Data Services for Disease Management

In order to inform the design of disease management programs for chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), Cambridge Health Alliance (CHA) hired ICH to assess patient population characteristics using electronic health record data. For each disease area, ICH defined a data set that included variables for patient demographics, healthcare service utilization, medications, labs and procedures, and co-occurring conditions. ICH worked closely with CHA’s Business Analytics department to define inclusion criteria, identify diagnosis and procedure code groupers, and create standardized variable definitions. ICH used the data to create a quantitative description of the patient population with each disease, which helped stakeholders identify service gaps that the disease management programs could address. The data sets are also being used to guide the development of patient registries within the electronic health record that can be used for ongoing population health management.