The act of collecting data doesn’t do much to improve patient care without the right processes, platform and people working together to make that data actionable.

Joe Conte, executive director of Staten Island Performing Provider System -- New York’s most successful branch -- has mastered that approach and brought real change to the health system. 

At its core, the PPS has set up a platform to ensure its 75 partners have solid data to make the best business and clinical decisions.

“Everyone has different levels of competency,” said Conte. “Even some larger organizations don’t necessarily have the best capabilities and can get overwhelmed with information.”

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Staten Island PPS leverages a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse.

Conte explained his team uses hot spotting and geomapping to really tease out pieces of information that they wouldn’t necessarily see if the data was pooled from one source.

“It provides a more complete picture of the population health than we would have individually,” said Conte.

One of the most crucial components is viewing cultural background of Staten Island PPS’s patient population. Conte said that all these variables of social determinants are added into the data warehouse and included into its formulas.

“Not only do we come up with common diagnoses, we find some interesting observations,” said Conte.

For example, the Liberian community is very large on Staten Island, and Conte said his team found high incidents of a certain condition. Another community in the area was more prone to asthma.

“Social determinants of health data is almost as important a variable as blood pressure,” said Conte. “It’s interesting if you’re a policy wonk. You can work with these community organizations to design programs to meet those needs.”

Using its data, Staten Island PPS now works with various community partners to provide obesity education programs in schools and free food access for people who live in public housing because there’s less access to fresh produce, along with other programs that educate its population based on specific health needs.

“We live in a world where many things are connected under the surface, and so many of these connections put into focus where we should make investments,” said Conte. This includes clinical programs and training.

“We realized there were very few community health programs that would truly reach these communities,” he added.

Staten Island PPS and its community partners also send staff into patient homes to address issues that may be contributing to a health concern, Conte explained.

“The idea of working with community-based programs increased over the years,” said Conte. “Even with the best clinical care, it only affects 30 to 40 percent of outcomes. The rest is affected by housing, education, food security, literacy and poverty.”

“That’s the sweet spot of community-based organizations, so we’re learning a lot from people we didn’t think we could learn much from. But it’s an eye opener,” he added.

Even with a solid value-based approach to care, Conte explained that you can’t really make an impact on patient health without realizing what others are doing. People have various providers, so it’s important to exchange information between providers in the community.

“It’s not an expensive proposition. But collecting those social determinants will give you a deeper understand of your patient’s needs,” said Conte. “There are some things that you won’t be able to change about some populations, but you can moderate the effects by understanding where they’re coming from and getting your clinicians to understand those needs and work within those parameters.”

“Understanding the power of big data doesn’t mean having a lot of it,” he added. “It means figuring out what’s important in your circumstance.”

Conte will speaking at the upcoming HIMSS and Healthcare IT News Big Data & Healthcare Analytics Forum in Boston, Oct. 23-24, 2017. Register here. 

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com