A lack of real-time data hinders the ability to provide accurate and effective care. And as a manager, it's a time-consuming challenge to assess the patients currently in the hospital – and to predict those with the greatest risk for readmittance once they're out.

"The analytics platform helps me to identify patients still in the hospital and create a tailored discharge plan long before they head out the door," said Jessica Taylor, RN care manager and clinical lead at St. Joseph Healthcare in Bangor, Maine.

And since the information is updated every evening, she can reach out to those patients to provide the greatest amount of support to reduce the risk for readmission.

The analytics software used by the staff at St. Joseph sits on top of Maine's statewide health information exchange, HealthInfoNet, which allows providers to access real-time data from all hospitals connected to the HIE – not just data collected from Medicaid, said William Wood, vice president, medical affairs, St. Joseph.

Wood handles the specificity of the analytics portion, while Taylor focuses on the population health package. She's able to input parameters to check risks and specific categories, such as disease and performance limitations.

"The frequent flyers and high-risk patients, we know who they are," Taylor said. "They're right in the forefront of our tool. We can be proactive instead of reactive with care, when before we were waiting for these patients to come to us."

[Also: Maine's HIE launches analytics business]

"Most of the folks she manages, she can figure out their needs without the tool," said Wood. "But it's that middle group that hides without analytics.

"Your ability to leverage valuable care management resources is really dependent on how good the data is and what you can do with that data," he added, noting that it's about filling in the gaps and meeting those patients typically lost in the shuffle to support population health.

One of the biggest uses of the analytics software for St. Joseph has been to reduce readmissions, Wood said, which have dropped below 10 percent - about 5 percent below the state average. That includes a 15 percent drop in emergency department readmissions in a six-month period.

St. Joseph became the first healthcare institution in the state to use analytics across the state's health information exchange for its daily operations, in January 2015. HealthInfoNet, was established in 2006 and launched its analytics business in partnership with Palo-Alto, California-based HBI Solutions in early 2015.

Maine was also one of the first states to achieve full-interoperability between all statewide hospitals. HealthInfoNet connects nearly all of the state's 1.3 million residents, collecting clinical information from 32 of the 36 state's acute care hospitals and 376 ambulatory provider sites.

Learn more at the upcoming HIMSS and Healthcare IT News Pop Health Forum 2016, May 19-20, 2016 in Boston. Register here