Population Health Management Enabled by GenAI

With the aging of the population and concomitant healthcare expenditure growth, multiple initiatives are being taken at global and local levels to improve the quality of care and overall population health while effectively managing the cost of care. Because a small percentage of the population accounts for a large share of overall health expenditures, it is important to predict which patients will be costly in the near future (predictive risk modeling) remains a core and key strategy to target individuals with complex medical, behavioral, and social needs. Based on a value-based care foundation, our solution identifies the non-clinical needs of patients in the form of social determinants of health (SDOH) and associates them with possible costs of care driven by clinical conditions. Receiving care at the right time and in the right setting – optimizing enterprise capacities and cost-effectiveness • Identify SDoH needs of the patient population and predict the cost of care of patients as soon EHR records are updated by physicians, nurses, and the care team. • Recommends personalized interventions in the form of services provided by partner/government-sponsored community-based programs and care management teams to avoid unnecessary ED visits, readmissions, and extended length of stay. • Continuous monitoring of correlations & outcomes to ensure quality patient engagement. More so, up to 80% of key patient information is present in the form of unstructured clinical notes within EHRs. Due to the nature of the data, it remains mostly unutilized. We used Azure OpenAI service along with prompt engineering and few-shot learning techniques to extract patients' SDoH needs and total cost of care to identify high-risk patients who need non-clinical interventions. This technique is novel compared to existing NLP-based approaches and offers many advantages, including higher accuracy, scale, and compliance. The net impact of this method will not only improve patient outcomes in the form of reduced utilization but also reduce costs and penalties for clients. Key benefits of our solution include: • Reduced overall costs- Personalized and targeted interventions to reduce ED visits and avoidable utilization. • 32-60% decrease in 30-day readmissions - Avoid recurring regulatory fines due to avoidable readmissions. • No additional data investment- Extract SDoH insights from existing EHR data automatically at scale • Actionable and trackable analytics- Refer patients with SDoH needs to Community-Based Orgs (CBOs) and other related groups via integrations thus closing the loop. • Improved outcomes- Healthier outcomes and reduced overall risks for patients thereby improving overall patient experience. • Patient Engagement programs to stay connected with patients leading to less patient churn. Persistent has leveraged technologies such as Open AI APIs for Generative AI, Microsoft's Power Apps, Power BI, Dynamics 365 stack, Dataverse, Dynamics 365 Customer Insights, and Dynamics 365 Marketing, to develop the Population Health Management (PHM) solution. Apart from many applications, these tools serve as a bridge between electronic medical records (EMR) and PHM solution