Analysis for Cleveland Clinic Hypertension Improvement

System (Enterprise)
1. Abstract

This Davies Report concerns the organization Cleveland Clinic, which implemented the
Hypertension Improvement System. This organization functions in the "world" of primary
care, with the specific imperative of addressing hypertension and the goal of minimizing
uncontrolled blood pressure levels to improve patient outcomes and reduce
healthcare costs. This report focuses on the role of Primary Care Providers (PCPs),
whose primary goals are to improve hypertension control rates and reduce associated
cardiovascular risks. I focus on the primary functions of hypertension detection,
management, and education and describe its success. I describe its workflow, providing
examples of the users' interaction with the system, including the cognitive processes
involved (“least eDort”). I describe the information system, which integrates analytics
platforms and electronic medical records (EMRs), supporting the workflow and the
functions. I also describe the modules, such as EPIC EMR, Optum Analytics, and MyChart,
and how they are systems in their own right. I describe the data, information, and
knowledge employed by the modules and the system to support those functions. Finally, I
describe the technology underlying the system.
I consider the standards in the system from each level of the Stack, in the context of
interoperability. I also describe the privacy, confidentiality, and security concerns
addressed and any ethical issues either explicit or implicit in their report.
I close with an assessment of the completeness of this report itself, an assessment of the
Stack for describing the project, and with my thoughts on what I gained from the exercise.

2. World

• World: Primary care within the U.S. healthcare system.

• Imperatives: Rising rates of hypertension, its status as the #1 risk factor for
premature death, and its associated healthcare costs ($46 billion annually).
• NAM Initiative Goals: Improving population health and enhancing care delivery.

Advanced: The complexity of the primary care environment influenced the need for an
integrated, scalable system capable of addressing hypertension through data-driven,
patient-centered care.

3. Organization

• Name: Cleveland Clinic.

• Type: Healthcare system with over 400,000 adult patients across 51 sites.
• Mission Statement: (Not explicitly stated; inferred) To deliver high-quality, value-
based care and improve patient outcomes through innovation and teamwork.
 • Goal: Maximizing the number of patients with controlled hypertension.
• New Policies or Models: Integration of care gap registries, virtual visits, and team-
based care models.
• Evidence of Success: Increased hypertension control rates from 46% to 54%, with
measurable reductions in strokes and heart attacks.
Advanced: Cleveland Clinic's large-scale, multi-site structure necessitated an adaptable
system to standardize care across diverse populations.

4. Role

• Role: Primary Care Provider (PCP).

Advanced: This role is mission-critical for hypertension management, as PCPs directly
interact with patients, manage medication, and educate them on self-management.

5. Functions

• Primary Function: Hypertension detection and management.

• Goal: Minimizing uncontrolled blood pressure levels.
• Evidence of Success: Reduction in premature deaths and cardiovascular events,
with 10,500 more patients achieving blood pressure control.
Advanced: If the system failed, a robust evaluation framework, such as the Donabedian
Model (structure, process, outcome), could assess areas for improvement.

6. Workflow

• Description: Hypertension is identified during intake or outreach, with follow-ups

via oDice visits or virtual consultations. The workflow incorporates patient
education, data visualization, and medication adjustments.
• Missing Elements: Specific challenges faced by frontline staD.
• User Interaction: Users interact with tools like EMR dashboards and BP
management modules.
• Theory: Information Seeking Behavior theory applies due to the reliance on
systematic, evidence-based queries.

7. Information System

• System Name: Hypertension Improvement System.

• Needs: High BP detection, eDicient workflow integration, patient engagement tools.
• Specifications: Integration with EPIC EMR, data visualization, and patient outreach.
• Development Process: Iterative enhancements based on stakeholder feedback.
• Architecture: Client-server with cloud-based analytics (Optum One).
• Dependencies: Interoperability with other health systems and national
hypertension management guidelines.
8. Modules
• Relevant Modules: EPIC EMR, Optum One Analytics, MyChart.
• Advanced: Optum One Analytics functions independently, oDering insights through
predictive modeling.

8. DIKW

• Data: BP readings, demographic details, and medication adherence logs.

• Information: Alerts for care gaps and trends in BP control.
• Knowledge: Clinical guidelines for hypertension treatment.

9. Technology

• Technologies: EPIC EMR, Optum Analytics, MyChart.

• Hype Cycle: These are mature technologies focused on eDiciency and scalability.

10. Interoperability

• Standards: HL7 for data exchange, ICD-10 for coding, role-based access for privacy.

11. Privacy, Confidentiality, Security

• Privacy: Patient consent for data usage.

• Confidentiality: Role-based access control.
• Security: Encrypted communication and secure login protocols.

12. Ethical Concerns

• Explicit: Ensuring equity in access to virtual care.

• Implicit: Balancing data usage with patient autonomy.

13. Reflection

• Completeness: The report comprehensively covers the implementation and

impact.
• Missing Elements: Detailed patient feedback and staD training outcomes.
• Learning: This exercise provided insights into integrating analytics into care
workflows to improve outcomes.
Analysis for Lanai Community Health Center (LCHC) Telehealth
Project (Community)

1. Abstract

This Davies Report concerns the organization, Lanai Community Health Center (LCHC),
which implemented the Self-Measured Blood Pressure (SMBP) Program. This
organization functions in the "world" of rural community healthcare, with the specific
imperative of improving hypertension management and reducing cardiovascular risk,
and the goal of maximizing blood pressure control rates through telehealth and patient
engagement. This report focuses on the role of the Patient, whose primary goal is to
engage in self-management of hypertension through telehealth and SMBP. I focus on
the primary functions of patient education and blood pressure tracking and describe its
success. I describe its workflow, providing examples of the users' interaction with the
system, including the cognitive processes involved (“ease of use”). I describe the
information system, which integrates SMBP devices with data management platforms to
support the workflow and the functions. I also describe the modules, such as the patient
portal and BridgeIT, and how they are systems in their own right. I describe the data,
information, and knowledge employed by the modules and the system to support those
functions. Finally, I describe the technology underlying the system.
I consider the standards in the system from each level of the Stack, in the context of
interoperability. I also describe the privacy, confidentiality, and security concerns
addressed and any ethical issues either explicit or implicit in their report.
I close with an assessment of the completeness of this report itself, an assessment of the
Stack for describing the project, and with my thoughts on what I gained from the exercise.

2. World

• World: Rural healthcare in the U.S., particularly underserved communities.

• Imperatives: High rates of uncontrolled hypertension, limited access to in-person
healthcare, and the need for community-driven solutions.
• NAM Initiative Goals: Improving patient-centered care and leveraging technology to
enhance access.
Advanced: The rural setting shaped the design, focusing on aDordability, ease of use, and
accessibility for a diverse patient population.

3. Organization

• Name: Lanai Community Health Center (LCHC).

• Type: Federally Qualified Health Center (FQHC) and 501(c)(3) nonprofit.
• Mission Statement: (Inferred) To provide holistic, integrated healthcare services to
the Lanai community.
• Goal: Maximizing patient engagement in self-monitoring blood pressure.
 • New Policies or Models: Integration of SMBP into routine care, leveraging
telehealth for medication management.
• Evidence of Success: A 70% hypertension control rate in 2015, compared to 58% in
2013.
Advanced: The small size of the organization allowed for rapid adoption of innovative
telehealth practices tailored to community needs.

4. Role
•
• Role: Patient.
Advanced: The role is central to this project as it relies on patient participation in SMBP
and telehealth for success.

5. Functions

• Primary Function: Self-monitoring of blood pressure and data sharing.

• Goal: Maximizing adherence to blood pressure monitoring protocols.
• Evidence of Success: High patient uptake of BP cuDs and engagement in remote
monitoring, with improved BP control rates.
Advanced: If the system failed, a patient satisfaction framework could evaluate barriers to
engagement.

6. Workflow

• Description: Patients receive BP cuDs and training on SMBP, upload data to the
system, and participate in telehealth consultations for feedback and medication
adjustments.
• Missing Elements: Challenges in patient adherence and technology literacy are not
explicitly addressed.
• User Interaction: Patients use SMBP devices and upload data via the portal or with
assistance from community health workers (CHWs).
• Theory: DiDusion of Innovation theory applies due to the focus on encouraging
technology adoption among patients.

7. Information System

• System Name: SMBP Program.

• Needs: Simplified BP monitoring, accessible data sharing, and patient education.
• Specifications: Integration with BridgeIT for population health reporting and CDMP
for clinical decision-making.
• Development Process: Incremental enhancements based on patient and provider
feedback.
• Architecture: Modular, cloud-based system with local data integration.
• Dependencies: Coordination with local pharmacies and healthcare providers.
8. Modules

• Relevant Modules: Patient portal, BridgeIT, SMBP dashboard.

• Advanced: The patient portal independently supports education, data uploads, and
communication, making it a standalone system.

9. DIKW

• Data: BP readings and demographic information.

• Information: Trends in BP readings over time.
• Knowledge: Clinical insights on BP management strategies.

10. Technology

• Technologies: Bluetooth-enabled BP cuDs, patient portal, BridgeIT analytics.

• Hype Cycle: Early majority stage, focusing on broad adoption.

11. Interoperability

• Standards: XML for data uploads, role-based access for privacy, and use of
standard diagnostic codes for reporting.

12. Privacy, Confidentiality, Security

• Privacy: Consent for data collection and sharing.

• Confidentiality: Local data storage with restricted access.
• Security: Encrypted data transfers and role-based permissions.

14. Ethical Concerns

• Explicit: Ensuring equitable access to SMBP devices.

• Implicit: Balancing the cost of telehealth technology with patient aDordability.

15. Reflection

• Completeness: The report provides a thorough overview but could include more
patient testimonials.
• Missing Elements: Long-term outcomes and scalability challenges.
• Learning: This analysis highlights the transformative potential of telehealth in rural
healthcare settings.
Stack Analysis for Florida Department of Health (FDOH) -
ESSENCE-FL (Public Health)
1. Abstract

This Davies Report concerns the organization, Florida Department of Health (FDOH),
which implemented the Electronic Surveillance System for the Early Notification of
Community-based Epidemics (ESSENCE-FL). This organization functions in the "world"
of public health, with the specific imperative of enhancing epidemic detection and
situational awareness, and the goal of minimizing delays in identifying and responding
to public health threats. This report focuses on the role of the State Epidemiologist,
whose primary goals are to detect outbreaks and provide timely public health
interventions. I focus on the primary functions of outbreak detection, situational
awareness, and data sharing and describe its success. I describe its workflow, providing
examples of the users' interaction with the system, including the cognitive processes
involved (“rapid decision-making”). I describe the information system, which
consolidates multiple data streams to support the workflow and functions. I also describe
the modules, such as syndromic surveillance and mortality data integration, and how they
are systems in their own right. I describe the data, information, and knowledge employed
by the modules and the system to support those functions. Finally, I describe the
technology underlying the system.
I consider the standards in the system from each level of the Stack, in the context of
interoperability. I also describe the privacy, confidentiality, and security concerns
addressed and any ethical issues either explicit or implicit in their report.
I close with an assessment of the completeness of this report itself, an assessment of the
Stack for describing the project, and with my thoughts on what I gained from the exercise.

2. World

• World: Public health at the state level in Florida.

• Imperatives: Rapid population growth, increasing frequency of public health
threats (e.g., hurricanes, pandemics), and the need for integrated disease
surveillance.
• NAM Initiative Goals: Ensuring public health preparedness and improving
population health outcomes.
Advanced: The diversity and large volume of Florida’s population influenced the system’s
design to accommodate multiple data sources and ensure scalability.

3. Organization

• Name: Florida Department of Health (FDOH).

• Type: State-level public health organization.
 • Mission Statement: To promote and protect the health and safety of all people in
Florida through quality public health services and health standards.
• Goal: Minimizing the time to detect and respond to public health threats.
• New Policies or Models: Adoption of syndromic surveillance standards and
incorporation of environmental data streams.
• Evidence of Success: Successful outbreak detection, enhanced situational
awareness, and integration of new data sources such as poison center calls and
mortality data.
Advanced: The centralized public health structure allowed for statewide implementation
and standardization.

4. Role

• Role: State Epidemiologist.

Advanced: This role is mission-critical, given its direct involvement in interpreting data and
guiding public health actions.

5. Functions

• Primary Function: Disease outbreak detection and monitoring.

• Goal: Maximizing situational awareness for rapid decision-making.
• Evidence of Success: Improved detection of small outbreaks and trends, such as
shigellosis spikes and post-hurricane dialysis needs.
Advanced: Without this system, a logic model evaluation could assess the inputs, outputs,
and outcomes to identify gaps.

6. Workflow

• Description: Data from emergency departments, poison centers, and vital statistics
is ingested, analyzed, and visualized for users. Alerts are generated for anomalies
requiring further investigation.
• Missing Elements: Specific challenges faced by county health departments in
using the system.
• User Interaction: Users interact with dashboards for real-time data visualization
and run ad hoc queries.
• Theory: Information Foraging theory applies as users seek the most relevant
information with minimal eDort.

7. Information System

• System Name: ESSENCE-FL.

• Needs: Real-time data collection, integration, and analysis to detect anomalies.
• Specifications: Multi-tier architecture with role-based access, automated data
ingestion, and real-time alert generation.
 • Development Process: Iterative design with input from stakeholders and
integration of advanced analytics.
• Architecture: Cloud-based infrastructure with modular components.
• Dependencies: Coordination with hospitals, laboratories, and national public
health networks.

8. Modules

• Relevant Modules: Emergency department data, reportable diseases, poison

center data, and mortality data.
• Advanced: The emergency department module independently performs syndromic
surveillance using natural language processing, making it a standalone system.

9. DIKW

• Data: Chief complaints, reportable diseases, and mortality records.

• Information: Alerts for unusual patterns or trends.
• Knowledge: Epidemiological models and outbreak response protocols.

10. Technology

• Technologies: HL7 data exchange, natural language processing, web-based

visualization tools.
• Hype Cycle: Advanced stages of maturity, focused on enhancement and scalability.

11. Interoperability

• Standards:
o Inter-organizational agreements: Syndromic surveillance guidelines (ISDS,
CDC).
o Use cases: Early event detection and trend monitoring.
o Functional standards: HL7 message mapping.
o Identifiers/privacy: De-identified data with unique record identifiers.
o Information exchange: Secure transfer protocols (sFTP, VPN).
o Data content: Syndromes and ICD-10 codes.
o Transport: HTTPS for web-based access.

12. Privacy, Confidentiality, Security

• Privacy: Use of de-identified data.

• Confidentiality: Role-based access controls for users.
• Security: Encrypted data storage and transfer, regular audits.

13. Ethical Concerns

• Explicit: Ensuring equitable data use across counties.
• Implicit: Balancing the need for rapid data access with patient confidentiality.

13. Reflection

• Completeness: The report is thorough in describing the system's design and impact
but lacks detailed user feedback.
• Missing Elements: More examples of local-level success stories could enhance
understanding.
• Learning: This analysis highlighted the complexity of integrating diverse data
sources for public health decision-making.
Stack Analysis for East Tennessee State University Family
Medicine (Ambulatory)
1. Abstract

This Davies Report concerns the organization, East Tennessee State University Family
Medicine (ETSU-FM), which implemented a Transitional Care Management (TCM)
Program. This organization functions in the "world" of ambulatory care, with the specific
imperative of reducing hospital readmissions and improving continuity of care, and the
goal of maximizing patient outcomes through eaective transitional care interventions.
This report focuses on the role of the Social Worker, whose primary goals are to support
patients in navigating post-hospitalization care plans and connecting them with
necessary resources. I focus on the primary functions of patient follow-up and care
coordination and describe its success. I describe its workflow, providing examples of the
users' interaction with the system, including the cognitive processes involved (“patient-
centered care coordination”). I describe the information system, which integrates
electronic health records (EHR) and care management tools to support the workflow and
the functions. I also describe the modules, such as patient tracking and automated alerts,
and how they are systems in their own right. I describe the data, information, and
knowledge employed by the modules and the system to support those functions. Finally, I
describe the technology underlying the system.
I consider the standards in the system from each level of the Stack, in the context of
interoperability. I also describe the privacy, confidentiality, and security concerns
addressed and any ethical issues either explicit or implicit in their report.
I close with an assessment of the completeness of this report itself, an assessment of the
Stack for describing the project, and with my thoughts on what I gained from the exercise.

2. World

• World: Ambulatory care in rural settings, focusing on transitional care.

• Imperatives: High rates of hospital readmissions and poor care continuity in
underserved populations.
• NAM Initiative Goals: Ensuring safe transitions of care and reducing avoidable
hospitalizations.
Advanced: The rural environment shaped the design to prioritize patient outreach and
integration of community-based resources.

3. Organization

• Name: East Tennessee State University Family Medicine (ETSU-FM).

• Type: Academic medical practice providing ambulatory care.
• Mission Statement: (Inferred) To deliver high-quality care and improve health
outcomes through patient-centered approaches.
 • Goal: Minimizing hospital readmissions through eaective transitional care
management.
• New Policies or Models: Implementation of TCM workflows and care coordination
tools.
• Evidence of Success: Reduced hospital readmission rates and improved patient
satisfaction scores.
Advanced: As an academic practice, the organization leveraged its research capabilities to
inform evidence-based care.

4. Role

• Role: Social Worker.

Advanced: This role is essential for addressing social determinants of health and ensuring
adherence to post-discharge care plans.

5. Functions

• Primary Function: Transitional care management.

• Goal: Maximizing adherence to post-hospitalization care plans.
• Evidence of Success: Increased follow-up rates and reduced preventable
readmissions.
Advanced: If the system failed, the RE-AIM framework (Reach, EDectiveness, Adoption,
Implementation, Maintenance) could evaluate program impact.

6. Workflow

• Description: Social workers coordinate with patients post-discharge, arrange

follow-up appointments, and connect them with necessary services. Automated
alerts assist in tracking deadlines for follow-up care.
• Missing Elements: Specific challenges in addressing patient compliance.
• User Interaction: Users rely on EHR-integrated tools to track patient status and
communicate with interdisciplinary teams.
• Theory: The Patient-Centered Care theory applies, emphasizing shared decision-
making and individualized interventions.

7. Information System

• System Name: TCM Program System.

• Needs: EDicient tracking of discharged patients, communication tools, and timely
follow-up alerts.
• Specifications: EHR integration with care coordination modules and automated
workflows.
• Development Process: Collaborative design with input from clinicians and social
workers.
• Architecture: Centralized system with modular components for flexibility.
• Dependencies: Integration with hospital discharge systems and community
resources.

8. Modules

• Relevant Modules: Patient tracking, appointment scheduling, and automated

alerts.
• Advanced: The patient tracking module independently functions as an information
system by monitoring post-discharge outcomes.

9. DIKW

• Data: Patient discharge summaries, follow-up schedules, and care plans.

• Information: Alerts for overdue follow-ups or missed appointments.
• Knowledge: Evidence-based guidelines for post-hospitalization care.

10. Technology

• Technologies: EHR with integrated care management tools, automated alert

systems.
• Hype Cycle: Mature technologies with incremental enhancements for specific
workflows.

11. Interoperability

• Standards:
o Inter-organizational agreements: Data sharing with hospitals and
community services.
o Use cases: Post-discharge follow-up and readmission prevention.
o Functional standards: HL7 data exchange for discharge information.
o Identifiers/privacy: Role-based access control.
o Information exchange: Secure messaging protocols.
o Data content: Standardized care plans and discharge instructions.
o Transport: Encrypted data transfer via secure servers.

12. Privacy, Confidentiality, Security

• Privacy: Compliance with HIPAA for patient data protection.

• Confidentiality: Role-specific access to sensitive data.
• Security: Encrypted data storage and transfer, routine security audits.

13. Ethical Concerns

• Explicit: Addressing disparities in access to care resources.
• Implicit: Balancing cost containment with comprehensive patient care.

14. Reflection

• Completeness: The report comprehensively addresses system implementation but

lacks specific patient testimonials or long-term outcomes.
• Missing Elements: Greater detail on how social determinants of health were
addressed.
• Learning: This analysis reinforced the importance of holistic approaches in
transitional care management to improve patient outcomes.