John Showalter, M.D., CHIO, University of Mississippi Medical Center, explains how he created population health monitoring programs to help identify high-risk patients that should receive extra attention to reduce readmissions.
He said electronic medical record data can be mined for information by smart computer algorithms to identify risk factors beyond clinical vital signs and test results. For example, if a heart failure patient has several doctor visits in his medical record for things that might be related to his heart failure symptoms, but there was failure for patient followup leading to a hospital admission. The algorithm also looks at things like the patient's address and its distance to their pharmacy, their socio-economic level and if they have a car and drive. He said these non-clinical factors outside of the hospital can have major impact on the ability of the patient to maintain medication compliance to help keep them out of the hospital.
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