With the shift toward value-based payment and population health improvement, the core data assets and services that health information exchanges (HIEs) have cultivated are in greater demand and can be leveraged effectively by sectors other than health care to improve health outcomes. These sectors, such as public health, human services, and housing, are both driving and supporting HIEs to share data with a wider set of partners and integrate additional data sources beyond those from health care.
A recent All In webinar featured three communities that are tackling population health priorities through the innovative use of HIE data, tools, and services. Representatives from the Baltimore City Health Department, Louisiana Public Health Institute, and San Diego Health Connect shared how they are leveraging the data and technical infrastructure of HIEs to facilitate integration of social determinants of health (SDOH) information with clinical data and drive solutions to pressing community health challenges. Presenters shared various approaches for utilizing HIEs to address social needs, which are summarized below.
1. Real-time public health surveillance
When Mike Fried, Chief Information Officer at the Baltimore City Health Department, embarked on a DASH-funded project to reduce falls among older adults, the best available data on fall-related injuries was 18-24 months old and data analyses had to be done manually. Community leaders needed more timely, actionable data so that they could continuously monitor how falls were impacting the population and use that information to guide decision-making. The health department partnered with CRISP, Maryland’s HIE, utilizing their data to create a “falls dashboard” that enables community partners to view fall-related hospitalizations and emergency department visits in near real-time. Fried commented:
“This is dynamic, it’s online, it’s updated, it’s compelling, and we are able to share it with our community partners. We’re bringing together groups all around Baltimore who are doing amazing work on falls prevention and helping to focus their efforts.”
As data on fall-related emergency department visits is collected through the HIE, the Baltimore City Health Department sends regular updates to a large network of community partners indicating when and where falls are occurring in the city. Pinpointing geographic “hot spots” where rates of falls are high allows partners to implement evidence-based exercise programs, facility repairs, and other falls prevention interventions in these areas. For example, Fried recalled that in the Hampden neighborhood of Baltimore, the HIE data illustrated that just a few buildings were responsible for 72% of all falls in that census tract, information that has helped the community prioritize their interventions for the greatest impact.
3. Social needs screening/assessment
Daniel Chavez, Executive Director of San Diego Health Connect, a former CHP grantee, worked with partners to develop a universal assessment tool for SDOH that could more accurately convey the complexity of social influences impacting residents than the tools currently available. The community information exchange, an HIE of social service agencies in San Diego, is the repository for the SDOH assessment data and has become a roadmap for care planning in San Diego. The assessment screens for fourteen social determinants of health and dynamically measures patient/client movement across a continuum with five phases—crisis, critical, vulnerable, stable, safe, and thriving.
4. Referrals to community services
San Diego Health Connect is working to improve interoperability between the HIE and other service providers in San Diego to enhance care coordination. They envision a process in which all relevant patient/client information is communicated to the appropriate health care and community stakeholders in a timely manner. Chavez noted:
“We want to have a closed-loop referral system between clinical health care and the community. We want to be able to take an order—for food, for transportation, for housing—and make that just like any other physician’s order…close the loop back and report accordingly across the continuum of care, between all users in the care team involved with that client.”
5. Risk analysis
Clayton Williams, Director of Clinical Transformation at the Louisiana Public Health Institute (LPHI), explained how through a CHP-funded project, LPHI used data from the Greater New Orleans HIE to enable population-level analyses to identify the most complex, high-need patients and intervene appropriately. LPHI and its partners used the HIE to look specifically at the chronically mentally ill population in New Orleans (about 400 individuals) and identify opportunities to reduce unnecessary medical utilization and incarceration and improve care coordination. LPHI worked with stakeholders from health systems, EMS, police, homeless service providers, social service agencies, and other sectors to conduct analyses that would help them understand and map where there are opportunities to bring information to the point of care that would improve the health and quality of life of these individuals.
6. Data-informed policymaking
With support from the BUILD Health Challenge, LPHI is utilizing data from the Greater New Orleans HIE in a new way—conducting data analyses to inform broader policy actions. Their BUILD Health Mobility project is aligning multiple partners to use the HIE data to advocate for policies that address transportation barriers to health. Williams emphasized:
“It’s important to recognize that HIE data and infrastructure can be used to inform analyses at the population-level for health care as well as other sectors in our society that will help advance people’s ability to stay healthy beyond what we understand as the traditional functions of an HIE. It’s really grown into an engine for information that informs policy beyond delivering information to the point of care.”
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