Integrative Informatics and Predictive Modeling Support for Population Health

This project targets development of proactive population health informatics methods in a geographically distributed medically and culturally heterogeneous population of app. 450,000 lives (Medicaid and Uninsured) served by 3000+ providers. The informatics infrastructure will be generally applicable to population health clinical informatics efforts. It is being developed in the context of the Suffolk Care Collaborative, a Performing Provider System (PPS) in Suffolk County, NY, funded for 5 years by the Center for Medicare and Medicaid (CMS) through the Delivery System Reform Incentive Payment (DSRIP) Program. Stony Brook University Hospital (SBUH) is the PPS Lead. Future payments to the PPS will be directly tied to performance on the key metrics of 25% reduction in potentially preventable hospitalizations (PPR) and emergency department visits (PPV) [3M Health Information Systems] and to improvements in patient quality indicators such as Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQI) and Pediatric Quality Indicators (PDI). Eleven intervention projects (see center panel) deployed across the PPS comprise a data-generating ecosystem in which a change in one place affects outcomes of the whole. From a bioinformatics viewpoint, it is not enough to merely identify outcomes and trends; we aim to design and use an in silico test bed to evaluate and thus steer proposed interventions or changes to the system. (PDF)