How a Digital ‘Baseball Card’ Supports Care Management

March 08, 2023 - The Agency for Healthcare Research and Quality (AHRQ) highlights care management as a fundamental means of managing the health of defined populations and supporting the triple aim of healthcare.

AHRQ and the Center for Health Care Strategies define care management as a patient-centered, team-based framework designed to help patients and their support networks more effectively manage medical conditions. The approach also includes the care coordination activities necessary for chronic disease management.

AHRQ outlines three key strategies for care management: identifying populations with modifiable risks, aligning care management services to the needs of that population, and identifying and training personnel appropriate to the needed services. However, carrying out the agency’s recommendations to achieve these goals, such as developing risk stratification approaches and leveraging EMRs to facilitate effective care coordination and patient outreach, can be challenging without the right support and tools.

Laura Merrick, senior director of eSolutions at Medical Home Network (MHN), a Chicago-based care transformation not-for-profit and ACO REACH Model participant with 13 federally qualified health centers (FQHCs) and three large hospital systems, discussed how a digital ‘baseball card’ can address some of these issues and help support population health and care management.

HOW THE BASEBALL CARD WORKS  

Merrick believes that to effectively support care management efforts, a digital tool must be developed with a deep understanding of the problem to be solved from the perspective of those most impacted.

The MHN Baseball Card seeks to address the hurdles clinicians face when accessing the right data at the right time within their workflows.

“The baseball card organizes disparate sources of data that's going to be external to the EMR,” Merrick stated. “So, for example, [admission, discharge, and transfer] feeds and real-time hospital activity from a health information exchange or other direct hospitals, so that we're pulling in activity that's occurring not just at that facility where the baseball card is integrated, [but also] where the patient’s going across the ecosystem. We're also pulling in medical and pharmacy claims data, directly working with payers to get that medical and pharmacy claims data in.”

The tool also pulls social determinants of health (SDOH) data and leverages artificial intelligence (AI) to organize these components for the provider.

“We present [the data] in a brief summary that makes them actionable to the primary care provider at the time of the patient interaction,” Merrick explained. This gives clinicians using the baseball card an at-a-glance view of a patient’s information.

The tool is also dynamic, meaning it's updated in near real-time and designed to help keep care teams abreast of the most important information about how the patient is interacting with the rest of the health system, including encounters in-hospital, at the pharmacy, and with care managers, she said

“When we integrate [the tool into EMR workflows], we're doing that in a way that doesn't require that PCP or that provider to sift through volumes of data to find all of these pieces,” Merrick added. “It's dynamically updated as activities happen.”

The dynamic nature of the tool also comes into play when considering patient risk scores for various conditions or outcomes. Risk scores are generated using several patient factors, but the risk may change as patient factors or activities shift over time. These changes may trigger an update to the baseball card, which is updated accordingly. This also ensures that there is always one relevant baseball card for clinicians to view. Old or outdated baseball cards are removed to streamline the clinician’s workflow and prevent them from getting overwhelmed.

However, integrating a tool like this and using it to connect data across a care network brings up its own host of issues, Merrick indicated.

“We want the technology to help connect the care team to each other and get those important updates; that’s why [we are] doing this work,” she said. “The challenges that come are how [the tool integrates] within that provider workflow. Well, in order to do that, you can imagine in a network of providers, they're all on different EMR systems, and we respect that. Everybody wants to be within their native system, and they don't want to leave. So, when we designed this, we needed to take an EMR-agnostic approach to work with any clinic anywhere, but we really needed it to support care delivery and integrate with clinical staff.”

In addition to considering integration with different EMRs, MHN had to take into account the resources and capabilities of the organizations implementing the baseball card. Many of the facilities initially deploying the tool were FQHCs, which often lack tech teams and resources, Merrick explained. This meant that the baseball card had to be scalable and flexible to meet the needs of different facilities.

“I think that sometimes there’s a gap in healthcare, where we have all these great things, except sometimes it's really hard to get towards implementing them to where it's usable and actionable,” she stated. “And I think that's what we had to lead with: ‘is this actionable and insightful?’”

DATA LIQUIDITY TO BOLSTER CARE COORDINATION

One of the significant ways the baseball card makes patient information actionable and insightful is by addressing data liquidity issues, which can hamper communication and care coordination within a healthcare network.

Merrick explained that the baseball card helps address this by making data sharing easier through the breakdown of data silos and improvements in information visibility. She also noted that leading with the provider’s workflow in mind can help guide that process.

“As we were doing that, what we started to see, or the impacts that we were making, was that this interoperability was benefiting the patient because these providers could now have conversations with patients around simple things because we were pushing medication comprehension and adherence within the workflow,” Merrick stated. “It's challenging for a patient to remember what [clinicians] tell them to do.”

“So, [the tool allows] conversations between a doctor and patient, which builds relationships,” she continued.

Most of these conversations center on a patient’s condition, test results, medications, and treatment plans. However, communication and relationship-building problems can arise when providers have to fax information back and forth, requiring a follow-up appointment, or when users have issues logging into or utilizing a patient portal.

Merrick pointed out that many of these issues can be avoided if data is accessible while the patient is already at an appointment with their provider. The baseball card aims to facilitate this by breaking down data barriers.

SUPPORTING COMMUNITY- AND POPULATION-BASED HEALTH

Facilitating these conversations and improving the relationship between patients and providers is also critical for community and population health. Thus, the MHN Baseball Card aims to support patient trust in providers, Merrick stated.

“I think the way that we've continued to evolve our technology and capabilities is really understanding, what do [those interactions] feel like for the patient?” she explained. “How can the patient have a trusted relationship with their doctor so that they do go see the doctor and not keep going to the ED for services that they can get with their doctor? What we focus on… [is] allowing the technology to help connect the care team to each other and get important information about the data that then allows them to build trust with the patient.”

This helps clinicians get a 360-degree view of their patients and engage with them in a more meaningful way, which can help address social determinants that may not typically get as much attention during an appointment. Merrick noted that some providers using the baseball card said the tool allows them to engage with patients “outside the four walls of their practice” by identifying SDOH, such as food insecurity, and making action plans to address them through community or other resources.

Moving forward, Merrick indicated that MHN is focused on growth within the healthcare organizations that are part of its network in various states, with particular emphasis on building healthier communities and proactively coordinating care for patients.

“I think the technology is only a part of our solution,” she said. “We acknowledge that, and I think where we've been able to grow and continue to evolve is creating a structured approach to care management. And we do that by supporting technology processes and staffing that allows us to close the loop with the patient wherever they are.”

With these pieces working in concert, Merrick believes it’s possible to reimagine how care delivery may improve in the future.

“Healthcare's constantly changing, and so we have to continue to understand the problems we're solving and allow that technology to grow and change,” she stated. “We are focused on our growth within some of the care models that we're serving across the different states so that everybody can benefit and experience what this can look like.”