rich in content. It’s timely and in this case, it can save a life. We are awash in data, but rarely information – and even information itself, is not enough. Back to the inbox – we bemoan that we have ‘300 unread’, but the truth is that within the 300 is the one or two that you not only need but want to drive your initiatives forward. The rest waste your time and create inefficiencies – even barriers – to getting the real work done. 

Clinical data is much the same way; it must be actionable information.  In each step along the way, more actionable information emerges from the start to finish.  Jack’s information started with a flat file from Medicare, was enhanced by data analytics, further enhanced by risk screening, Mary’s work, her qualitative analysis, the CaraMedic visit and eyes-on-patient, and the transmission of that data to the ER personnel – all of it was valuable and accretive to the point where the outcome was nearly certainly assured.

With our limited capacity to process the swirl of information swirling around us, we must find ways to discern the stuff that matters from that that does not. As we develop systems in population health, finding the relevant actionable information is ever more important. It’s rarely the case that we don’t have the ability to get the information that we need – it’s more likely that our time and attention is consumed by information that is at best not-actionable, and at worst completely irrelevant.

So we’ve taken on the task of trying to make certain that every process supports the purpose, and while we are far from perfect, we are getting better.

For motivation, I often reflect on Jack’s story and rather than feeling smug that we built a good system, I worry about the other Jacks that were not discovered – when was there a distracting piece of information that blocked our vision at a time that we might have intervened in a meaningful way.  While this causes real anxiety, it is also the rocket fuel that drives us to build ever better models to reach even more people in the population we serve.

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