Volume 5

When Tech Transforms Health Care

Christiana Care Health System uses artificial intelligence and big data to revolutionize care model

By Chris Rauber



Delaware’s largest health system, one of the largest on the East Coast, is “building a layer of care that does not exist in today’s world,” said Randy Gaboriault, chief information officer and senior vice president for innovation and strategic development for Christiana Care Health System.


What does that mean, exactly? It means that Christiana Care is building the technology-driven health care system of the future by combining artificial intelligence, big data, and coordinated care to troubleshoot chronic conditions and spot medical trends in large patient populations.


The result is support for patients across the state, regardless of where they go to get their care.


It started the transformation in 2012 with the launch of Carelink CareNow, an information technology-driven care coordination and management model that opened the door to a new focus on population health in the system.


It created the opportunity for Christiana Care to integrate information technology tools into its population health efforts, bringing them to the foreground and including clinical care as well as care coordination, according to Dr. Tabassum Salam, the Carelink CareNow project’s medical director.


A team of more than 40 Carelink CareNow clinicians, some centrally located and others embedded in medical practices and other clinical locations, is also critical.


“The old model of bricks and mortar and fee-for-service medicine is being gradually replaced with longitudinal population care,” thanks in large part to the vision of leaders such as Christiana Care President and CEO Janice Nevin, M.D., MPH, Salam said.


“You have to make it financially viable, and that’s where we’re headed,” with an accountable care organization, bundled payments from Medicare and similar programs, she said. “It’s real now.”


The project started with a three-year, $10 million grant from CMS Innovation, an arm of the federal Centers for Medicare and Medicaid Services designed to test alternative payment models and promote the use of technology to improve patient safety, reduce unnecessary visits, and assist providers in care coordination.


It initially focused on patients with ischemic heart disease (also known as coronary artery disease and coronary heart disease), and expanded in 2015 to include patients with a broad range of diseases and chronic conditions.


“We expanded disease state by disease state, bundle by bundle, population by population, and we’re now managing over 100,000 lives,” Gaboriault said.


Roughly half of those 100,000-plus patients are enrolled in an accountable care organization, or ACO, that links Christiana Care to other health systems and community physicians in Delaware. The other half are covered by commercial insurance or are part of a Medicare bundled payment program that consolidates payments for a single episode of care, such as joint replacement surgery.


More than 8,600 patients in the Medicare bundled payment program have been helped by the Carelink CareNow program, participating clinicians reported in a 2017 study in the Joint Commission Journal on Quality and Patient Safety. These include patients who have had joint replacement or cervical spine surgery, or who suffered from congestive heart failure.


In many cases, by using predictive modeling and a combination of digital and physical assets — including care coordinators and iPads “embedded” in participating physicians’ practices, ERs, other hospital settings, skilled nursing facilities, and the like — Carelink CareNow has improved coordination, identified patients who need help most urgently, and helped avoid unnecessary hospitalizations by a combination of preventive care and encouraging home care when appropriate.


Ten years from now, Gaboriault predicts, the use of such artificial intelligence-infused technology “will be the standard of how we deliver care, but decisions will still be made by the clinician, who can get to know who you are.”


The program has garnered national attention, including winning the John M. Eisenberg Patient Safety and Quality Award in the spring of 2017 from the Joint Commission, a major health care accreditation group, and the National Quality Forum, which helps set standards for the health care industry.


Such success “starts with the cultural leadership of the organization and making a commitment to the clinical community that we don’t get there without them,” Gaboriault said.



Information technology tools weren’t integrated into the Delaware-based Christiana Care Health System’s population health efforts.



The provider in 2012 launched Carelink CareNow, an information technology-driven care coordination and management model to open a door to focus on the system’s population health.



The Carelink CareNow program has helped more than 8,600 Medicare patients receive coordinated, high-quality care, including patients who had joint replacement or suffered from congestive heart failure.


Collecting multiple types of data


Carelink CareNow collects and analyzes various types of data from multiple sources, including clinical, claims, admission and discharge, and registry data. It capitalizes on a wealth of data supplied by the Delaware Health Information Network, as well as similar data exchanges in Maryland and the District of Columbia, with more such connections likely in the relatively near future.


Financial and claims data come from participating health systems and payers.


With help from the CMMI grant and a large financial investment of its own, Christiana Care created an IT system capable of collecting and integrating these data streams, including a shared electronic health records system to serve its geographically dispersed operations.


All or virtually all of Delaware’s acute care hospitals and ERs, and many of its skilled nursing facilities, school-based clinics, major reference labs, federally qualified health centers, urgent care centers, and other health care facilities, are linked electronically via the state’s Health Information Exchange. This gives Christiana Care a way to track its patients’ health care even when they get it outside the system.


If a patient is admitted to a non-Christiana Care hospital in southern Delaware, for example, information about the admission “is transmitted to the state health information network and to the Carelink CareNow platform in almost real time,” Salam said. The system alerts clinicians, typically RNs, “who can call the [ER] and talk to physicians or care coordinators to ask what we can do to help the patient.”


The alerts give Carelink CareNow “real-time awareness of where our patients are getting their care” and help shape that care, if needed, she said. One result of this is Carelink CareNow staffers can encourage outside providers to avoid performing unnecessary duplicative tests and procedures by giving them up-to-date data on the patient.


Sometimes patients are discharged early, for example, because other providers realize that Carelink CareNow will effectively coordinate follow-up care.


The health care system “needs to support our patients across the continuum,” Salam said, whether they come to its hospitals and doctors  or go elsewhere for care — or if they seek preventive care, such as a flu shot or a colonoscopy.



Using AI to spot trends, highlight problems


When coordinating care for patients with heart disease, diabetes, or other severe chronic conditions, the key is to target those who are the most likely to require hospital or emergency room care in the near future and take preventive steps to avoid that, if possible.


Using artificial intelligence and machine language technology to do predictive analytics, each of these patients is scored on a scale of 1 to 100, with those closest to 100 being at the greatest immediate risk of serious problems. The system pays closest attention, in the short run, to those in the 85th percentile or higher. They get the most intense coordinated care support, including disease management and other forms of coordinated care. Carelink CareNow staffers work with the patients’ physicians as liaisons to ensure the most appropriate interventions are used.


All of Carelink CareNow’s chronic patients get attention, of course, but the system “risk stratifies” that population to make sure that those with the most risk “get the most intensive support” when they need it, Salam said.


Via Carelink CareNow, the system focuses first on the top 5 percent — those most likely to require urgent preventive care or other clinical support in the near future — and secondarily on the next tier, the next-highest 5 percent cohort known internally as “rising risk patients.”


Carelink CareNow’s IT infrastructure uses a combination of patients’ individual clinical and claims data to identify where particular patients fall on the spectrum.


That large pool of population health data also is used to identify broader gaps or redundancies in care that can be addressed, such as identifying the portion of a particular patient population that hasn’t received a flu shot or highlighting patients who might have trouble affording a brand-name drug and for whom a generic version might be the best choice, Salam noted.


But medications — and even purely clinical care of any kind — aren’t always the entire solution.


One patient, a 68-year-old woman, had “a seemingly impossible-to-control case of diabetes,” according to Salam. She was taking increasingly large doses of her medications and driving her primary care physician crazy. Carelink CareNow identified her as someone who needed a more personal touch and sent a social worker to visit her home.


It turned out the woman had become the primary guardian for four grandchildren when their mother was incarcerated. The children had health and behavioral issues, and the grandmother was feeling overwhelmed, exacerbating her clinical and medication issues.


The Carelink CareNow social worker spent months working on the case and got the patient help from social services. Ultimately, the grandmother started taking her medications appropriately and got her diabetes under control.


The Carelink CareNow team — including staffers and electronic tools — “was able to fill many of the big gaps” in her situation, Salam said, leading to a significantly improved health outlook.


That team of more than 40 Carelink CareNow clinicians includes RNs/care coordinators, social workers, clinical pharmacists, medical directors, and others, she said. All work to coordinate care and engage patients, their families, other health care providers, and other caregivers, including home health workers.


Finding a financial fix


Christiana Care is taking other steps to move toward value-based care and away from the fragmented world of fee-for-service medicine.


In January 2016, Christiana Care launched the statewide Christiana Care Quality Partners ACO in conjunction with Bayhealth Medical Center, Nanticoke Health Services, and more than 200 primary care physicians and other providers in over 50 primary care practices.


The new ACO, which was renamed the eBrightHealth ACO in January 2017, includes all but one of Delaware’s health systems and nearly 300 physicians, and it cares for 48,000 people. Beebe Hospital, Atlantic General Hospital and Health System, La Red Health Center and eight additional primary care practices joined in January.


The ACO uses a risk-based model that gives Christiana Care and its partners accountability for the cost of care and its outcomes. Carelink CareNow serves as its care coordination team.


Together with other, similar measures, such as the Medicare bundled payment program, these risk-based approaches are geared to giving hospitals, doctors, and other providers financial incentives to move away from fragmented care and toward more coordinated models.


Christiana Care expects to continue to invest in the Carelink CareNow platform as a key strategy in building this new layer of care into the system and, in many cases, bringing care to patients in a virtual fashion, Gaboriault said.


“We know we’ve moved the needle in a world where moving the needle is very complicated,” Gaboriault said, noting that Christiana Care is in the early stages of most of these transitions.