Robust analytics can aggregate all of that data to build a more complete longitudinal view of each patient’s current health, risk and cost profile. These profiles can be compared against pre-established personas that classify patients who have similar attributes, and an “impactability” score can be developed for each. The data can then be placed into a dashboard that makes it easy to see which patients currently have care gaps and what impact closing the care gaps will have.

This information enables the health care organization to know where to focus. By dedicating care management resources to areas that will affect clinical and financial outcomes most positively, such as recommending a weight management program for a patient who has chronic hypertension and a higher-than-desired body mass index. It also helps prevent the organization from expending resources where they will make little difference, such as on a patient where attempting to close care gaps is never effective, or closing those gaps has very little to no effect on his/her health outcome or cost avoidance to the provider.


Financial impact
Analyzing clinical and claims data in tandem impacts more than patient outcomes. It can also provide valuable financial information that helps health care organizations navigate the transition to value-based care.

For example, it can show how much the organization is being paid to manage specific populations, helping executive management set priorities for improvement. It can also show whether current investments are delivering the desired results. By using predictive analytics, the organization can determine whether proposed program changes will have a positive or negative effect, while prospective analytics use the data to help health care organizations select between several potential courses of action.

Another area that can be impacted is resource utilization by population and facility. In other words, if a particular hospital is seeing a higher-than-average number of asthma patients in the emergency department, the organization will know that dedicating more resources to education and prevention is likely to have a direct impact on reducing its risk exposure. Organizations can go as far as segmenting the asthmatic population into cohorts to understand those with the greatest risk, as well as which gaps should be closed first in order to achieve the greatest clinical and financial outcomes.

Health IT Homepage