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Mapping the Fragmented Patient Journey

For decades, companies and policymakers have debated the best prescriptions to fix healthcare. Boost healthy behaviors. Expand access to care. Measure outcomes. Curb costs. The list goes on. It’s clear that we all want to reduce the overall disease burden while enabling greater efficiency and better outcomes.

But there’s an epidemic of uncertainty plaguing healthcare today, and that uncertainty is undermining every one of these bigger health system goals.

Consider a patient with diabetes who shows up at her primary care physician’s office following a knee replacement. She forgets to bring her post-op record and her PCP lacks access to her hospital’s EHR. With limited time, the PCP focuses on her diabetes, but doesn’t pick up on the conditions of her home environment that contribute to her moving less, eating more, and gaining weight. The PCP misses the subtle cues that may hint at an early infection that could signal a worse outcome for the patient.

For this patient, the three months between visits dictated by protocol may be too long, increasing the risk for more serious complications. More than 108,000 people with diabetes had knee replacements last year, and a portion of this high risk population would benefit from counseling, close follow up, and referrals to nutritionists and physical therapists. But these patients’ healthcare providers lack the tools needed to see and understand the individual risks.

Fragmentation in a Fee-for-Service World

The fundamental problem facing this doctor-patient interaction isn’t the patient’s behavior. It isn’t the physician’s capability. It isn’t the performance of the surgeon. And it isn’t the efficacy of their treatments. The problem is fragmentation. The experience of care delivery is a fragmented one, and so too is access to the information that could lead to better decision-making.

Fragmentation in today’s health data creates false signals that lead to even more uncertainty and inefficiency rather than driving improved outcomes. And so, despite an onslaught of data in healthcare today, there is a surprising absence of insights that doctors, patients, payers, life sciences companies, or any other stakeholder can act on with confidence.

This is exacerbated by the continued dominance of fee-for-service reimbursement structures, which reinforce the episodic approach to care delivery.

Providers continue to be incentivized to run tests, perform procedures, and prescribe drugs. A patient recovering from a knee replacement may fail to receive support that accounts for their social setting or health co-morbidities, such as getting a nutritionist involved or bringing a virtual physical therapist into the home. When risks are overlooked and symptoms are seen in isolation, six weeks of anticipated recovery time can quickly spiral into many months and more procedures. In the worst cases, inactivity and infection can result in years of life lost.

Mapping the Healthcare Journey

We believe that predicting the right set of interventions should be learned from the millions of journeys that have come before. And the good news is that technology today can facilitate bringing together a longitudinal perspective, end-to-end, across every possible episode of care as a foundation for these predictions.

Komodo’s Healthcare Map™ provides a view into the phenotype of disease, and we can use it to understand where latent diseases or complications exist, pinpoint opportunities for earlier intervention, and close gaps in care. We’ve undertaken the first effort at scale with the goal of mapping every single interaction with the healthcare system. This foundation allows us to  identify the right specialists for any patient and drive a deeper understanding of disease as well as the right interventions to address it. What appears at first to be an isolated symptom might in fact be an undiagnosed, but treatable, rare disease.

And, as novel sources of information such as data from sensing devices and patient reported outcomes enter the system, we can correlate findings with outcomes and create better predictive and ultimately more prescriptive AI models.

In the future, we believe data continuity will enable systems to perform more effectively in creating a more seamless experience for the patient. And as we tilt toward value-based reimbursement, this continuity will enable a more honest and transparent process for linking interventions to outcomes.

Fragmentation is the reality of care today, but it can and must be overcome. The technology is there. The desire is there. And through our Healthcare Map™, the foundation exists to tie disparate systems together, fill in the gaps in patient journey, and bring these visions to life so we, as a healthcare system and community, can achieve our bigger goals of reducing the burden of disease.

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