A century ago, X-rays transformed medicine forever. For the first time, doctors could see inside the human body, without invasive surgeries. The technology was so revolutionary that in the last 100 years, radiology departments have become a staple of modern hospitals, routinely used across medical disciplines.
Today, new technology is once again radically reshaping medicine: artificial intelligence (AI). Like the X-ray before it, AI gives clinicians the ability to see the unseen and has transformative applications across medical disciplines. As its impact grows clear, it’s time for health systems to establish departments dedicated to clinical AI, much as they did for radiology 100 years ago.
Radiology, in fact, was one of the earliest use cases for AI in medicine today. Machine learning algorithms trained on medical images can learn to detect tumors and other malignancies that are, in many cases, too subtle for even a trained radiologist to perceive. That’s not to suggest that AI will replace radiologists, but rather that it can be a powerful tool for aiding them in the detection of potential illness — much like an X-ray or a CT scan.
AI’s potential is not limited to radiology, however. Depending on the data it is trained on, AI can predict a wide range of medical outcomes, from sepsis and heart failure to depression and opioid abuse. As more of patients’ medical data is stored in the EHR, and as these EHR systems become more interconnected across health systems, AI will only become more sensitive and accurate at predicting a patient’s risk of deteriorating.
However, AI is even more powerful as a predictive tool when it looks beyond the clinical data in the EHR. In fact, research suggests that clinical care factors contribute to only 16% of health outcomes. The other 84% are determined by socioeconomic factors, health behaviors, and the physical environment. To account for these external factors, clinical AI needs external data.
Fortunately, data on social determinants of health (SDOH) is widely available. Government agencies including the Census Bureau, EPA, HUD, DOT and USDA keep detailed data on relevant risk factors at the level of individual US Census tracts. For example, this data can show which patients may have difficulty accessing transportation to their appointments, which patients live in a food desert, or which patients are exposed to high levels of air pollution.
These external risk factors can be connected to individual patients using only their address. With a more comprehensive picture of patient risk, Clinical AI can make more accurate predictions of patient outcomes. In fact, a recent study found that a machine learning model could accurately predict inpatient and emergency department utilization using only SDOH data.
Doctors rarely have insight on these external forces. More often than not, physicians are with patients for under 15 minutes at a time, and patients may not realize their external circumstances are relevant to their health. But, like medical imaging, AI has the power to make the invisible visible for doctors, surfacing external risk factors they would otherwise miss.
But AI can do more than predict risk. With a complete view of patient risk factors, prescriptive AI tools can recommend interventions that address these risk factors, tapping the latest clinical research. This sets AI apart from traditional predictive analytics, which leaves clinicians with the burden of determining how to reduce a patient’s risk. Ultimately, the doctor is still responsible for setting the care plan, but AI can suggest actions they may not otherwise have considered.
By reducing the cognitive load on clinicians, AI can address another major problem in healthcare: burnout. Among professions, physicians have one of the highest suicide rates, and by 2025, the U.S. The Department of Health and Human Services predicts that there will be a shortage of nearly 90,000 physicians across the nation, driven by burnout. The problem is real, and the pandemic has only worsened its impact.
Implementing clinical AI can play an essential role in reducing burnout within hospitals. Studies show burnout is largely attributed to bureaucratic tasks and EHRs combined, and that physicians spend twice as much time on EHRs and desk work than with patients. Clinical AI can ease the burden of these administrative tasks so physicians can spend more time face-to-face with their patients.
For all its promise, it’s important to recognize that AI is as complex a tool as any radiological instrument. Healthcare organizations can’t just install the software and expect results. There are several implementation considerations that, if poorly executed, can doom AI’s success. This is where clinical AI departments can and should play a role.
The first area where clinical AI departments should focus on is the data. AI is only as good as the data that goes into it. Ultimately, the data used to train machine learning models should be relevant and representative of the patient population it serves. Failing to do so can limit AI’s accuracy and usefulness, or worse, introduce bias. Any bias in the training data, including pre-existing disparities in health outcomes, will be reflected in the output of the AI.
Every hospital’s use of clinical AI will be different, and hospitals will need to deeply consider their patient population and make sure that they have the resources to tailor vendor solutions accordingly. Without the right resources and organizational strategies, clinical AI adoption will come with the same frustration and disillusionment that has come to be associated with EHRs.
Misconceptions about AI are a common hurdle that can foster resistance and misuse. No matter what science fiction tells us, AI will never replace a clinician’s judgment. Rather, AI should be seen as a clinical decision support tool, much like radiology or laboratory tests. For a successful AI implementation, it’s important to have internal champions who can build trust and train staff on proper use. Clinical AI departments can play an outsized role in leading this cultural shift.
Finally, coordination is the bedrock of quality care, and AI is no exception. Clinical AI departments can foster collaboration across departments to action AI insights and treat the whole patient. Doing so can promote a shift from reactive to preventive care, mobilizing ambulatory, and community health resources to prevent avoidable hospitalizations.
With the promise of new vaccines, the end of the pandemic is in sight. Hospitals will soon face a historic opportunity to reshape their practices to recover from the pandemic’s financial devastation and deliver better care in the future. Clinical AI will be a powerful tool through this transition, helping hospitals to get ahead of avoidable utilization, streamline workflows, and improve the quality of care.
A century ago, few would have guessed that X-rays would be the basis for an essential department within hospitals. Today, AI is leading a new revolution in medicine, and hospitals would be remiss to be left behind.
About John Frownfelter, MD, FACP
John is an internist and physician executive in Health Information Technology and is currently leading Jvion’s clinical strategy as their Chief Medical Information Officer. With 20 years’ leadership experience he has a broad range of expertise in systems management, care transformation and health information systems. Dr. Frownfelter has held a number of medical and medical informatics leadership positions over nearly two decades, highlighted by his role as Chief Medical Information Officer for Inpatient services at Henry Ford Health System and Chief Medical Information Officer for UnityPoint Health where he led clinical IT strategy and launched the analytics programs.
Since 2015, Dr. Frownfelter has been bringing his expertise to healthcare through health IT advising to both industry and health systems. His work with Jvion has enhanced their clinical offering and their implementation effectiveness. Dr. Frownfelter has also held professorships at St. George’s University and Wayne State schools of medicine, and the University of Detroit Mercy Physician Assistant School. Dr. Frownfelter received his MD from Wayne State University School of Medicine.
– Healthify and CareSource are teaming up to
build a statewide network of community-based organizations in Ohio.
– This new network will provide social services
to CareSource’s members throughout the state of Ohio with referrals
to address Social Determinants of Health (SDoH).
CareSource, a nonprofit multi-state managed care plan has partnered with Healthify to build a statewide network of community-based organizations in Ohio. The new network will provide social services to CareSource’s members throughout the state with referrals to address Social Determinants of Health (SDoH). This new collaboration will expand upon the existing CareSource Life Services program and Healthify OH social services network.
The network will be made up of community organizations that
provide a range of services that address SDOH such as food insecurity,
lack of transportation, unemployment, inadequate housing, and financial
instability. CareSource will also use Healthify’s population
analysis modeling to identify social risk across OH and target
hard-to-reach members to ensure they are connected to critical services.
Identifying Social Risk Across OH to Target Hard-to-Reach
In addition to the statewide network, CareSource will use
Healthify’s population analysis modeling to identify social risk across OH and
target hard-to-reach members to ensure they are connected to critical services.
By layering this on top of clinical and cost data, CareSource can meaningfully
improve member engagement among membership while tracking their long-term
outcomes. Please visit the following link to learn more and join the statewide
network to better coordinate care between healthcare and social services.
Why It Matters
“Healthify is committed to helping vulnerable populations get the social services they need to live their best lives,” said Manik Bhat, cofounder and CEO of Healthify. “I grew up in Ohio and it’s great to partner with like-minded organizations like CareSource that are dedicated to helping members with unmet social needs using strong local partnerships. We are excited that the partnerships established across the state will provide the infrastructure to also support COVID-19 recovery efforts.
Connected Communities of Care Definition: An innovative method for effective population health management using social determinants of health. A way to streamline effective coordination between medical, government, and community-based organizations.
We ask this type of question every day. For example, we may ask― “Is this product that I purchased making a difference?” or “Is this advanced training that I completed making a difference?” Implicit in this common question is the expectation that because we have made an investment in something to achieve a result, the result should be better or more improved than the pre-investment state. So too with a Connected Community of Care (CCC). As I have discussed in previous blogs, establishing a CCC requires a substantial investment in both time and money.
Therefore, it is only natural to ask― “Is this CCC making a difference, and how would I know?” Unfortunately, most CCCs are established with very little forethought given to this exact question. While we expect the CCC will help community residents improve their health and well-being, how will we know conclusively that this has happened? How will we demonstrate its impact to a potential partner or― more importantly― a funder? This is where data, measurement, and evaluation come into play. For most people, these three words cause anxiety levels to immediately rise. But this doesn’t need to be the case; a little planning and forethought can go a long way to assuaging one’s anxiety when asked the question, “Is your CCC making a difference?”
Before we think about what data we will need to answer this question or how we will collect it, we first need to establish what we mean by “making a difference”. Understand, there is no one correct answer to this question. What may constitute a positive difference or impact for one organization may be much different for another, even a similar organization. Many factors contribute to the final answer and each is usually organization-, ecosystem- and situation-specific.
In practice, there are many ways to define making a difference. First, we can look at quantitative or numeric information to make this determination. Are we providing more nutritious meals to indigent residents? Is the number of inappropriate Emergency Department visits declining or, conversely, is the number of residents having visits with a primary care provider increasing?
All of these effects can be counted and judged against some predefined goal (more on this later). Second, we can assess making a difference by asking the people that are being touched by the CCC. Through surveys or brief interviews, community residents can tell you in their own words what impact, if any, the CCC has on their lives.
While this qualitative (non-numeric) information can often be more informative than simple quantitative information because it represents the voice of the individual, to answer the question of whether your CCC is making a difference, you will also still likely need to establish numeric goals. A third way to assess whether your CCC is making a difference is indirect via the financial and non-financial opportunities that arise as a result of having a CCC versus not having one.
For example, having a CCC may make it much easier to perform contact tracing among vulnerable populations during a pandemic like COVID-19. Having a CCC may also enable a healthcare system or a community-based organization (CBO) to apply for a grant that it otherwise might not be competitively positioned to do if it did not have an integrated system of healthcare and social service providers such as a CCC.
Regardless of the approach to define making a difference, the importance of planning for 1) what things will be measured to generate the necessary data, 2) how and when that measurement will take place, and 3) how the resulting data will be analyzed and evaluated, cannot be underestimated. Similarly, these decisions cannot be put off until a later date as is often seen with start-ups, including CCCs. While it is natural to want to focus on the more immediate needs associated with launching a CCC, deferring the question of how we will know if the entity is making a difference can prove costly, both from an operational and financial perspective.
At the Parkland Center for Clinical Innovation (PCCI) we encourage those planning a CCC to devote the necessary time early on to setting performance goals and objectives and determining how and when they will be measured and evaluated. While it is important to explicitly build this step into your CCC planning phase, the scope and scale of the work does not have to be extensive.
In fact, at PCCI we strongly encourage CCCs to start small with a limited set of goals, objectives, and requisite measures and then scale up as the CCC grows and matures. This approach has the dual benefit of providing essential core information early on while also not overwhelming the CCC staff with data collection activities that may be a distraction from more pressing, day-to-day activities.
Based on this author’s work with literally hundreds of healthcare and social service provider organizations, experience suggests that most entities (both new and established organizations) do best if they initially establish 1) a limited number of goals― one or two at most, 2) a similar number of objectives to achieve each goal, and 3) no more than three to four performance measures to support each goal.
While this may seem like an insufficient number of performance elements in today’s data-obsessed world, remember that you can always add additional goals, objectives, and measures as your expertise and comfort levels allow and as your CCC evolves.
Even more important than the numbers, however, it is essential to get the selection of the goals, objectives, and performance measures correct. Each of these three performance elements plays an essential role in helping you answer the question “Is my CCC making a difference?”
Your goals focus on the long-term― what do you ultimately want to happen, while your objectives are the short-term accomplishments that help you achieve your goals. In both cases, you must be sure that what you are expecting is both realistic and appropriate for your CCC’s stage of development. For example, assuming a newly established CCC will reduce ED utilization in its first year or two may not be reasonable and may lead to frustration and disillusionment if the goal is not achieved. If you select a BHAG (Big Harry Audacious Goal), you must allow sufficient time (and then some) for all the necessary pieces to come together.
The rule of thumb for large-scale demonstration projects such as launching a CCC is that they 1) take (much) longer than expected, 2) cost more than budgeted, and 3) generally initially deliver less than expected. These facts should not dissuade you from your journey, but rather help you keep things in perspective as the project evolves to one that in the long-term is viewed as valuable in achieving your goals.
If getting the goals and objectives correct is important, then selecting the correct performance measures and designing a feasible measurement plan is paramount. Here again, quality is more important than quantity. A few well-chosen performance measures, implemented correctly, will generate far more in the way of actionable data than a plethora of randomly selected measures.
To optimize your ability to assess if your CCC is making a difference, your performance measures should be collected at regular intervals following the launch of the CCC. While many established programs collect, analyze, and evaluate performance data on a quarterly basis, for fledgling CCCs, PCCI recommends this data be collected monthly for at least the first one to two years or until the CCC reaches a stable level of operations.
While monthly data collection requires a little more work, the more frequent feedback allows you to make the necessary program or operational modifications more quickly and with fewer disruptions than that afforded with quarterly feedback. If measurement and evaluation is an area where you don’t have a lot of experience, reach out to others that do, especially individuals and organizations such as PCCI that have experience assessing performance in large-scale, multi-sector collaborative projects.
While we all hope that the answer to the question “Is my CCC making a difference” is yes, the answer may be no early on in the life of a CCC. As disheartening as this news may be, it’s important to not give up but to look critically at what is working and what is not and make adjustments where necessary.
Usually, this examination does not necessitate a complete “reboot” of the CCC initiative, but rather requires making minor changes accompanied by paying closer attention to the CCC’s operations. Seek feedback from your staff and those you serve and be open to change, where change is warranted. As indicated, these types of projects take a lot longer to reach fruition than most people believe, but with a solid plan, patience, and flexibility, you will be able to answer, “Yes, my CCC is definitively making a difference in the lives of the community residents it serves.”
As we re-examine the healthcare system in the wake of the pandemic, we are continually identifying opportunities to rebuild parts of the system to new and improved specifications. One critical facet is digital health, where we continue to struggle with what should really be table stakes: the ability to integrate data from disparate organizations and systems into a unified view of the whole person and take action.
During the height of the pandemic, telehealth made it possible to deliver care that was personal yet socially responsible. As a direct benefit, the use of digital health tools on both the clinical and consumer side picked up a tremendous and timely head of steam. But what will become of these innovations once we make our eventual return to normal?
Today, many healthcare consumers can talk to a therapist or a counselor through text, monitor glucose levels through a diabetes app and meet with their primary care provider over videoconference. The challenge is that a lot of this patient data is still landlocked in electronic medical record (EMR) systems that do not communicate or coordinate with one another or with payer systems or consumer apps.
The sustainability and applicability of digital health tools are still often questioned despite reports that investors had poured a staggering $5.4 billion into the digital health industry just by June of this year (Rock Health). The key to success is to seamlessly connect these tools with legacy systems and siloed access points to create a truly integrated healthcare continuum. Jumping between systems, each holding only its own limited slice of patient data, and then trying to take action on this data, is neither scalable nor sustainable.
Healthcare consumers have long looked at the seamless nature of apps in other areas of life and asked for a similar level of accessibility and on-demand, high-quality information from the healthcare system. Accenture found in its 2020 Digital Health Consumer Survey that although consumers are interested in virtual services, a cumbersome digital experience turns them off. Additionally, the survey found that concerns over privacy, security, and trust remain, along with difficulty integrating new tools and services into day-to-day clinical workflows.
The good news is that the Office of the National Coordinator (ONC) has made several major data exchange rulings this year that will push providers and payer organizations to update legacy systems to make consumer health data more assessable and sharable across all parties, all for the benefit of the patient.
The Stage is Set: Healthcare Leaders Must Act, Now
The incredible investments in the industry, increasing consumer demand, and data sharing regulation show that healthcare connectivity and interoperability have never been more essential. To ensure that the digital health transformation and remote healthcare delivery models progress optimally beyond the current environment, we must support healthcare organizations in evolving their infrastructure and software capabilities to support this kind of strategy. This is where health tech has a critical role to play in building flexible pipes to connect the full spectrum of repositories and players, including doctors, specialists, nurses, care managers, health coaches, caregivers, and, of course, the healthcare consumer.
What does this look like in practice? Imagine if an unusually high heart rate warning was triggered by a patient’s smartwatch, which then alerted the patient’s care manager to check-in. With a comprehensive view of that patient, the care manager calls the patient to assess if they are okay and learns the patient ran out of their prescription which helps lower the heart rate. Knowing that patient does not have access to a car and is afraid to take public transportation due to COVID-19, the care manager then sets up a prescription delivery straight to that patient’s doorstep.
Through this process, digital health tools, patient data, and social determinants of health all came together to equip that care manager to deliver personalized care to the patient. Sound like sci-fi? This innovative approach can actually be a reality for organizations that manage large populations. The key is educating more healthcare leaders about the benefits of a comprehensive healthcare platform that improves health outcomes, lowers costs and increases member satisfaction.
This all starts with a platform that coordinates and aggregates the siloes of data and tools (clinical and digital) into a central hub. that allows providers to oversee the access points, plans, and processes in a patient’s healthcare journey without the task of building or maintaining the system themselves. This can be a game-changer in the way we assess and treat patients and help the industry to fully realize the dream of truly comprehensive, coordinated care.
About Adam Sabloff
Adam Sabloff is the founder and CEO of VirtualHealth, provider of HELIOS, the leading SaaS care management platform, serving more than 9 million members across the U.S. Prior to VirtualHealth, Sabloff served as VP of Development and Chief Marketing Officer for Midtown Equities, a $7 billion real estate, media and aviation conglomerate, where he also oversaw its technology subsidiary, Midtown Technologies.
As we close out the year, we asked several healthcare executives to share their predictions and trends for 2021.
Kimberly Powell, Vice President & General Manager, NVIDIA Healthcare
Federated Learning: The clinical community will increase their use of federated learning approaches to build robust AI models across various institutions, geographies, patient demographics, and medical scanners. The sensitivity and selectivity of these models are outperforming AI models built at a single institution, even when there is copious data to train with. As an added bonus, researchers can collaborate on AI model creation without sharing confidential patient information. Federated learning is also beneficial for building AI models for areas where data is scarce, such as for pediatrics and rare diseases.
AI-Driven Drug Discovery: The COVID-19 pandemic has put a spotlight on drug discovery, which encompasses microscopic viewing of molecules and proteins, sorting through millions of chemical structures, in-silico methods for screening, protein-ligand interactions, genomic analysis, and assimilating data from structured and unstructured sources. Drug development typically takes over 10 years, however, in the wake of COVID, pharmaceutical companies, biotechs, and researchers realize that acceleration of traditional methods is paramount. Newly created AI-powered discovery labs with GPU-accelerated instruments and AI models will expedite time to insight — creating a computing time machine.
Smart Hospitals: The need for smart hospitals has never been more urgent. Similar to the experience at home, smart speakers and smart cameras help automate and inform activities. The technology, when used in hospitals, will help scale the work of nurses on the front lines, increase operational efficiency, and provide virtual patient monitoring to predict and prevent adverse patient events.
Omri Shor, CEO of Medisafe
Healthcare policy: Expect to see more moves on prescription drug prices, either through a collaborative effort among pharma groups or through importation efforts. Pre-existing conditions will still be covered for the 135 million Americans with pre-existing conditions.
The Biden administration has made this a central element of this platform, so coverage will remain for those covered under ACA. Look for expansion or revisions of the current ACA to be proposed, but stalled in Congress, so existing law will remain largely unchanged. Early feedback indicates the Supreme Court is unlikely to strike down the law entirely, providing relief to many during a pandemic.
Brent D. Lang, Chairman & Chief Executive Officer, Vocera Communications
The safety and well-being of healthcare workers will be a top priority in 2021. While there are promising headlines about coronavirus vaccines, we can be sure that nurses, doctors, and other care team members will still be on the frontlines fighting COVID-19 for many more months. We must focus on protecting and connecting these essential workers now and beyond the pandemic.
Modernized PPE Standards Clinicians should not risk contamination to communicate with colleagues. Yet, this simple act can be risky without the right tools. To minimize exposure to infectious diseases, more hospitals will rethink personal protective equipment (PPE) and modernize standards to include hands-free communication technology. In addition to protecting people, hands-free communication can save valuable time and resources. Every time a nurse must leave an isolation room to answer a call, ask a question, or get supplies, he or she must remove PPE and don a fresh set to re-enter. With voice-controlled devices worn under PPE, the nurse can communicate without disrupting care or leaving the patient’s bedside.
Voice-controlled solutions can also help new or reassigned care team members who are unfamiliar with personnel, processes, or the location of supplies. Instead of worrying about knowing names or numbers, they can use simple voice commands to connect to the right person, group, or information quickly and safely. In addition to simplifying clinical workflows, an intelligent communication system can streamline operational efficiencies, improve triage and throughput, and increase capacity, which is all essential to hospitals seeking ways to recover from 2020 losses and accelerate growth.
Michael Byczkowski, Global Vice President, Head of Healthcare Industry at SAP,
New, targeted healthcare networks will collaborate and innovate to improve patient outcomes.
We will see many more touchpoints between different entities ranging from healthcare providers and life sciences companies to technology providers and other suppliers, fostering a sense of community within the healthcare industry. More organizations will collaborate based on existing data assets, perform analysis jointly, and begin adding innovative, data-driven software enhancements. With these networks positively influencing the efficacy of treatments while automatically managing adherence to local laws and regulations regarding data use and privacy, they are paving the way for software-defined healthcare.
Smart hospitals will create actionable insights for the entire organization out of existing data and information.
Medical records as well as operational data within a hospital will continue to be digitized and will be combined with experience data, third-party information, and data from non-traditional sources such as wearables and other Internet of Things devices. Hospitals that have embraced digital are leveraging their data to automate tasks and processes as well as enable decision support for their medical and administrative staff. In the near future, hospitals could add intelligence into their enterprise environments so they can use data to improve internal operations and reduce overhead.
Curt Medeiros, President and Chief Operating Officer of Ontrak
As health care costs continue to rise dramatically given the pandemic and its projected aftermath, I see a growing and critical sophistication in healthcare analytics taking root more broadly than ever before. Effective value-based care and network management depend on the ability of health plans and providers to understand what works, why, and where best to allocate resources to improve outcomes and lower costs. Tied to the need for better analytics, I see a tipping point approaching for finally achieving better data security and interoperability. Without the ability to securely share data, our industry is trying to solve the world’s health challenges with one hand tied behind our backs.
G. Cameron Deemer, President, DrFirst
Like many business issues, the question of whether to use single-vendor solutions or a best-of-breed approach swings back and forth in the healthcare space over time. Looking forward, the pace of technology change is likely to swing the pendulum to a new model: systems that are supplemental to the existing core platform. As healthcare IT matures, it’s often not a question of ‘can my vendor provide this?’ but ‘can my vendor provide this in the way I need it to maximize my business processes and revenues?
This will be more clear with an example: An EHR may provide a medication history function, for instance, but does it include every source of medication history available? Does it provide a medication history that is easily understood and acted upon by the provider? Does it provide a medication history that works properly with all downstream functions in the EHR? When a provider first experiences medication history during a patient encounter, it seems like magic.
After a short time, the magic fades to irritation as the incompleteness of the solution becomes more obvious. Much of the newer healthcare technologies suffer this same incompleteness. Supplementing the underlying system’s capabilities with a strongly integrated third-party system is increasingly going to be the strategy of choice for providers.
Angie Franks, CEO of Central Logic
In 2021, we will see more health systems moving towards the goal of truly operating as one system of care. The pandemic has demonstrated in the starkest terms how crucial it is for health systems to have real-time visibility into available beds, providers, transport, and scarce resources such as ventilators and drugs, so patients with COVID-19 can receive the critical care they need without delay. The importance of fully aligning as a single integrated system that seamlessly shares data and resources with a centralized, real-time view of operations is a lesson that will resonate with many health systems.
Expect in 2021 for health systems to enhance their ability to orchestrate and navigate patient transitions across their facilities and through the continuum of care, including post-acute care. Ultimately, this efficient care access across all phases of care will help healthcare organizations regain revenue lost during the historic drop in elective care in 2020 due to COVID-19.
In addition to elevating revenue capture, improving system-wide orchestration and navigation will increase health systems’ bed availability and access for incoming patients, create more time for clinicians to operate at the top of their license, and reduce system leakage. This focus on creating an ‘operating as one’ mindset will not only help health systems recover from 2020 losses, it will foster sustainable and long-term growth in 2021 and well into the future.
John Danaher, MD, President, Global Clinical Solutions, Elsevier
COVID-19 has brought renewed attention to healthcare inequities in the U.S., with the disproportionate impact on people of color and minority populations. It’s no secret that there are indicative factors, such as socioeconomic level, education and literacy levels, and physical environments, that influence a patient’s health status. Understanding these social determinants of health (SDOH) better and unlocking this data on a wider scale is critical to the future of medicine as it allows us to connect vulnerable populations with interventions and services that can help improve treatment decisions and health outcomes. In 2021, I expect the health informatics industry to take a larger interest in developing technologies that provide these kinds of in-depth population health insights.
Jay Desai, CEO and co-founder of PatientPing
2021 will see an acceleration of care coordination across the continuum fueled by the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule’s e-notifications Condition of Participation (CoP), which goes into effect on May 1, 2021. The CoP requires all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. Due to silos, both inside and outside of a provider’s organization, providers miss opportunities to best treat their patients simply due to lack of information on patients and their care events.
This especially impacts the most vulnerable patients, those that suffer from chronic conditions, comorbidities or mental illness, or patients with health disparities due to economic disadvantage or racial inequity. COVID-19 exacerbated the impact on these vulnerable populations. To solve for this, healthcare providers and organizations will continue to assess their care coordination strategies and expand their patient data interoperability initiatives in 2021, including becoming compliant with the e-notifications Condition of Participation.
Kuldeep Singh Rajput, CEO and founder of Biofourmis
Driven by CMS’ Acute Hospital at Home program announced in November 2020, we will begin to see more health systems delivering hospital-level care in the comfort of the patient’s home–supported by technologies such as clinical-grade wearables, remote patient monitoring, and artificial intelligence-based predictive analytics and machine learning.
A randomized controlled trial by Brigham Health published in Annals of Internal Medicine earlier this year demonstrated that when compared with usual hospital care, Home Hospital programs can reduce rehospitalizations by 70% while decreasing costs by nearly 40%. Other advantages of home hospital programs include a reduction in hospital-based staffing needs, increased capacity for those patients who do need inpatient care, decreased exposure to COVID-19 and other viruses such as influenza for patients and healthcare professionals, and improved patient and family member experience.
Jake Pyles, CEO, CipherHealth
The disappearance of the hospital monopoly will give rise to a new loyalty push
Healthcare consumerism was on the rise ahead of the pandemic, but the explosion of telehealth in 2020 has effectively eliminated the geographical constraints that moored patient populations to their local hospitals and providers. The fallout has come in the form of widespread network leakage and lost revenue. By October, in fact, revenue for hospitals in the U.S. was down 9.2% year-over-year. Able to select providers from the comfort of home and with an ever-increasing amount of personal health data at their convenience through the growing use of consumer-grade wearable devices, patients are more incentivized in 2021 to choose the provider that works for them.
After the pandemic fades, we’ll see some retrenchment from telehealth, but it will remain a mainstream care delivery model for large swaths of the population. In fact, post-pandemic, we believe telehealth will standardize and constitute a full 30% to 40% of interactions.
That means that to compete, as well as to begin to recover lost revenue, hospitals need to go beyond offering the same virtual health convenience as their competitors – Livango and Teladoc should have been a shot across the bow for every health system in 2020. Moreover, hospitals need to become marketing organizations. Like any for-profit brand, hospitals need to devote significant resources to building loyalty but have traditionally eschewed many of the cutting-edge marketing techniques used in other industries. Engagement and personalization at every step of the patient journey will be core to those efforts.
Marc Probst, former Intermountain Health System CIO, Advisor for SR Health by Solutionreach
Healthcare will fix what it’s lacking most–communication.
Because every patient and their health is unique, when it comes to patient care, decisions need to be customized to their specific situation and environment, yet done in a timely fashion. In my two decades at one of the most innovative health systems in the U.S., communication, both across teams and with patients continuously has been less than optimal. I believe we will finally address both the interpersonal and interface communication issues that organizations have faced since the digitization of healthcare.”
Rich Miller, Chief Strategy Officer, Qgenda
2021 – The year of reforming healthcare: We’ve been looking at ways to ease healthcare burdens for patients for so long that we haven’t realized the onus we’ve put on providers in doing so. Adding to that burden, in 2020 we had to throw out all of our playbooks and become masters of being reactive. Now, it’s time to think through the lessons learned and think through how to be proactive. I believe provider-based data will allow us to reformulate our priorities and processes. By analyzing providers’ biggest pain points in real-time, we can evaporate the workflow and financial troubles that have been bothering organizations while also relieving providers of their biggest problems.”
Robert Hanscom, JD, Vice President of Risk Management and Analytics at Coverys
Data Becomes the Fix, Not the Headache for Healthcare
The past 10 years have been challenging for an already overextended healthcare workforce. Rising litigation costs, higher severity claims, and more stringent reimbursement mandates put pressure on the bottom line. Continued crises in combination with less-than-optimal interoperability and design of health information systems, physician burnout, and loss of patient trust, have put front-line clinicians and staff under tremendous pressure.
Looking to the future, it is critical to engage beyond the day to day to rise above the persistent risks that challenge safe, high-quality care on the frontline. The good news is healthcare leaders can take advantage of tools that are available to generate, package, and learn from data – and use them to motivate action.
Steve Betts, Chief of Operations and Products at Gray Matter Analytics
Analytics Divide Intensifies: Just like the digital divide is widening in society, the analytics divide will continue to intensify in healthcare. The role of data in healthcare has shifted rapidly, as the industry has wrestled with an unsustainable rate of increasing healthcare costs. The transition to value-based care means that it is now table stakes to effectively manage clinical quality measures, patient/member experience measures, provider performance measures, and much more. In 2021, as the volume of data increases and the intelligence of the models improves, the gap between the haves and have nots will significantly widen at an ever-increasing rate.
Substantial Investment in Predictive Solutions: The large health systems and payors will continue to invest tens of millions of dollars in 2021. This will go toward building predictive models to infuse intelligent “next best actions” into their workflows that will help them grow and manage the health of their patient/member populations more effectively than the small and mid-market players.
Jennifer Price, Executive Director of Data & Analytics at THREAD
The Rise of Home-based and Decentralized Clinical Trial Participation
In 2020, we saw a significant rise in home-based activities such as online shopping, virtual school classes and working from home. Out of necessity to continue important clinical research, home health services and decentralized technologies also moved into the home. In 2021, we expect to see this trend continue to accelerate, with participants receiving clinical trial treatments at home, home health care providers administering procedures and tests from the participant’s home, and telehealth virtual visits as a key approach for sites and participants to communicate. Hybrid decentralized studies that include a mix of on-site visits, home health appointments and telehealth virtual visits will become a standard option for a range of clinical trials across therapeutic areas. Technological advances and increased regulatory support will continue to enable the industry to move out of the clinic and into the home.
Doug Duskin, President of the Technology Division at Equality Health
Value-based care has been a watchword of the healthcare industry for many years now, but advancement into more sophisticated VBC models has been slower than anticipated. As we enter 2021, providers – particularly those in fee-for-service models who have struggled financially due to COVID-19 – and payers will accelerate this shift away from fee-for-service medicine and turn to technology that can facilitate and ease the transition to more risk-bearing contracts. Value-based care, which has proven to be a more stable and sustainable model throughout the pandemic, will seem much more appealing to providers that were once reluctant to enter into risk-bearing contracts. They will no longer be wondering if they should consider value-based contracting, but how best to engage.
Brian Robertson, CEO of VisiQuate
Continued digitization and integration of information assets: In 2021, this will lead to better performance outcomes and clearer, more measurable examples of “return on data, analytics, and automation.
Digitizing healthcare’s complex clinical, financial, and operational information assets: I believe that providers who are further in the digital transformation journey will make better use of their interconnected assets, and put the healthcare consumer in the center of that highly integrated universe. Healthcare consumer data will be studied, better analyzed, and better predicted to drive improved performance outcomes that benefit the patient both clinically and financially.
Some providers will have leapfrog moments: These transformations will be so significant that consumers will easily recognize that they are receiving higher value. Lower acuity telemedicine and other virtual care settings are great examples that lead to improved patient engagement, experience and satisfaction. Device connectedness and IoT will continue to mature, and better enable chronic disease management, wellness, and other healthy lifestyle habits for consumers.
Kermit S. Randa, CEO of Syntellis Performance Solutions
Healthcare CEOs and CFOs will partner closely with their CIOs on data governance and data distribution planning. With the massive impact of COVID-19 still very much in play in 2021, healthcare executives will need to make frequent data-driven – and often ad-hoc — decisions from more enterprise data streams than ever before. Syntellis research shows that healthcare executives are already laser-focused on cost reduction and optimization, with decreased attention to capital planning and strategic growth. In 2021, there will be a strong trend in healthcare organizations toward new initiatives, including clinical and quality analytics, operational budgeting, and reporting and analysis for decision support.
Dr. Calum Yacoubian, Associate Director of Healthcare Product & Strategy at Linguamatics
As payers and providers look to recover from the damage done by the pandemic, the ability to deliver value from data assets they already own will be key. The pandemic has displayed the siloed nature of healthcare data, and the difficulty in extracting vital information, particularly from unstructured data, that exists. Therefore, technologies and solutions that can normalize these data to deliver deeper and faster insights will be key to driving economic recovery. Adopting technologies such as natural language processing (NLP) will not only offer better population health management, ensuring the patients most in need are identified and triaged but will open new avenues to advance innovations in treatments and improve operational efficiencies.
Prior to the pandemic, there was already an increasing level of focus on the use of real-world data (RWD) to advance the discovery and development of new therapies and understand the efficacy of existing therapies. The disruption caused by COVID-19 has sharpened the focus on RWD as pharma looks to mitigate the effect of the virus on conventional trial recruitment and data collection. One such example of this is the use of secondary data collection from providers to build real-world cohorts which can serve as external comparator arms.
This convergence on seeking value from existing RWD potentially affords healthcare providers a powerful opportunity to engage in more clinical research and accelerate the work to develop life-saving therapies. By mobilizing the vast amount of data, they will offer pharmaceutical companies a mechanism to positively address some of the disruption caused by COVID-19. This movement is one strategy that is key to driving provider recovery in 2021.
Rose Higgins, Chief Executive Officer of HealthMyne
Precision imaging analytics technology, called radiomics, will increasingly be adopted and incorporated into drug development strategies and clinical trials management. These AI-powered analytics will enable drug developers to gain deeper insights from medical images than previously capable, driving accelerated therapy development, greater personalization of treatment, and the discovery of new biomarkers that will enhance clinical decision-making and treatment.
Dharmesh Godha, President and CTO of Advaiya
Greater adoption and creative implementation of remote healthcare will be the biggest trend for the year 2021, along with the continuous adoption of cloud-enabled digital technologies for increased workloads. Remote healthcare is a very open field. The possibilities to innovate in this area are huge. This is the time where we can see the beginning of the convergence of personal health aware IoT devices (smartwatches/ temp sensors/ BP monitors/etc.) with the advanced capabilities of the healthcare technologies available with the monitoring and intervention capabilities for the providers.
Simon Wu, Investment Director, Cathay Innovation
Healthcare Data Proves its Weight in Gold in 2021
Real-world evidence or routinely stored data from hospitals and claims, being leveraged by healthcare providers and biopharma companies along with those that can improve access to data will grow exponentially in the coming year. There are many trying to build in-house, but similar to autonomous technology, there will be a separate set of companies emerge in 2021 to provide regulated infrastructure and have their “AWS” moment.
Kyle Raffaniello, CEO of Sapphire Digital
2021 is a clear year for healthcare price transparency
Over the past year, healthcare price transparency has been a key topic for the Trump administration in an effort to lower healthcare costs for Americans. In recent months, COVID-19 has made the topic more important to patients than ever before. Starting in January, we can expect the incoming Biden administration to not only support the existing federal transparency regulations but also continue to push for more transparency and innovation within Medicare. I anticipate that healthcare price transparency will continue its momentum in 2021 as one of two Price Transparency rules takes effect and the Biden administration supports this movement.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Social Determinants of Health Goes Mainstream: Understanding more about the patient and their personal environment has a hot topic the past two years. Providers and payers’ ability to inject this knowledge and insight into the clinical process has been limited. 2021 is the year it gets real. It’s not just about calling an uber anymore. The organizations that broadly factor SDOH into the servicing model especially with virtualized medicine expanding broadly will be able to more effectively reach vulnerable patients and maximize the effectiveness of care.
Joe Partlow, CTO at ReliaQuest
The biggest threat to personal privacy will be healthcare information: Researchers are rushing to pool resources and data sets to tackle the pandemic, but this new era of openness comes with concerns around privacy, ownership, and ethics. Now, you will be asked to share your medical status and contact information, not just with your doctors, but everywhere you go, from workplaces to gyms to restaurants. Your personal health information is being put in the hands of businesses that may not know how to safeguard it. In 2021, cybercriminals will capitalize on rapid U.S. telehealth adoption. Sharing this information will have major privacy implications that span beyond keeping medical data safe from cybercriminals to wider ethics issues and insurance implications.
Jimmy Nguyen, Founding President at Bitcoin Association
Blockchain solutions in the healthcare space will bring about massive improvements in two primary ways in 2021.
Firstly, blockchain applications will for the first time facilitate patients owning, managing, and even monetizing their personal health data. Today’s healthcare information systems are incredibly fragmented, with patient data from different sources – be they physicians, pharmacies, labs, or otherwise – kept in different silos, eliminating the ability to generate a holistic view of patient information and restricting healthcare providers from producing the best health outcomes.
Healthcare organizations are growing increasingly aware of the ways in which blockchain technology can be used to eliminate data silos, enable real-time access to patient information, and return control to patients for the use of their personal data – all in a highly-secure digital environment. 2021 will be the year that patient data goes blockchain.
Secondly, blockchain solutions can ensure more honesty and transparency in the development of pharmaceutical products. Clinical research data is often subject to questions of integrity or ‘hygiene’ if data is not properly recorded, or worse, is deliberately fabricated. Blockchain technology enables easy, auditable tracking of datasets generated by clinical researchers, benefitting government agencies tasked with approving drugs while producing better health outcomes for healthcare providers and patients. In 2021, I expect to see a rise in the use and uptake of applications that use public blockchain systems to incentivize greater honesty in clinical research.
Alex Lazarow, Investment Director, Cathay Innovation
The Future of US Healthcare is Transparent, Fair, Open and Consumer-Driven
In the last year, the pandemic put a spotlight on the major gaps in healthcare in the US, highlighting a broken system that is one of the most expensive and least distributed in the world. While we’ve already seen many boutique healthcare companies emerge to address issues around personalization, quality and convenience, the next few years will be focused on giving the power back to consumers, specifically with the rise of insurtechs, in fixing the transparency, affordability, and incentive issues that have plagued the private-based US healthcare system until now.
Lisa Romano, RN, Chief Nursing Officer, CipherHealth
Hospitals will need to counter the staff wellness fallout
The pandemic has placed unthinkable stress on frontline healthcare workers. Since it began, they’ve been working under conditions that are fundamentally more dangerous, with fewer resources, and in many cases under the heavy emotional burden of seeing several patients lose their battle with COVID-19. The fallout from that is already beginning – doctors and nurses are leaving the profession, or getting sick, or battling mental health struggles. Nursing programs are struggling to fill classes. As a new wave of the pandemic rolls across the country, that fallout will only increase. If they haven’t already, hospitals in 2021 will place new premiums upon staff wellness and staff health, tapping into the same type of outreach and purposeful rounding solutions they use to round on patients.
Kris Fitzgerald, CTO, NTT DATA Services
Quality metrics for health plans – like data that measures performance – was turned on its head in 2020 due to delayed procedures. In the coming year, we will see a lot of plans interpret these delayed procedures flexibly so they honor their plans without impacting providers. However, for so long, the payer’s use of data and the provider’s use of data has been disconnected. Moving forward the need for providers to have a more specific understanding of what drives the value and if the cost is reasonable for care from the payer perspective is paramount. Data will ensure that this collaboration will be enhanced and the concept of bundle payments and aligning incentives will be improved. As the data captured becomes even richer, it will help people plan and manage their care better. The addition of artificial intelligence (AI) to this data will also play a huge role in both dialog and negotiation when it comes to cost structure. This movement will lead to a spike in value-based care adoption
– The governor of Virginia announced that the state
will allocate $10 million from the federal CARES Act to
implement a statewide integrated technology platform, Unite Virginia designed
to connect vulnerable Virginians to crucial health and social services.
– Unite Virginia will utilize the Unite Us platform to create
a statewide coordinated care network to help government
agencies, health care providers, and community-based partners ensure
medical care and social services are appropriately delivered to
Virginians, identify gaps in the system to better target resources, supporting
ongoing COVID-19 response/recovery, reduce barriers to care, and advance
Governor Ralph Northam announced that Virginia will allocate
$10M in federal Coronavirus Aid, Relief, and Economic Security (CARES) Act
funding to create Unite Virginia, a statewide technology platform designed to
connect vulnerable Virginians to health and social services. Powered by Unite Us, a technology company that builds coordinated care
networks of health and social service providers, the Commonwealth will
implement an integrated e-referral system that unites government agencies,
health care providers, and community-based partners and supports Virginia’s
response and recovery efforts.
Unite Us Network
Unite Us provides unifying infrastructure between health
care providers and community-based organizations as the foundation for social
care transformation at scale. With networks in more than 40 states, Unite Us is
the statewide technology platform in North Carolina and the company is
developing programs similar to what is planned in Virginia in communities in
Kansas, Minnesota, Missouri, Nebraska, North Dakota, Ohio, Oregon, and South
Dakota. In Virginia, Unite Us already powers networks in the Hampton Roads and
Shenandoah Valley regions. When fully established, this network will be an
integral part of the Commonwealth’s broader public health framework.
This initial funding allocation will cover startup and
implementation costs to operate the e-referral system, which can integrate with
widely used electronic medical record systems in place at hospitals, health
systems, and medical practice groups across Virginia. Establishing those links
will enable health care providers to refer patients to social service
organizations that can provide other supports such as food, transportation assistance,
housing, employment services, and more. In turn, participating organizations
will be able to refer patients and clients to each other.
This interconnected approach also increases the likelihood
that vulnerable Virginians will access support services to manage their health
conditions and the environmental factors that contribute to them. Data insights
gleaned from the integrated technology platform will help state government,
providers, and other partners identify critical needs and better focus efforts
to serve these Virginians.
“The ongoing and widespread impacts of the COVID-19 pandemic underscore the need to unite traditional health care settings and community organizations that address social determinants of health,” said Governor Northam. “This is about connecting people with the supports they need to live healthy lives. Having this critical infrastructure in place will also position our Commonwealth to better respond to and recover from the twin public health and economic crises we face, and advance health equity by ensuring medical care and social services are appropriately delivered to Virginians, reducing barriers to care, and identifying gaps to better our target resources.”
As 170 research teams race to develop a vaccine for COVID-19, some that are in late-stage approvals have seen recent progress, but it is still not yet clear when a vaccine will become widely available. Until then, healthcare organizations continue to rely heavily on data analytics to try to improve COVID-19 outcomes and public health.
Since the novel coronavirus became widespread in the U.S., healthcare data scientists have leveraged clinical and claims data to pinpoint which underlying conditions put patients at higher risk of complications from COVID-19. Health systems are mining clinical data to predict surges in COVID-19 cases and looking at key factors—including increases in hospital website traffic, such as searches for emergency department (ED) wait times and physician page clicks—to understand how COVID-19 is ramping up locally in real-time. Meanwhile, risk-based modeling has helped health plans address social determinants of health that could impede recovery.
Now, providers and health plans are refining their approach. The more they learn, the greater the benefit to public health and long-term outcomes. Three evolving use cases for using claims and clinical data to combat COVID-19 stand out.
Reduce disparities in care. Early in the pandemic, lack of complete information around patient demographics prevented the identification of members in communities that were most vulnerable to COVID-19 infection. The impact: severe differences in mortality rates. In Chicago, the rate of mortality among Black residents was alarmingly high—70% of COVID-19 deaths—even though these residents comprise just 29% of the city’s population. Meanwhile, Spanish-speaking residents account for 18.3% of the nation’s population, yet comprise 34.3% of coronavirus cases.
One of the reasons demographic data was often missing from COVID-19 lab tests is that laboratory and hospital staff were too overwhelmed with cases to have time to input all of a patient’s non-clinical information. Today, data scientists are working to fill in the gaps using clinical history and medical claims. With these analyses, healthcare organizations are closing gaps in care, such as by expanding access to COVID-19 testing for the nation’s most vulnerable populations and increasing access to professional interpreters to more effectively gather key patient details. They are also addressing social determinants of health that heighten risks, such as food insecurity and lack of access to prescription medications.
Alleviate reliance on spotty testing. Not everyone who contracts COVID-19 has a healthcare encounter. For instance, if one member of the household tests positive for the coronavirus, other members may decide not to undergo testing if their symptoms are mild. These are instances where analyses of clinical and claims information already in the system—both emerging and historical data—can help spot unconfirmed cases of COVID-19. Such analyses give public health officials the information they need to contact, test,s and quarantine individuals that have contracted the virus, helping to limit the spread of the disease.
On a wider scale, data analysis can also provide early warning surveillance of potential COVID-19 cases, strengthening the pandemic response. For example, by observing increases in medical claims for telemedicine, rapid flu tests, and chest X-rays, data scientists can detect patterns in claims that suggest a COVID-19 outbreak is likely to occur. From there, they can forecast demand for hospital care up to 10 days in advance, ensuring that facilities have sufficient staff, supplies, and beds available to meet their community’s needs. Similarly, disruptions to seasonal flu trends, which remain fairly consistent within a region year over year, could alert public health officials to a potential COVID-19 outbreak.
Avoid preventable deaths. Information regarding patients’ underlying medical conditions can be hard to come by during a public health crisis as overwhelming and widespread as the current pandemic. In fact, just 5.8% of medical records for patients hospitalized with COVID-19 in Q1 2020 had data available related to their underlying health conditions and other risk factors. Today, it is known that certain chronic conditions raise the patient’s risk for severe complications from COVID-19—and that list of conditions is growing. The insight gained from these analyses not only informs how healthcare providers treat an individual’s illness, but also gives those with chronic disease the ability to make informed decisions based on their risk level for infection.
Moreover, the availability of actionable, real-time intelligence to improve health can set the stage for increased care collaboration. During COVID-19, healthcare providers across geographies are sharing their knowledge, especially regarding treatment protocols. Such learnings include the value of using high-flow nasal oxygen in treating severe cases of COVID-19. Early results show that this technique has a positive impact on patients with mild to moderate respiratory failure. It also reduces intubation rates and improves clinical prognosis for patients with acute respiratory failure. By sharing data-driven insights, organizations can work together to improve COVID-19 outcomes and reduce avoidable deaths.
Improving Outcomes and Reducing Risk
Clinical and claims data analysis helps healthcare organizations respond proactively to COVID-19. With the race toward a COVID-19 vaccine well underway, these analyses will help identify which populations should receive the vaccine first, assess reactions to the vaccine by demographic group and spot trends that could affect vaccination protocols. They also give healthcare organizations up-to-date contact information to engage patients, which will be critical to clinical efficacy if a second dose of the vaccine must be administered. In 2020 and beyond, continued focus on clinical and claims data analysis will be key to facilitating a robust response that enhances outcomes and saves lives.
About Emad Rizk, M.D.
Emad Rizk, M.D., is President and CEO of Cotiviti and brings a 30-year, well-documented track record of delivering improved quality and financial performance to healthcare organizations through forward-thinking leadership, business acumen, and clinical expertise.
– DispatchHealth launches Clinic Without Walls, a new service line offering patients a telemedicine visit with in-person assistance for more complex medical visits.
– The initial service line will be available in a pilot to MultiCare patients in the Tacoma and Spokane areas in an effort to its senior patients’ alternative visits during the pandemic.
DispatchHealth, a provider of in-home high-acuity medical care, today announced
the launch of Clinic Without Walls. The new service line expands access to care
for vulnerable patients by offering enhanced virtual visits with hands-on
support. Clinic Without Walls is initially being offered to MultiCare patients
in the Tacoma and Spokane areas.
Meeting the Growing Needs of In-Home Medical Care Options
visits have become an increasingly popular option to help decrease a patient’s
risk of exposure to COVID-19. More
advanced capabilities are often required for vulnerable patients who are facing
chronic disease or require medically complex care. The Clinic Without Walls
model offers these patients hands-on support with an emergency medical
technician (EMT) to help guide them through a telemedicine presentation and
connect them with a physician.
“The pandemic has highlighted the need for more in-home medical care options during the pandemic and beyond,” said Dr. Mark Prather, chief executive officer and co-founder of DispatchHealth. “Our unique model continues to expand and meet the growing needs of patients, payers, and provider partners. We are excited to continue to grow our partnership with MultiCare to help their most vulnerable patients by treating medically complex issues through hands-on support and tele-presentation.”
How It Works
During a Clinic Without Walls visit, an EMT from DispatchHealth will visit a patient where they live. The EMT comes equipped with a handheld, telehealth exam kit developed by TytoCare, manufacturer of the hand-held telehealth device DispatchHealth uses. The kit allows them to assist a guided medical exam including assessment of the lungs, ears, throat, skin, and abdomen. In addition, comprehensive vital signs, social determinants of health intervention, and moderate-complexity lab work are available in the home. If additional lab work or imaging is required, the service will be coordinated by DispatchHealth.
“The goal of this program is to keep MultiCare’s vulnerable patients safe and healthy”, said Christi McCarren, senior vice president of retail health and community based care at MultiCare. “Many of these patients have been deferring care due to the fear of contracting COVID-19. Additionally, this program helps patients facing significant mobility and transportation issues receive the care they need.”
Clinical Without Models Care Model
DispatchHealth’s Clinic Without Walls model complements the organization’s additional service lines, which include Advanced Care, Extended Care, and Acute Care. Combined, DispatchHealth is able to reduce avoidable ER visits, hospital admissions, or a stay at a skilled nursing facility. The company has experienced a period of rapid expansion and record growth and has more than doubled its national footprint in 2020, with services available in 28 cities across the United States. DispatchHealth is open seven days a week, 365 days a year, including holidays. For more information, including market hours and areas of service, visit DispatchHealth.com
– Cityblock Health, a transformative, value-based healthcare provider focused on improving healthcare outcomes for marginalized communities, today announced a $160M Series C round, bringing its total raised to $300M.
– Cityblock is a care delivery trailblazer working to right the injustices of a healthcare system that cycles vulnerable communities through frequent ER visits and hospital stays. Its tech-enabled model delivers primary care, behavioral care, and social services, virtually and in-person, to the Medicaid and lower-income Medicare beneficiary communities.
– Cityblock provides social services that address core
aspects of poverty in order to improve health outcomes, including access to
nutritious food and support to safely care for oneself.
Health, a Brooklyn, NY-based healthcare provider for lower-income
communities, announced today the completion of a $160 million Series C funding
round and a valuation of over $1 billion. New Cityblock investor General Catalyst
led the round, with participation from crossover investor Wellington Management
and support from major existing investors, including Kinnevik AB, Maverick
Ventures, Thrive Capital, Redpoint Ventures, and more. The investment round
brings Cityblock’s total equity funding to $300 million, as they look to grow
their footprint to democratize access to community-based integrated care in a
more than $1.3 trillion market.
Care That Meets You Where You Are
Spun out of Sidewalk Labs, an Alphabet Company in 2017 and anchored in a first partnership with EmblemHealth, Cityblock is a transformative, value-based healthcare provider focused on improving outcomes for Medicaid and lower-income Medicare beneficiaries. The company provides medical care (both primary care and complex specialty services), behavioral health, and social services to its members virtually, in their homes, in the community, and in its neighborhood hubs. Their model reflects an underlying philosophy that improving health outcomes and minimizing systemic healthcare inequities requires fundamentals that address the root effects of poverty, like having access to nutritious food or the ability to safely care for yourself and others.
Value-Based Care Model
Cityblock leverages a value-based model, instead of a
fee-for-service basis, like most healthcare providers. Cityblock splits the
cost savings that come from better outcomes with the healthcare payer. Cityblock’s
financial structure squarely aligns the health needs of its members to continuously
deliver patient-centric care.
Cityblock is powered by Commons a groundbreaking care delivery platform that brings together distributed community-based care teams, care delivery workflows, data feeds, and multimodal member interactions. It allows social workers, pharmacists, doctors, paramedics, and our virtual care teams to all come together on the same page in real-time. With each new market we enter, our technology reinforces our care model, allowing us to serve more members while ensuring consistently high quality, empathetic, and effective care.
Integrated Care Team
Cityblock’s integrated care teams include doctors, nurses,
advanced practice clinicians, behavioral health specialists, licensed clinical
social workers, and community health partners, and leverage close partnerships
with existing healthcare providers and community-based social services
Today, Cityblock provides care to 70,000 members in Connecticut,
New York, Massachusetts, and Washington D.C., with high member engagement and
NPS scores of high 80s to 90s across its markets. Over the past year, Cityblock
members have seen reductions in in-patient hospital admission rates and
improvements in quality outcomes, keeping people healthier and driving down
costs across the board, while more than doubling membership and revenue,
The Impact of COVID Has Magnified Health Disparities
According to Cityblock, the COVID-19 pandemic has
significantly magnified health disparities highlighting three fundamental
– Inequity of
America’s social infrastructure, including the legacy of systemic racism, has
created unacceptably disparate health outcomes
– Healthcare’s volume-based, fee-for-service payment model contributes
poor outcomes, especially for marginalized communities
– The models that
have to-date addressed key components of these challenges have not successfully
Story of Cityblock Member Sonia
The story of Sonia, a Cityblock member, is featured in the blog post announcing the raise. Counted out and considered
a ‘nuisance’ by the healthcare system, Sonia was visiting the emergency room
several times a week for care and services, resulting in poor outcomes for the
health system and for herself. Cityblock enrolled Sonia in their high-risk
short-term housing program, placing her into a hotel during the peak of her
community’s Covid-19’s outbreak. As her trust in Cityblock grew, Sonia worked
with Cityblock and its community partners to secure permanent housing. Over the
course of two years, Sonia saw a 21% reduction in hospital use and a 24%
reduction in monthly costs, and has had zero ER visits since April 2020.
“The devastating impact of COVID-19 has been a painful
reminder of the vulnerability of lower-income communities and communities of
color,” said Iyah Romm, Cityblock Health co-founder and CEO. “We cannot turn a
blind eye to a healthcare system that cycles vulnerable communities through
frequent ER visits and hospital stays. We believe that new models of care
delivery, rooted in preventative care and augmented with social services, are
one major path forward to righting the injustices of our healthcare system.
This starts with listening to our members, extends through changing payment
models to create sustainability for primary care providers and building
technology to democratize access to the care models that we are building.”
– Virtual maternity care platform Babyscripts announced a
new round of investments from Banner Health, CU Healthcare Innovation Fund, The
Froedtert & Medical College of Wisconsin Health Network, and WellSpan
– Using internet-connected devices for remote monitoring,
Babyscripts offers risk-specific experiences to allow providers to manage up to
90% of pregnancies virtually, allowing doctors to detect risk more quickly and
automate elements of care.
the leading virtual care
platform for managing obstetrics, today announced a new round of
investments through their Strategic Partners Program,
a unique investment bloc composed of health systems interested in
forwarding Babyscripts’ cutting-edge digital solutions for pregnant
populations. Partners include Phoenix-based Banner Health, one of the largest
nonprofit health care systems in the country; the CU Healthcare Innovation Fund, located on
the University of Colorado Anschutz Medical Campus in Aurora, Colorado; the Froedtert & the Medical College of
Wisconsin health network, an integrated health care system based in
Wisconsin; and WellSpan Health, an
integrated health system serving central Pennsylvania and northern
This investment round is structured to leverage the input
and support of clinical and health system partners, ensuring that Babyscripts’
product development and future roadmap aligns with customer needs.
Babyscripts has spent the last six years building a
clinically-validated, virtual care platform to allow OBGYNs to deliver a new
model of prenatal care. Using internet-connected devices for remote monitoring,
Babyscripts offers risk-specific experiences to allow providers to manage up to
90% of pregnancies virtually, allowing doctors to detect risk more quickly and
automate elements of care.
3-Tier Approach Virtual Maternity Care
Babyscripts’ three-tiered approach to virtual maternity care
allows providers to deliver risk-specific care to pregnant mothers at any time,
in any place, through a mobile app and internet-connected monitoring devices:
Maternal Digital Education: Virtually connect with expectant and new mothers between visits with a custom mobile app.
Maternal Health Monitoring: Virtual management of
pregnant patients through remote monitoring for blood pressure, weight, blood
sugar, social determinants of health (SDOH)
Maternal Population Health: Improve patient/member
care through a unique collaboration between the care team and the payer.
The solution is powered by a robust set of vetted user
experiences, integrations, workflows, and best practices.
“From the beginning, we’ve set ourselves apart from other tech companies by partnering with physicians to make sure that we’re developing solutions that will actually be useful and improve outcomes, not just look and feel ‘cutting-edge’,” said Juan Pablo Segura, co-founder and President of Babyscripts. “This investment is validation that health systems see the value of our solution — and they’re willing to put their money on it.
Senior isolation is a health risk that affects at least a quarter of seniors over 65. It has become recognized over the past decade as a risk factor for poor aging outcomes including cognitive decline, depression, anxiety, Alzheimer’s disease, obesity, hypertension, heart disease, impaired immune function, and even death.
Physical limitations, lack of transportation, and inadequate health literacy, among other social determinants of health (SDOH), further impair access to medical and mental health treatment and preventive care for older adults. These factors combine to increase the impact of chronic comorbidities and acute issues in our nation’s senior population.
COVID-19 exacerbates the negative impacts of social isolation. The consequent need for social distancing and reduced use of the healthcare system due to the risk of potential SARS-CoV-2 exposure are both important factors for seniors. Without timely medical attention, a minor illness or injury quickly deteriorates into a life-threatening situation. And without case management, chronic medical conditions worsen.
Among Medicare beneficiaries alone, social isolation is the source of $6.7 billion in additional healthcare costs annually. Preventing and addressing loneliness and social isolation are critically important goals for healthcare systems, communities, and national policy.
Organizations across the healthcare spectrum are taking a more holistic view of patients and the approaches used to connect the most vulnerable populations to the healthcare and community resources they need. To support that effort, technology is now available to facilitate analysis of the socioeconomic and environmental circumstances that adversely affect patient health and mitigate the negative impacts of social isolation.
Addressing Chronic Health Issues and SDOH
When we think about addressing chronic health issues and SDOH in older adults, it is usually after the fact, not focused on prevention. By the time a person has reached 65 years of age, they may already be suffering from the long-term effects of chronic diseases such as diabetes, hypertension or heart disease. Access points to healthcare for older adults are often in the setting of post-acute care with limited attention to SDOH. The focus is almost wholly limited to the treatment and management of complications versus preventive measures.
Preventive outreach for older adults begins by focusing on health disparities and targeting patients at the highest risk. Attention must shift to care quality, utilization, and health outcomes through better care coordination and stronger data analytics. Population health management technology is the vehicle to drive this change.
Bimodal Outreach: Prevention and Follow-Up Interventions
Preventive care includes the identification of high-risk individuals. Once identified, essential steps of contact, outreach, assessment, determination, referral, and follow-up must occur. Actions are performed seamlessly within an organization’s workflows, with automated interventions and triggered alerts. And to establish a true community health record, available healthcare and community resources must be integrated to support these actions.
Social Support and Outreach through Technology
Though older adults are moving toward more digitally connected lives, many still face unique barriers to using and adopting new technologies. So how can we use technology to address the issues?
Provide education and trainingto improve health literacy and access, knowledge of care resources, and access points. Many hospitals and health systems offer day programs that teach seniors how to use a smartphone or tablet to access information and engage in preventive services. For example, connecting home monitoring devices such as digital blood pressure reading helps to keep people out of the ED.
Use population health and data analyticsto identify high-risk patients. Determining which patients are at higher risk requires stratification at specific levels. According to the Centers for Disease Control and Prevention, COVID-19 hospitalizations rise with age, from approximately 12 per 100,000 people among those 65 to 74 years old, to 17 per 100,000 for those over 85. And those who recover often have difficulty returning to the same level of physical and mental ability. Predictive analytics tools can target various risk factors including:
– Recent ED visits or hospitalizations
– Presence of multiple chronic conditions
– Food insecurity, housing instability, lack of transportation, and other SDOH
– Frailty indices such as fall risk
With the capability to identify the top 10% or the top 1% of patients at highest risk, care management becomes more efficient and effective using integrated care coordination platforms to assist staff in conducting outreach and assessments. Efforts to support care coordination workflows are essential, especially with staffing cutbacks, COVID restrictions, and related factors.
Optimal Use of Care Coordination Tools
Training and education of the healthcare workforce is necessary to maximize the utility of care coordination tools. Users must understand all the capabilities and how to make the most of them. Care coordination technology simplifies workflows, allowing care managers to:
– Risk-stratify patient populations, identify gaps in care, and develop customized care coordination strategies by taking a holistic view of patient care.
– Target high-cost, high-risk patients for intervention and ensure that each patient receives the right level of care, at the right time and in the right setting.
– Emphasize prevention, patient self-management, continuity of care and communication between primary care providers, specialists and patients.
This approach helps to identify the resources needed to create community connections that older adults require. Data alone is insufficient. The most effective solution requires a combination of data analytics to identify patients at highest risk, business intelligence to generate interventions and alerts, and care management workflows to support outreach and interventions.
About Dr. Jenifer Leaf Jaeger
Dr. Jenifer Leaf Jaeger serves as the Senior Medical Director for HealthEC, a Best in KLAS population health and data analytics company. Jenifer provides clinical oversight to HealthEC’s population health management programs, now with a major focus on COVID-19. She functions at the intersection of healthcare policy, clinical care, and data analytics, translating knowledge into actionable insights for healthcare organizations to improve patient care and health outcomes at a reduced cost.
Prior to HealthEC, Jenifer served as Director, Infectious Disease Bureau and Population Health for the Boston Public Health Commission. She has previously held executive-level and advisory positions at the Massachusetts Department of Public Health, New York City Department of Health and Mental Hygiene, Centers for Disease Control and Prevention, as well as academic positions at Harvard Medical School, Boston University School of Medicine, and the Warren Alpert Medical School of Brown University.
The Covid-19 pandemic has disproportionately affected some communities more than others. With a renewed focus on inequities, health leaders see an opportunity to drive change to reduce racial disparities in healthcare.
– Change Healthcare launches national data resource on
social determinants of health (SDoH) for doctors, insurers and life sciences
organizations to better understand the connection between where a person lives
and how they live their life to the care a patient receives and their health
– 80% of U.S. health outcomes are tied to a patient’s
social and economic situation, ranging from food, housing, and transportation
insecurity to ethnicity.
Change Healthcare, today announced the launch of Social Determinants of Health (SDoH) Analytics solution that will serve as an innovative national data resource that connects the circumstances of people’s lives to the care they receive. The SDoH Analytics solution is designed for health systems, insurers, and life sciences organizations to explore how geodemographic factors affect patient outcomes.
Understanding Social Determinants of Health
SDoH includes factors such as socioeconomic status, education, demographics, employment, health behaviors, social support networks, and access to healthcare. Individuals who experience challenges in any of these areas can face significant risks to their overall health.
“All the work I do—for Mayo Clinic, the COVID-19 Healthcare Coalition, and The Fight Is In Us— is predicated on equity,” said John Halamka, president, Mayo Clinic Platform. “The only way we can eliminate racism and disparities in care is to better understand the challenges. Creating a national data resource on the social determinants of health is an impactful first step.”
The SDoH Portrait Analysis includes financial attributes, education
attributes, housing attributes, ethnicity, and health behavior attributes.
3 Ways Healthcare Organizations Can Leverage SDoH
Healthcare organizations can now use SDoH Analytics to
assess, select, and implement effective programs to help reduce costs and
improve patient outcomes. Organizations can choose one of three ways to use
1. Receive customized reports identifying SDoH factors that
impact emergency room, inpatient, and outpatient visits across diverse
population health segments.
2. Append existing systems with SDoH data to close
information gaps and help optimize both patient engagement and outcomes.
3. Leverage a secure, hosted environment with ongoing
compliance monitoring for the development of unique data analytics, models, or
Why It Matters
Scientific research has shown that 80% of health outcomes
are SDoH-related. Barriers such as food and housing availability,
transportation insecurity, and education inequity must be addressed to reduce
health disparities and improve outcomes. Change Healthcare’s SDoH Analytics
links deidentified claims with factors such as financial stability, education
level, ethnicity, housing status, and household characteristics to reveal the
correlations between SDoH, clinical care, and patient outcomes. The resulting
dataset is de-identified in accordance with HIPAA privacy regulations.
“Health systems, insurers, and scientists can now use SDoH Analytics to make a direct connection between life’s circumstances and health outcomes,” said Tim Suther, senior vice president of Data Solutions at Change Healthcare. “This helps optimize healthcare utilization, member engagement, and employer wellness programs. Medical affairs and research are transformed. And most importantly, patient outcomes improve. SDoH Analytics makes these data-driven insights affordable and actionable.”
We’ve all experienced crises in our lives. They may be personal in nature (e.g., involving our interpersonal relationships), organizational (e.g., relating to our employment or retirement income), or nature-made (e.g., floods, tornados, or the COVID-19 pandemic). When crises hit our communities, the impacts can be widespread and far-reaching. Healthcare providers and community-based organizations (CBOs) are called upon to provide more rapid and extensive care and support to the community than is otherwise the norm. A well-established and highly functioning Connected Community of Care (CCC), as is the case here in Dallas, Texas, can provide a tremendous strategic and tactical advantage over non-connected peers.
Since 2014, the Parkland Center for Clinical Innovation (PCCI) has led an effort to bring together several large healthcare systems and a number of regional social-service organizations such as food banks, homeless assistance associations, and transportation service vendors, along with over 100 smaller CBOs (i.e., neighborhood food pantries, crisis centers, utility assistance centers) and area faith-based organizations to form the Dallas CCC. Over time, civic organizations, such as the Community Council of Greater Dallas, Dallas County Health and Human Services (DCHHS), and select academic institutions have begun to participate in various community-wide projects under the Dallas CCC umbrella.
Central to the success of the Dallas CCC are the partnerships that have been formed between the CBOs and a number of local healthcare systems (Parkland Health & Hospital System [Parkland], Baylor Scott & White Health, Children’s Medical Center, Methodist Health System, and Metrocare Services), clinical practices, and other ancillary healthcare providers serving the Dallas metroplex. These partnerships have proved essential in building a truly comprehensive and functional network aimed at improving both the health and well-being of Dallas residents.
Connecting these various entities and forming a two-way communication pathway is an electronic information exchange platform termed Pieces™ Connect, which allows for real-time, two-way sharing of information pertaining to an individual’s social and healthcare needs, history, and preferences. The information exchange platform is the glue that holds the physical network together and provides one of the mechanisms to disseminate information from public health and healthcare entities to social service providers in the community. It allows the individual community resident, via the CBO, to become better informed about important health issues, such as routine vaccinations or preventive care, such as social distancing and proper mask usage during a pandemic.
Until recently, the primary mission of the Dallas CCC focused on addressing residents’ social determinants of health (SDOH) issues through providing community resources (e.g., food assistance, housing, transportation) to improve the lives of Dallas County residents. While this mission has become even more critical during the COVID-19 pandemic, the work of the Dallas CCChas also evolved to include identifying COVID-19 sites within the County and directing community outreach efforts to help stem the rapid spread of the virus.
The Dallas CCC has provided an innovative model of community governance and cooperation to impact the consequences of the COVID-19 outbreak. From the first days of the pandemic, PCCI has been working with Parkland and DCHHS to help reliably identify and quantify the geographic location and incidence rates of positive COVID-19 cases within Dallas County. This problem is especially challenging when considering vulnerable populations and the transitory nature of these residents in inner-city communities.
Working with data provided by DCHHS, the Dallas-Fort Worth Hospital Council, and CBOs, PCCI built a series of dynamic geo-maps that were able to identify, at the neighborhood and block level, the location of hotspots of positive COVID-19 cases as well as attendant mortality rates. In addition to flagging at-risk patients and populations, the model continues to be used by public health and civic leaders to establish locations for testing sites within the city of Dallas based on COVID-19 incidence and community needs.
With the establishment of the hot-spotting, the next step was to get that information, along with general infection prevention protocols, in the hands of local CBOs to help raise awareness and slow the spread of the virus. With the aforementioned information in hand, public health workers have been able to develop targeted communications and tactical strategies to improve containment efforts through community-wide awareness and educational messaging.
By connecting local CBOs and faith-based organizations with public health workers and clinicians, the Dallas CCC is facilitating effective contact tracing and the implementation of care plans for high-risk individuals in a more efficient and scalable manner.
The value of the CCC communication network linking healthcare providers and CBOs cannot be underestimated, as it represents a highly effective and efficient mechanism to disseminate leading practice information aimed directly at high-risk populations. We have seen first-hand that communications delivered to community residents through familiar food pantries, homeless shelters, and places of worship are much more effective than community-wide public information campaigns broadcast via radio or television.
This increased effectiveness is based on the fact that many of these at-risk individuals frequent the CBOs on a regular basis for essential services and these individuals know and trust the CBO staff delivering the information. From one-on-one conversations to displaying infographic posters and take-away educational leaflets, CBOs provide a ready avenue to communicate with at-risk individuals in the communities they serve.
As mentioned, early work in Dallas County is beginning to demonstrate the value of CCC in facilitating contact tracing. In this case, the challenge is not simply identifying the location of positive COVID-19 cases but having the ability to connect those cases to other individuals within the neighborhood or community who may have come in contact with the infected individual, all while working in an environment where individuals frequently move from one location to another. Having a well-established communication system at the local neighborhood level can be extremely helpful in identifying contacts and potential contacts.
It is well-known that many individuals in impoverished, underserved neighborhoods are reluctant to speak with individuals they don’t know or trust, especially if those individuals are affiliated with government agencies, no matter how well-intentioned the agency personnel may be. Staff members at local faith-based organizations and CBOs frequented by these vulnerable residents are a highly effective resource for identifying inter-personal relationships and connecting with those individuals, which is something that has proved challenging for public health staff when working outside of a CCC environment. In Dallas, CBOs, public health, and civic staffers, as well as medical student volunteers have all been partnering to help facilitate the contact tracing process with positive results.
CCC’s can materially improve the health and well-being of a community’s residents, especially in times of crisis. The take-away lesson is clear. If you already have a CCC, lean on it to help you through crises impacting your community. If you don’t have a CCC, now is the time to begin the process of establishing one in your community. Even with the challenges that the current pandemic is generating, it is possible to begin building your CCC. Start small and gradually increase the CCC’s scope and scale; don’t be in a rush to grow. The most important thing is to take the plunge and begin the journey!
– The latest report from Chilmark Research examines the
new approaches and tools for utilizing community resources that can address
social determinants of health, giving providers the ability to extend care
beyond the confines of the clinic.
– This research indicates that the next two years will largely bring an expansion of product capabilities with slow and steady growth in implementation as the market better defines key variables and sets standards for performance.
COVID-19 has dramatically increased the overall population’s need for community resource engagement in traditional healthcare settings. The steady march to value-based care (VBC) continually amplifies interest in solutions that contribute to utilization management strategies. Vendors are rising to meet this need by connecting community-based organizations to various healthcare partners so that both may benefit from the coordination of service provision.
The latest Chilmark Research report, Addressing SDoH: IT Solutions to Engage Community Resources, evaluates these solutions, identifying the strengths and weaknesses of options in the market and predicting how the market will develop in the future. Research in this report is based on interviews with executive leadership teams of solutions vendors, executives from the major EHR companies, and extensive secondary research.
Vendors discussed in the report include aunt bertha, Cerner, Epic, HealthEC, Healthify, NowPow, Signify Health, Solera, Unite US, Xealth
Leveraging Community Partners Is Key
to Addressing SDoH
are some of the best resources providers can
utilize to address the social factors impacting patients’ health status, but
this is a new need for HCOs, which under fee-for-service (FFS) tried to keep
all care within the clinic to maximize revenues. Data management and liquidity
make effective integration with external partners a key barrier to
implementation, while legal and internal engagement issues continue to slow
Predicted 10-Year SDoH Adoption Trajectory
This research indicates that the next two years will largely bring an expansion of product capabilities with slow and steady growth in implementation as the market better defines key variables and sets standards for performance. Within five years, a public option for insurance will dramatically increase the rate of solutions adoption, culminating in >80% adoption in provider locations by 2030.
The report provides a roadmap and
predicts key inflection points for the greater adoption of these solutions, and which social determinants have historically been
the best predictors of increased health services utilization. It includes brief
profiles of key vendors providing this functionality, and how they plan to
impact community health.
“This has been a major challenge to healthcare systems, and people now get that we need to address [SDoH] better. The pandemic has proven to be an additional, critical driver for continued expansion of VBC, which requires understanding all of the factors that can influence a member’s health status,” according to report co-author Jody Ranck. “We see an opportunity here from the pandemic, that it has basically shown us where the failures are in the system today, and that going forward we need to do more to engage resources beyond the clinic.”
The COVID-19 Kidney Care
Challenge seeks to identify replicable solutions from providers, staff,
patients, and caregivers and share them across healthcare communities. KidneyX
is particularly interested in demonstrated solutions that consider the patient
experience and could be implemented without requiring significant effort,
expertise, money, or other resources.
These solutions may be
applied in a range of settings — such as dialysis centers, clinics, hospitals, homes,
and transport. Solutions may address, but are not limited to:
– Data collection and
– Patient management and
– Education, training, and
– Supply chain and
– Care setting logistics.
KidneyX is particularly
interested in solutions that consider the patient experience and could be
implemented without requiring significant time, expertise, money, or other
resources. Solutions that reduce the impact of the COVID-19
pandemic on communities facing existing health disparities are encouraged.
“COVID-19’s heavy impact will be felt for decades to come, drastically intensifying inequities within the American healthcare system,” said KidneyX Steering Committee Chair Dr. John Sedor. “The COVID-19 Kidney Care Challenge, alongside KidneyX’s ongoing work, offers us a way to potentially improve outcomes for patients in the near term — as well as help set innovation roadmaps for the health challenges of the future.”
The judging panel will
assign up to five points for each of the criteria below, for a maximum of 20
Impact: The confidence in the solution to reduce
SARS-CoV-2 transmission among people with kidney disease and/or reduce the risk
of kidney injury/disease among people who contract COVID-19.
Feasibility: The ease with which the solution could be
implemented, considering factors such as time, expertise, money, or other
Adaptability: The extent to which the solution could be
adapted for other people or used in other care settings and/or geographies.
Ingenuity: The degree to which the submission offers a new
solution, demonstrates an improvement on an existing solution, or applies an
existing solution in new ways.
Entrants are invited to submit their solutions via an online
submission form. The submission form asks entrants to provide an overview
of the solution; available data to demonstrate the solution has, or could have,
a positive impact; and additional information to assess how the solution may be
implemented in other settings.
Round 1 of the challenge
is now accepting solutions until December 4, 2020. Round 2 will be open to
eligible entrants from Round 1, as well as new eligible entrants who did not
enter the first round; the second round will accept solutions from December 9,
2020 to January 20, 2021. The judging panel will recommend winners from both
rounds to receive $20,000 each in recognition of their solutions.
After a launching their social determinants of health partnership in Nebraska over the summer, technology company Unite Us and the Nebraska Health Information Initiative have plans to expand it to six more states.
launches member engagement solution for healthcare payers to drive improvement
in healthcare cost and quality boosts member satisfaction and enhances member
enrollment and retention.
– Innovaccer’s solution create member-oriented care
plans, enhance connectivity with care managers, and drive interventions for
social determinants of health risks through the solution.
Innovaccer, Inc., a
technology company, has launched its member engagement
solution for healthcare payers. The solution will enable payers to use a
more consumer-oriented approach and allow the network members to take charge of
their own healthcare journeys. The solution will empower them with the right
information, resources, and the network’s best-performing providers.
Creating a Patient-Centered Care Paradigm
U.S. healthcare is making strides toward a more
patient-centered care paradigm. The latest Interoperability and Patient Access
final rule is one of the initiatives that put patients at the center of care.
The rule made it mandatory for payers to share electronic health data with
patients, which will enable them to participate more in their healthcare
In addition to meeting the regulatory requirements, the
member engagement solution enables payers to provide on-demand, mobile-based
educational materials, lab and test results, clinical visit notes, personalized
health assessments, and digitized services to health plan members.
Enabling Payers to Become More Patient-Centered
Innovaccer’s solution enables payers to become more
patient-centered. Payers can create member-oriented care plans, enhance
connectivity with care managers, and drive interventions for social
determinants of health risks through the solution.
“By building strong payer-beneficiary collaboration, we will be able to establish a more active, responsible, and value-driven care journey. Engaged members will know and understand exactly what is being done for the successful management of their medical conditions. A more informed and savvy member can potentially contribute to improving the quality of care, reduce excessive resource utilization, and decrease their costs,” says Abhinav Shashank, CEO at Innovaccer.
– Healthify in partnership with Algorex Health Technologies, announced the results of new social determinants of health (SDoH) population analysis of Excellus BlueCross BlueShield (BCBS) members.
– SDoH are non-clinical conditions that significantly
affect health outcomes. The analysis identified Excellus BCBS members who are
struggling with SDoH such as unstable housing, food insecurity and neighborhood
stress – which has enabled Excellus BCBS to develop a targeted SDoH strategy
focusing on members with the most need.
Healthify, a company that works with managed care organizations to integrate social determinants of health (SDoH) into the healthcare ecosystem, in partnership with Algorex Health Technologies, today announced the results of SDoH population analysis of Excellus BlueCross BlueShield (BCBS) members that identified high-risk members and the value of implementing SDoH initiatives. The data identified members who are struggling with unstable housing, food insecurity and neighborhood stress, which has enabled Excellus BCBS to develop a targeted SDoH strategy focusing on members with the most need.
Excellus BCBS turned to Healthify and
healthcare data analytics company Algorex Health to
provide deep analytic insights about how social determinants of health affect health quality
and cost. The SDoH data showed significant social needs
among members in Medicaid and other government sponsored programs and the value
of addressing the most prominent social determinants of health of
Healthify creates the infrastructure that drives
collaboration among community-based organizations, healthcare payers, providers
and policy makers to address social disparities with
aligned incentives and accountability. Healthify recently announced a
partnership with Algorex Health Technologies to expand its SDoH capabilities
to include SDoH predictive analytics that help health plan
and provider organizations better understand and proactively address the social needs
of vulnerable populations.
“SDoH analytics are critical for health plans that are implementing SDoH solutions,” said Manik Bhat, Founder and Chief Executive Officer of Healthify. “Analytics helps health plans build financial cases to solve for SDoH, prioritize highest-impact interventions in an accountable network and determine the right level of investment for SDoH initiatives.”
Even though Covid-19 is distinct from any health crisis the country has previously faced, assessing U.S. public health strategies during past crises can provide insight into what has contributed to a more or less equitable response.
– Unite Us, the tech company building coordinated care
networks nationwide announced a significant expansion to its partnership with
Nebraska Health Information Initiative (NEHII), a health information exchange,
to six additional states.
– This growing partnership aims to break down existing obstacles between
clinical and social service providers to allow for improved SDoH workflows, comprehensive,
whole-person care with trackable outcomes and data, and the creation of
sustainable long-term models for care.
Unite Us, the technology
company building coordinated care networks nationwide, announced today that it
is expanding its partnership with Nebraska Health
Information Initiative (NEHII), a Health Information Exchange (HIE), to six
additional states including Iowa, Missouri, South Dakota, North Dakota, Kansas,
and Minnesota. This growing partnership aims to break down existing obstacles
between clinical and social service providers to allow for comprehensive,
whole-person care with trackable outcomes and data.
This expansion between Unite Us and NEHII comes on the heels
of Unite Nebraska, the pair’s first joint statewide network that was announced
in June 2020 and launched last month, and will allow more people in need across
the country to get the services they need. Unite Us and NEHII have begun
rolling out the partnership into the additional states, and all networks will
be live by August 2022.
Why It Matters
Beyond the clinical care a person receives, 80% of an
individual’s health and quality of life is affected by their social
determinants of health (SDoH), conditions in the environment where people
are born, live, work, play, and worship.* It is critical that health care
providers have access to this full picture of their patients’ lives beyond the
clinic and hospital walls, in order to identify and help eliminate potential
barriers to their health and well-being.
NEHII is committed to helping organizations addressing SDoH
improve their workflows, track results and metrics, avoid wasteful and repeated
care, and create sustainable long-term models for care. NEHII will utilize
Unite Us’ person-centric platform to provide transparency, accountability, and
outcomes data to providers, and to incorporate community-based social care into
state ecosystems, particularly in rural areas with geographic variations in
access to critical services. This expansion and continued partnership paves the
way for additional collaborations with other HIEs, multiple health systems and
state Medicaid departments as they collectively move towards systems change.
“NEHII is thrilled to be expanding our partnership with Unite Us into six new states, to enable better support and health outcomes for all Americans,” says Jaime Bland, President and CEO of NEHII. “We know patients don’t seek care in a single institution, let alone a single state, especially along our borders. Statewide infrastructures for health and social care are more crucial than ever as COVID-19 continues to devastate the nation. We’re eager to help additional states combine their clinical and social care data in one secure location to provide patients and providers a more comprehensive view of their longitudinal health record.”
Radically improving health outcomes for vulnerable populations requires a multifaceted proactive, community-wide approach focused on better understanding social determinants of health and simultaneously addressing social and health inequalities.
– Healthify’s social determinants of health (SDoH) infrastructure will be integrated into Altruista’s GuidingCare® platform to support health plans in addressing the social needs of members.
– SDoH such as poverty, housing instability, and food insecurity can significantly impact health outcomes, so it is imperative that they are not overlooked.
company that works with managed care organizations to integrate social
determinants of health (SDoH) into the healthcare ecosystem,
today announced that its technology will be included in Altruista Health’s care
management platform, GuidingCare®, to help health plans
seamlessly and efficiently address SDoH.
Addressing SDoH Impacting Health Outcomes
Healthify creates an infrastructure that drives collaboration among community-based organizations, healthcare payors, providers, and policymakers to address social disparities with aligned incentives and accountability. Altruista will integrate Healthify into its GuidingCare platform to help health plans more effectively address SDoH – nonclinical factors such as poverty, housing instability, and food insecurity that impact health outcomes.
Altruista and Healthify will
implement an immersive integration using Healthify’s application programming interfaces (APIs)
which will make it easy for health plans to identify social needs among
their members, identify the right social service providers to address those
needs, coordinate referrals among clinical providers and community resources,
and track outcomes. The integration is scheduled to launch in December 2020
with GuidingCare Version 8.14.
“Health plans rely on care management platforms to coordinate healthcare services for members. This is especially important for people who either have or are at risk for developing complex medical conditions. However, previous care management technologies have primarily focused on clinical care,” said Manik Bhat, Founder and Chief Executive Officer of Healthify. “SDoH significantly impact health outcomes as well, and it’s imperative that they are not overlooked as part of whole-person care. We are proud to collaborate with Altruista to incorporate SDoH into care management strategies to improve member outcomes by simultaneously addressing both clinical and social needs.”
This question initially brings to mind many possibilities such as connection to the latest 5G cellular service, a new super-fast internet provider, or maybe one of the many new energy suppliers jockeying for market share from traditional utility companies. While all of these might represent legitimate opportunities to improve one’s community, here we are talking about a different concept; specifically, whether your community is ready to have a Connected Community of Care (CCC) to advance whole-person health.
The image of a CCC may seem obvious. After all, we all live in communities where we have some connections between hospitals, physician practices, ambulatory care centers, and pharmacies to name just a few. But here we are talking about a broader sense of connected community that includes not just health care organizations, but social service organizations, such as schools and civic organizations and community-based organizations (CBOs) like neighborhood food pantries and temporary housing facilities. A true CCC links together local healthcare providers along with a wide array of CBOs, faith-based organizations, and civic entities to help address those social factors, such as education, income security, food access, and behavioral support networks, which can influence a population’s risk for illness or disease. Addressing these factors in connection with traditional medical care can reduce disease risk and advance whole-person care. Such is the case in Dallas Texas, where the Dallas CCC information exchange platform has been operating since 2012. Designed to electronically bring together local healthcare systems, clinicians, and ancillary providers with over a hundred CBOs, the Dallas CCC provides a real-time referral and communication platform with a sophisticated care management system designed and built by the Parkland Center for Clinical Innovation (PCCI) and Pieces Technologies, Inc.
Long before this information exchange platform was implemented, the framers of the Dallas CCC came together to consider whether Dallas needed such a network and whether the potential partners in the community were truly ready to make the commitments needed to bring this idea to fruition. As more and more communities and healthcare provider entities realize the tremendous potential of addressing the social determinants of health by bringing together healthcare entities and CBOs and other social-service organizations, the question of community readiness for a CCC is being asked much more often. But how do you know what the right answer is?
Before looking at the details of how we might answer this, let’s remember that a CCC doesn’t don’t just happen in a vacuum. It requires belief, vision, commitment― and above all― alignment among the key stakeholders. Every CCC that has formed, including the Dallas CCC, begins with a vision for a healthier community and its citizens. This vision is typically shared by two or more large and influential key community stakeholders, such as a large healthcare system, school district, civic entity, or social- service organization like the United Way or Salvation Army.
Leaders from these organizations often initially connect at informal social gatherings and advance the idea of what if? These informal exchanges soon lead to a more formal meeting where the topic is more fully discussed and each of the participants articulates their vision for a healthier community and what that might look like going forward. This stage in the evolution of a CCC is perhaps the key step in the transformation process, as while all stakeholders will have a vision, achieving alignment among those visions is no small feat. Many hopeful CCCs never pass this stage, as the stakeholders cannot come to an agreement on a common vision that each can support. For the fortunate few, intrinsic organizational differences can be successfully set aside to allow the CCC to move forward.
It’s at this point in the CCC’s evolution that details begin to matter in truthfully answering the question, “Is this community ready to be connected?” While there may be agreement among the key stakeholders on a vision, the details around readiness may still divert or delay the best-laid plans. It is safe to say that the key to understanding a community’s readiness to form a CCC lies in the completion of a formal, comprehensive, and transparent readiness assessment.
A readiness assessment is a process to collect, analyze, and evaluate critical information gathered from the community to help identify actual clinical and socio-economic needs, current capabilities and resources (including technology), and community interest and engagement. Taken together, a comprehensive readiness assessment can help identify a community’s strengths and weaknesses in preparation for establishing a CCC.
A readiness assessment is not a tactical plan for building a CCC, nor is it a governance document that provides how all members of the CCC will relate to each other. Instead, the readiness assessment provides communities interested in establishing a CCC with an honest and unbiased yardstick to measure preparedness. Conducting and using the results of the readiness assessment is one of the best ways to ensure a successful CCC deployment.
A typical CCC readiness assessment covers five areas: (1) community demographics; (2) clinical areas of need (including trends); (3) social areas of need (including trends); (4) technology competency (e.g., what percent of the potential network participants are computer literate?), availability (e.g., what percent of the potential network participants have internet access?), and suitability (e.g., is the internet access, high speed?); and (5) what are the needs of potential network participants and can these be modeled as use cases for the information exchange network? This information is essential to help key stakeholder decision-makers decide to move forward with establishing a CCC and to know what specific challenges may lie ahead.
The collection of this essential information can be done in a number of ways, such as making use of existing publicly reported data or conducting surveys, interviews, focus groups and town hall meetings with community leaders and residents and clinical and CBO leaders and staff. Experience conducting the readiness assessment that provided the foundation for the Dallas CCC showed that no single information-collection method was sufficient to collect the necessary level and robustness of the data. In Dallas, we utilized all five approaches but found that in addition to researching publicly available data, initial surveys, followed by interviews and focus groups, yielded the most voluminous and reliable information to chart the course ahead.
In addition to the various methods to collect this essential information, the key to obtaining useful and reliable information requires a sufficient number of respondents/participants who are drawn from various organizations and organizational levels. Simply put, you must have a large enough sample and you must have diversity within the sample. It’s not enough to just interview leaders of potential network participants, as their understanding of the needs, trends, and capabilities may look very different from that of frontline staff.
Similarly, surveying only one category of potential network participants may not provide enough information to fully understand the socio-economic needs in the community or even the perspectives surrounding the prevalence of chronic conditions. Beyond the qualitative methods involved, it is important to note that if done right, this process takes a lot of time to complete. Cutting corners by reducing the sample size, for example, or doing selective sampling to speed the readiness assessment process along will only cause problems later when this insufficient information results in erroneous decision-making.
Once the data has been collected, it is important to carefully analyze what the data is trying to tell you. Results of the readiness assessment must be shared openly and honestly with all key stakeholders, particularly those serving in a governance capacity. The governance group (a topic for another day) that has formed in parallel with the readiness assessment must be able to evaluate and understand the main messages from the readiness assessment to make an informed decision as to whether to move forward with establishing a CCC.
Like the need for alignment around the key stakeholder’s vision for the CCC, there must be universal agreement by the key stakeholders as to the message of the readiness assessment and its implications for the road ahead. As with the vision alignment stage, substantive disagreements among the group at this stage are a sign of trouble ahead unless differences can be resolved.
At this point, you might be thinking that this all seems very complicated and fraught with potential land mines waiting to derail your effort to answer the original question “Is your community ready to be connected?” Again, I would emphasize the importance of unwavering commitment and alignment to achieve the vision. But I would also offer advice gleaned from working in the CCC space for the last eight years, which is to get help early and don’t wait until the horse is out of the barn!
We have seen first-hand many communities and consultants approach the conduct of a readiness assessment with a cavalier attitude, often exemplified by the statement, “we already know all of this,” only later to have to backtrack their pronouncements at substantial additional cost in time and resources. Fortunately, today there are a number of excellent organizations, including PCCI, with the experience, credibility, and integrity in the CCC space to help you on this journey. Don’t be afraid to seek them out. It will be a wise investment that you will not regret, particularly when you begin to see the results of improved whole-person health and well-being in your community.
The COVID-19 pandemic is not just a medical crisis. Since the highly contagious disease hit American shores in early 2020, the virus has dramatically changed all sectors of society, negatively impacting everything from food supply chains and sporting events to the nation’s mental and behavioral health.
For some people, work-from-home plans and limited access to entertainment are manageable obstacles. For others, the shuttered schools, lost wages, and social isolation spell disaster – especially for individuals already living with socioeconomic challenges.
The social determinants of health have always been important for understanding why some populations are more susceptible to increased rates of chronic conditions, reduced healthcare access, and shorter lifespans. COVID-19 is throwing the issue into high relief.
Now more than ever, healthcare providers need to gain full visibility into their populations and the non-clinical challenges they face in order to help individuals maintain their health and keep their communities as safe as possible during the ongoing pandemic.
Exploring correlations between socioeconomic circumstances and COVID-19 vulnerability
Clinicians and researchers have worked quickly to identify patterns in the spread of COVID-19. Early results have emphasized the danger posed by advanced age and preexisting chronic conditions such as obesity, diabetes, and heart disease.
Further, data from the Johns Hopkins University and American Community Survey indicates that the infection rate in predominantly black counties is three times higher than in mostly white counties. The death rate is six-fold higher.
Data from the Centers for Medicare and Medicaid Services (CMS) confirms the trend: black Medicare beneficiaries are hospitalized at a rate of 465 per 100,000 compared to just 123 per 100,000 white beneficiaries. Hispanic Medicare beneficiaries had 258 hospitalizations per 100,000, more than double the white population’s hospitalization rate.
Researchers suggest that the social determinants of health may be largely responsible for these disconnects in infection and mortality rates. Racial, ethnic, and economic factors are strongly correlated with increased health concerns, including longstanding disparities in access to care, higher rates of underlying chronic conditions, and differences in health literacy and patient education.
Leveraging data-driven tools to identify vulnerable patients
Healthcare providers will need to take a proactive role in identifying which of their patients may be at enhanced risk of contracting the virus and experiencing worse outcomes from the disease.
They will also need to ensure that person gets adequate treatment and participate in contact tracing efforts after a positive test. Lastly, providers will have to ensure their public health reporting data is accurate to inform local and regional efforts to contain the disease.
The process begins by developing confidence in the identity of each individual under the provider’s care. Healthcare organizations often struggle with unifying multiple electronic health record (EHR) systems and other health IT infrastructure, resulting in medical records that are incomplete, inaccurately duplicated, or incorrectly merged.
Access to current and complete medical histories is key for highlighting at-risk patients. An enterprise master patient index (EMPI) can provide the underlying technical foundation for initiating this type of population health management.
EMPIs help organizations create and manage reliable unique patient identifiers to ensure that records are always associated with the correct individual as they move throughout the healthcare system.
When paired with claims data feeds, health information exchange (HIE) results, and interoperability connections with other healthcare partners, EMPIs can bring a patient’s complete healthcare status into focus.
This approach ensures that providers stay informed about past and present clinical issues and service utilization rates. It can also support a deeper dive into the social determinants of health.
Combining EHR data with standardized data about socioeconomic needs can help providers develop more comprehensive and detailed portraits about their patients’ holistic health status.
By including this information in EHRs and population health management tools, providers can develop condition-specific registries to guide outreach activities. Providers can deploy improved care management strategies, close gaps in care, and connect individuals with the resources they need to stay healthy.
Healthcare organizations can acquire socio-economic data about their communities in a variety of ways, including integrating public data sources into their population health management tools and collecting individualized data using standardized questionnaires.
Once providers start to understand their patients’ non-clinical challenges, including the ability to avoid situations that may expose them to COVID-19, they can begin to prioritize patients for outreach and develop personalized care plans.
Conducting effective outreach and interventions for high-needs patients
COVID-19 has taken a staggering economic toll on many families, including those who may have been financially secure before the pandemic. Routine healthcare, prescription medications, and even some urgent healthcare needs are often the first to fall by the wayside when finances get tight.
Healthcare providers have gotten creative about staying connected to patients through telehealth, drive-in consults, and other contactless strategies. But they must also ensure that their vulnerable patients are aware of these options – and that they are taking advantage of them.
Contacting a large number of patients can be challenging since phone numbers, emails, and home addresses change frequently and are prone to data entry errors during intake. Organizations with EMPIs can leverage their tools to ensure contact information is up to date, accurate, and associated with the correct individual.
Care managers should prioritize outreach to patients with complex medical histories and known clinical risks for vulnerability to COVID-19. These conversations are a prime opportunity to collect social determinants of health information or refresh existing data profiles.
Looking to the future of healthcare in a COVID-19 world
Combining technology-driven strategies with targeted outreach will be essential for healthcare organizations aiming to provide holistic support for their populations during – and after – the COVID-19 pandemic.
By developing certainty about patient identities and synthesizing that information with data about the social determinants of health, providers can efficiently and effectively connect with their patients to offer much-needed resources.
Taking a proactive approach to addressing the social determinants of health during the outbreak will help providers maintain relationships with high-needs patients while building new connections with those facing unanticipated challenges.
With a combination of population health management strategies and innovative technology tools, healthcare providers and public health officials can begin to view the social determinants of health as a fundamental component of the fight against COVID-19.
Andy Aroditis, is CEO of NextGate, the global leader in healthcare enterprise identification.
– Independence Blue Cross and Signify Health launches
social determinants of health network, CommunityLink to connect data from multiple
CBOs to integrate social directly into medical care in the Philadelphia area.
– CommunityLink represents one of the first examples
nationwide of combining in-home health with social care.
Independence Registered Nurse Health Coaches, Signify Health
social care coordinators, and local community-based organizations are now all
connected via the CommunityLink network and are able to coordinate on behalf of
Independence Medicare Advantage members and other people throughout the region
for non-medical services. Starting in 2021, clinicians and other healthcare
providers will be able to use CommunityLink to refer patients as well.
Independence and Signify Health are now among the first in
the nation to have designed a community-based network that combines management
of social determinants of health with in-home health visits. The new
community-based network expands Independence’s existing relationship with
Signify Health, which sends clinicians into the homes of Independence Medicare
Advantage members to assess overall health, facilitate the management of
chronic conditions, and provide diagnostic and other clinical services.
By using Signify Health’s privacy-enabled collaboration platform, organizations can leverage CommunityLink to safely and securely collaborate, share, and track an individual’s whole-health needs longitudinally across different care settings to address their social determinants of health. This gives Independence – as well as other community-based organizations that may be referring to CommunityLink – the ability to track and measure an individual’s whole-health needs over time as they interact with multiple social and clinical providers and community organizations.
“Creating a more equitable health care system includes acknowledging that health not only happens in the doctor’s office, but in our members’ homes and communities. That is why we are so pleased to work with Signify Health on developing CommunityLink,” said Daniel J. Hilferty, Independence Blue Cross President and CEO. “We will be able to identify obstacles our members may be facing and offer solutions that are available to them right where they live through this new network.”
In rearchitecting the system by training every care provider in every specialty, and enable lower-cost providers and communities, we will provide a new model of care where a physician isn’t the person who helps us when we’re sick — they help us be healthy.
With just a few clicks, patients can book appointments, speak to their doctor, access billing information and pay for care, all without leaving their homes. Online health services have been a lifesaver for many during the pandemic, and the reliance on digital tools has sky-rocketed over the last few months. But for some older consumers who may be less comfortable using digital devices, this shift towards “healthcare from home” feels daunting and isolating.
Many seniors are not immersed in the digital culture and navigate life just fine without a touchscreen. The sudden shift in healthcare delivery channels has demanded many to venture into unfamiliar technology in a rushed and urgent manner. Others face barriers related to things like dementia, hearing loss and vision loss.
Closing the digital divide
Whatever their age, those left out of the digital loop face a higher risk of missed appointments, delayed care and anxiety about how to get tests and treatment. Providers will want to ensure that all of their digital offerings are designed to help patients of every age access care in a way that works for them. That means creating a consumer experience with pathways and channels to suit different patient needs and expectations, including “analog” options for those who aren’t inclined to learn new technologies.
4 ways to make digital health technology more senior-friendly
1. Use data to determine what’s working and what’s not
The starting point for providers who want to improve seniors’ digital engagement is to understand how they’re actually using it (or not) right now. Non-clinical data can give insights on technology engagement, lifestyle and socioeconomic circumstances across all ages in a patient population. When providers know what patients are looking for, and where the gaps are, they can tailor their services to meet their patients’ needs.
For example, let’s say a proportion of an organization’s older members have smartphones or tablets, but aren’t using them to access their patient portals. It’s likely they have the skills so but may not be aware of the service. This can be solved with a simple omnichannel outreach campaign to provide step-by-step instructions explaining how to get started.
One way for providers to capture useful data is with “Z codes” — the ICD-10-CM codes included in categories Z55-Z65. These identify non-medical factors that may influence a patient’s health status. Utilizing Z codes will enable better tracking of seniors’ needs and identify solutions to improve their health and wellbeing.
Providers can also leverage data to better understand seniors’ activity in the continuum of care. Are older patients continually presenting for care at a facility that is out of network? A tool like MemberMatch can deliver these insights in real time, alerting care teams as early as possible so that they can rally around active episodes of care proactively and efficiently. This helps risk-bearing organizations optimize the quality and cost of member activity in the continuum of care, leading to better outcomes for patients and a better bottom line for organizations responsible for their health.
2. Give patients choices about how they access services
Adoption of healthcare technology is increasing among older adults: 76% of over 50 say they welcome services to help them “age in place”, or live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level. At CareMount Medical, 27% of primary care appointments made using Experian Health’s online scheduling tool are initiated by those aged 60 and over. The demand is there; support should follow.
That said, an omnichannel approach is still important. Given a choice, more than half of people aged 50 and over prefer their health be managed by a mix of medical professionals and technology. This means giving patients the option to easily schedule appointments by phone. Automated outreach and integration, combined with practice management systems, will ultimately make patient scheduling easier.
3. Make virtual care easier to use
More than half of seniors cancelled or delayed appointments due to COVID-19. Despite the promise of safety measures, many are hesitant to return. Virtual care may be the answer.
Providers are quick to learn that telehealth is not a panacea, in particular for the senior population. As some patients may not have the technology and skills to access telehealth, providers may want to consider a hybrid “facilitated telehealth” model where medical professionals visit patients’ homes to help them get set up for telehealth visits.
4. Create a smoother patient financial experience
As older patients become newly eligible for Medicare, many are unclear about their coverage status. To take the burden off the patient, providers should consider a tool such as Coverage Discovery, which allows staff to find MBI numbers quickly. This often proves helpful, particularly for new Medicare beneficiaries who may not have received their MBI card yet.
A way to ease the stress of payments is to offer more transparent pricing so patients know what to expect as they start their healthcare journey. Experian Health’s Patient Financial Advisor gives a breakdown of their bill and payment options, helping them feel financially confident and more in control of their ability to pay – resulting in fewer collections issues.
As older patients become more accustomed to paying for other everyday items through their smartphones or laptops, online patient payment solutions will become less foreign and more convenient, allowing them to manage medical payments in a time and place that suits them.
It’s never been more important to help older patients stay connected, access care and feel supported during their healthcare journey. Contact us to explore how Experian Health’s solutions can help you close the digital divide.
– Bridge Connector raises $25.5 million in Series B funding to advance interoperability layer for healthcare organizations as demand for integrated health data intensifies during COVID-19 pandemic.
– The investment will support the growth of Destinations,
the company’s new integration-platform-as-a-service (iPaaS) that connects
health data systems using use-case-based interoperability blueprints to speed
integrations with major vendors.
a Nashville, TN-based interoperability company changing the way health care
communicates, today announced it has raised $25.5 million in Series B funding led
by Axioma Ventures. The round was also joined by all existing investors,
including veteran investor Jeff Vinick, and brings Bridge Connector’s total
funding to over $45 million.
COVID-19 Underscores Growing Demand for Integrated Health
The last decade has seen an explosion of digital health platforms and the U.S. health care system has taken incremental steps toward achieving interoperability between them. In March, the Department of Health and Human Services (HHS) issued new rules that force formerly closed vendor solutions to become interoperable.
However, the COVID-19 pandemic has exposed the urgent need for data liquidity as healthcare providers across the country have struggled to share essential patient information and provide comprehensive care via remote delivery methods such as telehealth. In the face of the pandemic’s disproportionate effect on minority communities, the industry has also recognized the critically important role that social determinants of health — the environments in which we are born, live and work — play in our overall well-being and the need to make this information available to health care providers.
A True Interoperability Layer for Healthcare
Founded in 2017, Bridge Connector provides a suite of vendor-agnostic integration solutions and a full-service delivery model, helping health care vendors, providers, and payers more easily share data between disparate systems, such as electronic health records (EHRs) or patient engagement solutions. The company’s technology is designed to democratize health care by allowing organizations of any size to equitably connect data systems and empower care teams with the most accurate patient data in real-time. Unlike other health care interoperability vendors, Bridge Connector’s unique approach does not lock customers into a forced data model or proprietary APIs, instead of employing a vendor-agnostic integration layer that works across data models without the need for standardization.
The investment will further support the company’s increasing
market share in healthcare interoperability and growth of Destinations, a new
integration-platform-as-a-service (iPaaS) that connects health data systems
using use-case-based interoperability blueprints to speed integrations with
Recent Integrations with Key HIT Stakeholders
The new funding comes shortly after Bridge Connector finalized various collaborations with some of the most influential stakeholders in health IT, including Epic, Allscripts, and Salesforce, as well as other system integrators such as MuleSoft. Those collaborations represent calculated steps toward creating a centralized hub of integration solutions for all data platforms that any health care provider or payer can access. The average hospital today uses approximately 16 disparate electronic health records platforms that limit data sharing within the walls of a single hospital, let alone between separate hospitals.
– Innovaccer launches a perioperative
optimization solution for surgeons to realize clinical and financial goals with
– The solution redefines surgical planning and
post-surgical recovery with machine learning-based patient stratification for
optimized surgery experience and personalized patient care management.
Innovaccer, Inc., a San Francisco, CA-based healthcare technology company, recently launched its perioperative optimization solution for health systems. The solution optimizes surgeries and ramps up volumes by identifying high-risk patients for pre-surgical intervention while reducing the length of stay, readmissions, and cost. The solution uses advanced analytics and machine learning-based algorithms to proactively identify patients at greater risk for post-surgical complications. Patients are then referred to the pre-surgical optimization clinic for pre-surgical strategies which are personalized for individual patients and specifically designed to minimize post-surgical complications.
Impact of COVID-19 on Elective Surgeries, Non-Essential
has challenged traditional healthcare delivery systems and caused the
postponement of elective surgeries and other non-essential medical care. As
patients wait for their surgeries, it is likely their conditions could
deteriorate and/or patients would return to clinics during a pandemic surge.
Health systems will need to be prepared to address the potential for more
complicated patient health conditions with careful risk assessment.
Pre-Surgical Optimization Platform Features
Innovaccer’s “Pre-Surgical Optimization” solution guides patient prioritization based on an algorithm that factors medical history, patient demographics, allergies, chronic conditions, history, and social determinants of health. Based on the previous data on these patients from the electronic medical record, claims, and the individual’s risk factors, the algorithm estimates the future cost of care for the patient. The algorithm also assigns patients to appropriate case managers using a smart rule engine that assesses a variety of factors including the number of appointments, and the surgeon’s expertise to map the patient to the provider. This approach helps hospitals identify high-risk patients and focus on the patients that will benefit most from pre-surgical interventions.
Return on Investment Model for Healthcare Organizations
Innovaccer has also incorporated a refined return on
investment model designed to make the optimization process revenue positive for
healthcare organizations. The three key pillars of the exclusive model are
sensitivity analysis tools, deep data insights, and performance analytics.
Using this solution, hospitals can track their return on investment in
real-time on a customizable dashboard with metrics including reduced
readmissions, reduced length of stay, and emergency department visits with
their associated costs.
“With about 28 million surgeries canceled worldwide, non-COVID medical care has suffered tremendously. Canceled elective surgeries have impacted patient health conditions and the economic sustainability of health systems,” says Abhinav Shashank, CEO and Co-founder of Innovaccer. “As health systems plan to resume surgical procedures, care managers will need to engage the patient remotely for pre-surgical interventions. Our solution is created to redefine the entire process of optimizing surgery planning and to become more patient-centered and adaptable to the changing care environment. We want to ensure exemplary pre-optimization and post-discharge engagement to reduce readmissions and improve the hospital’s financial impact using the pre-surgical optimization process.”
– Geisinger inks a partnership Aunt Bertha to launch a
new social care platform, Neighborly for Pennsylvania residents.
– Powered by Aunt Bertha, Geisinger’s Neighborly platform provides residents in Pennsylvania the ability to easily search and connect with organizations that provide social services including food, housing, childcare, transportation, utility assistance, healthcare, financial assistance, and other needs.
Geisinger, one of
the nation’s largest health service organizations has announced a partnership
with Aunt Bertha, a
search and referral platform of social service organizations to support the
launch of Geisinger’s new social care platform, Neighborly.
Growing Importance of Social Determinants of Health
determinants of Health – such as where people live and work – play a
significant role in a person’s overall wellbeing. Ensuring individuals have
access to the proper social care services is key to any healthcare effort – yet
navigating the web of providers and coordinating care for patients is often a
challenging process. That’s why Geisinger is now partnering with Aunt
Bertha to help healthcare providers streamline the process of connecting
patients with vital social services.
How Neighborly Works
Powered by Aunt Bertha, Geisinger’s Neighborly platform
provides residents in Pennsylvania the ability to easily search and connect
with organizations that provide social services including food, housing,
childcare, transportation, utility assistance, healthcare, financial assistance
and other needs. The platform also helps social care providers more easily and
effectively coordinate care for clients in need of multiple forms of social
assistance. With Aunt Bertha’s technology, organizations can now provide a
simple and easy path to refer patients to free and reduced-cost services in
their local communities. Since 2015, nearly 130,000 Pennsylvanians have used
Aunt Bertha to connect to social services.
Why It Matters
Currently serving more than 3 million residents throughout
central, south-central, and northeastern Pennsylvania — as well as counties in
southern New Jersey — Geisinger has long been a leader in defining strategies
for addressing social determinants of health (SDoH) such as where individuals
live, work, and socialize. After exhaustive research into the social care
landscape and all available solutions over a two-year period, Geisinger
selected Aunt Bertha to create their new community resource network. After
initially planning for a community-by-community rollout of the platform across
an 18-month timeline, the healthcare provider realized it needed to rapidly
accelerate its deployment in the wake of COVID-19 and its impact on
Pennsylvania communities. With Aunt Bertha’s experience and understanding of
the social care landscape in Pennsylvania, as well as its extensive nonprofit
network that was already in place in Pennsylvania, Geisinger was able to move
swiftly from a pilot in Lackawanna County to a social care platform available
to every community in just 18 days.
Pilot Phase Results
Following the launch of the platform’s pilot phase in March
this year, more than 2,400 neighbors have been able to connect with, and
benefit from, social care providers on Neighborly in just a 4-month period.
Even in its early stages, the platform is changing the way Geisinger cares for
its patients, serves its members, and partners with the community. Search data
on the platform provides new insights on the services Pennsylvanians need the
most, uncovers coordination gaps that currently exist, and guides the
allocation of resources.
“Neighborly opened its doors in March amid a global pandemic with a laser focus on making it easy for our neighbors to connect with the resources they need close to home,” said Brian Ebersole, Senior Director of Springboard Health at Geisinger, “the partnership with Aunt Bertha was the right choice for our communities and our organization.”
– Innovaccer has recently partnered with CareSignal to
address healthcare’s urgent need amidst the COVID-19 pandemic: to create and
maintain solid, clinically actionable relationships with patients in a new set
of predominantly virtual care.
– CareSignal offers evidence-based end-to-end support services for chronic medical conditions such as asthma, CHF, COPD, diabetes, depression, hypertension, and hospital discharge support, and maternal health monitoring.
Innovaccer, Inc., and CareSignal today announce a partnership to address healthcare’s urgent need amidst the COVID-19 pandemic: to create and maintain solid, clinically actionable relationships with patients in a new setting of predominantly virtual care.
The partnership combines more than two dozen
condition-specific patient monitoring programs with population
health data insights for a more integrated care and improved clinical
outcomes with industry-leading financial returns.
CareSignal offers evidence-based end-to-end support services for chronic medical conditions such as asthma, CHF, COPD, diabetes, depression, hypertension and hospital discharge support, and maternal health monitoring. With a focus on prevention and addressing the social determinants of health, each program offers personalized clinically-validated features to deliver even more value from Innovaccer’s population health, care management, and organization-specific offerings.
“Innovaccer has always stayed on top of delivering on promises to our customers, and our partnerships with leading organizations have been instrumental in achieving 100% client satisfaction,” says Abhinav Shashank, CEO at Innovaccer. “Working with CareSignal supports our mission to help healthcare care as one. With CareSignal as our partner, we will strengthen our approach towards better patient engagement and enable smart deviceless remote patient monitoring.”
Healthify, a social determinants of health company
(SDOH), announced a national partnership with Ride Health to offer
transportation to medical and non-medical services for people faced with
– Each year, an estimated 3.6 million Americans do not
obtain medical care due to transportation issues such as cost, lack of access
to vehicles and inadequate public transportation. These barriers are
particularly prevalent among poor communities, people with disabilities and
other disadvantaged populations.
– The new partnership will allow managed care, provider,
and social service organizations to easily request transportation for
individuals to and from medical and social services appointments through Heathify’s
SDOH platform at no cost to patients.
a company that works with payers and providers to create social
determinants of health (SDoH) infrastructures, today announced a national
partnership with Ride Health to offer transportation to
medical and non-medical services for people faced with transportation barriers.
The collaboration will enable managed care, provider and social service
organizations to easily request rides for patients to doctor’s appointments, screenings,
lab visits and other non-acute medical services, as well as transportation to
support social needs, such as transportation to food banks, job training
programs, childcare facilities and mental health providers, via the Healthify
Through this new
offering, managed care, provider, and social service organizations will be able
to easily request transportation for individuals to and from medical and social
services appointments via the Healthify SDoH platform. The platform
automatically matches a patient’s needs to select the best driver and vehicle,
monitoring each ride in real-time to prevent potential ride disruptions and
ensure a seamless ride experience. Ride Health’s comprehensive network of
transportation providers include standard curbside services such as taxis and
ride-hailing services as well as specialized medical transportation including
COVID-19 transportation, wheelchair-accessible vehicles, stretcher vans and
non-emergency ambulances. The service is available at no cost to patients.
“Maintaining access to care – both medical and social – is more important than ever as growing numbers of people struggle to stay safe and healthy during the COVID-19 pandemic,” said Imran Cronk, CEO and Founder of Ride Health. “We are proud to collaborate with Healthify to help healthcare organizations improve care for at-risk populations by providing safe, dependable transportation for patients who might not otherwise have the means or ability to access healthcare and social services.”
Safe, Reliable Transportation
Is Fundamental to Social Determinants of Health
Each year, an
estimated 3.6 million Americans do not obtain medical care due to
transportation issues such as cost, lack of access to vehicles and inadequate
public transportation. Transportation
barriers are particularly prevalent among poor communities, people with
disabilities and other disadvantaged populations, and can result in missed or
delayed healthcare appointments, poor management of illnesses and adverse
health outcomes., Transportation
barriers also impact the ability to access much-need non-clinical social
service programs, which puts vulnerable populations
at increased risk.
“Safe, reliable transportation is one of the most fundamental social determinants of health, yet many of the most vulnerable people in our communities struggle to find rides to take advantage of social services and to access routine medical care,” said Manik Bhat, Chief Executive Officer of Healthify. “At Healthify, our mission is to build a world where no one’s health is hindered by their need. Together with Ride Health we can address the transportation barrier at the national level and make a real difference in the lives of people across the country.”
– In the age of COVID-19, healthcare CIOs cite interoperability,
cybersecurity, and operationalizing SDOH data priorities as top three priority
areas, according to the third annual LexisNexis focus group of CHIME
– The survey results also highlighted the importance of
a team approach with support across the organization in helping CIOs
achieve the vision of connected healthcare.
The Health Care business of LexisNexis® Risk Solutions announced
the results of its annual
focus group, comprised of over 20 healthcare IT executives that are members
of the College of Healthcare Information
Management Executives (CHIME). The focus group participants accepted more
accountability than in previous years to provide the safe and
reliable technology tools necessary to deliver high-quality, connected,
and cost-effective care. The survey results also highlighted the importance of
a team approach with support across the organization in helping CIOs
achieve the vision of connected healthcare.
In light of the COVID-19
pandemic, data sharing and security to using data analytics to help vulnerable
populations – have become more urgent in light of the pandemic challenges. For
example, recent months have illustrated the need for data access to inform
decisions about population health, wellness and care capacity.
The surveyed healthcare CIOs identified three main priority
1. Managing interoperability: Members acknowledged
challenges amid the surge of digital touchpoints, such as mobile phones, smart
devices and remote services. Goals include a common patient identifier to combine
and verify disparate patient records for a true health information exchange.
2. Bolstering cybersecurity: Members are confronting
new cybersecurity risks, confusion over who bears the ultimate responsibility
for patient data, and the competing goals of seamless user experience and data
safety. To address that final challenge and strike an appropriate balance,
executives are moving to multifactor authentication strategies for optimal user
workflow and security.
3. Integrating Social Determinants of Health (SDOH):
As the pandemic has highlighted, incorporating SDOH
data is a vital, immediate requirement for improving the delivery of patient
support and value-based care, and ultimately, outcomes. Executives shared SDOH
implementation challenges, including data aggregation and operationalization
within IT and EHR systems, especially when not utilizing third-party data to
support their efforts. While CIOs previously had not perceived specific
accountability for SDOH data, that changed as its value was demonstrated.
“CHIME’s executive health IT members are approaching evolving patient and industry needs with careful consideration, ingenuity and focus,” said Josh Schoeller, chief executive officer of LexisNexis Risk Solutions Health Care. “Our annual focus group presents valuable insights about how healthcare decision-makers are strategically using technology solutions to overcome hurdles regarding cybersecurity, data governance, and interoperability, all of which have become more urgent during the COVID-19 pandemic. It’s a big challenge but with the right data integration and analytics they continue to make great progress even in the face of the COVID-19 pandemic.”
To access the group insights, download the report here.
In comparison to other developed countries, we spend the least amount of money on social care and the most on medical, with the worst overall health outcomes. We must intentionally and strategically reallocate some healthcare dollars to invest in communities.
Health has been selected as the pilot site to participate in the Advancing
Standards for Precision Medicine (ASPM) project.
– The ASPM project
is focused on how healthcare providers can systematically identify the
socio-economic factors that may impact the health of patients in order to
provide more individualized care that reflects patients’ needs.
Fenway Health, a
Boston, MA-based Federally Qualified Community Health Center (FQCHC) dedicated
to making enhancing the wellbeing of the LGBTQIA+ community, people living with
HIV/AIDS and the broader population has been selected as the pilot site to participate
in the Advancing
Standards for Precision Medicine (ASPM) project. Conducted by the U.S. Department of Health and
Human Service’s Office of the National Coordinator for Health Information
Technology (ONC), in partnership with Audacious
Inquiry, the University of Washington’s Clinical Informatics Research Group
and athenahealth, the project aims to develop standards for the
collection of social determinants of health data (unmet needs in areas such as income, educational attainment, employment
status, food security, housing, and more).
Advancing Standards for Precision Medicine Background
Data sharing is critical to realizing the future of
precision medicine. Launched in 2018, the Advancing Standards for Precision
Medicine (ASPM) project works to further the development and testing of
standards for new and diverse types of health data. The ultimate goal is to
make health data easier to share, curate, aggregate, and synthesize.
The project will leverage digital tools and questionnaires
to advance the standardized collection of data. Social determinants of health
play a major role in individual health outcomes. “athenahealth’s
partnerships with Fenway health and others ground us to the realities and
challenges of healthcare today to improve health outcomes” said Kedar
Ganta, athenahealth’s Product Leader for Interoperability Strategy.
“Transforming Patient Care by prioritizing the collection and sharing of
interoperable SDOH data will better identify patient needs and create impact
across the communities”
In fact, patients’ unmet social needs have been found to
account for up to 40 percent of individual health outcomes. Increasingly,
health care organizations are focused on addressing these needs to help improve
treatment and care in a way that addresses the whole patient.
EHR Data Collection Approach
Fenway Health will employ their current web-based assessment
tool, ePRO, which was developed by the University of Washington’s Clinical
Informatics Research Group (CIRG), as a prototype for testing and transmitting
the systematic capture of SDOH data, as well as ASPM’s proposed standards and
implementation guides as part of their effort. That data will then be sent to
athenahealth, Fenway Health’s electronic health record (EHR) vendor, and be
incorporated into the patient’s health record in a standardized format.
“Standardizing SDOH data and incorporating that information into the EHR along with other patient-reported outcomes, allows health care providers to better understand the context in which their patients live and what they experience, and helps providers offer more personalized and relevant care”, said Dr. Bill Lober, Professor at the University of Washington, and director of CIRG.
Pilot Project Timeline
The ASPM project is set to last through the Fall of 2020 and
will culminate in an evaluation report to be shared with ONC and the National
Institute of Health (NIH). The evaluation will be used to identify challenges
in data collection and sharing between health care providers and to develop
solutions that will lead to better implementation of collection initiatives and
protocols in the future.
The project hopes to expand the types of data that can be
integrated into EHRs
to create a more complete picture of the patient that would reflect the
patient’s practical reality and the issues that may impact their health in the
future. Ultimately, the project’s goal is to give health care providers the
data and tools needed to provide patients with individualized treatment and to
help them achieve better outcomes.