Opinion
INNOVATIONS IN HEALTH CARE DELIVERY
VIEWPOINT
Integrating Predictive Analytics Into High-Value Care
The Dawn of Precision Delivery
Ravi B. Parikh, MD, U n ite d S tates h e a lth care costs are tw ice as high as
MPP spending in m ost industrialized countries. One key o p ­
Department of p o rtu n ity fo r health systems to im prove value is by lim ­
Medicine, Brigham
itin g overuse o f costly resources, in pa rt by focusing
and Women's
Hospital, Boston, these resources tow ard high-risk patient groups.1Some
Massachusetts; and health systems have been using retrospective claims data
Harvard Medical or o ther approaches, like the Framingham risk model, to
School, Boston,
Massachusetts,
identify high-risk individuals. However, most systems to ­
day are doing little in the way o f risk stratification, and
Meetali Kakad, MD. physicians o fte n fin d it d iffic u lt to apply these charac­
MPH terizations o f risk to th e care o f an individual patient.
Department of
Electronic health records (EHRs) have held the prom ­
Medicine, Brigham
and Women's ise o f allow ing clinicians and health systems to d e ter­
Hospital, Boston, m ine an in d ividual's real-tim e risk o f a clinical event
Massachusetts; and through predictive analytics. The use o f EHRs is becom­
Harvard Medical
ing ubiquitous in the United States. This sea change can
School, Boston,
Massachusetts. be linked w ith advances in big data techniques and com ­
puterized decision support to transform health care de­
David W. Bates, MD, livery. Just as "precision medicine" is generally linked to
MSc the concept o f using genetic and genomic data to per­
Department of
sonalize treatments, "precision delivery" involves using an
Medicine, Brigham
and Women's individual's electronic health data to predict risk and per­
Hospital, Boston, sonalize care to substantially improve value. In this View­
Massachusetts; and
point, we make the case for precision delivery by describ­
Harvard Medical
School, Boston, ing how some health systems are beginningto successfully
Massachusetts. im plem ent analytics into practice and discussing future
directions for using predictive analytics to improve value.
Lessons F rom O th e r Fields
O ther industries have successfully used predictive ana­
lytics to ta ilo r service delivery in real tim e. Familiar ex­
amples include Amazon's product recommendation sys­
tem fo r online shopping based on an individual's prior
purchases, and American Airlines' ticke t pricing system
based on prior customer purchasingtrends. Sports teams
like the Oakland Athletics have relied heavily on analyt­
ics to select player rosters, o u tp e rfo rm in g exp e cta ­
tions despite having a much smaller payroll than other
teams. These organizations use large am ounts o f data
and sophisticated machine learning algorithm s to meet
consumer and organizational needs.
In health care, predictive analytics offers an a u to ­
mated means to forecast future health outcomes for in­
Corresponding dividuals or populations based on algorithms derived from
Author: David W. historical patient data. Some smartphone apps have suc­
Bates, MD, MSc,
cessfully applied predictive analytics to influence health
Brigham and
Women's Hospital, care; Ginger.io, fo r example, uses analytics based on cell
1620Tremont St, phone data to identify patients at risk fo r depression cri­
Boston, MA 02120 ses, cueing physicians and caregivers to intervene.2 As
(dbates@partners
m ore ele ctro n ic health data becom e available, some
org).
health systems have begun to develop predictive m od­
jama.com
els around clinical issues, such as acute intensive care unit
decompensation and hospital readmissions.1
As organizations like Am azon and Am erican A ir­
lines have shown, however, developm ent o f these m od­
els is only a firs t step. Few health systems currently use
predictive analytics at scale to influence health care de­
livery. Health systems m ust id e n tify strategies to im ple­
m ent predictive risk algorithm s into clinical practice.
U sing P re d ic tiv e A n a ly tic s t o Focus In te n s ity
o f S ervices Across th e Care C o n tin u u m
Acute Care
Antibiotic overuse predisposes patients to adverse events
and resistant infections, the treatm ent o f which results in
significant health care costs in the United States. Kaiser
Permanente o f Northern California (KPNC), an integrated
health service organization, has used predictive analytics
to reduce antibiotic overuse in neonates. KPNC used ma­
ternal health data from more than 6 0 0 0 0 0 live births to
determ ine the probability o f early-onset neonatal sepsis
in nonpremature infants prior to birth. These data were in­
tegrated w ith objective clinical data from the newborn at
birth to assess the probability o f sepsis by categorizing
newborns as at low, medium, or high risk o f sepsis. KPNC
obstetricians and neonatologists then used this score to
determine whether to administer antibiotics.3After imple­
mentation o f this algorithm, use o f systemic antibiotics in
the neonatal period among newborns o f 34 weeks or more
gestation was estimated to decrease by 33% to 60% , and
up to an estimated 250 0 0 0 newborns nationally could
potentially be spared antibiotics at birth annually.3
Postdischarge Care
Hospital readmissions represent an im p orta n t driver o f
spending, w ith all-cause 30-day readmissions costing
the US health system more than $41 billion annually, and
thus are a major quality indicator fo r health systems.4
Parkland Health and H ospital System used an a lg o ­
rithm based on 29 clinical, social, behavioral, and u tili­
zation factors available w ith in 24 hours o f admission
to p re d ict risk o f readmission fo r patients w ith heart
failure.5 In a prospective study, 228 patients w ith heart
failure deemed at high risk o f 3 0 -d a y readmission re­
ceived targeted evidence-based interventions includ­
ing (1) detailed patient education by a m ultidisciplinary
team in clu d in g a pharm acist, n u tritio n is t, and case
manager; (2) follow -up telephone calls w ith in 4 8 hours
to ensure m edication adherence; (3) o u tpa tie n t heart
fa ilu re sp e cia list a p p o in tm e n ts w ith in 7 days; and
(4) a prim ary care a p p ointm e n t scheduled according
to th e urgency o f noncardiac issues. Compared w ith
JAMA February 16,2016 Volume 315, Number 7 651
 Opinion View point

8 3 4 patients enrolled in the study prior to intervention, there was
a 26% relative reduction in risk-adjusted odds o f readmission among
913 patients w ith heart failure enrolled in th e postintervention pe­
riod (26% vs 21% 30-day readmission rates).5
Serious Illness
The Veterans Health Adm inistration (VHA) applied analytics to im ­
prove quality o f care for serious illness by creating its Corporate Data
Warehouse (CDW), a repository fo r patient-level data aggregated
from across th e VHA, in 2 0 0 6 .6 The CDW was used to calculate risk
scores predicting hospitalization and death fo r VHA's prim ary care
population, based on variables including demographics, vital signs,
laboratory results, and prior utilization. Accessed 3 0 0 0 to 4 0 0 0
tim es m onthly by more than 1200 clinicians, these scores are w idely
used in practice. Nurse care managers used these scores to guide
services, including end-of-life and palliative care, delivered by m ul­
tidisciplinary patient-aligned care teams (PACTs) to high-risk indi­
viduals. Compared w ith 87 practices w ith the lowest im plem enta­
tion o f PACTs, the 77 practices w ith highest PACT im plem entation
demonstrated a 17% reduction in hospitalizations (4.42 vs 3.68 quar­
te rly admissions per 1 0 0 0 veterans) fo r am bulatory care-sensitive
conditions and a 27% reduction in emergency d e partm ent visits
(188 vs 245 visits per 1 0 0 0 patients) over a 7-m onth period.7
Future Directions
These organizations are examples o f health systems th a t apply pre­
dictive analytics to im prove value fo r high-risk patient groups. Un­
der accountable care, successful organizations will use a broad ar­
ray o f tools to predict im p o rta n t outcom es, including to id e n tify
patients likely to require expensive care, be readm itted, or experi­
ence a specific type o f adverse event.1 However, ju st as im portant
as prediction is how the predictions are integrated w ith clinical sys­
tem s to help physicians and o th er health care professionals make
decisions and track real-tim e quality.
Organizations th a ta im fo r precision delivery o f care will need sev­
eral key pieces o f infrastructure. First, they will need an integrated EHR
infrastructure and access to long-term data, like the VHA CDW, on
which to base predictive algorithms. Second, they w ill need robust,
responsive tools to address suggestions and improve clinicians' work-
flo w w ithin clinical systems. Third, outputs o f the algorithms will need
to be actionable and p ro m p t prespecified, evidence-based a ctivi­
ties, similar to the KPNC antibiotic guidelines. Fourth, predictive al­
gorithm s w ill need to be flexible enough to quickly adjust fo r real­
tim e patient data, as th e Parkland readmission m odel does. Such
iteration allows fo r flexible ''dosing1'o f services across the continuum
o f care, w ith intensity geared up and down as the need requires.
Some health professionals have raised concerns about the ap­
plication o f predictive analytics, n o t th e least o f which is the per­
ceived dim inution o f the role o f the physician in managing clinical
uncertainty.8 Other concerns include protection o f patient privacy,
d im in ish m e n t o f p a tie n t preferences, and inadequate m edical
training.9 Health professionals had similar hesitations more than a
decade ago when considering im plem enting EHRs. However, algo­
rithm s routinely outperform practitioners' clinical in tuition w ith o u t
decision support. Algorithm s also may enhance th e quality o f inter­
action between physicians and p a tie n ts-fo r example, machine learn­
ing algorithms based on retrospective data can provide survival pro­
jections th a t may help inform discussions regarding end-of-life care
fo r patients w ith advanced cancer. However, physicians will still need
to exercise clinical judgm ent, and w ith appropriate training can com ­
bine new insights learned from predictive analytics alongside pa­
tie n t preferences to make higher-value trea tm e nt decisions.
The tim e fo r precision delivery is now. W ith th e advent o f ac­
countable care, th e health care organizations th a t succeed w ill be
those th a t deliver high value. Perhaps th e m ost im portant step to
improving value will be implementing clinical analytics in routine care.
Organizations th a t adapt by integrating these tools may do better
both clinically and financially going forward.

ARTICLE INFORMATION
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure o f Potential Conflicts o f Interest.
Dr Bates reported receiving equity from Intensix,
which makes software to support clinical
decision-making in intensive care; being named as
coinventor on patent No. 6029138 held by Brigham
and Women's Hospital on the use o f decision
support software for medical management,
licensed to the Medicalis Corporation, and holding a
m inority equity position in Medicalis, which
develops web-based decision support for radiology
test ordering; serving on the clinical advisory board
fo r Zynx Inc, which develops evidence-based
algorithms: consulting for EarlySense, which makes
patient safety m onitoring systems: receiving equity
Funding/Support: Dr Kakad is funded by The
Commonwealth Fund and the Research Council of
Norway under the Norwegian Harkness Fellowship
in Health Care Policy and Practice.
Role of the Funder/Sponsor: The funders had no
role in neither design and conduct o f the study;
collection, management, analysis, and
interpretation o f the data; preparation, review, or
approval o f the manuscript; nor decision to submit
the manuscript fo r publication.
Disclaimer: The authors have no commercial or
financial ties to any o f the organizations or
companies mentioned in this manuscript.
REFERENCES
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5. Amarasingham R, Patel PC, Toto K, et al.
Allocating scarce resources in real-time to reduce
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6. Fihn SD, Francis J, Clancy C, e t al. Insights from
advanced analytics at the Veterans Health
Administration. Health A ff (Millwood). 2014:33(7):
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and cash compensation from QPID Inc, a company
focused on intelligence systems fo r electronic
health records; receiving cash compensation from
CDI (Negev) Ltd, which is a not-for-profit incubator
for health IT startups; receiving equity from Enelgy,
which makes software to support evidence-based
clinical decisions, from Ethosmart, which makes
software to help patients w ith chronic diseases, and
from MDCIone, which takes clinical data and
produces deidentified versions o f it. No other
authors reported disclosures.
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