Population Data Analytics
Population health management represents a new era of knowledge in healthcare. It is an interdisciplinary approach that focuses on the health outcomes of a group of individuals. Health is viewed as the product of multiple determinants (genetic, social, behavioral, environmental) that interact to create disparities of care among different populations. The aggregation of evidence-based data through electronic medical records (EMR) will provide physicians with a comprehensive clinical picture of each patient, as well as the impact of the environmental characteristics of the community itself. The SUNY Global Health Institute will provide leadership in genomics and population health data analysis to support physician decision-making in yielding better patient outcomes for the communities. The knowledge generated yields insight on predictive disease risk, quality of care, and future strategies for both the individual and population as a whole.
Better outcome in chronic illnesses are due to proactive follow-up by the care team; patient interaction cannot be left to chance. Data analytics supports physicians in understanding and tracking the state of a patient’s health. Inefficient and expensive care is marked by a lack of timing in clinical intervention. Whether it is failing to prevent a patient’s T2D, or failing to prevent a patient’s T2D-induced stroke or amputation, better informed decision-making improves the patient’s health outcome and reduces cost. With evidence-based data analytics, your primary-care-physician is held directly accountable for the outcome of your health. Quality care does not end at diagnosis and prescription; it extends to assuring that the comprehensive profile of the patient’s health is correctly considered when crafting a long-term plan of care. The Sheehan Patient First Initiative will improve clinical effectiveness and patient satisfaction, while reducing healthcare costs in the communities with the power of big data analytics.
This health disparity of T2D is not solely due to diet, exercise, and other environmental factors. There is growing evidence that genetics play a significant role in increasing the risk of onset. Furthermore, in assessing a patient’s diabetes state, health factors vary in priority depending on their genome. Benchmarks of care and screening thresholds should be based on evidence-based data from population-specific research and studies, not arbitrary guidelines.
Proper management of T2D is a daily struggle that can be eased with proper medication. Unfortunately, for many patients, side effects and personal tolerance leads to unfavorable health outcomes. Whereas a drug may help someone maintain stability, the same drug may cause dangerous drops in glucose in others because of differing genetics and environment. Decision-making on a plan of care should involve the patient and include valuable information about their genome, phenotype, and culture. SPFI seeks to support community healthcare practitioners in providing effective personalized care tailored to the patient’s behavior, traits, and needs.
Patient Health Monitoring
Type 2 Diabetes is a chronic disease that requires long term management and continuous effort to improve and maintain health. Typically, a newly diagnosed patient with T2D visits their doctor for a check-up every 3 months. Care is administered based on the results of the visit. However, what happens during the 3-month span when the patient is out of the clinic?
During that time, a patient’s health can worsen significantly without obvious symptoms. It is critical to implement systematic follow-ups to determine patient compliance to the plan of care and the state of their health. Community organizations can play a significant role in supporting a patient in managing life with their prescribed care plan. Community involvement through compliance follow-ups, lifestyle intervention support groups, or simply sharing diabetes stories increases the likelihood of the patient reaching their treatment goals.
Patient-centered care is challenging because physicians are typically outside of the sphere of a patient’s day-to-day activities. With telemedicine, the patient can partner with his care team and integrate them into their daily lives. Interventions become more timely, as the patient’s health risk is more frequently assessed. The occurrence of preventable complications are reduced, as care is more comprehensive. Health outcomes improve, while care is more cost-effective for both the healthcare provider and the patient.