Optimizing Workflows to Share Data Across Sectors: Promising Approaches to Improve Care Coordination
Written by Jenna Frkovich, MPH, Data Across Sectors for Health (DASH), Illinois Public Health Institute
To provide coordinated care that meets patients’ needs, many networks and communities are developing information systems to share data across clinical and social service settings. In order for these systems to be effective in connecting patients to the right services at the right time, care teams need access to relevant individual-level data that is seamlessly incorporated into their work process.
Data Across Sectors for Health (DASH), a Robert Wood Johnson Foundation funded initiative, was launched to support multi-sector collaborations in sharing data to improve health. Of the ten collaborations that have received support from DASH, five are focusing on improving care coordination between medical and community services through enhanced information sharing that helps orient care around the whole person, not just their healthcare needs. As these collaborations moved from planning to implementation, they generated several lessons related to adapting new workflows based on integrated data and developing end user trainings.
When designing a new care coordination workflow, it is important to answer the following questions:
Depending on the environment, care teams may choose to: 1) design workflows around existing technology capabilities or 2) build new technology to fit new workflow needs. It will be important to determine early on the infrastructure and data required to modify workflows. Four of the five DASH collaborations chose to create new data collection forms for their workflows, while one chose to integrate existing data sources into their system. Some common technical tools that were used to coordinate care included shared plan of care documents, automated alerts and notifications sent across systems, and analytics that draw on multiple types of data to predict risk and identify people in need of more intensive services.
Approaches that Work
Below are five promising approaches taken by DASH collaborations—all of which have unique target populations, goals, partners, and resources, yet are collectively generating lessons with respect to multi-sector data sharing, specifically for care coordination.
1. Understand what end users value and gain their buy-in early on.
Before HealthInfoNet set out to develop a new workflow for integrating social determinant data from Community Action Agencies (CAAs) into their state health information exchange, they documented how the CAAs were already collecting and using data for other purposes as part of their existing workflow. For example, they began by focusing on Head Start data that is already collected during the regular enrollment process and explained the clinical value of this data for at-risk pediatric populations. Taking time to understand the staff’s needs and how the new workflow could add value to their existing data rather being burdensome was key to gaining their buy-in. Read more »
2. Ensure community voices are heard during the process development. For Altair Accountable Care Organization (ACO), designing a new care coordination workflow began with understanding the personal preferences of the individuals served as well as those of their care team members. To inform the development of an e-Health infrastructure to coordinate mental and behavioral health services for people with intellectual and developmental disabilities, they gathered input from their clients about who should be on the multi-sector support team, what types of behavioral health events care team members should be alerted about, and how they should be guided to act on those events. Read more »
3. Choose a workflow that minimizes extra steps or makes work processes easier. The Center for Health Care Services, a mental health authority in Bexar County, TX, developed an alert system to notify behavioral health case managers when their clients arrive at emergency departments so that they can intervene earlier and prevent inappropriate hospitalization. By doing so, they automated the manual entry or list management that is often required of their case managers, saving them time to attend to clients. Read more »
4. Communicate roles/responsibilities clearly to all stakeholders. When the White Earth Nation began implementing WECARE, a care coordination database that screens families on the reservation to a wide range of community services, it was imperative that various tribal programs work in partnership when forming a comprehensive care team around the client’s priorities. Having great educators who could effectively discuss the benefits of WECARE, explain how to implement the screening, and work through any challenges with 800 staff from different community programs has been instrumental in building the momentum needed to implement WECARE reservation-wide. Read more »
5. Test and retest your process and allow for edits by people who complete the workflow. When the Parkland Center for Clinical Innovation, a part of Parkland Health and Hospital System, began recruiting participants into a program to share patient data between hospitals and food pantries, the health system originally led the recruitment effort. However, social workers found that providers were more focused on treating patients’ clinical needs and were not responsive to food security screenings. Instead, they decided to recruit participants from food pantries where individuals were more comfortable and accustomed to discussing social needs. Read more »
DASH has learned from these grantees how to design new care coordination workflows when leveraging new data sharing technologies. You can find more in-depth descriptions of these projects in our new issue brief, Coordinated Whole-Person Care that Addresses Social Determinants of Health. Additional resources and updates about sharing data across sectors to improve health are available on our website.
Jenna Frkovich, MPH, is the Communications Associate at the Illinois Public Health Institute, where she leads the development and execution of the communications strategy for Data Across Sectors for Health (DASH), a national initiative of the Robert Wood Johnson Foundation. DASH aims to align health care, public health, and other sectors to systematically compile, share, and use data to understand factors that influence health and develop more effective interventions and policies. Ms. Frkovich works to engage and grow a nationwide network of stakeholders by disseminating lessons learned, stories, and promising practices to help advance the field of multi-sector data sharing.
This article was written by Rene S. Cabral-Daniels, JD, MPH, CEO of Community Care Network of Virginia, Inc., for the July 2017 edition of “Networking News.” Isaiah Dolcee and Eliza Singleton, interns at Community Care Network of Virginia, also contributed to the article. The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center
The impact of health information technology (IT) on the healthcare industry is irrefutable. According to the Department of Health and Human Services’ Office of the National Coordinator (ONC), nearly 90% of office-based physicians have adopted an Electronic Health Record (EHR). Moreover, the percentage of hospitals that provide patients the ability to view, download, and transmit their health records online accelerated from 10% in 2013 to 69% in 2015. Patients are likewise availing themselves of this resource in greater numbers. The ONC reports patient use of information technology to interact with their health care provider, view their personal health information, and track their health and wellness grew significantly between 2013 and 2014. Patient use of one or more of the selected types of IT significantly grew between 2013 and 2014, from 39% to 48%.
The growth in EHR utilization by patients and providers alike likely reflects the many benefits of this technology. Providers value the ability to make medical decisions based on the most current information. As patients may receive care in a variety of healthcare settings, the ability to coordinate the most recent medical information in deciding future treatment is an imperative for providers. EHRs also enhance patient safety, particularly by assuring greater reliability in prescribing pharmaceuticals. Patients requesting their medical records through an EHR can expect to receive complete documentation free from handwritten notes that often prove difficult to read.
The significance of interoperability within health care performance
All of these benefits, as well as the benefit of cost reduction, help communities realize health system performance Triple Aim goals:
Interoperability of EHRs has the ability to enhance each of the Triple Aim benefits. The American Hospital Association asserts interoperability progress will support all three Triple Aim goals, each of which has a positive impact on rural communities.
Enhancing the rural patient experience
The challenge each Triple Aim criterion seeks to address is greater in rural communities; interoperability of electronic health records therefore has a greater advantage in rural communities. The first Triple Aim criterion, patient experience of care, may have a geographic correlation. A study of health center patients found urban patients were more satisfied with their physicians than rural patients. This finding is likely influenced by the challenges faced by rural health providers. Rural American communities face substantial healthcare disadvantages compared to urban and suburban communities. The 40 to 45 percent of people who reside in these areas (approximately 150 million people) report higher levels of chronic conditions and a lower per capita income. These factors, combined with the lack of specialists in rural communities, force many patients to travel to more populated areas to find certain providers. Patient care is often solely provided in the few hospitals in these areas, causing most to be overextended and under supplied.
EHR interoperability can play an important role in enhancing patient satisfaction. The Rural Health IT Corporation asserts improving customer satisfaction in healthcare depends on complete data interoperability. The Bipartisan Policy Center report on the role of health IT in transforming healthcare stated studies indicate high levels of patient satisfaction with online consumer tools. Clearly, patient satisfaction can be positively influenced by EHR interoperability. This finding is particularly relevant to rural communities, as rural patients tend to be less satisfied with their care than their urban counterparts.
Improving the health of rural populations
Improving the health of populations is the second goal of the Triple Aim. Population health management includes the methodologies for providers and payers to contain and lower costs, thereby increasing operational efficiencies such as the ability of providers to streamline care and improve treatment outcomes. One of the main benefits of EHRs is increased access to information. Interoperability of EHRs escalates that benefit by assuring the information is comprehensive and not site-specific, a necessary element in improving population health.
This advantage of comprehensive data review by providers is imperative for rural communities, as residents need to travel greater distances to access different points of the health care delivery system. Healthcare facilities in these areas are small and often provide limited services, thereby requiring rural residents to travel to seek care, particularly tertiary care. Often, due to geographic distance, extreme weather conditions, environmental and climatic barriers, lack of public transportation, and challenging roads, rural residents may be limited/ prohibited from accessing healthcare services in their communities.
Utilizing health IT has benefits for rural providers and patients alike. For example, patients can exchange secure messages, have “e-visits” with their physicians and decrease the hassle of traveling to a specialist. Specialty referrals are also made easier, which is valuable since access to them is often limited.
Reducing costs by increasing interoperability
The third criterion of the Triple Aim involves reducing the per capita cost of healthcare. Every year, providers lose millions of dollars due to the amount of time spent searching for paper medical records. In the past, knowledge of a patient’s medical history relied on physical records held by a primary physician and the memory of a patient, both of which were not completely reliable. These inherent discrepancies in health data are even more prevalent in patients from rural areas since most tend to see multiple physicians. By increasing interoperability, time is used more effectively to solve a patient’s concerns and therefore save money for both the practice and the patient. The Office of the National Coordinator’s Connecting Health and Care for the Nation: A Shared Nation Interoperability Roadmap stated interoperability can help reduce care delivery redundancy and cost by allowing test results to be reused while supporting analyses to pinpoint waste.
The per capita cost of healthcare is significantly reduced with the implementation of interoperable EHRs. This is because patients no longer have to pay for both the cost of administering care as well as complex IT systems that are necessary to access health data in siloed information systems to administer effective care. The West Health Institute calculated the aggregate financial benefit to be projected at $30B saved in the healthcare industry per year. Efforts to lower costs will therefore positively benefit rural communities as their local providers will have access to a full panoply of tests if interoperability of EHRs is complete.
The nation as a whole benefits from true interoperability of electronic health records. When these benefits are viewed through the lens of the Triple Aim, the benefit to rural communities is even greater.
Community Care Network of Virginia, Inc. (CCNV), a community health center-owned and governed provider network, was legally incorporated as a statewide network organization in. CCNV has a long, successful history of providing integrated, network-based services and programs to Virginia’s health centers, including the acquisition and implementation of a centralized practice management system, help desk, and support infrastructure commencing in 1999.
With over two decades of experience as a leader in health policy, finance, and law, Rene Cabral-Daniels has been the CEO of CCNV since 2013. She currently serves on the Healthcare Information and Management Systems Society (HIMSS) North America Board of Directors as well as the National Cooperative of Health Networks (NCHN) Board of Directors.
Isaiah Dolcee is a rising senior at Princeton University, and Eliza Singleton is a rising junior at Elon University.
 Quick Stats by healthit.gov
 The IHI Triple Aim by Institute for Healthcare Improvement
 National Alliance for Health Information Technology. “What Is Interoperability?” 2005. Available online at www.nahit.org
 Achieving Interoperability that Supports Care transformation: A Report of the American Association Interoperability Advisory Group
 Influences on patient satisfaction in healthcare centers: a semi-qualitative study over 5 years by Ruth D. Thornton, Nichole Nurse, Laura Snavely, Stacey Hackett-Zahler, Kenice Frank and Robert A. DiTomasso
 Why Health IT Integration Must Assist Rural Healthcare by HIT Infrastructure
81% dissatisfied with healthcare, Interoperability can help by ruralhealthit.com
 Transforming Health Care: The Role of Health IT (fix citation) pg 23
 Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. “Physician Adoption of Electronic Health Record Systems: United States, 2011.” 2012.
 Healthcare disparities & barriers to healthcare by Stanford eCampus Rural Health
Healthcare Interoperability can reduce costs and improve care by iShare Medical
West Health Institute finds medical device interoperability could save more than $30 billion a year by West Health Institute
This article was written by Joe Wivoda, CIO of the National Rural Health Resource Center/Rural Health Innovations.
The news is filled with stories of health care organizations that have had their data held hostage by hackers. Sometimes they choose to pay the ransom, sometimes they don’t. Regardless, the damage has been done because it is still a breach of Protected Health Information (PHI) and often needs to be reported to the Office of Civil Rights (OCR) as well as local media. Of the 168,000,000 reported breaches in the OCR database, 126,000,000 list hacking or IT as a factor. Clearly we have to take malicious software, known as “malware”, seriously.
What are the threats?
Malware comes in many forms, from computer viruses, worms, Trojan horses, spyware, adware, scareware and who knows what else! Ransomware, where a user is usually tricked into allowing a malicious program or web page encrypt and hold their data files hostage are getting a lot of attention and causing a lot of stress on IT leaders. Many of these attacks are difficult to stop with traditional AntiVirus software. Some use “social engineering” to convince a user to click on the malware and enable it.
“Warning! Your PC is infected. Click here to clean your PC NOW!”
This is not a virus warning, this is likely a malware attack, perhaps even ransomware!
How do you protect yourself?
Of course every computer on your network needs antivirus, but it is much more than that. In an environment with many computers, which includes all rural hospitals and many other rural providers, it can be difficult to manage all of the updates without central management of the antivirus software. Further, antivirus software will only stop so many threats. Some will get through even with a well-managed antivirus package running, it just depends on how well the users are trained and aware that they are targets!
That message that says “your computer is infected, click here to repair it” might as well say “feel free to click this and we will charge you money to get your data back” because that is one of the likely results. All organizations, including rural health care facilities, need to protect themselves in several ways:
The best intentions and efforts to protect your facility do not mean you won’t get caught by one of these nasty programs! Ransomware in particular seems to be showing up everywhere, and you have to be ready to respond when it does happen (see that mention of “incident response team”? That’s important!)
What if you are a victim of ransomware?
Many rural hospitals and clinics have been hit by ransomware in the last year. CMS and the Office of Civil Rights (OCR) have determined that if Protected Health Information (PHI) has been encrypted then it has been “acquired”. That is a key term! “Acquired” means that it is considered a data breach under HIPAA and needs to be reported.
Do you pay the ransom or not? Either way you will need to report the data breach and offer identity theft protection services to the patients affected, so it becomes a question of cost-benefit analysis. If the ransom is low enough, it may be less expensive than doing a full restore of the data (you do have good, well-tested backups, right?). Even if you pay there is no guarantee that the data-kidnapper will release the data. Now that you have agreed to pay, why wouldn’t you pay a little more? For these reasons most experts feel you should not pay. Estimate what the costs in time, money, patient safety, and other factors are before making the decision to pay the ransom or restore the data.
Rural IT leaders and others need to be aware of the risks that malware presents and understand how to mitigate those risks. The HIPAA regulations provide good practices, like risk assessment and incident response teams, that will protect your network but they need to be put in place. It is very hard in a rural setting to get everything done, particularly when most CAHs and RHCs have limited staff. It is necessary in most cases to use outside experts, at least to some extent. Talk about these threats with your end users and leaders, because they are the front lines in safeguarding your precious PHI!
Fact Sheet: Ransomware and HIPAA
Health IT Playbook
The National Rural Health Resource Center (The Center) is a nonprofit organization dedicated to sustaining and improving health care in rural communities. Rural Health Innovations, LLC is a subsidiary of the National Rural Health Resource Center.