Figure. PCCI Pediatric Asthma controlled analysis. Comparison 1: DFWHC Medicaid <18 yo:
5% drop in asthma ED visits. Comparison 2: All Health Plan Members <18 yo: 10% drop in
asthma ED visits. PCCI Asthma Program: 31% drop in asthma ED visits.
November 2018 Dallas Medical Journal 17
Improving practice performance
In the DFW area, 21 community
practices — including the two largestvolume
Medicaid pediatric providers,
Parkland Community Oriented Primary
Care Clinics and Clinicas Mi Doctora —
participate in the program, now in its fourth
year. They receive monthly work list reports
to facilitate proactive preventive steps
as well as progress reports and, in some
cases, EMR real-time alerts embedded
in their EMR. These activities resulted
in 32% to 50% improvement in asthma
controller medication prescriptions and a
5% improvement in the asthma medication
ratio, a published best-practice Hedis
metric. The injection of analytics into care
has spurred further frontline innovations.
Some clinics are using the reports to
redesign asthma care delivery programs
and roll out shared medical appointments as
needed, and to guide spirometry scheduling
and testing.
Personal engagement technologies
enhance the patient experience
High- and very high-risk patients engage
with their care system through succinct,
precise and educational text messages
delivered by a simple effective mobile
platform. Patients are surveyed about
their condition, have emergency inhaler
use monitored, and are reminded of
appointments and medication refills. These
innovative features allow the clinician to
continuously monitor symptoms to ensure
continuity of care and positive outcomes.
Patients have displayed satisfaction with the
program, with over 70% top box satisfaction
and an attrition rate of less than 15% on
mobile engagement over a two-year period.
The figure highlights the difference and
impact of the comprehensive program
across a market. PCCI’s Pediatric Asthma
Population Health Framework has reduced
unnecessary utilization and costs, and
improved the healthcare experience for
hundreds of pediatric patients and their
parents.
Analytics provide actionability for
social determinants
Through focusing on the community of
very high-risk children determined by risk
stratification, it was determined that these
children live in distinct neighborhoods.
Home visits by payer outreach resources
uncovered substandard housing conditions
hazardous to asthma control — a critical
deteriorating factor for poor, inner-city
children. In this way real time analytics can
inform advocacy and appropriate resourcing in a municipality.
PCCI also is creating a communities-of-care network in Dallas to connect communitybased
organizations to health systems using intelligent, electronic information exchange
platforms. Children who are identified as at risk and are discovered to have a social
determinant of health needs can be referred to community-based organizations in a seamless
electronic closed loop referral system which can provide comfort to healthcare providers who
worry about at-risk patients falling through the cracks.
Innovations in the pipeline
Despite tremendous success, opportunities still exist to improve results and to further engage
providers, patients and the community. We are designing and in early-stage implementation
of additional innovation pilots:
• Testing the effectiveness of disease-specific in-home personal assistance devices (Amazon
Echo) to engage groups of homogeneous, high-risk, pediatric asthma children in a
gamified home environment.
• Integrating within a home or community to allow remote monitoring of asthma medication
adherence and in-home air quality by using “Internet-of-Things” integration.
• Engaging with local schools. We are evaluating how to create processes, workflows and
user-friendly electronic dashboard systems so school nurses can receive alerts about highrisk
children and help coordinate care in those settings.
• Applying predictive analytics and mobile technologies to other patient populations and
health conditions.
About PCCI
PCCI is an independent, not-for-profit healthcare intelligence organization focused on
creating connected communities through data science and machine learning. It combines deep
clinical expertise with advanced analytics and artificial intelligence to enable the delivery of
precision medicine at the point of care. PCCI is a recipient of more than $50 million in grants
directed at developing and deploying patient-centric cutting-edge technologies connecting
communities, Parkland Health & Hospital System, and beyond. DMJ
Donna Persaud, MD, is a board-certified pediatrician with 30
years’ experience serving the medically underserved. She has
extensive experience in advancing healthcare delivery systems and
population health by connecting traditional medical practices and
innovative technology with a focus on social determinants of health.