A health information exchange is at the center of an effort to reduce emergency department utilization by the indigent, high-need, super-utilizer population in Humboldt County, Calif., by 15 percent over the next year. The project has involved working through some thorny data governance and interoperability issues.
Humboldt County has one of the highest percentages of homeless populations in the country, according to Martin Love, CEO of the North Coast Health Improvement and Information Network (NCHIIN), a nonprofit HIE that connects the county’s hospitals and labs with most of its ambulatory providers, including the federally qualified health centers (FQHCs), NCHIIN has built an interface between the Humboldt County Department of Health and Human Services Social Service Homeless Management Information System and North Coast’s HIE to share data from electronic health records and public and private records. Social services case managers will receive alerts about clients’ health center/hospital visits for follow-up care coordination.
The project is part of the Community Health Peer Learning Program, a national peer learning collaborative managed by AcademyHealth through a $2.2 million award from the Office of the National Coordinator for Health Information Technology.
Challenges with interface: Love said several issues arose as they tried to bring data together from different types of systems. “I think it is fair to say we were naïve when we started the project, and had a sense that the data systems at the county would be like the data systems in healthcare but a slightly different color, but that is not true,” he said. “They are very different. The Homeless Management Information System is HUD-required software used throughout the United States. It is ‘big iron,’ — old and not very flexible. It has a lot of problems.”
In fact, he said, one of the early findings of the project was that the system was useful for brining information into the project, but it wasn’t going to be useful for the HIE to send information back to it. “It wasn’t used day to day by case managers,” he said. So they found a care coordination platform from a company called ACT.md that will be used by the social service case managers and later by ED and FQHC case managers. Social services case managers and social workers will use ACT.md’s cloud-based platform, the Care Coordination Record, to understand when clients have had encounters with the healthcare system and to engage in follow-up with clients after clinical encounters and other life events.
At first, the social service case managers will have access to basic demographic information on the patient, information on who is working with the patient, what programs the patient is involved with, and information about the healthcare event. “We are still in the discovery stage of trying to understand the information they will be putting in and how they will use it,” Love said.
Another challenges involved creating and tracking consent forms for patients to sign, allowing data to be shared across agencies and providers. “That has been one of the more complicated parts of the project,” Love said. “It has been very interesting to try to understand data governance around systems that have both protected health information (PHI) and non-PHI.” There are some questions about mixed care teams of healthcare providers and social services caseworkers that have surfaced in this project and others. “It may be something that requires policy or regulatory clarification on the national level,” he added.
Yet another issue for the HIE has been trying to understand the organization of all the county programs. There are non-governmental organizations that contract with the county to do some of the work, and there are overlapping programs. “It is interesting to us how many different programs there are, and sometimes it is hard to keep it all straight,” Love said. “But it has been a pleasure working with the county. In some ways, they have been easier to work with than healthcare.”
Nine months into its 18-month timeline, the project is about to implement the Act.MD software and has made the interface between the county system and the HIE live. Love said he is optimistic that despite the early challenges they ran into, the 15 percent reduction in ED utilization by this population is attainable. ”These folks are ending up in ED because they don’t know what else to do. But what else to do is to make the connection for them with the FQHC, and that does work.”