SSM Well being innovates kidney care with predictive analytics and machine studying

SSM Well being, a nonprofit with $8 billion in income, supplies its communities with high-quality look after weak populations. Probably the most weak populations is made up of sufferers with kidney illness.


Kidney illness is complicated as a result of 90% of individuals with the illness have no idea they’ve it till they want dialysis or a transplant. There’s little illness schooling or preventive efforts within the preliminary phases, making persistent kidney illness costly to deal with. Sufferers usually wind up receiving decrease outcomes and decrease high quality of life than physicians wish to see.

CKD and end-stage renal illness sufferers handle 15-20 drugs day by day and have a number of comorbid situations, complicating therapy.

“Sufferers with kidney illness make up underneath 5% of our affected person inhabitants, however account for greater than 20% of our whole prices,” stated Carter Dredge, chief transformation officer at SSM Well being. “We wanted the main target and experience that our accomplice Try Well being delivers by means of predictive analytics and the care crew to raised assist our most at-risk inhabitants.

“Throughout the broad main care base, suppliers are seeing sufferers with a spread of well being issues, and CKD usually entails simply 5 to 10 sufferers of their panel,” he continued. “Throughout every go to, PCPs have restricted time to satisfy these complicated wants, and CKD signs are delicate. Typically, sufferers have been under-diagnosed for superior CKD.”

SSM Well being wanted a targeted resolution that helped predict the most effective time to interact sufferers to optimize the affected person expertise, enhance outcomes and decrease prices.

“At SSM Well being, as our core medical groups construct the principle applications that embody all our sufferers and interventions throughout a number of populations, partnering with Try Well being has delivered targeted look after a very complicated situation that connects to the bigger innovation pipeline, aiding the transfer to extra risk-based contracts by serving to construct the required care coordination and analytics applications for extra particular affected person cohorts,” Dredge stated.


Analytics can provide diagnostic help and information therapy selections. Combining knowledge from a number of sources, together with claims, medical knowledge, stay feeds from well being exchanges, dialysis machines and demographic data for social determinants of well being, algorithms can predict adversarial occasions, together with kidney failure throughout a given time-frame or a cardiology occasion.

“This system we developed with Try Well being delivers complete medical providers for CKD and ESRD sufferers that considerably enhance high quality of care and outcomes whereas reducing the entire value of look after sufferers,” Dredge stated. “Thirty-three algorithms help with treating CKD, together with one that may predict CKD development to ESRD with 95% accuracy.”

“A 36-year-old affected person had acquired 16 hospital stays in two years with frequent readmissions and declining well being. This affected person has since had just one emergency division go to and nil readmissions, lowering inpatient days by about 14 occasions her earlier utilization.”

Carter Dredge, SSM Well being

Try Well being’s expertise and full medical mannequin deliver a targeted method to care, he added.

“We’re intervening with the proper sufferers on the proper time,” he defined. “Our care crew can see when a affected person is progressing extra quickly towards kidney failure and may take the time to completely educate and coach the affected person by means of making the most effective renal substitute remedy choice for them, whether or not that is dwelling dialysis, in-center dialysis, preemptive transplant or conservative care.”


There are numerous distributors of predictive analytics expertise in the marketplace right this moment. A few of these distributors embody Alteryx, Anodot, Domo, Gainsight, IBM, Infer, Microsoft, Qrvey, RapidMiner, SAP, SAS Institute, Sisense and Try Well being.


“Try Well being’s CareMultiplier platform, powered by proprietary machine studying algorithms, is smart of large quantities of knowledge, cuts by means of the noise and permits our clinicians to concentrate on doing what solely they’ll do, ship high-touch affected person care,” Dredge defined.

“Our medical groups use predictive analytics of their day-to-day care,” he continued. “Every affected person receives an total threat rating that serves as a place to begin for therapy and flows by means of our medical care programs. As we have interaction our members, our crew then makes use of targeted initiatives developed by means of the analytics to be extra proactive of their care.”

For example, SSM Well being has a affected person cohort referred to as Deliberate Begins. Try’s expertise has recognized them as progressing towards dialysis within the subsequent six to 12 months. These analytics permit clinicians to deploy targeted interventions and care plans to assist forestall these sufferers from “crashing” into dialysis.


“Try Well being brings economies of scale, regionalization and nationalization to a fragmented kidney care course of,” Dredge reported. “This system was launched in June 2020, throughout the COVID-19 pandemic. Whereas the pandemic impacted most within the nation, the primary 4 months of knowledge are promising, displaying a greater than 20% discount in acute utilization for each CKD and ESRD populations and a greater than 25% discount in emergency division utilization for each CKD and ESRD populations.”

A number of sufferers have benefited from this method, together with one feminine affected person who was predicted to have a 57% probability of kidney failure inside two years. After greater than a yr of “watch and wait,” the affected person prevented a crash into dialysis by means of a high-touch care crew coordinating between her nephrologist and first care doctor. They addressed her issues and engaged her in applicable therapy.

“Individually, a 36-year-old affected person had acquired 16 hospital stays in two years with frequent readmissions and declining well being,” Dredge recalled. “This affected person has since had just one emergency division go to and nil readmissions, lowering inpatient days by about 14 occasions her earlier utilization.”


“As well being programs transfer into inhabitants well being and value-based contracts, analytics are wanted to establish affected person populations and comply with them by means of their care journey,” Dredge suggested. “When choosing a accomplice, guarantee there’s alignment on targets and metrics.

“Perceive what the healthcare group ought to personal versus accomplish with a accomplice,” he continued. “Controlling all facets of care by means of inner sources can stifle innovation. SSM Well being’s transformation crew acknowledges {that a} accomplice delivering an exterior, devoted focus with tight integration and collaboration can velocity innovation and lift all concerned collectively for a greater expertise.”

This results in a virtuous cycle of innovation the place the extra profitable one is at making progress, the sooner they’ll go, he added.

“SSM Well being turned to a accomplice so it may dedicate its efforts to what the well being system does effectively, which is offering high quality care to its communities,” he concluded. “The partnership utilized a devoted focus to informing care that’s innovating kidney care.”

Twitter: @SiwickiHealthIT
E mail the author: [email protected]
Healthcare IT Information is a HIMSS Media publication.

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