Mining Laboratory Data to Identify High Risk Patients

Dallas, Fort Worth, Texas


Premier Patient Healthcare is an Accountable Care Organization (ACO) operating in Dallas, Fort Worth, and Oklahoma. The organization’s philosophy is that providers need the best information in front of them so they can make the right decisions and optimize patient care.

Premier Patient Healthcare is currently focusing on programs for diabetes and chronic kidney disease. Undiagnosed disease is an ongoing problem. Only 12% of patients with kidney disease are diagnosed in the early stages (Stages 1 and 2), when it is treatable. Those who are diagnosed in Stages 3 to 5 have limited options, such as kidney dialysis or a kidney transplant.

Prior to becoming an ACO in 2014, Premier’s individual providers operated independently and patients were generally treated on the basis of the provider’s judgment, rather than actual laboratory data. Premier sought to use more clinical data in their system, and to use that data to better manage undiagnosed and undermanaged patients with chronic conditions, especially those with early stage kidney disease. Premier identified lab data as a means to identify patients earlier in the disease process. In particular, Premier wanted to leverage the clinical knowledge in pathology reports, essentially including the pathologist as a more active player on the care team.


Premier attributed the problem of undiagnosed disease to lack of clinical data integration. For example, creatinine tests were not being analyzed for patterns consistent with chronic kidney disease using the eGFR (Estimated Glomerular Filtration Rate) equation.

Premier Patient Healthcare has a suite of technology applications that allows them to monitor and use claims data for financial and patient care management. Over the last year, the technology has progressed to the point that the ACO can use it to link clinical, pathology, and claims data to identify high-risk patients in an efficient way. Technology progressed from focusing on collecting data, to exchanging data, and now to applying analytics. Clinical data can now be displayed in a way that is useful and provides actionable information.

Premier partners with a medical diagnostics company to augment their robust ACO management tools with laboratory and other clinical data. The first step involved pulling historical laboratory data from pathology reports into the Premier 360 software. For chronic kidney disease, these data show the filtration rate of the kidneys (i.e., eGFR, or glomerular filtration rate) over time.

With the new process, the organization has seen reductions in admissions and readmissions for kidney disease. Patients are also managing their diseases more effectively and slowing the progression of these diseases.

The ACO has also been working to adapt its user interface to display more clinical insights in a way that clinicians can use. Physicians and pilot sites provide feedback on the displays, and receive training on how to use the analytics.

Lessons Learned:

While the technology provides the necessary tools to implement change, those changes must be supported by an effective workflow. Premier is experimenting with different workflow models to assess their effectiveness. One strategy involves using a team approach to collect the laboratory data in a centralized care coordination effort. Another strategy relies on individual providers to use the program to proactively manage high-risk patients. With the second strategy, Premier has found that providers may need quality care initiative incentives to motivate their active participation. Practice managers play a key role in highlighting the data generated by the software to promote provider engagement.

Next-Steps/Future Vision:

Staff is encouraged by the program results because their ACO has been successful and received payments for improving costs and patient management. Patients show that they are receptive to changes in the preemptive use of clinical data. Providers are better able to provide optimal care because they have diagnostic information in hand before and during the medical visit, rather than after the patient leaves the office.

Besides analyzing the financial savings from the prevention of hospital admissions and readmissions, Premier also monitors the number of patients diagnosed, as well as the stage of disease at which they are diagnosed to establish number and proportion of patients diagnosed with diabetes and chronic kidney disease who would not have been identified in the past. They are also interested assessing how many patients meet clinical guidelines and follow up appropriately to slow progression of their disease, particularly in the early stages.

Success Story Topic
Health Info Technology