C-CDA Ingestion Into Data Cloud

Patient Segmentation and Improved Care Management

Context: A large healthcare system frequently receives patients who have been treated by multiple providers, some outside of its network. These patients bring with them a variety of clinical documents in CCDA format, such as medication lists, problem lists, and recent procedure reports. Managing and integrating this information to derive meaningful insights poses a significant challenge. The information is often siloed, making it difficult for healthcare providers to get a comprehensive view of a patient’s medical history. This fragmentation can lead to missing patients during segmentation processes, leading to lower outcomes.

Scenario: A healthcare organization aims to improve its chronic disease management programs, focusing on conditions like diabetes and heart disease, which are prevalent among its patient population. Despite having access to vast amounts of clinical data, the organization struggles to efficiently utilize this information for targeted patient care and program development due to the disparate formats and sources of the data, including CCDA documents from various healthcare providers.

Solution: By implementing this integration, data from CCDA documents is extracted, transformed into FHIR bundles, and ingested into Salesforce Data Cloud so that the organization can leverage unified patient data for advanced analytics and segmentation. This process enables the healthcare organization to analyze comprehensive patient records, identifying patterns, risk factors, and outcomes associated with chronic diseases.

For instance, using the structured data now available in Salesforce, the organization can apply analytics to segment the patient population based on risk factors such as age, other conditions, and HbA 1c levels for diabetes management. This segmentation allows for identifying high-risk patients who benefit most from intensive management programs or preventive interventions.

Many clinical data exchanges through Health Information Exchanges also happen through CCDA documents.

Outcome: Armed with this insight, the healthcare organization can tailor its chronic disease management programs to address the specific needs of different patient segments. High-risk patients can be enrolled in specialized care plans that include regular monitoring, personalized health coaching, and targeted educational content. The care plans aim to manage the patients' conditions more effectively and prevent complications. It ensures that all patient data have been appropriately considered during segmentation processes and that no patient is missed on care management.