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Collaboration Software Supports California’s Ambitious ‘Whole Person Care’ Pilots

January 2, 2019
by David Raths, Contributing Editor
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Assessment will study IT implementations for cross-sector data sharing in 25 counties
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The State of California is piloting an ambitious effort called “Whole Person Care” within its Medicaid program by working with counties to coordinate health, behavioral health and social services. Twenty-five counties are starting to share data and coordinate care for vulnerable Medi-Cal beneficiaries who have been identified as frequent users of multiple systems and who continue to have poor health outcomes.

Underpinning these efforts are the technology solutions that will allow previously siloed organizations to share data, create shared care plans and evaluate individual and population progress.

Mark Elson, executive director of the San Joaquin Community Health Information Exchange, said the pilot program is challenging the safety net delivery system to coordinate services and requiring data sharing across sectors, including housing organizations and jails.

Elson leads the San Joaquin Community HIE, and his Berkeley-based consulting firm, Intrepid Ascent, also works with five other counties to implement IT systems to support data sharing for Whole Person Care. “We are doing an assessment for the California Health Care Foundation on IT models across all of the pilots,” he said. A report is expected to be published early in 2019.

San Joaquin Community HIE and the Marin County pilots have both begun working with, a provider of healthcare collaboration software. says its social health information network will support intensive care management, referrals between healthcare and community organizations, and community-wide care planning and task sharing processes.

Elson noted that in many of the counties, community-level HIEs are starting to take off, but they were not built to meet the needs of Whole Person Care. “Along with the requirements for care coordination across sectors, there are requirements for shared care planning for high-risk, high-cost Medicaid beneficiaries, many of whom are homeless,” he explained.  Every individual must have a shared care plan created within 30 days of enrollment in Whole Person Care. “If you think of EHRs as providing the historical clinical record, and you want that to be available across organizations through HIE, there is still a gap,” he said. “Most HIEs don’t enable care teams to collaborate on future-oriented goals and planned interventions. and other care management vendors have jumped into this space and are performing a critical role.”

San Joaquin and Marin counties chose because it has a strong user interface and because the platform supports the creation of care teams that include people from multiple sectors, Elson said. “They can set permissions so that a housing coordinator has access to an appropriate level of data based on the policy and legal framework,” he said. “They also have strong interoperability chops. That is important because part of the implementation in these two counties involves integration with the local HIE.”

Based on the procurements his firm ran for the two counties, he said, the data-sharing capabilities of care management vendors are quite variable, but there are a handful that have the ability to integrate with HIEs or EHRs. The challenge, he added, is being able to pull in a curated clinical data set rather than creating a massive data repository. “They just want to get actionable information to people actively engaged in care management across organizations, which makes them complementary to HIEs,” he said. “We’re seeing a similar approach in Santa Cruz County, for instance, with the Santa Cruz HIO bringing the care management vendor CrossTX to the table to support Whole Person Care and similar programs. And Alameda County, where there’s not a pre-existing community HIE, has selected a vendor, Thrasys, that does care management, HIE, and analytics all under one roof.”

A longer-term goal involves pushing some of the social data that will be generated in back into the partnering clinical systems via the HIE. “There is no consensus yet on what social data is helpful for clinical providers to receive back in their own system,” Elson said.  “We are exploring making’s user interface accessible from specific partners’ EHRs so clinicians don’t have to make that decision about what data elements they want coming back.”


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NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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New Analysis in the New England Journal Finds the Leveraging of IT for Population Health To Be Inadequate

January 14, 2019
by Mark Hagland, Editor-in-Chief
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A new analysis published in The New England Journal of Medicine, and looking at the policy and IT elements around population health development, concludes that healthcare leaders need to up their game around all those elements
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A new analysis published in The New England Journal of Medicine, and looking at the policy, payment, and information technology elements around population health program development, concludes that healthcare leaders need to considerably up their game around all those elements, if they are to make population health management successful at scale.

As the authors, Aaron McKethan, Ph.D., Seth A. Berkowitz, M.D., M.P.H., and Mandy Cohen, M.D., M.P.H., note, in the article, entitled “Focusing on Population Health at Scale—Joining Policy and Technology to Improve Health,” speaking of such areas as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Housing Choice Voucher Program (Section 8), and other social welfare programs, “A growing body of research supports the value of investments outside health care for improving health and fiscal outcomes, and many pilot programs are investigating how to implement such an approach. On a population level, however, much work remains to be done.”

As the authors note, many of the combined policy and technology changes come together in the ongoing evolution of the North Carolina Medicaid program. They write, “A telling example comes from our own state of North Carolina. In 2017, North Carolina Medicaid covered prenatal and delivery services for 58,159 births — nearly half (48.4%) of the total births in the state. Yet 31% of these births were to mothers not enrolled in WIC (see graph), despite similar income eligibility criteria for WIC and Medicaid. Since WIC provides nutritional support from the prenatal period through five years of age and has been shown to improve participants’ health, this mismatch risks undermining the benefits of the prenatal, labor and delivery, and pediatric care that Medicaid supports.”

But, they note, “Moving from establishing pilot programs to addressing these issues at scale presents major challenges. Information technology in both the government and health care sectors lags behind what is needed to support seamless integration of Medicaid and other services and programs. Even new payment models explicitly designed to link reimbursement to health outcomes may not effectively stimulate performance of tasks such as WIC enrollment. Perhaps most important, addressing all the factors that affect health will require new ways of thinking, collaboration, and accountability on the part of both health care and government leaders. We suggest three considerations for advancing broader, sustainable initiatives that improve health and use fiscal resources wisely.”

Among the authors’ recommendations: human services programs need to be “integrated into a systematic population health approach,” one that coordinates workflows “that facilitate identification and enrollment of eligible patients”; “it will be important to promote both policy and information-technology innovations that make program enrollment seamless”; and, the researchers write, “[W]e believe policymakers should explicitly consider the effects of human-services programs on health and total cost of care. This approach will require developing rigorous evidence regarding the combined effects of health care and human-services programs as well as evaluations of new ways to integrate such services.”

They further state that, “As health care payments are increasingly tied to population-level outcomes, the sustainability and effectiveness of human services should be an increasingly important priority for health care leaders. SNAP resulted from a political coalition of rural, conservative advocates for farmers and urban, liberal advocates for alleviating poverty; we envision a similar partnership between health care leaders taking on risk for population health and cost-related outcomes and human services leaders supporting the same populations.”




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Global Genomics Alliance Working to Break Down International Data Silos

January 3, 2019
by David Raths, Contributing Editor
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Seeking innovative solutions to enable federated data analysis

The Global Alliance for Genomics and Health (GA4GH) has published a paper reviewing the diverse approaches being taken around the world to integrate genomics into healthcare and presenting a roadmap for sharing strategies, standards, and data internationally to accelerate implementation.

The paper, released Jan. 3 in the American Journal of Human Genetics, notes that while genomic sequencing has traditionally been a research tool, genomic data in the clinical setting will outpace research genomics within the next five years, with 60 million genomes expected to be sequenced by 2025. By 2030, China hopes to reach its goal of adding another 100 million genomes through the Chinese Precision Medicine Initiative. (Saudi Arabia, Estonia, Finland, Denmark, Japan, and Qatar are all developing their own national strategies.)

“The international genomics community has a responsibility to work together to effectively and efficiently role out clinical-based genomics care for the benefit of all,” said Kathyrn North, director of Australian Genomics and Murdoch Children’s Research Institute and lead author on the paper, in a prepared statement. “If we don’t get this right, patients will be the ones to suffer.”

After summarizing the national genomics strategy in the United States, U.K., France and Australia, the authors stress the importance of “breaking down data silos to accelerate the development of knowledge databases that directly improve patient outcomes cannot be underestimated.” Because national regulatory frameworks are unlikely to allow large-scale data migration, innovative solutions will be required to enable federated data analysis without data movement across geographical borders while maintaining public trust.

GA4GH is working with national genomic medicine programs to promote best practices in data sharing by structuring data access and consent processes, collecting clinical and genomic data in interoperable formats, committing to global data sharing, and informing public debate and policy development. The group recently launched a 5-year strategic plan, GA4GH: Connect, that focuses on the development of standards for responsible sharing of clinical-grade genomic, phenotypic and metadata. Genomics England, Australian Genomics, and All of Us in the United States serve as early “Driver Projects” for GA4GH, to inform the iterative development of tools and policies for data sharing, test them under real conditions and disseminate best practice.

“Without global inter-program dialogue and collaboration, clinical implementation stands to proceed in a haphazard fashion,” said co-author Brad Ozenberger, program official for the Data and Research Center for the All of Us Research Program at the U.S. National Institutes of Health, in a prepared statement. “This could mean inappropriate testing at high cost, inaccurate data interpretation, misdiagnosis, and policy that extends existing healthcare inequalities.”




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