Brian Altonen, MPH, MS

Note: this page and neighboring pages are from older teaching materials used for a lab on GIS and the corresponding lecture/discussion series on ‘GIS, population health surveillance, epidemiology and public health’.  This page has been significantly updated.

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Closure: Making Sense of Data and its Applications, Goal Setting

I could be a little too ambitious by adding this page to this part of my review of improving upon Managed Care programs. My long term goal is to initiate the application of GIS into standard population health monitoring procedures in the distant future. To achieve that, corporations have the be prepared and educated a lot more about the value of these skills normally alien to their way of thinking about people’s health and health care. The new Managed Care program requirements will have some new requirements that many agencies and companies will find hard to meet in the distant future if they are not prepared for making such a change in their system. The winners in the end will be those companies that downsize the amount of work and time requirements to more effectively make population of people healthier. Such a process has a spatial and cultural link to it, which companies have been either ignoring for the most part or unwilling to foresee the economic value of.

So why add fuel to a fire with regard to utility and efficiency of the systems at large using all of this rhetoric? These statements I just made add more stressors to programs already exist in the health care system that are already under pressure for making these change. My claim is that in order to make such a change, they have to engage in what I am recommending them to do, which are as follows.

1. Improve your Local Popularity, Regional Uniqueness and Corporate Brand.

One reason to add your own unique studies or metrics to a program is to add your own institutional stamp or signature to your work and your projects. By doing this, you are announcing to your community your commitment to solving local health problems, and by doing so thereby involving the community at a more personal level with your attempt to improve local health care opportunities while reducing costs, allowing for continued internal growth and expansion. You are also advertising your program and its unique features thereby increasing the possibility for patient or public involvement with its processes and its overall value to the local marketplace, not only as patients but also as volunteers and potential employees.

To accomplish this task, to give your program the signature needed to define its uniqueness, specific kinds of metrics need to be added, testing for and then evaluated and reported. These must encompass health related concerns, issues or features which are unique to your local community and service industry setting. If you are a local health care provider for example trying to monitor its own performance, as a unique locally born social issue arises, it helps to focus on developing a way to monitor and analyze such a public health problem. If you have a unique high percentage of a certain group unrepresented elsewhere in this country, by differentiating that group from the rest of the local population and duplicating an analyses already in place just for that population with special needs, you then turn the focus of your work on a much needy social issue. You can report your results, publicly or not, for both the overall population and this specific group, resulting in a project that has much more prestige attached to it, with a better social sense and the increased likelihood that proper professional and political interactions will ensue. Ultimately, your outcome is your facility or program receiving more financial support from local funding institutions, grant providers, communities, and investors.

Examples of these kinds of studies that could be added are as follows:

• A. Low income group focus studies–for example, compare certain conditions liked to low income settings such as asthma, smoking and other chronic disease problems to overall or matched middle/upper middle income area differences (high income households are excluded due to the scope of the social inequality issues linked to such a study).
• B. Ethnicity/Culturally-defined focus studies–for example, compare income status and chronic disease rates between standard ethnic group categories provided by census data, such as a spatially defined cultural region contrasted with a non cultural setting, or a rural setting versus and urban setting with similar demographic age-gender-culture-income features. Compare one facility that services one ethnic or religious group with another designed to serve another such group or all groups of patients in general.
• C. Specific High Risk/High Cost Population Cluster studies–Compare timeliness for a variety of health behaviors for different high cost chronic diseases; evaluate costs at several levels in relation to these variables, focusing on compliance issues.

2. Take on New Opportunities.

By adding unique studies to your routine, even if you do not ever report them to the national agencies monitoring the quality of care your institution provides, you set the stage for more new opportunities to be discovered, explored and even supported.

In the case of standard asthma quality assurance assessments, only steroid use and preventive/managed care are emphasized as basic population health metrics. Children with this medical problem experience it differently from young adults, and there are a number of preventive activities that could be measured in the older teen age population, which in turn can be compared with the young adult population. This would be done to see where there are breaks in the long term care provided for individual with severe asthma cases. Such a study I anticipate would involve anywhere from about one to two dozen individuals per 10,000 members of an insured population. Therefore, the numbers are low, allow for more personalized evaluations to be performed, and for more personalized, effective intervention activities to be developed for these predesignated highest risk asthmatics.

An example of a metric for this would be monitoring changes in visits and compliance with filling out an allergies history or asthma risk evaluation during teen age-adolescent years, followed by a review once the patient becomes eligible for adult care from a separate program. Typically, the new health care programs will probably allow for continued care administration in many cases once a child reaches 18 years of age, providing us with the opportunity to see in children who leave home and attend a college or vocational school receive the same value of care received by children who either become unemployed, or remain partially or unemployed during the immediate post-graduation years. Whether or not such a study is feasible of course depends upon how post-high school children engage in continuing their chronic disease care.

Situations where this kind of study could be crucial to long term health outcomes include similar studies linked to chronic diseases that are potentially debilitating, such as epilepsy which can have a higher risk for loss of control during the post-high school, early employment or college years. The same may be the case for childhood-related diagnoses of specific high risk, high cost-associated psychological and psychiatric ICDs.

3. Prepare for Change.

Engaging in more detailed population studies better prepares certain programs for growth and change. For example, my emphasis on GIS utilization is made because ultimately this way of viewing population health statistics will become a major asset to the public health care and prevention program as a whole. To not prepare and not engage in such activities suggests to me a lack of long term thinking on behalf of CEOs, directors, managers, strategists and future planners.

4. Incorporate Long Term Improvements into the Process.

Engaging in more detailed studies is necessary to demonstrate long term benefits of these programs. Cost reductions cannot be adequately demonstrate in any reliable sense if the billing and analysis methods undergo systems changes. By maintaining a watch on the methods of monitoring billing and cost related metrics, we can better understand this system and determine the best changes and updates to be made in the ongoing re-evaluation process. Currently, many companies deal with these problems as they arise and have not developed any plans for how to standardize their methods of review. This results in reporting methods and outcomes reporting tools that are questionably relatable from one year to the next. Due to these problems we never really know the true progress and success a program provides for us, except at some generic qualitative level. Even then, looking back upon such reports, they can often appear untrustworthy to ongoing clients that base important decisions upon these reports.

Some metrics have the ability to be constant, no matter what changes occur in the billing, database development or analytic departments and systems. These basic metrics should be defined and maintained, and if possible, re-explored in order to retroactively pull together lengthier reports detailing overall public health related results over longer periods of time.

5. Include Timeliness to your agenda and your Ability to Create and Expand upon your Projects.

New manpower with new skillsets are needed for expansion to occur. Older workers are generally not sufficient in applying these new skills due to an inherent bias often related to experience, past performance generated comfort, and an incomplete understanding of the related skill set need for the next generation of outcomes and their applicability.

This goes back to my criticism of the herding effect that appears to be rampant within large workplace settings. The herding effect is when individuals in upper levels of management use their internal philosophy and instinct to guide a company along, but due to improper or partial background, and failures to advance the training sufficiently, ultimately become the cause for failure within these systems. There are specific forms of human behavior that demonstrate when such problems exist. Idealists like to talk about what they or their company can do but lack the background needed to know how to accomplish this. Traditionalists are against corporate change.

There are companies that fantasize about great forethought, members of which even attend sessions devoted to making such accomplishments, but then following their return to the work environment and fail to initiate any new activities or try to integrate what they learned into the corporate workplace. Ideally. a successful place capable of inducing change will demonstrate a significant change in relationships., meeting content and output generated in 3 to 4 months, or in the worst of situations 6 months. To accomplish this, then need to have the manpower and skillset required for such changes already present in the employee population. Without such a skill set, they delay the possibility for making such an accomplishment from presentation within 9 to 15 months to presentation within two to three years. This outcome is not sufficient when corporate growth is the goal of these changes.

There are also companies that do not engage in the basic requirements at all for improving the appropriate internal skillsets exist within the system. They fail to manage or make adequate use of these untapped skills, demonstrate poor management along the way, reduce internal confidence and respect with the system at the employee level, and in the long run result in some sort of interpersonal and professional systemic failure. When the failure to make better use of skillsets exists due to hierarchical reasons (personal insecurities), and no attempts are made to try new methodologies due to lack of sufficient personal understanding of the process, implying a lack of trust as well, failure proceeds in spite of whatever forethought might have existed for the value of these skills at large.

For the above two examples of failure, the underlying requirements for success that are implied are essential to maintaining a program ten years from now, allowing for internal growth and development along the way. The lack of such growth is generally the reason such companies fail in the long run. This tells us that the herding effect is good in the beginning, but is never self-sustaining once the initial rise in performance has passed its peak performance level. All new ideas and discoveries demonstrate similar rises and falls during their earliest period of development. In terms of corporate financial growth, if we apply some bell curve thinking to this, this suggest that 95 to 99 out of 100 companies have the potential of behaving much the same, lacking that 1 to 5% of creativity needed to continue to prosper and flourish.

6.  Make your projects and their influence long-lasting.

Don’t let your skills and methods become extinct following your departure.  This requires teamwork, without which not only are your years of testing, analyses and labor wasted, but the chance for any progress and growth to be maintained.  Skillset sharing helps to prevent this from happening.  Companies can fail even when they are successful at being creative, by failing to pass on their creativity to others.