- As value-based approaches to healthcare reimbursement become more popular across the industry, provider groups are becoming increasingly focused on addressing the social determinants of health (SDOHs).
Social determinants, such as transportation access, housing security, and socio-emotional health, play a critical role in access to care and the ability to sustain engagement with recommended treatment plans.
But understanding the complex patterns of patient behaviors outside of the clinical environment is a massive challenge for health systems.
Community-based services often operate more or less independently, and few have standardized record management systems that can share data with colleagues in other social service disciplines – let alone with clinical care systems in the region.
Even in a relatively unified administrative environment like a county health system, tracking the movement of individuals as they touch different components of the care continuum can be a daunting task, says Eric Raffin, Chief Information Officer for San Mateo County Health (SMCH) in California.
“When I started at SMCH about six years ago, there was really no awareness of who was receiving what services from what part of the system,” he explained to HealthITAnalytics.com.
The county operates a wide range of services, including acute care, behavioral health, elder care, correctional facilities, and preventive healthcare, Raffin said.
And despite the fact that the county is home to some of the most lucrative technology companies in the country, SMCH’s safety net serves about 100,000 patients a year, the majority of whom are Medicaid/CHIP beneficiaries or uninsured.
“It’s impossible for us to identify all the permutations of how a person will interact with the county,” he said. “A senior citizen, for example, might have history with Aging and Adult Services. They probably go to the medical center. Maybe they’re seen in behavioral health; maybe there’s a social worker involved, or they receive Meals on Wheels.”
“It was clear that we needed a much better sense of how our patients were moving through the system. So many best intentions are thwarted by unintentional gaps. No matter what path an individual is on, we must have the visibility that will help to coordinate what they need.”
Soon after taking on the CIO role in 2012, Raffin oversaw the implementation of an enterprise master patient index (EMPI) from NextGate that would offer SMCH much more actionable visibility into patient access patterns.
“It seems like it should be a simple thing to know who your patients are, but it’s really not,” he said. “It’s even more difficult if you have a very diverse application environment with a number of different EHRs and case management systems, like we do.”
“As a county health department that has undergone several different reorganizations in the past few decades, we have some issues with legacy systems. Everything we have was best-of-breed when it was implemented, once upon a time. The problem is that we’re still using a lot of it.”
Layering an EMPI over the health system’s patchwork of health IT tools to create a single source of truth for patient identities was an imperative first step for being able to manage the county’s complex population at scale.
SMCH has a separate EHR environment for its behavioral health services, several case management systems, and three EHRs for the medical center.
While the medical center’s EHRs could deterministically match identities, they could not use probabilistic methods to reconcile potential errors, resulting in numerous duplicate records.
“Standardization is the foundation of being able to do more with big data, to unify experiences for our clients, and gain visibility into what we might want to change in the future,” Raffin stressed.
“We are the safety net for these people – we’re it. The more information we can share across the community, the better we’re going to be at catching people before they fall through the cracks.”
Being a safety net does have one significant advantage, however, added Raffin. Because most patients utilizing the system’s services are beneficiaries of Medicaid – known as Medi-Cal in California – getting access to claims data requires only one major connection.
“We have a very tight and very productive relationship with Medi-Cal,” he said. “We get claims information and eligibility information from them once a month, which we can add to the EMPI to give us a highly accurate picture of what people are doing.”
SMCH now has the ability to assign enterprise unique patient identifiers (EUID) to each individual, preventing duplicate records and giving all service providers the ability to access a complete record of that person’s interactions across the county’s social and healthcare programs.
“The last thing you want to do when treating patients is have the wrong Maria Gonzales,” he said. “Nor do we want to add three versions of Maria Gonzales to your diabetes registries and have care managers call the same number three times and get the same person – or get dinged on a quality measure three times when really it’s only one person that needs a service.”
SMCH is also one of the few health information exchange organizations (HIOs) in California, rendering it even more important to ensure that patients are clearly identified as their data travels between disparate systems.
“There are plenty of people who seek services in all parts of California, so the more we know about them, the better,” Raffin said.
“And we’re hoping that we can encourage other entities in the Bay Area to share data. If we can do that in a standardized manner, our environment as a whole is only going to get stronger as a result of knowing more about patterns of care.”
The next step for San Mateo County Health is to integrate the correctional health environment into the larger EMPI environment, said Raffin.
“The correctional system is still on paper. I guess I shouldn’t say that too loudly,” he laughed. “It’s pretty obvious that we needed to address that at this point.”
Correctional health is a very fluid environment that offers its own unique challenges, he continued.
“Sometimes an inmate will receive a medication in one location, but the next day they’re transferred somewhere else, and their record doesn’t always go with them,” he explained.
“In order to transition away from paper and create a pillar in the EMPI for jail management systems, we had to work with the sheriff’s office. They were totally amenable to it, and it’s very helpful that we’re all in this county framework working together.”
The goal is to ping the EMPI every time a corrections officer books an inmate. If no results for that individual are present, the action will create a new file. If data does exist on the individual, the officer can simply add to that base record without opening a duplicate record.
“That will be a major improvement within the correctional environment, and the benefits will carry over into the rest of the health system, too,” said Raffin.
“If that person seeks care when they’re back in society, they’ll already be registered and we’ll have their history from the correctional facility as well as anywhere else they’ve been seen within SMCH. There’s a lot of crossover with behavioral health, naturally, so that keeps both departments aware of how to best address the needs of each person.”
Visibility into the county’s complex and high-needs population is the foundation for coordinating care while taking the social determinants of health into account, he said.
“We know that we started at the bottom of the data ladder with all the different health IT tools we had. But I like to think that if we can make this happen for our patients, then anyone take the next steps they need to take into more comprehensive population management,” said Raffin.
“Identity management is critical, whether you’re a large health system or a smaller organization. You have to understand behavior patterns before you can start to address them. Once you know who is accessing what and why, then you can become really good at managing individuals as they move through your different services.”