Innovations in Chronic Care Delivery Using Data-Driven Clinical Pathways

This paper demonstrates that data-driven clinical pathways can be developed using electronic health record data to facilitate innovations in practice-based care delivery for chronic disease management. ABSTRACT Objectives: Chronic diseases are common, complex, and expensive health conditions that can benefit from innovations in healthcare service delivery enabled by information technology and advanced analytic methods. This paper proposes a data-driven approach, illustrated in the context of chronic kidney disease (CKD), to develop clinical pathways of care delivery from electronic health record (EHR) data. Study Design: We analyzed structured and de-identified EHR data from 2009 to 2013 of 664 CKD patients with multiple chronic conditions. Methods: Machine learning algorithms were used to learn data-driven and practice-based clinical pathways that cluster patients into subgroups and model the co-progression of their encounter types, diagnoses, medications,…


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