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      Research Area: Advancing Digital, Technology, and Data Solutions

      AMGA works every day supporting members’ application of data driven and digital innovations to improve evidence-based decision making, enhance outcomes and reduce costs. By leveraging large longitudinal EHR and claims datasets and with the use of artificial intelligence (AI), AMGA helps members optimize patient and population health. AMGA is also using these tools for a deeper, data-driven understanding about how social determinants drive or hinder health equity for all patients. We are working with members to evaluate and deploy new and emerging innovations in digital technology and genetics to improve screening, diagnosis, prognosis, and treatment of diseases in both clinical and home-based or remote settings. 

      Predictive models and other data algorithms
      AMGA works with members to develop, test and evaluate predictive models and other data-based algorithms that identify at- or high-risk risk patients to encourage health systems to intervene earlier in the disease process, and optimize treatment outcomes. Based on trends in the data, we produce actionable predictions about risks, which can improve patient care, keep patients healthier for longer, and reduce treatment costs. 

      • Chronic Kidney Disease Algorithm for ASCVD Risk Calculator: In partnership with the Welch Center at Johns Hopkins University, AMGA helped to develop and calibrate a new kidney measure in the American Heart Association’s PREVENT equation to enhance identification of people at risk for ASCVD. Learn More

      • Chronic Opioid Use Among Patients with Osteoarthritis: Using data from 13 healthcare organizations, AMGA applied four machine learning models to estimate patients with osteoarthritis (OA) at risk of opioid use disorder (OUD). Some patients have 10-times the risk of developing chronic opioid use if prescribed an opioid for chronic pain. Learn More
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      • Individualized Treatment Benefits for Patients with Prediabetes: Working with Tuft’s Predictive Analytics and Comparative Effectiveness (PACE) Center, AMGA evaluated the application of a prediabetes predictive model at two healthcare organizations using data elements routinely available in the EHR. The model estimates individualized benefit of taking metformin or participating in an intensive lifestyle intervention for use in shared decision making with patients with prediabetes. Learn More

      • Predicting Adverse Kidney Outcomes in the General Population and in Patients with Diabetes: AMGA worked with ~70 collaborators to predict 5-year risk of incident chronic kidney disease. Equations predicting risk of adverse kidney outcomes, included age, sex, race/ethnicity, eGFR, history of cardiovascular disease, ever smoker, hypertension, BMI, albuminuria concentration, and diabetes medications demonstrated high predictability in diverse populations. Learn More
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      • Application of the Million Hearts Hypertension Prevalence Estimator: The CDC’s Million Hearts Hypertension Prevalence Estimator enables health systems to determine prevalence of hypertension in the patient population for actionable use in addressing undiagnosed hypertension. AMGA validated the tool using medical billing data alone and in combination with clinical data collected from 25 AMGA organizations. Learn More 

      Telehealth, remote, and home-based technologies
      AMGA members have proved their capacity to make nimble, rapid, and consequential changes to health care with rapid deployment of telehealth. AMGA is supporting members in this large natural experiment by evaluating patient outcomes in telehealth and working to enhance care quality, by evaluating and testing remote patient monitoring and screening innovations, including wearable devices, genetically designed screening tools for use with SMART apps, along with other emerging technologies.

      • Implementing Continuous Glucose Monitors in Primary Care for Patients with Type 2 Diabetes: Use of continuous glucose monitors (CGMs) has been increasing among patients with type 2 diabetes mellitus (T2DM). This study examined the effects of real-time CGM in real life settings on blood glucose levels in primary care patients with T2DM, particularly those not on intensive insulin therapy. Learn More

      • Exploring Implementation of a Home-Based Test for Kidney Disease—Clinical guidelines for people with type 2 diabetes recommend screening annually for kidney disease (CKD) using urine albumin-to-creatinine ratio (uACR). AMGA analyzed data from 24 diverse health care organizations and found only 45% of patients with type 2 diabetes and 17% with HTN had uACR measured in the past year. AMGA worked with one member to evaluate use of the first FDA-approved home-based uACR test with the potential to increase timely CKD identification and management. Learn More

      • The Impact of Telemedicine Use During COVID-19 on At-Risk Patients with Type 2 Diabetes and Hypertension: In January 2020, <1% of visits were conducted via telehealth, but by April 2020 this had increased to 64%. In a collaboration with UC-Berkley, AMGA evaluated the impact of telemedicine use during COVID-19 on outcomes and racial/health disparities for patients with diabetes and hypertension. Black patients had the smallest declines in visits and the greatest use of telehealth. Learn More 

      • Rates of Follow-up Colonoscopy after a Stool-Based Test during COVID-19: The COVID-19 pandemic significantly reduced rates of follow up colonoscopy among patients with a positive stool-based test (SBT) for colorectal cancer (CRC). Patients with positive SBTs had much lower rates of follow-up in 2020 relative to 2019, which created a backlog of patients at high risk for CRC. Learn More

      • Expanding Access to Diabetes Prevention in Remote Rural Communities Via Telemedicine: Evaluation of a multi-site Diabetes Prevention Program (DPP) demonstrated that services delivered via telehealth to multiple remote rural communities from a single urban site showed no observable differences in effectiveness when compared with the face-to-face intervention. Learn More

      • Improving Blood Pressure Control Using Smart Technology—Wireless Home Blood Pressure Monitoring (HBPM): Study determined HBPM with integrated smartphone technology improved BP control in patients with uncontrolled HTN provided the technology is easy to use and is integrated into the EHR. Learn More

      Quality improvement and meaningful measure development
      AMGA works with members to develop, test, and evaluate measures that can be used by providers and practices to improve patient care. We can increase confidence in the effectiveness and administrative burden of measures we develop by applying measures in AMGA’s large quality improvement campaigns and myriad quality initiatives in which hundreds of AMGA members have participated.

      • Follow-Up Measure to Ensure Complete Screening for Colorectal Cancer (CRC): When a patient receives an abnormal result on a stool-based screening test (SBT) for CRC, there is no measure for completing the process with follow-up colonoscopy. This observational study included adults from 38 health care organizations aged 50 to 75 years with an abnormal result on an initial CRC-SBT to determine rates of follow-up colonoscopy within 6 months. AMGA developed a draft measure, tested for validity, reliability, and for feasibility and applied the measure at three AMGA member healthcare organizations. Results were stratified by race, ethnicity, sex, and insurance. 2024
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      • Developing and Testing Multi-Level Interventions to Ensure Health Equity in Treatment of COVID-19: Three AMGA member organizations are developing and implementing interventions to address health equity in the management of COVID-19 including vaccination and treatment. Participating organizations convened for an in-person meeting to strategize on multi-level interventions to address equity challenges identified in their data by race and ethnicity. Learn More

      • Using Claims and EHR Data to Establish Quality Measures for Homebound Older Adults: AMGA worked with AARP and OptumLabs to identify homebound patients in an integrated administrative claims and electronic health record (EHR) database and develop quality metrics related to functional status assessment (FSA) and transitional care management (TCM). The study included commercial, Medicare, and uninsured individuals, age 65 and older with evidence of home-based medical care. An algorithm was developed in claims data and translated into specifications for an EHR. A portion of patients had FSA information required for measure development. TCM services were seldom recorded. Learn More

      • HEDIS Adult Immunization Composite Measure: In collaboration with DISCERN, AMGA aimed to identify gaps and facilitators affecting health system application of a voluntary composite HEDIS measure on Adult Immunization Status (AIS). To accelerate uptake of adult vaccinations, three AMGA member healthcare organizations tested and confirmed feasibility of use of the AIS measure in practice. The study identified significant gaps in rates of immunization among adults aged 50 years and older. Learn More
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      • Improving Outcomes for Patients with Type 2 Diabetes: A Bundled Measure Approach: Ten AMGA members applied targeted interventions in primary care for patients with type 2 diabetes. AMGA measured patient care and clinical outcomes using an all-or-none bundle measure, the Together 2 Goal® Core Bundle. The composite measure included hemoglobin A1c control, blood pressure control, lipid management (prescribed a statin), and medical attention for nephropathy. All 10 AMGA members improved outcomes in the bundle measure. Overall, rates improved from 40.2% to 42.8%, a relative increase of 6.5% (P < 0.001). Learn More
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      • Quality Measures to Improve Care for Patients with Obesity: AMGA evaluated the feasibility and perceived value of 7 operational and patient-centered quality measures at primary care practices at 10 AMGA member organizations. Measures included: (1) operational tracking (obesity/overweight prevalence and prevalence of obesity-related complications); (2) quality performance (obesity diagnosis, change in weight over time, anti-obesity medication prescriptions, and assessment of obesity-related complications); and (3) patient-centered care (patient-reported outcomes). Learn More
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      • Importance of Capturing Precise Blood Pressure Measurement: Sharing data with health systems on imprecise diastolic blood pressure (BP) readings, down to the provider and care team level, led to improvement in precision of measurement and BP control rates. Learn More

       

       
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