Visualizing HR 660

Politics is a topic we are supposed to stay away from. It turns friends into enemies. Plus House Resolutions are just a bunch of boring text who has time for all that jazz. Certainly won’t find any in other data visualization blogs so why here.

Well my friends HR 660 isn’t just any other House Resolution and it’s about Population Health which you know is my jammy jam. You can read the entire text here but as this is primarily a visualization blog let’s visualize it.

Word Cloud of HR 660
Word Cloud of HR 660


Word Clouds present the words from text, say HR 660, in a form where the words that are used the most are larger so that they stand out. Without any commentary from me and without reading the bill itself you should be able to immediately recognize that this bill is about “community” “health.” That’s the beauty of data visualization. Your eyes should be drawn to immediate insights.

HR660 Word Frequency
HR660 Word Frequency

Oh wait I hear my data friends shouting … “but how many times were those used I can’t hover over the image inside your blog.” So before they whine to loudly and miss the rest of my post here it is.

If you look at the frequency of “community” and “communities” you will see that it is referred to 59 times.

Clearly this bill is all about the community. Whis is exactly what I would expect being that my friend Fred Goldstein helped put it together and is leading a charge to get this thing passed. Fred is all about … ta dah … Community Health as the President and Founder of Accountable Health.

Child Actors?

I follow Fred on Twitter and 99.9999% of the time I immediately understand what he is writing about. I recently saw a post from him telling people to get behind HR660 the CHILD Act.

I thought well this is odd usually Fred is all about health. Why would he care about a house bill to support children actors? So I reached out to him. He immediately explained I was way off base and CHILD stands for “Community Health Improvement and Leadership Development.”

Now that’s more like it. I asked Fred if I could interview him and he graciously agreed. I took notes but didn’t actually record the interview since it was for a blog, not a Dork Cast. I feel the need to share that as a courtesy to my friend he is a brilliant man. If my response marked “Fred” seems goofy I probably took some liberties in adding humor.

Background commentary

A small amount of background is probably needed before the interview so here goes. HR 660 is sponsored by Congressman Jeff Fortenberry (R NE). It is also has bipartisan sponsorship from Eddie Bernice Johnson (D TX) and J French Hill (R AR).

Fred worked with Reyn Archer , MD who is the Chief of Staff for Congressman Fortenberry and former Commissioner of Health for the State of Texas . Reyn has a history of working on public policy in health, nutrition and international development. He also worked with Douglas Goldstein who works on all sorts of things a technology Dork like me appreciates. More importantly to this post he focuses on behavioral economics to improve health and happiness that the population health side of me appreciates.


Qlik Dork: Seems incredible that overnight you started working with such great folks on such an ambitious and bold goal.

Fred: More like over a few thousand nights. When I was part of the Population Health Alliance I proposed a similar but different approach. My original design was that it would be a community based health plan. All of the people on the same street/same community would be on the same insurance plan. As a community they would share in any savings they were able to achieve and the money would come back to their community. 

Qlik Dork: What was your thinking behind such an approach?

Fred: Population Health is a very abstract theory until it is implemented within communities themselves. That people are much more likely to participate and hold each other accountable if they are incentivized to do so.

Qlik Dork: I love that concept. I know that in my own life I would like to be more active, but I’m hit or miss on achieving it. But I’m nearly 100% when a friend comes by and invites me to walk or do something with them.

Fred: That was the idea. Improve health behaviors while also leveraging and improving the social networks within a community. I called them Havens of Health.

Qlik Dork: I take it your Health Plan concept never really got off the ground since you said that was years ago and was your original design.

Fred: Launching a health plan is a big lift and while CMMI expressed interest when I met with them, finding a community and getting the funding has proven difficult.  But, I haven’t given up and others are beginning to look more closely at similar models.

Qlik Dork: I can imagine. In what I read from HR 660 it sounds very similar but slightly different. Can you explain to me the highlights of the Child Act?

Fred: The bill is the brainchild of Reyn who was introduced to me by Doug after Doug learned of my community owned Medicaid health plan idea. Reyn’s concept was to create  a Community Health Savings Accounts instead of a full blown health plan.  That concept is what ultimately became HR 660, which creates a Community Shared Savings Account for Medicaid. . If the communities are able to demonstrate a savings then 70% of the savings goes back into the community.

Qlik Dork: Are the savings going to be stacked up in a pile of dollars or something for neighbors to come and grab?

Fred : Not quite. The bill requires the appointment of a local community board and they would choose how the money would be spent within their community.

Qlik Dork: That probably makes more sense.

Fred: The community leadership might use the money to enhance a park, build sidewalks or whatever they deem necessary to keep the healthy momentum going.

Qlik Dork: So basically they could use the money to address the Social Determinants of Health that they as a community, really feel need addressed.

Fred: You caught on pretty quickly. We know that Social Determinants of Health are real, and are important but the idea that a Health System or insurance company knows what is best for individual communities and neighborhoods is kind of silly. Each is unique. Putting the control within the communities themselves provides more accountability for the residents themselves.

Qlik Dork: One of the concepts that I learned from Drew Harris at the Jefferson Population Health Academy was a term called Social Contagiousness. It sounds like HR 660 is intended to try and help residents want to not only become healthier but spread those healthy behaviors.

Fred: That’s pretty much it in a nutshell. Provide the incentive for the community and the individual to change behaviors and continue that ball rolling.

Qlik Dork: Fred I’ve got to tell you that is a pretty bold goal.

Fred: It is. But we aren’t going to change the health system by thinking small or even by thinking that would be considered reasonable. Affecting policy change on a large scale is something I’m passionate about.

Qlik Dork: Growing up I loved watching the Schoolhouse Rock special on how a bill becomes a law it must be the thrill of a lifetime to be working on this bill.

Fred: It is a thrill because I believe in it, but it isn’t my first time.

Qlik Dork: Get out of here. What other things have you worked on.

Fred: I am proud to say that I helped get a provision into the Affordable Care Act.

Qlik Dork: I love provisions … what was it?

Fred: It was GO438

Qlik Dork: Help a brother out … that seems cryptic.

Fred: Most CPT codes are Dalton. GO438 is the CPT code for a Medicare Wellness Visit …

Qlik Dork: So a physical.

Fred: That’s the misperception because most people don’t read the whole code description which is “Annual wellness Visit, including a personalized prevention plan of service (PPPS), first visit.”

CPT Code Differences
CPT Code Differences

Qlik Dork: Wow and people tell me I’m verbose. That seems awfully descriptive. I’m assuming the personalized prevention plan is where it differs from a regular physical.

Fred: You are correct. It involves the physician working with the patient to understand their health risks and document a 5 year preventative plan for how to stay ahead of those risks. Best part for those on Medicare G0438 is covered while annual physicals are not.

Qlik Dork: Wait a minute. Are you saying that those on Medicare have to pay out of their own pockets for physicals, but if they have a GO438 they can focus on a plan for health instead of just dealing with sickness and it’s paid for. I’m not a senior yet, but that is flat out awesome.

Fred: Exactly. With the added benefit that it’s about preparing to stay healthy rather than waiting to treat the sickness.

Qlik Dork: No wonder we get along so well together. I feel like a broken record when I challenge peoples use of EHR or EMR and tell them I call it an Electronic Sickness Record and we should use ESR instead. What can I or my 3 readers do to help?

Fred: Pretty simple. Tell them to read the bill. If they believe in communities being more proactive in becoming healthier instead of treating sickness. If they believe it should be the communities themselves who should share in the savings. Lastly if they believe that the communities should dictate how their specific community could best put funds to use to continue to improve health they should contact their congressperson. And if they want more information they can always reach out to me

Call to Action

Personally there are times I feel overwhelmed by the mess that the healthcare system is in. I feel like there is nothing I can. That the players behind the system will never change. But then I have some Mountain Dew and I realize the system will never change unless people 1 by 1 start standing up and demanding change. I understand how politics can be divisive. But hopefully HR 660 is one thing we can all agree is a positive step forward. I encourage you to read it, contact your congressperson, and support it on social media using #HR660ChildAct and @CongressDotGov.

Update 5/2/2019 – Fred was recently interviewed on the “Unlocking Accountable Care” Podcast and details the bill so check it out.

Posted in Population Health, Storytelling, Visualization | Tagged , , , , , | 2 Comments

Visualizing Data Governance

Wait a minute. Data Governance is just a theory. A concept. It’s abstract. You can’t visualize it. Stick with me for a few minutes and see if I can’t prove you wrong.

As I travel the country speaking, I put up a simple Power Point slide that has only the word Governance on it. I ask the audience for a show of hands of who thinks the word has a negative connotation. Inevitably, the audience responds that it is negative and their faces look like this player who I was teaching to dive head first into a base.

Fear of Governance
“I don’t want to”

To many, the word governance implies that IT will keep you from accessing your data. To many it reminds them of the failed multi-year Electronic Data Warehouse projects that they’ve endured that still never allowed business users to access their data.


The history and the fear have cause many to run screaming for Self-Service. “It’s our data and we want access to it now. Free our data! Free our data!”

That’s a great concept. Right? There are plenty of technologies out there that allow users to simply point at the data and start creating pretty pictures. So why am I writing this post? Let me visualize self-service for you and get your thoughts.

Word Cloud of Story
Unhappily Ever After

That is a word cloud of my latest short story. All the words are there. The larger the word appears the more times it’s used. All I need you to do is recreate the story. You wanted self-service didn’t you?

18 Versions of the Truth

Every organization I’ve ever spoken to has some version of the phrase “18 versions of the truth.” It means that the same data has resulted in 18 different answers.

I’m not trying to be dramatic, I’m being honest. But sometimes the truth stings a little at first. I could give you access to every 0 and 1 your company possesses and petabytes of publicly available data as well. I could give you the prettiest data visualization tool on the market to access it. But that doesn’t mean you will magically get the data modeling or coding skills to make sense of it.

One of the misconceptions in the world is that data is the greatest asset a company has. First the customer and employees are the greatest thing any company has. More importantly 0’s and 1’s by themselves are costly and offer no intrinsic value at all … apart from the business rules that govern them.

Business Rules

Business Rules are those things that for most organizations exist only in the head of a certain few people. You may call them subject matter experts. You may call them data stewards. Or you may just call them Bob and Susie. They are things that drive how the 0’s and 1’s are supposed to fit together.

  • We use this category code for testing.
  • We use a prefix of zzz_ before last names to indicate that they are only for testing.
  • Cost codes that end with _99 imply the sales should be counted.

Business Rules also include the code to calculate values. IF this … then do that … else do this type things. Code that was used to create aggregates in the old days, but needs to be applied on the fly inside of your analytical applications.

You know … the stuff that IT is really really good at but business users have never been trained on.

There is hope

Excuse the sales pitch if you consider it to be one … but Qlik Sense provides organizations the data governance that is required while also providing the “I want it now” access that business users demand and deserve.

How? Great question. Via a role based development environment.

The data gurus get to construct the data models without caring how the data will be consumed.

The coding gurus then get to work with subject matter experts and build out the code. That code is then stored in things called Master Items. Master items include the code, as well as a thorough description. Those master items can be pushed out across all of your applications.

Now you have not only a single source of data, you have a single source of the business rules that provide the form for the data.

Data visualization experts (hooray for y’all) get to do what they love. Build really pretty screens, flip them upside down, turn them inside out all without having to ever lift a finger to code.

What about …

I know the naysayers are already thinking “my company has spent years trying to agree on and create a catalog of business logic and it’s failed every time.” I was in meetings like that so I feel your pain. The problems were always “we have groups that look at things differently and none of the groups was willing to change.”

With Qlik Sense nobody says that they have too. Build master items for all 5 versions. Just include the description along with them. When designers build the screens or end users start doing their own thing they can choose which of the 5 versions is the one that they want to see.

So what happens to all of my IT people if they don’t have to build 1 off reports anymore because we are using Governed Self-Service? Another insightful question. Let me try and suggest … they work on building out the next data source. Then the next data source. Then the next data source. Because unless I miss my guess your organization isn’t going to run out of data sources.

After 30 years doing that kind of work I can share that I hated the phone ringing interrupting me and I hated being asked to adjust the width of a column on a report or change a color in an application to something .003 shades darker. Data geeks love focusing on data. Coders love focusing on code. Designers love focusing on design. So why are you making them do everything.

Eye on the Prize

I traveled the country teaching softball players how to be aggressive on bases by getting over their fears and keeping their eye on the prize. To attack the bases like winning the ball game and becoming a Champion depended on it. You know … because it does.

My friends your businesses depend on the level of governance which you are applying. You can wish for self-service. You can hope for data democratization to just magically occur. But without data governance end users simply can’t get the right story from your data anymore than you could by using the word cloud I provided you of mine.

You can close your eyes, kick and scream and ignore it. Or you can open your eyes, attack data governance and start kicking butt.

Eye on the prize
Eye on the prize

PS – If you are attending the Qlik Qonnection’s 2019 event May 13-16 please consider attending my friend Laura Madsen from Route Twenty Five’s breakout session on Radically Democratizing Access to Data where she will take a deep dive into Data Governance.

Posted in Self Service, User Adoption | Tagged , , , , , , , , | Leave a comment

Actionable Intelligence

For my entire 35-year career I have been focused on “Actionable Intelligence.” It’s a worthy goal. One that you have likely dedicated your career to if you are reading my blog.

  • How do you convert data to information?
  • How do you turn information into knowledge?
  • How do you convert knowledge into insights?

There is a simple workflow for analytics and we all know it.

  1. You are given some data.
  2. You create super cool visuals following all kinds of visualization guru advice
  3. Then you slap labels to the charts correctly and perhaps add some reference lines so that the visuals tell a story.

4 years ago, I wrote a post called Visualizing Length of Stay. In it I espoused my own principles for you to follow as you march towards producing “Intelligence” for your end users.

  • Numbers themselves are useless
  • Don’t compare unlike things to each other
  • Context is king
  • There is tremendous value in using visuals that depict more than a single number

I’m guessing that you’ve been following a similar pattern in your work as well. Hopefully you have had success in your career as I have had in mine. We must be doing it right. Right?

Flipping the script

In November I sat down with David Ciommo the Data Visualization Principle for Humana in their Visualization Center of Excellence to talk “Data Storytelling” for one of my Dork Casts. As a customer/partner I’ve seen the results of his work for several years now. They’ve been nothing less than stellar. Applications with huge adoption from thousands of users across a wide spectrum of positions and data literacy levels. All that was important for me to remember when he told me that I had been doing it completely wrong.

He said we needed to flip the script and that the workflow should be:

  1. Develop the story
  2. Decide if you have the data needed to tell the story and if not go get it
  3. Design the visuals needed to convey the story

You know what? He was right. Actionable intelligence is a simple 2 word phrase and yet we spend 99% of our time on the word “intelligence” completely ignore the primary word “actionable.” We focus on the data. We focus on creating pretty visuals. Then we complain to each other about how we just spent 1.5 years building something that isn’t adopted across the organization.

We spend 99% of our time on the word “intelligence” completely ignore the primary word “actionable.”

His workflow starts with “what will it take to move someone to action?” Once you identify that then you go after the data needed to tell that story. Finally, find or create the right way to visualize the data in a way that tells the story. Crazy right? But that’s how genius works.

Real world example

I’ve spoken with several people who watched my Dork Cast with David and they all asked for a practical example. So let’s use my original post on Visualizing Length of Stay and follow David’s workflow and see where we end up.

Who is the audience going to be for the Length of Stay project we have been asked to undertake and what is going to motivate them to take action? For this example we will say that the audience are administrators who are motivated financially. After all healthcare is a business and one of the biggest drivers of our entire economy so no rush to judgement on their motives.

So on to step 2 in David’s workflow. Do we have the data needed to tell a length of stay story about finance? No. We have the raw clinical data about patient encounters. If we display our Length of Stay as a number without a $ they are going to ignore it even if they admire how pretty we showed it.

We need more data

Let’s find out what the costs are to the system for each additional amount of time for Length of Stay. What aren’t we reimbursed for? What are the costs that we pay out of pocket? What are the dollars we miss capturing because a bed was tied up that should be free and we off load patients to another hospital? We postpone surgeries because we have nowhere to put them? That’s a lot more data sources that we need.  

Are you seeing where that goes? We could rush to deliver a project that will result in no user adoption, or we can delay the start of the development in order to create a product that actually drives action and is highly adopted.

Finally we come to agreement on that type of financial data. Now it’s time to display it for end users. Woohoo now I can use a spinning 5-dimensional chart. You know the kind that requires us to spend hours explaining to the administrators so that we can enlighten them on how to read it. Or we could keep it really simple and textual.

KPY instead of KPI

Closing thoughts

What David opened my eyes to was that the phrase “Actionable Intelligence” starts with the word action. Hopefully I’ve helped you see that as well.

I’m not suggesting for a second that my Length of Stay example above is the only thing you would ever build for Length of Stay. I only used it to draw your attention to how diametrically opposed that KPY is to the KPI’s I utilized in my original post on Visualizing Length of Stay 4 years ago.

All I’m asking you to do is ponder David’s workflow very carefully as I have for the last 3 months. Especially if you find yourself banging your head against the wall due to such low user adoption project after project. Maybe you need to rethink your approach. Consider stepping back from the mad rush to “just do something with the data you have” and think about what you really need in order to drive “action” on it. That’s how you will increase your user adoption.

Hug me or scream at me I’d love to hear your thoughts on this.

Posted in Data Literacy, Storytelling, User Adoption | Tagged , , , , , , , | 2 Comments

Visualizing Analytics in Virtual Reality

Patients are to complicated for 2D analytics

Total Immersion

How cool is this image of a physician totally immersed in patient data in this virtual world?

As soon as the coolness wheres off your brain is left scrambling for reality. Can we really do this? Would it add any value if we could?

The answer to both questions is an emphatic YES!

The technology is there. Over 2 years ago I helped one of the super geniuses at Qlik, Todd Margolis, create a demonstrable use case for Augmented Reality. The premise was augmenting the reality of the triage worker with analytics they could interact within a crisis setting.

The value potential is there. In our demo the value was seeing the patient while also seeing the potential issues they could and watching the options narrow as each question is answered.

Our use case was pretty basic and if you watch the video and see a monkey on a chair interacting with a chart you might even think it was goofy. Ignoring our comedy routine, imagine the impact if the questions were being driven based on artificial intelligence and best practices for workflow.

Easy as Pie

The real question is “Are you ready for it?” “Can it add value for you?” Because that’s what really matters. So instead of suggesting you place yourself in the image above let’s back up about 1,000 steps and start from the beginning. Analysis of Admissions by Age Group

Let’s say you are analyzing admissions. A very simple way to break down admissions would be by Age Group.

As you look at the chart the question pops into your head “How long has the distribution been like this?”

In other words you want to see a trend. In the real world that is common, yet sometimes difficult. Is there a line chart showing the trend over time already built? What page is it on? How do I move from where I am to that page? Shoot now I’m looking at the trend chart but what happened to my pie? “Uggh you starting wishing there was a better to actually interact and engage with my data.”

I’m just spit balling here, imagine instead of being in the “real world” you were immersed in Virtual Reality instead. You simply raise your hand, point at the pie chart, squeeze the controller’s trigger and swipe to the right indicating you want it over time. Now you see the pie chart and beside it a trend chart over time. Well that doesn’t seem like such a stretch.

More Pie Please

As we approach the holiday season it’s always about the pie. You know what I mean we eat 19,398 calories and yet still find room for just 1 more slice of pie. Figured that would be as good a way as any to transition to another concept for interacting with pies in analytics.

Analysis of Admissions by Age Group

If viewing 1 pie is good, viewing 2 pies must be better. Or is it? What insights can we gain from looking at both of these pie charts? None. They are 2 distinct items that have nothing in common, there is no context for how they relate. Yet we know they are both for patients.

What if in Virtual Reality you could reach out and grab both pie charts and smoosh them together. Insisting that we see the relationship between them via a Sankey.

Sankey's allow you to view relationships

Don’t get me wrong, I’ve written and talked about Sankey Diagrams in the past. They certainly play a part of our “real world 2 dimensional” visual analytics. The problem is that if they aren’t already constructed for you, they don’t help. Whereas, in a virtual reality world the interface of bringing things together is more intuitive and possible. You simply use your hands.

Year over Year

Seasonality is what Year over Year line charts are great at depicting. In the following chart I can clearly see that for both years we are up 1 month, and down the next. Up down. Up down. Just like the heart pounding roller coaster videos that are so prevalent in virtual reality.

Year over Year charts are great for viewing seasonalityBut honestly other than seeing the seasonality these year over year line charts are pretty useless at conveying the real story behind the data. And as my most recent Dork Cast illustrates, I’m a big believer in visual data storytelling. (Click here to watch it when you finish reading.) 

Like with the pie chart example you need to establish a contextual relationship between the years right? That’s what Year over Year means. Comparison. Yet that up and down, roller coaster ride, makes it impossible to retain the very context you asked for.

If I’ve done my job you are already wondering what you could do with your hands in a virtual reality world to provide you with that context. If I haven’t then let me spell it out. In a virtual reality imagine you reach out your hand, grab 2014 and drag it downward. Implying you want it as the “base” for a new chart.

The system then converts the YoY line chart into a context based bar chart and you see Year over Year is best visualized with Context2014 as the baseline. The bars are the amount of difference that 2015 represents over 2014. The context.

Here is why I mentioned storytelling. Notice that for the first 5 months of the year we are up and down. That either means we are dealing with completely varying data, or that our process isn’t working. Yet for the last 7 months of the year we are over every single month. Likely the process improvement changes we made actually worked.

Step beyond Static Reporting and Pause

Analytics is one of those vague concepts that those who like to pontificate about can do so at great length. In my mind analytics isn’t about visualizing flat static reporting type data in pretty charts. It’s about allowing you to engage with the data so that you can:

  • Ask and answer the next question.
  • Argue with the data to ensure they are right.
  • Drive so deep in the data that they would fight an army to make the changes they believe are needed to improve.

So far we’ve only taken a few baby steps together to help you grasp the concept that in a virtual reality world we can add more ways to engage. To literally immerse yourself in the data and let you go any direction you want.  That may take time to sink in. Let it.

It’s a scary world out there

The unknown is scaryI’m not talking about this selfie image I took when AltspaceVR created a new Halloween themed world to explore.

I’m talking about the fact that there are so many technologies out there like Artificial Intelligence, Machine Learning, Deep Learning, Natural Language Processing and Natural Language Generation that it’s hard to keep up. 

If you can’t keep up, you don’t trust them. That lack of trust makes it hard to act upon the data, and it should. Yet, that action is what we are looking for. Rasu Strestha, Chief Innovation Officer at UPMC, puts it this way “Data is nice but we really need is behavior change.”

Bringing the virtual world to life

Imagine that the good looking dude above wasn’t a selfie of me in that scary world, but was instead a computer. A “bot” if you will that used those “black box” concepts above like Artificial Intelligence, Natural Language Processing and Natural Language Generation to converse with you.

I recently posted a video where I demonstrated those very things. The technology is in place via one of our partners called Crunchbot AI. As you watch the video I want you to imagine how much more believable it would be if it was in Virtual Reality and had a face on it?

Imagine you are wandering around your data and something is unclear. You could simply say “help” out loud and that “governance” system that contains all of your systems data definitions and metadata showed up … as another image.


I’m not a hypnotist. There is no way in a few minutes I can completely get you to change your mind and suddenly demand your company utilize Virtual Reality as an analytics platform. What I hope I have done is to help you understand that initial image of a physician totally immersed in data. So that you can begin seeing it’s not so far fetched after all, even for you.

As humans we have the ability to interact beyond what our 2 dimensional monitors allow us to. A virtual world provides the ability to interact in all those ways. It allows us to put faces on the technologies that scare us, thus making them less scary and more believable. So that we can immerse ourselves in our data, then take action on the insights that we discover.

[Updated 11/16/2018]

That Qlik genius Todd Margolis guy I mentioned early in the post. Just found out that he’s co-authored the first published book on Immersive Analytics. So many great use cases and information for those of you that really want to dive in. Click here for the book.

Book on Immersive Analytics


Posted in Data Literacy, Self Service, Visualization | Tagged , , , , , , , , , , , , , , , | 1 Comment

From Walmart to Quadruple Aim

Among the millions of great nuggets I’ve picked up from Robert Pearl in his awesome work “Mistreated: Why we think we’re getting good health care and why we’re usually not” one was especially memorable and challenging. He shared a story about Lee Scott, former CEO of Walmart. Scott spoke at a conference and spent most of his time discussing bath towels.

Crazy right??? That’s what intrigued me. Scott painted a vivid tale about the typical family that shops at Walmart each week. Middle-class, blue collar family with average income of $35,000 per year. By the time they’ve paid all the usual bills a set of bath towels is a significant purchase. Their world according to Scott is far different than the lives of the families that shop at Macy’s. If “Walmart families” can purchase two sets of bath towels for $20-$30 they’ll have enough money left in their budget to go out for pizza. But if those towels fall apart quickly that will really set this family back. He further described the arduous process of searching the world for quality products and fighting through bargaining on behalf of these families.

Talk about knowing your customers.

Talk about caring for your customers.

Pure american hero right there. Am I right or am I right?


Unless you talk to to leadership in the AFL-CIO that would classify Walmart’s treatment of it’s employees as horrific. In fact the treatment of their employees garnered tons of media attention and I’m sure the coverage didn’t escape you and Walmart was characterized as evil.

Well now I was really challenged. How did I feel? Which side did I lean on? Was Lee Scott and american hero because of his caring for shoppers or was he an evil villain for not caring about his own workers?

None of you care about my feelings which is ok. That’s not the point of this post at all so let me get to the point…

The AFL-CIO stood up for the workers at Walmart as they have stood for the workers in so many other industries throughout the years. Electrical unions have fought for the conditions of their workers. The list goes on.

So let me ask you this “Who is standing up for the clinicians who are burning out, facing depression and committing suicide at alarming rates?” The residents being worked like dogs and treated the same? The ICU nurses?

Yes we need quality, affordable healthcare for those very same Walmart families. But is it fair to do it on the backs of the clinicians? If the conditions of the Walmart workers wasn’t acceptable and the world felt sorry for them where is all of the media attention screaming that the suicide and burnout rates for clinicians is out of control? Are their lives not as important as any others?

Sharp Index

I’ve previously talked about Janae Sharp and the work she does raising awareness of this very issue. She recently launched the with resources to help organizations monitor and track burnout and they provide resources to help physicians who recognize that they need help, anonymously. One of the resources that she provides is a survey. Qlik Healthcare has partnered with the Sharp Index to provide analytics regarding the data and support the cause.

One of the most obvious insights based on the first 250 surveys was that the more physicians reported having to work at home, the worse their Sharp Index Score was based on the algorithms they use. Meaning the more burnout they were feeling.

You are probably screaming “well duh if I had to work an excessive amount of time at home I’d probably be burned out as well.”

That’s kind of my point.

The “system” is rigged against clinicians. When you clock out and head home to unwind, they don’t have the luxury of actually clocking out. Their workflows cause them to take their work home with them in order to complete their mandatory tasks.

Perhaps you are thinking “well it’s just a survey they probably just feel like they are working excessive hours.” Possibly. Possibly.

However, Janae and I have worked with Baber Ghauri to analyze audit records of physician hours regarding hours when they enter documentation. The results were sad and validated the survey. There were many document types where up to 65% of the work was being done after the physicians ‘working’ hours.

Quadruple Aim

There is some good news on the horizon. I applaud the efforts of those across the country who are pushing towards a Quadruple Aim.  Those that acknowledge that it’s hypocritical to talk about healthcare while ignoring the health of the very caregivers that provide the health-care.

I recently read a tremendous article entitled “Healthcare IT’s stealth weapon: Empathy” written by Santosh Mohan and Rasu Strestha. As you can guess they suggested  actually showing empathy for caregivers and asked a rather basic question “What if technologists instead invested their time in truly understanding healthcare workflows and clinicians’ needs?”

So they proposed what I thought was pretty unimaginable.

They actually had the nerve to suggest that healthcare IT workers get out of their padded office chairs and walk on rounds with clinicians.

The horror of it. Actually having to walk with physicians and watch them in action. I mean it’s not like they do this on a daily basis so how in the world would your schedule ever possibly line up to make that happen? Seriously it’s not like this topic is important enough that YOU need to take action. Is it?

Many of you who are in the analytics space have probably written applications like our friends at Johns Hopkins to track which physicians have signed or haven’t signed their documentation. After all … nobody get’s paid if things aren’t signed. But what Etter Hoang did was add in … you’ll love this … the time documents were being signed so that they could proactively reach out to physicians to help with their workflows. Here’s the kicker … they’ve been doing this for years. They actually care about their clinicians not just the check marks.

Getting other organizations to behave like John’s Hopkins and is the goal of the Quadruple Aim.

Getting you to think about what you can personally do, since you are likely in IT/BI, and not allow clinicians to continue to be treated like Walmart’s workers is the goal of my post. 
















Posted in Population Health | Tagged , , , , , , , | 2 Comments

Visualizing Population Health from a Personal Perspective

Great People

One of the lessons in life that I’ve found to be very true was that you should surround yourself with great people. Gotta say I’m so amazingly blessed to have been able to learn from some of the greatest in the past few years. Bare with me as I mention just a few and point out why.

Vision – If you’ve spent 10 minutes thinking about Population Health then you are probably aware of Dr. David Nash. But why? Because people don’t follow plans – they follow vision and Dr. Nash has a vision that he shares so passionately and with such clarity that nearly anyone you talk to in the field is going to bring his name up.

Dreams – On a daily basis my life can go go in a thousand directions. The one cohesive thing about our healthcare team within Qlik is our leader Brad Copeland. Brad is the Vice President of the Qlik Healthcare team. Don’t tell him I said so but the practical knowledge and leadership he offers our team is secondary in my opinion to what I value him most for … his ability to “dream.” “How will blockchain revolutionize healthcare?” I expect questions like that from other dorks, nerds, geeks … you know people like me. A sales VP though? Are you kidding me that’s not what I expected. But in my 2.5 years with Qlik Brad has never ceased to amaze me with the things he dreams about. I love dreaming and without Brad the daily chaos of “sales” might be a trap for me. He constantly fuels my fire to imagine actually making a gigantic impact on the healthcare system.

Cruise Director – Growing up I loved the show The Love Boat. You may not have a deep enough appreciation for the term “love” when I use it to express my feelings for that show. “Hey I’m Janae Sharp and I’m going to be your Cruise Director for this population health voyage.” That’s what goes through my head when it comes to my learning regarding population health. Because like Julie on The Love Boat, Janae is kind of the social media cruise director for the movement. Twitter book club conversations? Hot topic conversations weekly? Connecting people in the industry who have common visions/dreams? Yep you know Janae’s on it. There is an image for you … a global population health cruise and we have our very own cruise director and her name is Janae Sharp.

EncouragerI recently posted a tweet in which I half jokingly indicated that the transition to population health wasn’t easy. I tagged a population health evangelist Asha Gaines who was seeing the premier of Star Wars with me and said we were there hoping the force would be with us. I say “half jokingly” because it really isn’t an easy transition. The current healthcare system is a giant machine physically and mentally. It would be easy for those in the movement to burnout quickly as a result of having to beat their heads against so many walls at times. It would be, fortunately the movement has Nick Adkins. Nick started a “gifting” movement focused on gifting pink socks to others. Simple way to bring attention to the movement and simply encourage others by saying “you matter.”

You Matter

I have to admit the phrase “you matter” is not original it is something I picked up from watching a video that Bomy Yun who is a Nurse Practitioner at Neighborcare Health shared with me. You may need to reread their name if you think you read “neighborhood” because it’s just “neighbor.” Because the heart touching message that their video conveys about their work isnt’ about how they have smaller needs that hurt less, or that their physicians have ESP and can better diagnose patients in the community. Their message to the community is “I see you and YOU MATTER.”

They hire people who live in the community. Why? Because people in the community actually “feel” that specific areas unique “social determinants of health.” The biggest being “the need to know that they aren’t disposable as so much of society conveys and that they matter.”

I imagine that within their organization they have someone who has a strong vision, someone who is a grand dreamer, someone who directs and socializes the work within the community and someone who encourages the others within their team.

The One Thing

What is the one thing that all of these folks have in common?

The fact that “I hate them.”

I mean I love them … but I also hate them. Because you can’t possibly be around these kind of people without being moved to action. I’m 53 years old for crying out loud. I’m set in my ways. I’m comfortable with my existing patterns. I don’t have room in my life for a new calling. Thus … I resent these people challenging me to rise up and DO SOMETHING.

I think in many respects there are tons of grand things in the world that we love to talk, dream or wonder about … all the while knowing we can’t personally have any impact. Once you start seeing others having massive impact on the world and realize that they only thing that enables them to be such catalysts is their desire to do so … you are then challenged personally. I’m smiling as I type this … I resent these people challenging me to rise up and actually use my gifts, talents and experience to make a difference.

Clearly as you can tell from this series of posts something has been churning in me for a long time. Well it finally boiled over when I attended the Population Health Academy at Thomas Jefferson University October 23-27. After having spent the last 7 years preparing my home for retirement in 9 years I returned home from this life changing week and told my wife I felt like we desperately needed to move.

I braced myself for what I assumed would be either a physical slap upside the head (the affectionate type) or a verbal slap upside the head. What I got instead was one word. “Why?”

I’m Moving

The “why” in this case was a new deep seeded belief that despite our best intentions to focus on our finances and home for retirement we were in an unhealthy community. No sidewalks. No social activity. People who wanted to be secluded. So my response was “I really think we need to focus on our health more and need to be surrounded by others who think the same way so that we are encouraged to be more social and more active.”

Her response this time was 3 words “I agree 100%.”

Within 1 week we had put a contract on a new home in an active adult community and today my friends I’m closing on that new house. We are beginning a life today that represents what I now believe 100% in my heart (and now my wallet) that there are things that are “socially contagious” and we are surrounding ourselves with other like minded individuals. The Social Determinants of Health that will dominant our lives are going to be: Activity, socialization and accountability.

Tell – Show – Tell

I started this series of posts back in July talking about population health concepts as a way to help broaden the base of people thinking about Social Determinants of Health and as a focal point to challenge me to learn more in order to share.

This post is a steep transition to very practical and very personal things. How in the world could I possibly wrap the whole series together 5 months later in a cohesive way that demonstrates the proper  Tell – Show – Tell model that I learned was important on my 3rd day of employment with Qlik sitting in a Demo 2 Win course?

It bothered me. Understand the OCD nature in me when I share the fact that I “needed” a clean finish. I couldn’t simply write the above and until Saturday I didn’t have that finish and was really getting concerned.

Fortunately the community I move in to today had a holiday cocktail party on Saturday. Hundreds of people mingling around a giant clubhouse. Most had lived in the community for years and have built strong bonds. Within about an hour I met a man named Tom Flaim who was also closing on his home today, and we talked for nearly 2 hours.

Tom isn’t in healthcare and has probably never heard the phrase Social Determinants of Health. But here is where Tom fit’s into the story and provides me my “final tell” to tie all of this together for you.

Tom visited the Dominican Republic years ago on a missions trip and was struck by lack of clean water for it’s population. As a “coffee bean” driven to make an impact, Tom started Water At Work. An organization that now supplies a tremendous amount of clean water for the Dominican Republic and Haiti. Tom took the challenge he saw “personally” and used his engineering talents to get that started.

But wait there’s more. Water at Work doesn’t just provide water. They do it by employing local talent, using the right technology and achieving their goal of sustainability. The story got even better for me when I read their website from front to back. Check this line out.

“Stories abound about the health and social benefits that have accompanied our water plants …”

Are you kidding me … there it was in black and white for me. I started this process trying to help and relate Social Determinants of Health to you back on July 24’th. Having no idea at the time where the “story” would go but I knew then I needed to just dive in. Throughout the process of sharing I became determined to dig in and learn more. Was literally moved inside to physically move. And 3 days before publishing my final piece of the series I meet another “coffee bean” who’s organization discovered that their efforts in water were meeting both the health and social components of an entire country.

It is Personal

Yes Population Health is Global and can be effectively driven in the Community but my friends don’t miss this … Population Health isn’t just a theoretical concept being worked on by others it is very personal.

Very, very, very, very, very personal. In fact the most important person in the entire movement is the one reading this right now. The next most important person in the entire movement is the next person you come in contact with.

Posted in Population Health, Uncategorized | Tagged , , , , , , , , , | 3 Comments

Visualizing Data Fluency

The real question that’s plagued the world has never been “Should I visualize the data?” it’s always been “How should I visualize the data?” Because it’s not that people don’t want to see things visually it’s a matter of how “data fluent” they are and how creative you can be in displaying the data.

For the sake of this post (which may never be completed) I’m going to use a set of data that represent Healthcare Quality Measures. I will gradually unveil deeper and deeper dives into the data (Analytics and Data Discovery) and as I go forward hopefully you will realize that ones “data fluency” is going to limit what you can do. At the same time driving you to increase your own and encouraging others to do the same.

Let’s start really simply and imagine that we want to show Ed Zecutive the # of measures that we are dealing with in our dashboard.

Wow that’s a big number of records and it’s a completely accurate account of the volume of data we are dealing with. Two things to consider “Ed is a busy guy, does he have time to read that many digits and does he really care about that kind of precision.” If Ed can interpret the following KPI (with M for million) instead … wouldn’t this allow him to consume the value faster?

Ed also asks to see “our compliance” which of the following do you think answers Ed’s question? Do you think he really means he wants to see both? Does the color indicate anything to you? What does it imply?

Now we have to ask ourselves if we need to waste that much screen real estate to show ED those 2 numbers? But if I show only him 1 or the other which is most important? If he is “data fluent” enough to figure it out by combining them in a single KPI object that shows both, but in a way that he sees the %, always most important but the number is there in case he wants it. All in a single compact KPI that saves space.

That may well be all that Ed Zecutive cares to see. But what about Candi Stryper won’t she want to drill in and see the number for the most recent compliance versus last years compliance? Of course she will. If she is used to “fitlers” we can do something like the following where we let her simply click “Yes” or “No” to indicate what she wants to see.

But perhaps she’s afraid to “filter” anything for fear she’ll do something wrong. Or what if we simply want to save her time as opposed to just doing the minimal work necessary to give her what she asked for. Then we can calculate and show her both values at once.

Ok you are screaming “Well duh if you could show both numbers don’t give her a filter in the first place just show her both numbers.” To which my response is “It’s never about 2 numbers instead of 1 or 1 simple filter.” Her very next question is going to be “Can you show me those numbers for each system. Of course we can. Now all Candi has to do is process all of those cells and do some mental gymnastics in her head.

Here is where the rubber starts meeting the road. If we can increase Candi’s data fluency so that she can handle something like this we can present what I’m about to instead of the table above.

Each cell represents a different system and contains SO much more information. Clearly the green immediately lets her know that all 7 systems have improved year over year. The one that hasn’t … is “unknown” meaning the data doesn’t identify the system name for the quality records.

What is the next thing you notice about each cell of this KPI?

The sizes of the triangles of course. I didn’t have to explain that to you and she didn’t need me to explain it to her either. Numbers tend to blend together size wise their isn’t much difference 0.01 and 0.09 but by golly if the arrow is 9 times the size wow that makes a difference in her ability to immediately focus on big/small etc. Don’t believe me scroll back to the table version and honestly consider if your eyes are immediately drawn to systems 2 and 5?

On any given day she may want more meat on the visual bones. The lower right corner shows the % of compliance for the current year. Above that is the change from year over year. In the lower left corner that difference is calculated as a percentage of difference. System 2 has improved 16% year over year, whereas System 5 is virtually unchanged (when rounded) but did in fact improve slightly.

But if Candi isn’t ready to handle this kind of a chart we are wasting our time using it. The fact that we can produce it, doesn’t mean that end users like Candi can consume it.

…. Updated 8/31/2017

Introducing the Tree Map

Great news is that I heard from Candi and she completely got it. When I told her that she could actually click on any of the KPI’s to “drill down” into the Practices for that system she was ecstatic as well. Said she had never dreamed of having that much information at her finger tips. But she called back a short time later and said that her boss wanted to know if they could see Systems and Practice groups together instead of having to drill into each. Apparently they had seen a Pivot Table at some point and liked that kind of flexibility. Of course we could show a pivot table, but again, that isn’t very visually appealing and it forces you to do lots of mental gymnastics.

I told her that viewing 2 dimensions at the same time is absolutely presentable in what is called a Tree Map. Each System can be shown with blocks inside of it for each practice. (Any 2 dimensions.) The blocks are sized by the value represented. “What about Year over Year she asked, we really love being able to see that?” Hehe I knew where she was going and told her that we can color the blocks based on whether or not each practice within each system had improved year over year or not.

Those of you who are familiar with this type of thing are probably waving your finger at me saying “But Qlik Dork you can’t use red and green because people are color blind you should have used a different color scheme.” I can use any colors I want, we all can, but rather than focusing so much on color blindness the point of this article is to focus on moving people along the Data Consumption Continuum and helping them become more Data Fluent. For those used to Red and Green Scorecards that are manually produced in Excel making a shift to another color scheme will slow the process down for them to immediately recognize “good versus bad.” The fact is that the red/green jumped out at you before you ever looked at the numbers themselves. You immediately knew which was getting worse and which was getting better.

You will notice that the blue/grey version contains more practices than the red/green version. That’s because the world isn’t always as simple as what we want to display in a given amount of space. And this is no exception. You see the systems that Candi and her boss work for has lots and lots of practice groups within each system. I mean lots. The above were simple captures of just a small region of the actual tree map in the application I’m building for this post which is below.

So why didn’t I just start with the full screen shot?

Great question. I’m not sure that you could consume it. Because as you will see many of the cells don’t show the practice names and values. Figured that might freak you out because you aren’t ready for the next step in the journey to data fluency.

The entire chart is meant to take you from what you are familiar with. You might tell me that you get every name and every value in a pivot table. To which my come back will be “Liar, liar pants on fire.” In fact you can’t see them all the same time you have to scroll throw. You have to take action to move around.

What smart responsive objects like those in Qlike Sense do is present to you the high level overview and as much detail as the real estate will allow. You can see the systems sorted by the highest ranking of compliance. Then you can see how many practices each has and get a really quick understanding of how many practices within each system have improved year over year.

What I’m going to suggest is that you can actually obtain more information without the numbers than you can with them. Let me give you some examples:

Notice System 7 does not have the best compliance, but every single practice has improved year over year.

System 5 is kind of mid range of the systems in terms of its overall compliance but the vast majority of the practices within the system did poorer this year than last. But perhaps the volumes of those that did better pulled it up.

Now that you are seeing things that wouldn’t jump out at you otherwise, let’s keep going. Out of the top 24 practices in terms of compliance at System 2, only 5 of them performed poorer this year than last.

Stark comparisons and insights that we can obtain regarding System 2, System 5 and System 7 that we would very likely miss entirely if we simply saw numbers in a pivot table. None of which really involved knowing or caring about the values or the practice names.

However, I do need to ensure that people are ready to deal with this concept. They have to be “data fluent” enough to understand that the system isn’t going to simply display .00002 font sizes that wouldn’t be readable anyway. They have to understand that they can zoom too see more data. They have to be willing to want to gain the insights that numbers alone don’t show. Because if they are focused on numbers they might be missing the much bigger picture.

…. Updated 9/1/2017

How do I know what to target?

That’s the call I received this morning from Esta Mate. A Junior Business Intelligence Analyst assigned to the Quality Improvement team. Apparently Esta sorted a list of the practices with the worst percentages of compliance and started working with the lowest group. They laughed at her when she told them what she was there for and thus the call to me.

What Esta had missed in looking at the list was that when you are trying to move the dial of quality for a large system you have to account for not only the percentages, but the number of items. If a practice has a compliance of only 12%, but they only have 100 quality measures all together, out of our 63 million total, getting them to 100% isn’t really going to move the dial. Counter intuitively we might actually want to focus on the group doing the best already if they have more overall records.

But how do you relate 2 different measures to someone so that they can consume both numbers at 1 time? A great way to do that is a Scatter Plot. It means that Esta will have to learn how to consume both measures at 1 time though and make inferences.

Being the Data Fluent person you are can you read the scatter plot below and determine which System we should focus our efforts on?

Often times we focus on what we are thinking. Our goal is “Compliance” so we measure it.

What if in order to improve, we shifted our focus to “non compliance” and plotted that in a scatter plot instead. Does this help at all determine which system we should focus on initially?

Poor Erma is pretty new. She sees the benefit of a Scatter Plot and we ended up talking about it’s usage for other types of measures but she still wasn’t confident using it as a way to explain to her boss why she wanted to focus on System 6. BTW — Is that the one you chose?

I then made another suggestion to Esta. Since she understood the concept of focusing on the non compliant measures instead of the compliant measures perhaps we could avoid the complications of two measures by looking at the Overall % of Non Compliant Measures instead of making her guess the relationships to the whole. Meaning look at all of the measures that were non compliant, then figure out who had what % of them.

The following very simple bar chart shows that System 6 has over 30% of the overall systems non compliant measures. While the next closest were Systems 1 and System 3.

But a system is just made up of practice groups. So I built the bar chart so that she could drill into each system. When she drilled into System 6 she could clearly see that Practice 399 was obviously the practice within the system that needed her focus.

My eyes got a little salty when Esta asked if she could have the same kind of bar chart but not have to drill into the System first in case there were practices that had a lot of non compliance but the overall system wasn’t near the top of the list. You better believe I gave her that immediately. How about that for a guess? Esta won’t be a Junior BI Analyst for long and her data fluency is growing as well.

…. Updated 9/8/2017

Quit taunting me!!!

I’ve enjoyed the flexibility that writing and updating has given me as I’ve played with this data set while also tackling what I believe to a real issue that impacts User Adoption. I realize that many of you are probably getting tired of my updating an existing blog every couple of days so I’ll end your suspense now.

You are welcome to play with the application I actually built to see one potential real world approach to visualizing 62.5 million quality records for 2.76 million patients, covering 8 health systems, with 685 Practice Groups employing 5 thousand physicians. Simply click this link  and you can start playing with the application on our demo site. 

Your turn

If you would like to try your hand at Visualizing this data set just email me at Dalton.Ruer@Qlik.Com and I will send you a link to the QVF used for the demo application and the data set (CSV files) you can download.

I would love to read your thoughts, experiences and approaches to increasing Data Fluency within your organizations and how you’ve seen it impact the User Adoption of your applications.

Posted in Data Literacy, User Adoption, Visualization | Tagged , , , , , | Leave a comment

Visualizing Population Health from a Community Perspective

In my previous post I asked you to consider Population Health from a Global Perspective. I understand completely how hard that is to do.  The world can be a scarier enough place without having to imagine how we can improve “health” care all around the world.

In this post I’m going to bring it down a notch and talk about Visualizing Population Health from a Community Perspective.

My first “Community” Health Impression

A few years ago the health system I worked with could not negotiate a contract with one of the Big 5 insurers. It affected me from a business standpoint as we stood to lose a substantial income business wise, but my wife’s insurance was with that particular insurer as well. What our CEO did has had a profound impact on me ever since.

She wrote a letter to every single patient with that insurance and sent it to every single employee as well. The point of her letter was basically … “The mission of our health system is to serve the health needs of this community. While our negotiations have failed with _______ we want you to know that regardless of the fact that they no longer considers us to be “in your network” we care about your health more than the finances and want to continue our relationship with you and will continue to accept the lower payments from your insurer so that you aren’t impacted because you are still our community.”

Of course as CEO her letter didn’t have a really long run on sentence like mine, but that was the gist of it. She absolutely wanted the community to know that they were our mission. AND she wanted every employee to remember that as well. Mission statements on walls are nice. But when they get lived out they can be life changing. Make no mistake there was a financial impact that was felt, but the warmth of our hearts drew us together as a system more than ever and our vision of “community” became solidified then and there.


Growing up I was pretty poor. The concept of fancy smancy physician offices was totally unknown to me. We went to what we called “Free Clinics.” Free was what we could afford so they were our families version of a Primary Care Provider.

Today they are called Federally Qualified Health Centers. They still operate on shoe string budgets primarily from grants and are still lacking the marble rotundas of premier physician practices. I suppose many consider them to be the safety nets for communities like the one I lived in growing up.

However, that’s not the point of this blog. If you look at their logo you will see something pretty amazing … they call out the Q as “Quality” rather than Qualified. Why is that important to me? Beecause they are the poster child for Population Health in my book. As the large physician groups and large health system’s are still trying to understand the concept of quality initiatives and “health” not “sickness”, things like MACRA, MIPS, MAPS, MUMPS, BUMPS and BRUISES (some liberty in names has been taken) they have been focusing on those things for a long time.

The lesson to learn is in the WHY?

As I’ve shared in my previous posts Population Health is about keeping people Healthy rather than treating sickness. If you get to bill for every sickness your business model is naturally going to focus on charging for sickness. Many systems don’t even have cost accounting systems to know what their costs are for their procedures. If you are going into the red you raise the prices to compensate. Cutting costs? If you don’t know what the costs are you can’t possibly figure out where the variances are that are putting you in the red.

But if you are on a tight budget. I mean one that you can’t change. Guess what? Your operating model is to keep people from getting sick so that they don’t use up your scarce resources.

Community Health Center of Southeast Kansas

I recently met a coffee bean named Janae Sharp who is passionate about putting other coffee beans together. (If you are wondering what I mean by coffee beans be sure to read my first post.) She even has a site Healthcare Scene Blog that is like a super blog for healthcare.  I will be sharing more about Janae and her work in my next post:

Visualizing Population Health from a Personal Perspective

For the sake of this post I bring her up because within no time of meeting she introduced me to another coffee bean, Karlea Trautman, who is a consultant who works with lots of FHQC’s one of whom is CHC-SEK. Her passion for these organizations is like my passion for data … way out there. So as you can imagine we had lots to talk about and all of it was enjoyable.

When she mentioned that data regarding quality of the nations health centers was available online … boom … my attention was really piqued. The Health Resources & Service Administration maintains a phenomenal nationwide database that is freely downloadable. 

As the Qlik Dork I figured I owed it to you to do some research on this data, and well I flat out enjoy playing with new 0’s and 1’s. So before going to bed that night I downloaded all 4 years of nationwide data and ingested it into Qlik Sense and started playing. I had no idea what to look for so my natural first step was to look at the center that we had spent so much time talking about.

What I saw was pretty amazing. Continuous improvement across the board on clinical indicators. The things that keep people in the COMMUNITY HEALTHY. What Karlea and CHC-SEK are doing is making an impact on the community. Their numbers are not only high for the State of Kansas their numbers are high in contrast to the entire country.

Oh shoot. I just realized that simply seeing their numbers doesn’t help you understand how they fit into the “Community.” So how about this instead. The dots represent the CHC-SEK sites. The census tracts are color coded by per capita income. The darker the color the higher average income. The lighter the colors the lower the income. All of the areas these clinics are in are just above or are below the poverty line.

Of course we might want to zoom in to see even more details. The dot pictured is their main clinic in Pittsburg.

Here is a thought. A crazy one perhaps. But Karlea agreed so if I’m way off base, at least I’m not alone … what if instead of thinking of these clinics as the “safety nets” for the poor … we flipped the script and started applauding the true “health” care that they are practicing and the mega systems turned to them for advice?

What if as the rest of the world struggles to grasp for answers to what “Population Health” is around the world and what Social Determinants of Health are … these FQHC’s have had the answers for years?

How can I wrap this section up in a really cool way? What if I told you that CHC-SEK recently appointed a Director of Population Health, Mallory Roberson,  to help them continue moving further forward. How awesome is that?

Ladies and Gentlemen we are now arriving in New Ulm, Minnesota

If you aren‘t sure where New Ulm, Minnesota is don’t worry. I had no idea either and I play with maps almost daily. So I figured before talking about them I would give you a visual of where they were located as a point of reference.

Kind of out of the way right? Which is perfect for my story. Completely ordinary community that has been radically changed as a few coffee beans decided to focus on Population Health in their Community.

How did they get restaurants to offer better foods?

How did they encourage people to think about their health instead of waiting to deal with their sickness?

I could’t begin to do it justice. So take a few minutes and enjoy this incredible video of how a community you never heard of, but will never forget, has been radically transformed by Population Health.

Entertainment or Inspiration?

That’s the question only you can answer.


Update: 8/29/2017 – Felt like I needed to update this post after the finalized 2016 data was released on the UDS site. CHC-SEK once again managed to improve their numbers and I’m happy to report that they were also the proud winner of a National Quality Award. This link is for the award site for Kansas but all you have to do is adjust the last two characters to see your state:

I also reached out to Jason Wesco the Executive Vice President for Community Health Center of Southeast Kansas and he was willing to be a guest for my second Dork Cast. He shared his secret with me about how he “transforms organizations thru the use of data.” He said the trick is “consistently being curious.” Be sure to pay attention the part in the video where you see the coal miners. Jason shares from the heart why community health centers are so vital to this country. So thankful for his willingness to give his time so generously. Click here to watch our interview.


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Visualizing Population Health from a Global Perspective

The Problem(s) with Population Health

I’ve got a nickel that says you are probably undertaking a Population Health Initiative. Everyone else in the world is so it’s safe to say you are as well. As the Qlik Healthcare team travels the globe we’ve seen 3 common factors that impede most folks.

  1. Data is Everywhere – There are so many publicly available data sources to pull from. The problem is that there are too many 0’s and 1’s and it’s hard to deliver a comprehensive view.
  2. If you can get that the next issue quickly becomes how to you utilize that comprehensive view to find the members/patients that are most at risk.
  3. Finally how can you track the efficacy of the numerous community-level programs to find out if your time and resources are having the greatest impact.

The Basics of Population Health

I guess I should slow my roll a bit … as I may not get a nickel from you as very well may never even heard the term “Population Health.” Like with many things it’s the kind of phrase that is easier to define by describing what it’s not. It’s the opposite of the sickness care that is now practiced in many areas of the world. You know what I mean. You have a medical problem so you go and have that problem treated then you go back to your unhealthy lifestyle.

At the core of Population Health is the notion that it’s far better to practice the things that will keep you healthy instead of treating the consequences of poor choices. For a diabetic it might mean keeping regular appointments and monitoring sugar. For pre-diabetics it might mean, this is crazy, changing their diets before having to deal with the severe consequences in terms of sickness and finances of becoming diabetic. It means getting checkups for colon cancer, breast screenings and so on.

In an ideal world every single person on the face of the earth would eat healthy, exercise, have no stress and live 2 minutes walk from a physician. They would be a lot healthier and it would cost a whole lot less to treat them.

Unfortunately Qlik Dork’s universe doesn’t exist. The universe we live in has it’s complications. Other stuff comes up and “health” isn’t a priority, or there are factors that prevent people from being as healthy as they would like to be …  hence the need for Population Health.

I would suggest at it’s core you think of the simple fact that the very term “Health Care” is totally incorrect. It’s Sickness Care. We don’t have “Health Insurance” we have Sickness Insurance.

Social Determinants of Health

A recent study revealed that up to 90% of patient risk is directly attributed to social determinants of health, individual behavioral patterns and genetics.

But what in the world does “Social Determinants of Health” (SDOH) mean? I would like to suggest the most primary SDOH would have to be the very word “Health.”

I would suggest at it’s core you think of the simple fact that the very term “Health Care” is totally incorrect. It’s Sickness Care. We don’t have “Health Insurance” we have Sickness Insurance. We don’t have “Electronic Health Records” we have Electronic Sickness Records.

If we can’t distinguish between those things we probably aren’t going to truly be “healthy. Once we understand the difference between Health and Sickness then we can look at other Social Determinants of Health. The things that keep people from being healthy.

In my previous post: Visualizing Population Health I introduced the absolute basic social determinant of health outside of vocabulary … basic drinking water. I wrote that post to help everyone see immediately that there are conditions regarding the environment that a person lives in that can dictate their health. And that correcting SDOH can be far less expensive than treating the sicknesses that result.

Felt compelled to go there before you mocked me for the SDOH that is primary in my life. The total lack of sidewalks. You see walking and listening to music is a huge destresser for me and as you know walking is just flat out good for the human body. But living off a rural highway with no sidewalks puts my life at risk when I walk. Jumped right from basic drinking water to a middle aged, middle income issue. That’s the point of SDOH they effect everyone … including me and you.

When I visited the Qlik office in Sweden I was shocked and impressed to see that their sidewalks were more like roads themselves. They had lanes just for biking and lanes just for walking. EVERYWHERE I went. They believe in walking, riding bikes and it shows. The lack of belief in walking and riding bikes surrounds me nearly everywhere I go in the United States. Why? Because so many still believe that sickness care is valuable, but health care isn’t. Good news is that the County Health Rankings  documents a score for Walkability so that should I decide to move I will certainly choose an area of the country that demonstrates it’s believe in caring for ones health before becoming sick. Of course they also document so many more.

They aren’t the only publicly available data source for SDOH another popular one is the CDC’s Social Vulnerability Indicators. These sources and others like them provide data that let’s you begin understanding “how” your patients/members are living not just where they live. They can also help you see the areas where your patients/members may be at the most risk.

The list goes on and on and on

Another SDOH is absolutely air quality. Living in Hotlanta I deal with allergies about 75% of the year due to 8 gajillion varieties of pollen. Nuisance headaches, tired feelings … beyond my control totally environmental. What about what it gets worse … when it effects people with asthma? My mother grew up in a coal mining town and is now dealing with the last stages of COPD. Totally beyond her control.

What about hidden and very dangerous SDOH. Lead paint. Lead pipes. Asbestos. Carbon monoxide. Radon.

What about crime? Would you consider that a social determinant of health?

What about the lack of cars in a family? Is that something you would consider a social determinant of health? Hard to pick up that prescription that was handed to you if you are in a taxi and it will cost $50 + to sit and wait 20 minutes at the pharmacy.

What about the inability to speak a native language? My wife and I have had occasion to visit Pharmacia’s while traveling the world. What if they don’t understand us or we don’t understand them and take the wrong thing?

What about a basic misunderstanding or complete lack of education on things as fundamental as hand hygiene?

How about fundamental health issues as they change over time? I’ve recently be doing data science research on comorbidities and discovered that Vitamin D deficiency is linked to a number of serious problems (I’m not a clinician so I had no idea. But data science doesn’t lie so I know now.) Fortunately my wife has a phenomenal PCP who got her onto Vitamin D supplements awhile back. But what about those woman in society who haven’t been told about that or a myriad of other issues and instead face consequences of those illnesses?

The lists go and on of these things that in most cases are way beyond anyone’s choices of things they are forced to live with which cause negative impacts to their health. Regardless where on the socioeconomic scale you are, SDOH effect us all. Seriously with a lack of education, lack of communication, lack of interoperability between practices and the abundance of commercials promoting the wrong things … what do you really expect our “health” to be.

I would love to be able to purchase true HEALTH INSURANCE but unfortunately I can’t. My sickness insurance kicks in only once I’ve become sick.

But wait … there’s hope

There are many many people out there working diligently to bring SDOH to the forefront. I follow #SDOHImpact driven by Mandi Bishop on Twitter who daily drives the issues home in a way that anyone can understand. If your appetite has been wet to dig in jump on board.

Physicians like Dr. David Nash and Dr. Fred Goldstein pouring the life work into helping others realize that it’s not only cheaper but better to look at the “HEALTH” of a population as something that should occur prior to issues arising and treating their sickness.

Lots and lots of resources. Lots and lots and of data available. Which sort of brings it back to my opening … The problem is how can I possibly consume it all in a way that actually provides insights. Lists of of data in Excel don’t translate well to peoples minds.

I’m about to do something totally crazy, kind of like what you would expect of the Qlik Dork, I’m going to suggest that the answer to consuming all of this Population Health and all of this SDOH data lies within a 7 Layer Chocolate Cake.

The 7 Layer Chocolate Cake

If you will indulge me for a moment I’d like to suggest that the answer lies within a 7 Layer Chocolate Cake. It’s a chocoholics dream because instead of just 1 chocolate taste, it lights up every single one of the gajillions of taste buds in their mouth. I think the same is true for consuming data. If I can layer multiple types of data together then it lights up every single one of the gajillions of triggers in our brains.

Like a chocolate pastry chef in the world’s finest pâtissier, Qlik GeoAnalytics can create as many layers as the taste buds in your brain can consume. You want to visualize your members/patients add them. You have the taste for Social Determinants of Health pour some in. Need a nice ganache on the top? Carefully layer on a live source of air quality data.

Getting hungry yet? Me too so I better move on.

You see knowing that zip code 12345 has terrible living conditions is 1 thing, but seeing your patients/members living in that zip code brings the data to life.

Seeing your patient/member in an area that is 32 minutes from the nearest pharmacy tells a different story than just plotting them on the screen.

Once the data starts being visualized together, in unison, you begin seeing HOW your patients/members are living and not just WHERE they are living. You begin seeing and understanding their HEALTH RISKS prior to dealing with their SICKNESS.

[Tweet You begin seeing and understanding their HEALTH RISKS prior to dealing with their SICKNESS.]

In my, perhaps geospatially jaded, mind I believe that the single best way to really drive home the points of Population Health and of Social Determinants of Health is to paint a vivid layered portrait of the data on a map.

Population Health is a Global issue

Working on the Qlik Healthcare team is an amazing opportunity for a coffee bean like me because I get to see “health” care from a global perspective. I get to consume data from sources around the world and you know I love consuming data.

And boy did I put some data on the barbie working with this Australian Census data. Gotta tell you the Aussies are serious about their Census SDOH data. To the tune of 8,492 COLUMNS of data. Capitalized the word column so that you would know it wasn’t a typo of the word rows. Seriously 8,492 different columns for the Qlik Dork to consume. My style is to be comical, but don’t let that fool you … Visualizing Population Health from a Global Perspective is not a game to me.

I began by suggesting that one of the serious issues is that there is to much data. How would you possibly go about visualizing data from 8,492 columns of data. This 8 minutes just might be the best 8 minutes you ever spend. Enjoy!

If you are intimidated by Population Health from a Global Perspective I can certainly understand that. Hard enough trying to deal with the pressures of your own organization without trying to solve the entire worlds problems. Never fear my next 2 posts will be:

Visualizing Population Health from a Community Perspective

Visualizing Population Health from a Personal Perspective

PS – Yes I’m aware that my image was a 24 Layer Chocolate Cake. Kind of proves the point that the Qlik Dork loves his chocolate and always wants to consume more layers of data than the average data junkie.

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Visualizing Population Health


Several years ago I read the term Wintality via posts from Auburn softball players. I liked the term so much that I proceeded to write not 1, not 2 but 8 posts to my own softball related website.

Each post began with a made up definition of the word such as:

[Wintality] – win-tal-i-ty – noun; The act of mentally attacking everything on the field as though it may be the last time you ever play the game. “That player’s wintality is just infectious.”

Recently I decided to post the word with a hashtag in a Tweet just to catch peoples attention. The person it made the most impact on was me. You see I accidentally clicked on #Wintality and as expected Twitter took me to the page for it.

Normally I’m not a ‘rah-rah-rah’ motivational speech kind of reader because there are more than enough books on consuming data to keep me busy. But seeing a book by Baylor Barbee called Wintality was to much a coincidence to resist so I had to purchase it. 

I’ve found the book to be very trans formative and therapeutic. If you read the book you’ll understand when I say that “I’m a lion on a surfboard” and that isn’t easy. If you don’t read the book you’ll just have to guess what I mean.

Are you a Carrot, Egg or Coffee Bean?

That is a question that Baylor asks early on in the book. Most people would be freaked out by a strange question like that and put the book down, but having written a post years ago called “What Kind of Bird Are You?” I was all about digging to see where Baylor’s creativity was going to go. Of course as the Qlik Dork I ended up realizing this crazy question had a lot of applicability to the Business Intelligence and Data Consumption communities let’s see if  you agree.

A carrot is an object that starts hard but when put under the pressure of boiling water becomes soggy and limp. Still called a carrot but clearly merely a shadow of it’s former self. Kind of like the workers in this field who started out with a vision and wanting to change the world. But they end up apathetic and believing nothing they do can change anything. They are the ones behind closed doors that will tell you things like “just go along to get along” “don’t make waves” “it’s no use to offer ideas.”

An egg is an object that was soft, had a hear but under the pressure of boiling water becomes hardened. Kind of like the workers in this field who clearly no longer have any empathy nor patience for others. It’s not that they don’t think they can help, they see no reason to “waste their time.”

In other words under the pressure of the boiling water they are changed. The yield to their environment. A coffee bean on the other hand knows who it is and when put under the pressure of boiling water changes the water. It takes ordinary water and converts into one of the most desired substances on earth.

This isn’t a therapy session so I won’t ask you to take the time now to determine which you are most like. I know in my own life I’m the coffee bean. Everyone probably wants to be a coffee bean and “change the world” but I can assure you it’s not easy. Water doesn’t want to change.

What’s this have to do with Population Health?

Great question … just hang tight a while longer.

Mercy Ships

Mercy Ships is a charitable organization that could be referred to as a floating hospital. Medical professionals donate their time to reach out to the world around them by volunteering their time to help those in great need around the world. I first heard about them via a colleague, Joe Warbington, who traveled with them as they are one of Qlik’s CSR partners. 

More recently I heard about them via a gentleman named Scott Harrison. Scott also traveled with Mercy Ships for a year. On one trip (this is important later on so pay attention) the team he was with was going to conduct 1,500 surgeries. I won’t share the graphics of the type of facial tumors they were removing, so just visualize mouth tumors that were literally suffocating the patients. The kind of things you just don’t see in the United States. While walking around the community Scott was touched by the fact that woman and children were literally pulling their water from swamps. While not a clinician, it doesn’t take one to realize that what we would label as a health hazard and run from is the source of water for 10% of people in this world.

Scott went to the clinicians to tell them and his thoughts that drinking that sewage can’t be good and their response was something to the effect “Well duh 52% of the disease in developing nations is a direct result of the water they have to drink” (my inflection) but then in his words challenged him “So what are you going to do about it?” Scott could have chosen to be a carrot and just said “this is a global problem there is nothing a little old guy like me can do about” and just lived in apathy. Scott could have been a non empathetic egg who simply focused on the surgeries. But Scott’s a “coffee bean.”

What’s this have to do with Population Health?

I’m getting there just give me a little more time it will all make sense soon.

Charity: Water

Ironically in describing the conditions Scott used the phrase “children shouldn’t have to drink water that looks like coffee.” So he started Charity: Water. A mission focused solely on raising awareness of the problem and raise funds to provide clean drinking water to those around the world. To date his organization has already completed 23,377 projects and have provided 7,128,152 people around the world which can be visualized here:

What’s this have to do with Population Health?

I’m glad you asked. I’m about to write 3 posts all about Population Health and Social Determinants of Health.

Visualizing Population Health from a Global Perspective

Visualizing Population Health from a Community Perspective

Visualizing Population Health from a Personal Perspective

One could easily decide that “fee for service” is the way things have always been in healthcare and this whole population health mumbo jumbo is unneeded. One could easily argue that it’s not a hospital’s responsibility that people do the right thing in their own live’s. One could easily argue that it’s not financially up to insurance companies to reimburse people for doing the right thing for their own health. One could easily become a soggy carrot, or a hardened egg when it comes to healthcare.

But coffee beans like Dr. David Nash have been fighting the battle for population health because they know full well … it’s the right thing to do and they have gradually proven to healthcare systems that from a financial perspective it’s cheaper to focus on health rather than on the costs of sickness.

Remember I mentioned the 1,500 surgeries. While Mercy Ships donates those procedures, imagine the costs for 1,500 surgeries. Now tie that in with Scott’s work at Charity: Water. It costs only $10,000 to provide a clean drinking source. Providing “health” is both right and cheaper. Clean water is one of the social determinants of health that I will talk about in my coming posts.

Population Health and Social Determinants of Health aren’t just new buzzwords.  They are in fact the proper terms to use when talking about HEALTHcare instead of SICKNESScare.

Visualizing Population Health

Visualizing Population Health is easy. Next time you take a sip of your Starbucks imagine the 10% of people in the world whose only water supply looks like your coffee. Washing their hands in water with cholera. Ingesting water with leaches in it. Too graphic for you?

Ok don’t think about all those people around the world … just focus on those in Flint, Michigan and realize that our “health” is a product of the environment around us. Realize that changing our current fee for system isn’t going to be easy. It involves change and with change of this magnitude there is going to be a lot of pressure. How you handle the change is up to you. I sincerely hope that you will join the population health movement and prove to be a coffee bean.

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