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Strive Health通过自研机器学习提升关键KPI指标

Strive Health improves key KPIs with homegrown machine learning

HealthcareITNews 等信源发布 2025-04-03 15:00

可切换为仅中文


Global Edition

全球版

AI & ML Intelligence

人工智能与机器学习智能

Strive Health improves key KPIs with homegrown machine learning

Strive Health通过自研机器学习改进关键绩效指标(KPI)

The kidney care provider's build-not-buy effort has shown great results: 30-day readmissions are down 36%, hospitalizations among high-risk patients are down 49% and optimal starts are up 67%.

肾脏护理提供商的“自建而非购买”努力取得了显著成果:30天再入院率下降了36%,高危患者的住院率下降了49%,最佳治疗启动率上升了67%。

By

通过

Bill Siwicki

比尔·西威基

April 03, 2025

2025年4月3日

11:47 AM

上午11点47分

Matthew Temba, chief technology officer at Strive Health

斯特莱夫健康公司的首席技术官马修·坦巴

Photo: Matthew Temba

照片来源:马修·坦巴

Strive Health, a value-based kidney care provider, noticed many of its health IT vendors, like the provider itself, operate extensively in the value-based care space and collaborate with accountable care organizations and health systems.

以价值为基础的肾脏护理服务提供商Strive Health注意到,其许多健康IT供应商本身也如服务商一样,在基于价值的护理领域广泛运营,并与责任医疗组织和卫生系统合作。

THE CHALLENGE

挑战

These systems' models need to be manifested in Strive's technology and workflows, and Strive was having a hard time finding a technology vendor that could provide that unique use case the provider required.

这些系统模型需要在Strive的技术和工作流程中体现出来,而Strive很难找到能够提供该供应商所需独特用例的技术供应商。

That spurred the need for Strive staff to build their own technology versus buying it. They needed a tool that helped with everything from identifying which patients should be a part of which care pathways while leveraging

这促使Strive的员工需要自己开发技术,而不是购买技术。他们需要一种工具,能够帮助他们完成从确定哪些患者应该参与哪些护理路径,同时利用...

data science and machine learning modeling

数据科学与机器学习建模

to understand what patient care characteristics best align with parts of Strive's care model.

了解哪些患者护理特征最符合Strive护理模型的各个部分。

Staff wanted a technology that was customizable and could be integrated directly into the tools already being used by its Kidney Heroes – nurse practitioners, nurses, social workers, care coordinators and dietitians trained to provide highly specialized care and understand the intricacies of kidney disease.

员工希望找到一种可定制并且能够直接整合到其“肾脏英雄”已经在使用的工具中的技术——这些“肾脏英雄”包括护士从业者、护士、社会工作者、护理协调员和营养师,他们经过培训提供高度专业化的护理,并了解肾脏疾病的复杂性。

Further, the technology had to be able to be flexible as staff continue to learn what works..

此外,随着员工不断学习哪些方法有效,这项技术必须能够灵活适应。

'It is best to have that ownership to be able to upgrade and update any components of either the underlying data model or the user interface as quickly as we can,' said Matthew Temba, chief technology officer at Strive Health. 'We never want our business to be able to innovate faster than our technology, which is why having ownership control is key.'.

“最好拥有所有权,以便能够尽快升级和更新底层数据模型或用户界面的任何组件,”Strive Health首席技术官马修·坦巴表示。“我们绝不希望我们的业务创新速度超过技术,这就是为什么拥有控制权是关键。”

PROPOSAL

提案

The risk stratification logic that many other value-based care vendors use looks at a much broader population, and so they are typically identifying all patients with late-stage chronic kidney disease (CKD).

许多其他价值导向型护理供应商使用的风险分层逻辑着眼于更广泛的人群,因此他们通常会识别出所有晚期慢性肾病(CKD)患者。

'Our proposal and what our technology sought to focus on is identifying the most high-risk patients within that group who we can have the most impact on,' Temba explained. 'We wanted to use our technology to develop individualized care plans for people with CKD, guiding them on a care path that addresses the issue early – preventing progression to dialysis or transplant..

“我们的提议和技术所要关注的重点是识别出这一群体中风险最高的患者,我们可以在他们身上产生最大的影响,”坦巴解释说。“我们希望利用我们的技术为慢性肾病患者制定个性化的护理计划,引导他们在病情早期走上一条护理路径——防止病情进展到需要透析或移植。”

'The first big piece for

“第一个重要的部分是

resolving the VBC challenge

解决VBC挑战

was around patient identification and figuring out who the patients with late-stage CKD and end-stage renal disease (ESRD) are who would benefit the most from our intervention,' he continued. 'Our risk stratification logic identifies those who need a more extensive care team.'

是围绕患者识别,并找出哪些晚期慢性肾病(CKD)和终末期肾病(ESRD)患者最能从我们的干预中受益,他继续说道。我们的风险分层逻辑可以识别出那些需要更广泛护理团队的患者。

Once identified, staff then could better manage these patients' health, giving them more healthy days at home, reducing their healthcare utilization management by keeping patients out of the hospital, and generating shared savings by focusing on this preventative care through a value-based care model..

一旦确定,工作人员就可以更好地管理这些患者的健康,让他们在家里享受更多健康的时光,通过避免患者住院来减少他们的医疗资源利用,并通过基于价值的护理模式专注于这种预防性护理来产生共享储蓄。

'In addition to being more precise about the risk stratification, the other piece is making sure our technology is integrated into our operations and presenting data, analysis and care plans to our care team within their existing workflow,' Temba noted. 'This way, our care team knows that a patient who is complex in risk is going to need more care naturally, and they can be prepared with the right frame of mind when they approach that patient..

“除了更准确地进行风险分层外,另一个重要部分是确保我们的技术整合到日常运营中,并在现有工作流程中向护理团队提供数据、分析和护理计划,”滕巴指出。“这样,我们的护理团队就会知道,一个风险复杂度较高的患者自然需要更多的护理,他们在接触这位患者时也能做好充分准备并保持正确的思维方式。”

'Care teams then can use their clinical judgment in concert with the risk stratification to make the right judgment calls on the patient,' he added.

“护理团队然后可以结合风险分层运用他们的临床判断,对患者做出正确的判断。”他补充道。

MEETING THE CHALLENGE

迎接挑战

The technology Strive Health created is called CareMultiplier. It aggregates and standardizes data from a multitude of sources and leverages a suite of predictive analytic models that support deep insights into kidney patient data profiles.

Strive Health创建的技术被称为CareMultiplier。它聚合和标准化来自众多来源的数据,并利用一套预测分析模型,为肾病患者的数据档案提供深入的洞察支持。

'The model has always been about building technology for our internal care teams and our Kidney Heroes who are our primary users,' Temba explained. 'This way, all of our patient-facing staff – from nurse practitioners and medical assistants to care coordinators and social workers – are using the customized workflows we've built..

“该模型的重点一直是为我们内部护理团队以及我们的‘肾脏英雄’(主要用户)构建技术,”滕巴解释道。“这样一来,我们所有面向患者的工作人员——从执业护士、医疗助理到护理协调员和社会工作者——都在使用我们定制的工作流程。”

'The user interface they engage with on a day-to-day basis to manage documentation and manage their care activities is all part of our technology as well as the data modeling and risk profiles we create are all embedded into that user environment,' he continued.

“他们每天用来管理文件和管理护理活动的用户界面,以及我们创建的数据模型和风险概况,都嵌入到了那个用户环境中,”他继续说道。

The model also is integrated with a few other systems, such as Salesforce,

该模型还与一些其他系统集成,例如 Salesforce,

AWS (which is used as the cloud service provider)

AWS(用作云服务提供商)

, and AdvancedMD, an electronic health record system. When nurse practitioners deliver care and need to create a claim, they do that documentation in AdvancedMD.

,以及电子健康记录系统AdvancedMD。当护士从业者提供护理并需要创建索赔时,他们会在AdvancedMD中进行该文档的记录。

'To accomplish these tasks, our KidneyHeroes are the ones making a direct impact,' Temba said. 'As an IT team, we enable them to make the best judgment for each patient. It also has a lot to do with streamlining their workflow and giving them information and insights and allowing it to populate so that when they're having a conversation with a patient, all of that information is readily available and easy to use..

“为了完成这些任务,我们的KidneyHeroes正在产生直接影响,”坦巴说。“作为IT团队,我们要使他们能够为每位患者做出最佳判断。这也与优化他们的工作流程、提供信息和洞察,并使其自动填充有很大关系,这样当他们与患者交谈时,所有信息都能随手可得且易于使用。”

'By embracing these technologies, healthcare organizations can improve efficiency and reclaim time in their daily operations to give back to patient care,' he added.

“通过采用这些技术,医疗机构可以提高效率,并在日常运营中节省时间,用于回馈患者护理,”他补充道。

RESULTS

结果

At the beginning of 2024, Strive Health rolled out a new assessment workflow that made a huge impact on initial documentation time, cutting it almost in half. That created more time for the Kidney Heroes to spend with patients and not just collecting assessment information.

2024年初,Strive Health推出了一项新的评估工作流程,极大减少了初始文档处理时间,几乎缩短了一半。这为肾病英雄们创造了更多与患者相处的时间,而不仅仅是收集评估信息。

'We've got a lot more work ahead of us this year on how to make their time even more valuable, which is a KPI we continue to track against,' Temba reported.

“今年我们还有很多工作要做,思考如何使他们的时间更有价值,这是我们继续追踪的关键绩效指标(KPI),”坦巴报告说。

'We also can look at the effectiveness of our risk stratification model to showcase hard results,' he continued. 'That is one area we're always tracking and always improving. Our machine learning environment allows us to tune our models as we get new patients, making that another area where we are always focused on doing new development.'.

“我们还可以查看风险分层模型的有效性,以展示切实的成果,”他继续说道。“这是我们一直在追踪并不断改进的一个领域。我们的机器学习环境允许我们在接收新患者时调整模型,这使得我们始终专注于进行新的开发。”

Because of the insights and data analysis CareMultiplier delivers to care teams, Strive has achieved a 36% reduction in 30-day hospital readmissions, a 49% reduction in hospitalizations among high-risk patients, and a 67% increase in optimal starts – a planned start of renal replacement therapy by receiving a preemptive kidney transplant, initiating home dialysis or initiating in-center hemodialysis..

由于CareMultiplier为护理团队提供的洞察和数据分析,Strive已经实现了30天内再入院率降低36%,高风险患者住院率减少49%,以及最佳启动率增加67%——通过接受预防性肾移植、启动居家透析或在中心进行血液透析来实现肾替代治疗的计划启动。

'One example is our work with Oak Street Health,' Temba recalled. 'Throughout our relationship with them, they have trusted us to do more and more transitional care management (TCM). That is a testament to what they saw in our workflows. They saw our team as an organization that has been doing TCM for many years and this solidified their trust in us to use our TCM program on our shared patients.'.

“一个例子是我们与橡树街健康的合作,”滕巴回忆说。“在我们与他们的合作关系中,他们越来越信任我们进行更多的过渡期护理管理(TCM)。这证明了他们在我们的工作流程中所看到的能力。他们将我们的团队视为一个多年来一直在从事TCM的组织,这进一步巩固了他们对我们使用TCM项目管理共同患者的信任。”

ADVICE FOR OTHERS

给其他人的建议

'Other healthcare provider organizations should have a long-sighted worldview, though it takes a lot of investment capital for a business to have that luxury,' Temba advised. 'There are multiple external factors at play and you have to have that organizational commitment to do it.

“其他医疗保健机构组织应该具有长远的世界观,尽管对于一个企业来说,拥有这种远见需要大量的投资资本,”滕巴建议道。“有多种外部因素在起作用,你必须要有这种组织承诺才能做到这一点。

Custom building a technology

定制构建技术

to suit the operational and clinical model of a startup organization is one that is filled with uncertainty.

适合初创组织的运营和临床模型是充满不确定性的。

'Organizations must think about how to build reusable technology that is extremely flexible,' he concluded. 'Finding that right balance, and more important, ensuring the relationship with the operational teams and the clinical teams is really strong so there are tight feedback loops, is critical to success.'.

“组织必须考虑如何构建极其灵活的可重用技术,”他总结道。“找到正确的平衡点,更重要的是,确保与运营团队和临床团队的关系非常紧密,以便形成紧密的反馈循环,这对成功至关重要。”

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比尔·西威基

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Healthcare IT News is a HIMSS Media publication.

医疗保健 IT 新闻是 HIMSS 媒体出版物。

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Strive Health, a value-based kidney care provider, noticed many of its health IT vendors, like the provider itself, operate extensively in the value-based care space and collaborate with accountable care organizations and health systems.

Strive Health是一家基于价值的肾脏护理提供商,该公司注意到其许多健康IT供应商像它自己一样,都在基于价值的护理领域广泛运营,并与责任医疗组织和卫生系统合作。

THE CHALLENGE

挑战

These systems' models need to be manifested in Strive's technology and workflows, and Strive was having a hard time finding a technology vendor that could provide that unique use case the provider required.

这些系统的模型需要在Strive的技术和工作流程中体现出来,而Strive很难找到能够提供该供应商所需独特用例的技术供应商。

That spurred the need for Strive staff to build their own technology versus buying it. They needed a tool that helped with everything from identifying which patients should be a part of which care pathways while leveraging

这促使Strive的员工需要构建自己的技术,而不是购买现成的技术。他们需要一种工具,能够帮助他们完成从确定哪些患者应该参与哪些护理路径,同时充分利用资源等所有工作。

data science and machine learning modeling

数据科学与机器学习建模

to understand what patient care characteristics best align with parts of Strive's care model.

了解哪些患者护理特征最符合Strive护理模型的各个部分。

Staff wanted a technology that was customizable and could be integrated directly into the tools already being used by its Kidney Heroes – nurse practitioners, nurses, social workers, care coordinators and dietitians trained to provide highly specialized care and understand the intricacies of kidney disease.

员工希望拥有一种可定制并且能够直接集成到其“肾脏英雄”已经在使用的工具中的技术——这些“肾脏英雄”包括经过培训的执业护士、护士、社会工作者、护理协调员和营养师,他们提供高度专业化的护理并了解肾脏疾病的复杂性。

Further, the technology had to be able to be flexible as staff continue to learn what works..

此外,随着员工继续学习什么有效,这项技术必须能够灵活应对。

'It is best to have that ownership to be able to upgrade and update any components of either the underlying data model or the user interface as quickly as we can,' said Matthew Temba, chief technology officer at Strive Health. 'We never want our business to be able to innovate faster than our technology, which is why having ownership control is key.'.

“最好拥有所有权,以便能够尽快升级和更新底层数据模型或用户界面的任何组件,”Strive Health 首席技术官马修·坦巴表示。“我们绝不希望我们的业务创新能力超过技术能力,这就是为什么拥有控制权是关键。”

PROPOSAL

提案

The risk stratification logic that many other value-based care vendors use looks at a much broader population, and so they are typically identifying all patients with late-stage chronic kidney disease (CKD).

许多其他价值导向型护理供应商使用的风险分层逻辑着眼于更广泛的人群,因此他们通常会识别出所有晚期慢性肾病(CKD)患者。

'Our proposal and what our technology sought to focus on is identifying the most high-risk patients within that group who we can have the most impact on,' Temba explained. 'We wanted to use our technology to develop individualized care plans for people with CKD, guiding them on a care path that addresses the issue early – preventing progression to dialysis or transplant..

“我们的提案和技术所要关注的重点是识别出这个群体中最高危的患者,我们可以在他们身上产生最大的影响,”滕巴解释说。“我们希望利用我们的技术,为慢性肾病患者制定个性化的护理计划,引导他们在护理路径上及早解决问题,防止病情恶化到需要透析或移植的地步。

'The first big piece for

“第一个重要的部分是

resolving the VBC challenge

解决VBC挑战

was around patient identification and figuring out who the patients with late-stage CKD and end-stage renal disease (ESRD) are who would benefit the most from our intervention,' he continued. 'Our risk stratification logic identifies those who need a more extensive care team.'

是围绕患者识别,并找出那些晚期CKD(慢性肾病)和终末期肾病(ESRD)患者,他们将从我们的干预中受益最大,”他继续说道。“我们的风险分层逻辑能够识别出哪些患者需要更广泛的护理团队。”

Once identified, staff then could better manage these patients' health, giving them more healthy days at home, reducing their healthcare utilization management by keeping patients out of the hospital, and generating shared savings by focusing on this preventative care through a value-based care model..

一旦确定,工作人员就能更好地管理这些患者的健康,让他们在家里享受更多健康的日子,通过避免患者住院来减少他们的医疗资源利用,并通过基于价值的护理模式专注于这种预防性护理来产生共享储蓄。

'In addition to being more precise about the risk stratification, the other piece is making sure our technology is integrated into our operations and presenting data, analysis and care plans to our care team within their existing workflow,' Temba noted. 'This way, our care team knows that a patient who is complex in risk is going to need more care naturally, and they can be prepared with the right frame of mind when they approach that patient..

“除了更准确地进行风险分层外,另一个重要部分是确保我们的技术整合到日常运营中,并在现有的工作流程中向护理团队提供数据、分析和护理计划,”滕巴指出。“通过这种方式,我们的护理团队就会知道,一个风险复杂度较高的患者自然需要更多的护理,他们在接触该患者时也能有充分的心理准备。”

'Care teams then can use their clinical judgment in concert with the risk stratification to make the right judgment calls on the patient,' he added.

“护理团队随后可以结合风险分层,运用他们的临床判断,对患者做出正确的判断。”他补充道。

MEETING THE CHALLENGE

迎接挑战

The technology Strive Health created is called CareMultiplier. It aggregates and standardizes data from a multitude of sources and leverages a suite of predictive analytic models that support deep insights into kidney patient data profiles.

Strive Health创建的技术名为CareMultiplier。它聚合并标准化来自众多来源的数据,并利用一套预测分析模型,为肾病患者数据档案提供深入见解。

'The model has always been about building technology for our internal care teams and our Kidney Heroes who are our primary users,' Temba explained. 'This way, all of our patient-facing staff – from nurse practitioners and medical assistants to care coordinators and social workers – are using the customized workflows we've built..

“该模型的目标始终是为我们的内部护理团队以及作为主要用户之一的‘肾英雄’们构建技术,”坦巴解释道。“这样,我们所有面向患者的工作人员——从执业护士、医疗助理到护理协调员和社会工作者——都在使用我们定制的工作流程。”

'The user interface they engage with on a day-to-day basis to manage documentation and manage their care activities is all part of our technology as well as the data modeling and risk profiles we create are all embedded into that user environment,' he continued.

“他们每天用来管理文档和护理活动的用户界面,以及我们创建的数据模型和风险档案,都嵌入到了这个用户环境中,”他继续说道。

The model also is integrated with a few other systems, such as Salesforce,

该模型还与一些其他系统集成,例如 Salesforce,

AWS (which is used as the cloud service provider)

AWS(用作云服务提供商)

, and AdvancedMD, an electronic health record system. When nurse practitioners deliver care and need to create a claim, they do that documentation in AdvancedMD.

,以及电子健康记录系统AdvancedMD。当护士从业者提供护理并需要创建索赔时,他们会在AdvancedMD中进行该文档的记录。

'To accomplish these tasks, our KidneyHeroes are the ones making a direct impact,' Temba said. 'As an IT team, we enable them to make the best judgment for each patient. It also has a lot to do with streamlining their workflow and giving them information and insights and allowing it to populate so that when they're having a conversation with a patient, all of that information is readily available and easy to use..

“为了完成这些任务,我们的KidneyHeroes正在产生直接影响,”坦巴说。“作为IT团队,我们要使他们能够为每位患者做出最佳判断。这也与优化他们的工作流程、提供信息和见解以及实现信息的自动填充有很大关系,这样当他们与患者交谈时,所有这些信息都易于获取和使用。”

'By embracing these technologies, healthcare organizations can improve efficiency and reclaim time in their daily operations to give back to patient care,' he added.

“通过采用这些技术,医疗组织可以提高效率,夺回日常运营中的时间,用于回馈患者护理,”他补充道。

RESULTS

结果

At the beginning of 2024, Strive Health rolled out a new assessment workflow that made a huge impact on initial documentation time, cutting it almost in half. That created more time for the Kidney Heroes to spend with patients and not just collecting assessment information.

2024年初,Strive Health推出了一项新的评估工作流程,大大减少了初始文档处理时间,几乎将其缩短了一半。这为肾病英雄们腾出了更多时间与患者相处,而不仅仅是收集评估信息。

'We've got a lot more work ahead of us this year on how to make their time even more valuable, which is a KPI we continue to track against,' Temba reported.

“今年我们还有更多的工作要做,以研究如何使他们的时间更有价值,这是我们继续追踪的关键绩效指标(KPI),”坦巴报告说。

'We also can look at the effectiveness of our risk stratification model to showcase hard results,' he continued. 'That is one area we're always tracking and always improving. Our machine learning environment allows us to tune our models as we get new patients, making that another area where we are always focused on doing new development.'.

“我们还可以查看风险分层模型的有效性,以展示具体成果,”他继续说道。“这是我们一直在追踪并不断改进的领域之一。我们的机器学习环境使我们能够在接收新患者时调整模型,这也成为我们始终专注于新开发的另一个领域。”

Because of the insights and data analysis CareMultiplier delivers to care teams, Strive has achieved a 36% reduction in 30-day hospital readmissions, a 49% reduction in hospitalizations among high-risk patients, and a 67% increase in optimal starts – a planned start of renal replacement therapy by receiving a preemptive kidney transplant, initiating home dialysis or initiating in-center hemodialysis..

由于CareMultiplier为护理团队提供的洞察和数据分析,Strive实现了30天内再入院率降低36%,高风险患者住院率减少49%,以及最佳起始率提升67%——即通过接受预防性肾移植、启动居家透析或在中心启动血液透析来实现肾替代治疗的计划性开始。

'One example is our work with Oak Street Health,' Temba recalled. 'Throughout our relationship with them, they have trusted us to do more and more transitional care management (TCM). That is a testament to what they saw in our workflows. They saw our team as an organization that has been doing TCM for many years and this solidified their trust in us to use our TCM program on our shared patients.'.

“一个例子是我们与Oak Street Health的合作,”坦巴回忆说。“在我们与他们的合作关系中,他们越来越信任我们进行更多的过渡性护理管理(TCM)。这证明了他们在我们的工作流程中看到的价值。他们把我们的团队视为一个多年来一直在从事TCM的组织,这巩固了他们对我们使用TCM项目来管理共同患者的信任。”

ADVICE FOR OTHERS

给其他人的建议

'Other healthcare provider organizations should have a long-sighted worldview, though it takes a lot of investment capital for a business to have that luxury,' Temba advised. 'There are multiple external factors at play and you have to have that organizational commitment to do it.

“其他医疗保健机构组织应该具有长远的世界观,尽管对于一个企业来说,拥有这种视野需要大量的投资资本,”坦巴建议道。“有多种外部因素在起作用,你必须要有这样的组织承诺才能做到。”

Custom building a technology

定制构建技术

to suit the operational and clinical model of a startup organization is one that is filled with uncertainty.

适合初创组织的运营和临床模型是充满不确定性的。

'Organizations must think about how to build reusable technology that is extremely flexible,' he concluded. 'Finding that right balance, and more important, ensuring the relationship with the operational teams and the clinical teams is really strong so there are tight feedback loops, is critical to success.'.

“组织必须考虑如何构建极其灵活的可重复使用技术,”他总结道。“找到正确的平衡点,更重要的是,确保与运营团队和临床团队的关系非常紧密,以便形成紧密的反馈循环,这对成功至关重要。”

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关注 Bill 在 LinkedIn 上的 HIT 报道:

Bill Siwicki

比尔·西维基

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给他发邮件:

bsiwicki@himss.org

bsiwicki@himss.org

Healthcare IT News is a HIMSS Media publication.

医疗保健 IT 新闻是 HIMSS 媒体出版物。

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