Simita Mishra – Northwell Health

Simita Mishra has a vision for what she says is the not-so-distant future of health care.

It’s one in which patients will have the tools to monitor and manage their health and well-being—all while keeping their physicians informed and in the loop. Providers, in turn, will be able to access resources to not only keep tabs on individual patients, but to assess the needs and risk factors of the populations they serve.

“It may all sound too good to be true—we haven’t yet succeeded in every aspect, we haven’t perfected anything,” acknowledges Mishra, who serves as service line lead for Population Health Informatics at Northwell Health in New York State. “But we’re definitely moving the needle in the right direction.”

Progress works

Northwell, a massive system that has 68,000 employees and two dozen medical facilities throughout New York, is pushing that needle forward by looking beyond clinical measures—as Mishra explains, “managing health care from every aspect, from a more holistic view.”

A social shift as much as a technological one, this process begins with interacting with patients beyond doctor visits. Using analytics coupled with clinical guidance, patients are identified based on risk and compliance, and are contacted prior to intake, post-discharge or anywhere in between, Mishra says. This could come by way of simple text reminders or phone calls, regular contact with a “care navigator,” or even home visits from nurses involving triage via mobile care management platforms.

All told, this helps to ensure that they are keeping with physician recommendations and scheduling appointments on time and as needed, she notes. Patient portals also enable more highly engaged patients to manage, track and report their chronic conditions—such as their sugar levels and weight if they are diabetic.

Physicians work from “clinical snapshots” that are tied to a patient’s electronic medical record (EMR), alerting them when procedures such as colonoscopies or pap smears should be scheduled. As the system evolves, it will become a digital one-stop physician aide to serve patients and drive evidence-based outcomes, Mishra says.

These snapshots are particularly helpful with Medicaid patients, who might otherwise be out of touch or unreachable due to socioeconomic factors, she says. Similarly, behavioral health metrics help physicians define other “outliers” and gaps in care.

“If a physician is aware of those gaps in care, it helps them to be that one-stop shop,” Mishra says.

Meanwhile, Northwell has linked with Healthix, a Health Information Exchange (HIE) in New York state and Long Island. Through Healthix’s database, all medical providers who interact with a patient can access his or her medical records “agnostic of at which facility the patient is being seen.”

Although many of these efforts are still in their infancy, Mishra says Northwell has seen more patient engagement and greater profitability, as well as a significant reduction in re-admission that can often be prevented through proactive means.

Quality, not quantity

Mishra says she wants to plumb further into data and analytics and look at social health metrics and “social determinants of health” as defined by the Centers for Disease Control (CDC)—that is, the backdrops of where people work and live and how those impact their overall health.

This could eventually enable Northwell to identify food insecurities in certain areas and tackle them by providing fresh food options through partnerships with Amazon or FreshDirect. Working with artificial intelligence and machine learning capabilities could also help the health system predict patient health based on certain scenarios and indicators.

“This is not just from a Northwell perspective; this is my drive and goal with overall population health,” Mishra says. “That’s certainly why I was driven toward health care, to contribute to that noble cause.”

Holding a master’s in health care management and a PhD in medical informatics, she started out in the field doing “strategic data mining.” At Northwell, she works with a team of project directors specializing in population health informatics as well as a “huge” business intelligence competency center. Northwell has a research institute, and because of its size and reach, it is often the location for new and innovative pilot programs—so there is always research to be done and discoveries to be made.

“Our footprint is so expanded, we get exposure to everything that’s new in population health,” she says.

But data and analytics are nothing without clinician input. “We always seek clinical guidance and advice,” she says. “We are not experts in every area of health care.”

Meanwhile, improved health care also requires a cultural shift in physician payment incentive models, from productivity-based to value-based.

“It’s focusing not just on how many patients are seen, but how clinicians see patients, when they see patients, how they take care of patients beyond that encounter and even before they get sick,” Mishra says. “They have to be driven to see the right amount of patients and provide the right amount of care and quality of care. It boils down to really taking better care of patients.”