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.

SOH 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. 

The accompanying two exhibits illustrate how the SOH analyzer is used for stratifying a population to into risk cohorts.

Exhibit 1

Web Extra_Reddy_Exhibit1

Exhibit 2

Web Extra_Reddy_Exhibit2

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.

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