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The Value of Deploying a Social Determinants Screening Tool in EHR

July 5, 2018
by David Raths
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Michael Hanak, M.D., associate chief medical informatics officer at Rush University in Chicago, describes its early SDoH efforts

As accountable care organizations and multi-sector groups seek to identify the causes of poor health in their communities, they are starting to develop social determinants of health (SDoH) screening tools within their EHRs to combine with clinical registry data.

In a recent webinar hosted by the Great Lakes Practice Transformation Initiative, Michael Hanak, M.D., associate chief medical informatics officer at Rush University in Chicago, described the SDoH screening implementation at Rush.

Dr. Hanak serves as Co-Chair of the Quality Committee of Rush University Medical Group. He also serves as a Vice President of the Illinois Academy of Family Physicians and is a member of their Health Equity Workgroup. Rush University is one of eight institutions participating in “Pursuing Equity,” a national collaborative with Institute for Healthcare Improvement. He serves on the Rush leadership team for this project and, for the last three years, served as the site principal investigator for the CMS Transforming Clinical Practice Initiative.

Hanak began by noting that the Chicago neighborhoods between Rush University Medical Center and Rush Oak Park have some of the highest levels of economic hardship, lowest life expectancy and highest unemployment rates in the region.

Rush partnered with the leadership of West Side ConnectED collaborative to implement an SDoH screening tool that asks patients about:

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• Housing

• Transportation

• Food Security

• Utilities

• Primary Care/Insurance

To some providers, this screening seems like an add-on or separate ask, Hanak said, but he stressed that the health system’s mission is to be a good steward of health for the community and find those not thriving and bring them into the fold. He said Rush is seeking to empower those at the front lines of care to better understand struggles of patients and bring that up and say we need to do something about it. “It is important that we include everyone in that,” he said. “It is not the work of a committee or group. It is important to remind people to think outside of what they see every day in the exam room.”

He said it is helpful that the SDoH work touches areas it was already focusing on such as hypertension and diabetes. “We also looked at making sure it was operationalized into daily workflow. He stressed that the work must include clinical and operational leaders. After a pilot has taken place, the return on investment will become more apparent, he added.

Of an initial 50 patients screened, it took an average of 3 minutes per screening. Of those screened, 33% screened positive for one or more need. Food insecurity was the most frequent need (25% of screened patients). Among patients with SDoH needs, 65% were on a hypertension registry; 30% were on the coronary artery disease registry and 30% fell in the highest-quartile cost (internal charges) for the Rush system.

Rush built the SDoH screening form into its Epic EHR workflow. With the information in Epic, he said, they could drive a better understanding how the social issues connect to clinical measures and what they should be focusing on.

Another step in the process involved working with Chicago technology firm NowPow. This was described in greater detail in a press release on the Rush website:

“After the provider completes the patient intake process, the Rush EMR combines the social data with the medical history into a patient profile that it sends to NowPow instantly and securely. Within seconds, NowPow’s software queries the company’s database of local community resources to identify where patients can receive needed services. NowPow then draws on its national database of clinical evidence to find how the most commonly diagnosed chronic conditions have been managed successfully in areas demographically similar to Chicago’s West Side.   

NowPow then provides a curated list of resources and services — called a HealtheRx, a combination of a tech pun and the Rx symbol for prescriptions — that matches the patient’s needs. The technology enters the HealtheRx in the patient’s EMR, sends it to the identified community-based providers, and emails and/or texts it to the patient. 

For example, outcomes data shows that people are more likely to manage diabetes successfully if they have sufficient access to fruits and vegetables, get frequent blood sugar screenings and receive foot care. So in addition to a prescription for a medication to regulate blood sugar, a patient with diabetes might also be referred to a Federally Qualified Health Center for free blood sugar screenings and foot care, and to a Greater Chicago Food Depository partner site for free healthy food.”

The deployment is not without challenges, Hanak stressed. He listed several:

• Clinician engagement (“not in scope of my care.”)

• Support staff burn-out. People might say,  “not my job” and/or “not enough time.”

• Requires social work engagement for greater SDoH needs, which means more financial investment.

• Operational challenges:  “Where and when and what’s the ROI?”

• Closing the loop on referrals requires personnel to follow cases if they are not fully integrated with EHR.

• Preferred social work resources may not be part of NowPow.

• Some screenings took a very long time

• Interpreter sometimes needed for screenings

• Patient preference to answer sensitive questions with doctor only

• Adequate training for all staff participating in screening

In a written answer to questions raised during the webinar, Hanak said Rush is currently performing this screening in the Emergency Department and more recently the ambulatory setting. “SDoH screening is not routinely part of our inpatient assessment for those admitted outside the ED. Certainly any patients requiring care management or social work engagement are being screened, but we aim to capture most of our inpatient volume by way of the process we have set up in the ED.”

 

 

 


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All of Us Team Building Data Browser, Researcher Workbench

January 23, 2019
by David Raths, Contributing Editor
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Software tools to help researchers explore, analyze research data set

As the national All of Us research program begins collecting health data, its Research Hub, which will house an array of data collected in the program, is developing software tools to help researchers explore and analyze the All of Us Research Data Set.

The Data and Research Center (DRC) located at Vanderbilt University Medical Center houses the All of Us research database. In a newsletter, the Research Hub noted that in 2019 it expects to release information that participants provided via surveys, physical measurements, and electronic health records. Researchers will be able to access participant research data, with personal identifiers removed in order to explore how various factors contribute to individual health and disease.

The EHR information included depends on what kinds of healthcare has been received and what types of providers a patient has seen. The All of Us Research Program employs Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) Version 5 infrastructure to ensure feasibility and standardization across EHR data for researchers. EHR data will be accessed longitudinally throughout the life of the program. Within the context of the Research Hub tools, EHR data will be presented at the highest level of granularity, which is by EHR Domain. Domains include: Demographics, Conditions, Procedures, Drugs, Measurements, and Visits.

In the first half of 2019, the DRC plans to release a Data Browser that will allow anyone to view aggregate counts of participant research data. Counts will be available for survey data collected from participants, physical measures collected during exams, and medical concepts from electronic health records (EHR) data. This tool will be available to anyone, with no registration or login required.

A “Researcher Workbench” is slated for release by the end of 2019. The Workbench is an analysis platform designed for researchers to create cohorts of individual-level participant research data, review these cohorts, and analyze and visualize the data in a Jupyter notebook using Python or R.

The initial version of the Workbench provides three tools for working with data:

• Workspaces: Create a project workspace. Store cohorts and notebooks. Share with team members.

• Cohort Builder: Build and review a custom data set.

• Notebooks: Analyze your cohort. Create graphs or tables to showcase your work.

To ensure participant privacy, researchers will be required to register and verify their identity in order to use the Workbench.

The DRC noted that it has sought input from an array of potential users of the Research Hub, collated their feedback, and leveraged these insights to help guide iterative development of the tools. 

Currently, the Research Hub is in its first beta launch within the DRC. The purpose of this release is to open the Research Hub up to vigorous internal testing that includes quality control, quality assurance, data characterization, data validation, and user testing as well as security and functionality testing. 

 

 

 

 

 

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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.

 

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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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