Nemours

Alexander Koster

At the end of 2020, amid the COVID Pandemic, my department was celebrating a win during what had been a very difficult year.    Despite clinic closures, a move to virtual visits, parents’ fears about bringing their kids out to public settings, and more, we had somehow managed to provide routine vaccinations to as many children in 2020 as in 2019.    This was before COVID vaccinations provided the confidence that brought many families back into Primary Care, so the fact that we were able to achieve this success despite the pandemic was cause for celebration.   It took a lot of effort, including vaccination tents, community events, replacing unused sick visit slots with more well visits, and copious amounts of texting and phone calls and patient portal messages and emails.   A lot of outreach.    More than we had ever done before.    

As the Director of Analytics and Technology for our Value-Based Services Organization at Nemours Children’s Health, my role in this work was to lead the team that identified the populations to target and help coordinate the messaging.    Active primary care patients, with a gap in care, not deceased, not contraindicated, XYZ age range, no “do not contact” communication preference, etc.  Our lead data analyst had a “rinse and repeat” query written to check all of the boxes for the different communication modalities, and filter the lists by geography/PCP/payer based on the specific gap in the care we were tackling at the time and clinic capacity.   Our job was also to measure and trend our performance for the HEDIS- related “Gap in Care” measures.    And by year-end we were celebrating.   We had improved our vaccination rate for the flu from under 38% to over 42% by year-end when compared to 2019.  This meant that an additional 5000 children had documented flu vaccines in 2020 compared to 2019 despite the Pandemic!  A win for sure (Note:  flu season runs from July to June, but we measure our progress at year-end because we typically administer the majority of our flu vaccines in the Fall before the Holidays).

By the end of 2020 we had hit 4 out of 5 of our prevention goals for the year, projected great scores and payouts from our Pay-for-Performance (P4P) contracts, and started the poster-and-conference submissions work to talk about how we did it all.   Soon after I was invited by two Nemours executives Dr. Kara Odom Walker EVP and Chief Population Health Officer, and Cindy Bo, SVP Delaware Valley Strategy to help support the creation of a new Health Equity Dashboard for Nemours Children’s Health, modeled after the great work by Children’s Minnesota.    After much debate, analysis, consideration and reconsideration we chose flu vaccination rate as one of our first three equity measures to examine across populations.   We knew there were disparities between populations, with a much lower vaccination rate among our African-American patients, so it seemed like a prime candidate.  The data was relatively easy to gather - it could be drilled down by location and physician, and the N was high – all good characteristics for an initial measure to learn from.   What we were not expecting from this equity analysis was to find that our great success during the 2020 flu season, built upon repeated texting, emailing and portal messages, did not result in improvements for our African-American patients.   In fact, despite the overall rate improvement, our disparity in flu vaccination rates for African-American patients actually got worse.

Another study we kicked off around the same time involved examining our telehealth usage and disparities during the pandemic.  With Drs. Edward Mougey and James Franciosi as lead investigators, we explored not only patient demographics (REaL and financial class) but also community characteristics down to the census block.   We identified that Telehealth was not as accessible to households whose native language is not English, lower education rates, lower income rates, and without access to broadband internet.    Our data supports the increasing inequity among those who are and are not able to access and utilize technology, a digital divide in pediatric telehealth.

What these two projects had in common is that they were facilitated by analytics capability that was put in place before the requests for the data emerged.  The models exist, can be repeated, and can be scaled with some fairly basic resourcing.   We built standards, informed by system SMEs, because we knew they would be needed eventually.

Like many health systems today, we have workgroups of leaders focused on diversity, equity, and inclusion, disparities in patient outcomes and prevention rates, turnover rates among our under-represented staff, and more.    These groups are actively working on community outreach strategies, education, budget planning for interpreters, patient experience transformation, and recruitment strategies.   From my seat on the Analytics and IT side, a lot of the planning will ultimately translate into requests and tickets, new projects and additional data work for my team.   It is critical work that will engage the team and help drive improvement, but it is not the only work we can do.

“As IT leaders we can help drive change through the way we think of our tools, the standards and expectations we set for our data analysts or BI developers, the way we coach our analysts to interact with data requestors, and the way we share expertise for technology projects.”

As IT leaders we can help drive change through the way we think of our tools, the standards and expectations we set for our data analysts or BI developers, the way we coach our analysts to interact with data requestors, and the way we share expertise for technology projects.   Unlike health system advocates and leaders that have to walk a fine line politically as they co-author or co-sign policy statements and public letters, we are able to promote insight about health disparities through the much less controversial lens of technical specifications or approaches to analysis.   We can help educate our customers about the importance of building an equity lens into every dashboard, every pathway, and every new digital health tool or system by referencing ROI and the benefit of broadening the audience for new products.   We can explain how this data and analysis are critical to quality improvement, better performance on payer contracts, and every population health strategy.   Our analysts have the amazing power to introduce new concepts to a new audience with a simple “hey, check this out”; “did you see this in the data?”; or “I built this extra data sheet for you”.  

Our improvement work during the pandemic in 2020 is still a source of great pride, with great lessons in teamwork, in leveraging technology and analytics, and in being nimble to pivot our care delivery models in response to unexpected change.   What makes me even more proud, however, is knowing that thanks to the lessons we learned through our disparities work, and the analytics models and capabilities we had the foresight to build, we could do it all again even better, for all our patients, tomorrow.