Identifying high risk patients

Patients with given condition

Zus customers are often interested in segmenting their population by disease prevalence. Segmenting patients in this way is straightforward with Zus data marts using the Lens SNOMED Conditions table. This table is built off of the Conditions Summary Lens, which normalizes and de-duplicates conditions data SNOMED CT (or the available CodeSystem if mapping to SNOMED CT is not possible). The following query returns all patients with a record of SNOMED code 73211009, 313436004, 44054006, or 111552007, indicating that they’ve previously been diagnosed with diabetes mellitus.

📘

Sample query available here

Alternatively, you could filter on ICD-10 E11.9 using the following code.

📘

Sample query available here

Patients on given medication

Zus customers are often interested in segmenting their population by medication usage. Segmenting patients in this way is straightforward with Zus data marts using the Lens RxNorm Medication Statement table. This table is built off of the Medication Summary Lens, which normalizes and de-duplicates medication resources for a patient (i.e., MedicationStatement, MedicationRequest, MedicationDispense, and MedicationAdministration) by RxNorm (or their available CodeSystem if mapping to RxNorm is not possible).

The query below returns the Zus UPID for each patient with a record of RxNorm code 31265 in the last 12 months, indicating a record of the patient taking prednisone 20 MG Oral Tablet in the past year.

📘

Sample query available here

Patients with recent ED/IP visit

Following an emergency department (ED) visit or inpatient (IP) admission, patients are particularly vulnerable and at risk for a repeat visit or readmission. Therefore, many health care organizations set goals around reaching out to patients following an ED visit in order to reduce 7 and 30-day readmission rates by tackling communication challenges and/or adverse health outcomes that arise following admission or discharge.

The Transition of Care Lens, which can be queried from the Lens Transition of Care table, summarizes and aggregates information from inpatient, emergency, observation, and preadmit encounters. It provides information on where and when the ED visit occurred, the recorded diagnoses for the visit, the final place or setting to which a patient is discharged from a healthcare facility (discharge disposition), and whether additional documentation is available within Zus.

To identify patients with a recent inpatient admission, replace AND t.encounter_class_code = 'EMER' with AND t.encounter_class_code = 'IMP'.

📘

Sample query available here