Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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4 Leveraging Data and Digital Tools
4 Leveraging Data and Digital Tools
Pages 85-108
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From page 85... ...
By leveraging data and technology, the health care sector and its s cial care partners have an opportunity to improve the efficiency, ef o fectiveness, and sustainability of efforts that address health-related social needs as a regular component of health care delivery (Dameff et al., 2019)
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From page 86... ...
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 20091 stimulated unprecedented growth in the adoption of electronic health records (EHRs)
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From page 87... ...
. W ONC was tasked by the 21st Century Cures Act of 20162 to develop a trusted exchange framework to significantly improve data sharing and to administer penalties to any entity engaged in data-blocking practices, such as vendors requesting excessive fees to access health data (Rucker, 2018)
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From page 88... ...
This creation of a digitized health care system is associated with a growing set of opportunities to leverage data and digital tools that can not only improve health care, but also support efforts aimed at identifying social risks and addressing social needs along the spectrum described in Chapter 2. As other sectors, particularly those involved with the consumer experience (e.g., retail, banking, and entertainment)
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From page 89... ...
. Beyond the data and their application are new digital tools that are only just beginning to be used to address social risks and social needs.
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From page 90... ...
. These lessons include from the outset requiring non-proprietary standards to enable TABLE 4-1 Potential Sources of Data and Digital Tools to Support the Integration of Social Care into Health Care Social Care Integration Spectrum Potential Data Sources Structured and unstructured Social data from determinants Retail and Health care electronic data from purchasing claims health record surveys data Awareness X X X X Adjustment X X X X Assistance X X X X Alignment X X X X Advocacy X X X X Social Care Integration Spectrum Potential Applied Analytic and Technology Tools Natural language processing of Point-of-care Predictive unstructured Geocoding/ decision analytics data hotspotting support Awareness X X X Adjustment X X X Assistance X X X X Alignment X X Advocacy X X X X
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From page 91... ...
Awareness Data and digital tools are instrumental to increasing the health care sector's awareness of social risks. The tools and processes needed to facilitate the systematic assessment of individual-level, health-related social needs is an area of active development.
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From page 92... ...
Part of building screening capabilities into the clinical workflow includes the integration of data on health-related social risks into the EHR, which already houses important medical information. Federally qualified health centers (FQHCs)
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From page 93... ...
Limitations: Limitations: Subject to "ecological Can use only social determinants fallacy": Some patients in this of health data that are available neighborhood may not be at (practitioner has less control over higher risk. how data are collected)
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From page 94... ...
It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020)
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From page 95... ...
Organizations also are using big data from a wide range of sources and sectors to paint a detailed picture of social risks and needs at the population level in order to inform place-based community improvement strategies as well as individual interventions. Various tools are in use to integrate neighborhood-level data into EHRs to help inform patient-level interventions.
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From page 96... ...
In making such adjustments, doctors and other clinicians need patients' social risk information to inform their diagnostic and care plan. As an example, people who are homeless may have their diabetic therapeutic regimens hampered by the addition of nsulin i b ecause they do not have an easy opportunity to store insulin.
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From page 97... ...
In the latter scenario, the health sector will also need to consider what data systems can be used in partnering with social care providers. North Carolina, through a public–private partnership, is establishing a shared utility for plans and providers to use across all populations and payers, including Medicare, Medicaid, and commercially insured and uninsured populations, to assist in making referrals to social service providers; one purpose is to avoid the need for each plan and provider to establish a separate referral platform.
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From page 98... ...
including asset maps of local social services and geocoded data population health needs are needed to connect people with social needs with the appropriate resources. Such work will require the sharing of health and social care information across a wide array of community partners and with the consumer.
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From page 99... ...
Accountable Health Communities aims to: • Conduct systematic health-related social needs screenings of patients in partner clinics • Refer patients to community services that may be able to address the identified social needs • Navigate Medicare and Medicaid beneficiaries to community service pro viders in their communities • Align community partners to optimize capacity to address health-related social needs. MyHealth is using a mobile screening process that sends a text message with a link to a screening that will identify health-related social needs and provide the patient a list of customized resources to help address the identified needs.
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From page 100... ...
Some of the key challenges are: • Access to sufficient social services data and digital infra structure. HITECH provided billions of dollars to support the Box 4-5 Advocacy Approach: AIR Louisville "Cross-sector partnerships benefit public health by leveraging ideas, resources, and expertise from a wide range of partners.
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From page 101... ...
The social services sector did not benefit from these funds, and in most cases the IT infrastructure of commu nity-based organizations that provide services is incapable of meeting the data standards, cybersecurity, and other technologi cal needs to build a robust health care and social care data sharing infrastructure (Amarasingham et al., 2018)
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From page 102... ...
Though people working in the health care sector have become more accus tomed to and comfortable with data and technology (as a result of the increased utilization of EHRs) , the social care sector lags be hind in these capabilities and will require adequate training and peer champions to ease the transition (Wyman and SeaChange Capital Partners, 2017)
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From page 103... ...
• Billions of dollars in federal resources spurred the digitization of health care through the widespread adoption of the electronic health records and interoperability. Social care has not benefited from the same resources and policy attention as has the health care sector, and it lags far behind in digitization.
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From page 104... ...
• Interoperability and data sharing between health care and social care are hampered by the lack of infrastructure, data standards, and modern technology architecture shared between and among organizations. • With an increasing number of stakeholders sharing protected health information in order to coordinate care, data privacy and security remain challenging elements to manage.
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From page 105... ...
2019b. Medicare and Medicaid programs; Patient Protection and Affordable Care Act; interoperability and patient access for Medicare Advantage Organization and Medicaid managed care plans, state Medicaid agencies, CHIP agencies and CHIP managed care entities, issuers of qualified health plans in the federally-facilitated exchanges and health care providers.
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From page 106... ...
2018. Incorporat ing social determinants of health in electronic health records: A qualitative study of perspectives on current practices among top vendors.
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From page 107... ...
2018. As sessing the capacity of social determinants of health data to augment predictive models identifying patients in need of wraparound social services.
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From page 108... ...
2014. Big data analytics in healthcare: Promise and potential.
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