Ideally, blood sugar, measured by an A1C test, rests at 5.9 or less. A 7 is elevated, according to the Diabetes Council. Over 10, and you’re into the extreme danger zone, at risk of every diabetic crisis from kidney failure to blindness.

This patient’s A1C was 10. Let’s call her Jen for the sake of this story. (Although the facts of her case are real, the patient’s actual name wasn’t released due to privacy laws.). 

Jen happens to live in Pennsylvania’s Lehigh Valley, home of the nonprofit Lehigh Valley Health Network, which has eight hospital campuses and various clinics and other services. This network has invested more than $1 billion in IT infrastructure and founded Populytics, a spin-off firm that tracks and analyzes patient data, and makes care suggestions based on that data. 

When Jen left the doctor’s office, the Populytics data machine started churning, analyzing her data compared to a wealth of information about future likely hospital visits if she did not comply with recommendations, as well as the potential positive impacts of outreach and early intervention.

About a month after Jen received the dangerous blood test results, a community outreach specialist with psychological training called her. She was on a list generated by Populytics of follow-up patients to contact.

“It’s a very gentle conversation,” says Cathryn Kelly, who manages a care coordination team at Populytics. “The case manager provides them understanding and support and coaching.” The goal, in this case, was small behavioral changes that would actually stick, like dietary ones.

In three months of working with a case manager, Jen’s blood sugar had dropped to 7.2, a much safer range. The odds of her cycling back to the hospital ER or veering into kidney failure, or worse, had dropped significantly.

While the health network is extremely localized to one area of one state, using data to inform precise medical decision-making appears to be the wave of the future, says Ann Mongovern, the associate director of Health Care Ethics at the Markkula Center for Applied Ethics at Santa Clara University in California.

“Many hospitals and hospital systems don’t yet try to do this at all, which is striking given where we’re at in terms of our general technical ability in this society,” Mongovern says. 

How It Happened

While many hospitals make money by filling beds, the Lehigh Valley Health Network, as a nonprofit, accepts many patients on Medicaid and other government insurances that don’t cover some of the costs of a hospitalization. The area’s population is both poorer and older than national averages, according to the U.S. Census data, meaning more people with higher medical needs that may not have the support to care for themselves. They end up in the ER, or worse, again and again.

In the early 2000s, LVHN CEO Dr. Brian Nester started wondering if his health network could develop a way to predict who is most likely to land themselves a pricey ICU stay — and offer support before those people end up needing serious care.

“There was an early understanding, even if you go back to the (federal) balanced budget act of 1997, that we were just kicking the can down the road to having a functional financial model to deliver healthcare to everyone with a reasonable price,” Nester says. ”We’ve got a lot of people living longer without more of an investment in the healthcare trust.”

Popultyics, founded in 2013, was the result of years of planning and agonizing over those population numbers and cost concerns.

“We looked at our own health plan,” Nester says. Out of all the employees and dependants on the LVHN’s own insurance network, “roughly 1.5 percent of our 25,000 people — under 400 people — drove $30 million of our $130 million on insurance costs — about 25 percent.”

“You don’t have to boil the ocean to take cost out of the system,” he says. “You just have to focus on that 1.5%.”

Take Jen, the diabetic patient. High blood sugar can lead to kidney failure, which can mean weekly expensive dialysis for 20 years. Investing in the data and staff to reach patients, he says, is “pennies compared to $100 bills.”

For most doctors, “there’s no awareness for providers to know who they should be seeing vs. who they are seeing. There’s no incentive, because the incentive is to see as many patients as you can,” he says.

To change that, first the LVHN invested in the popular medical management system, Epic. Then, they negotiated with the top 18 insurance companies that cover patients in the region to allow access to their patient care data, which means they have reams of patient history to feed the analytics machine in order to make predictions about outcomes. Nester admits not every hospital could do that — with 52 percent of the market share, LVHN had a very strong negotiating position.

Third party services take that data and churn out analytics that feeds models and care management plans. All identifying information is stripped from the data.

“We can do predictive modeling in patients,” says Populytics President and CEO Gregory Kile. “We can identify care gaps. Those care gaps are noted as alerts when the patient presents at the office.”

Kile uses himself as a hypothetical patient.

“I pull up Gregory Kile, and boom, I see a flag or an alert. I see he hasn’t been in for his last blood test. There is a care gap there we need to complete.”

“There’s just so much more you can do with that information,” he says, envisioning a future where follow-up for, say, knee replacement surgery and outcomes could be tracked, and either validated or changed.

Ethical Issues at the Forefront

Of course, embracing data use in such specific ways also brings up issues of security and patient safety. For example, says medical ethicist Mongovern, there are many touchpoints where breaches could occur. The public has a growing awareness of how data used to personalize their experiences, such as social media analytics, can also be monetized and sold in ways that benefit a company, but not the user. That’s not to say data supporting medical decisions is a bad thing, she says, just one with potential for public distrust if not handled thoughtfully.

“You’re going to need to do this to stay competitive,” she says. “But there’s obviously big challenges, not the least of which is patient trust.”

Among the ways the LVHN uses the data is monthly reports they call registries, which include patients who have just come in contact with the health network, either through the hospital or a doctor that works with them. The community outreach team members at Populytics take the names from the list, pull their records, and start calling. So far, a majority of the patients targeted – 62 percent — appear to embrace the effort.

Says Nester: “Most of these are vulnerable people who are thrilled to have someone care about them. So they engage, and when a person engages in their care, they take their insulin shots. It’s not rocket science. The rocket science is in identifying who the people are — the delivery of care is easy.”