The population state-of-health (SOH) analyzer is a
provider-centric patient risk predictor and care management analytical
application. SOH models use sophisticated but clinically accepted
disease model algorithms to compute
a score from 1 to 100. The analyzer uses electronic health record, claims,
and pharmacy data for each
patient at each encounter (visit) for each chronic disease, with points
assigned for indicators of potential risk. The SOH model uses
patient age, gender, ethnicity, family history, all clinical factors (such as
BMI, lipid panel, blood HM, HcA1C) and comorbidities to calculate an accurate
SOH score. The model does not use prior inpatient or emergency department
admissions as an input (the inputs to the models are purely clinical). A cumulative low score indicates excellent
health, and as the number increases, so does the likelihood of high cost
interventions and/or hospitalization within 12 to 18 months. Disease-specific
SOH scores represent the risk of high-cost intervention and hospitalization of
the patient for the particular disease. The overall composite score across all
diseases represents overall risk for that patient factoring in all the disease
conditions and comorbidities.
scores are used to stratify populations by risk—high, moderate, and low. More important, the average SOH score for a
population over time indicates care effectiveness. A trend that shows
decreasing average population score means the population is getting healthier. SOH
stratification provides actionable insight and measurable information about
actual health at population and patient levels, with visibility of controllable
and uncontrollable factors. If the SOH
score trends down over time, health is improving because the quality of care is
improving, providing a measure for the quality of primary care.
accompanying two exhibits illustrate how the SOH analyzer is used for stratifying
a population to into risk cohorts.
For more information, see Jay Reddy and Karen Kennedy's "From Medical Home to ACO: A Physician Group's Journey", hfm, September, 2013
Jay Reddy, MBA, is CEO, PSCI
Solutions, Allen, Texas.