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Social determinants of health (SDOH) are deeply integrated with clinical care at San Mateo County Health in San Mateo, CA, says Eric Raffin, FACHE, CHCIO, chief information officer. The county has about 130,000 Medi-Cal recipients, well over 10% of the population.
“In addition to providing standard medical services at multiple locations across the county, we are intrinsically tied to our behavioral health and recovery services program, which covers the range of mild to moderate mental illness through severely mentally ill patients who have very specialized needs and through to our alcohol and drug programs,” Raffin says. “We also have nonmedical, nonbehavioral social support structures like services for seniors, pregnant women, and kids with disabilities.”
Many patients are co-managed between, for example, a medical center and a behavioral health recovery organization in the community, Raffin explains.
“We had no way to understand who was co-managed because we had a very traditional best-of-breed working environment with four electronic health records, two case management electronic systems for behavioral management, and none of them really interoperated,” he says. “So, we had to start with getting all the stakeholders at the table to get on board with the idea that if we could first exchange information internally, then we could provide a richer experience for both day-to-day operations and decision-making, but also for strategic planning and care coordination. That is especially beneficial for our most complex clients, who tend to be co-managed between our medical area and behavioral health area.”
That led to formalizing an internal health information exchange (HIE) that went live in April within the organization, Raffin explains. A significant health information governance project produced a HIE that can provide broad patient information to clinicians, social workers, and care coordinators. The project involved hundreds of hours of measuring workflow processes at multiple sites, from the hospital emergency department to behavioral health clinics and the local jail. “There were great opportunities to inject social determinants of health information in our nonclinical environments and make them part of the HIE,” Raffin says.
The HIE includes information about members who are incarcerated in the county jail, for instance. When that person is incarcerated, that encounter appears in the HIE, Raffin says. The information is publicly available, but the HIE automatically manages it, and anyone authorized to access the HIE can factor the incarceration into care treatment plans or offer resources.
Raffin and his colleagues also realized that the HIE could reflect whether the member is conserved, an important point to know because conservatorship can affect whether the person is able to make decisions about healthcare and financial issues.
“We realized we had that information because we manage that process for the county. So, we now bring in data on whether the client is conserved, as well as the conservator’s contact information,” he says.
The San Mateo HIE is moving into the optimization phase that will involve connecting it to external networks across the state. The goal is to improve quality of care for patients who transferred out of the San Mateo system to a specialty center, for instance, or who show up in another county’s hospital ED, Raffin explains.
“Another big improvement was that we are now getting the same information from our behavioral health and recovery centers as we do from our hospitals clinics. When you look at a diagnosis summary, or medications or lab results, you’re actually seeing a merged set of those that include information from the hospital and the behavioral health centers,” Raffin says. “You don’t see a lot of HIEs out there that include behavioral health information, but in our system, you can pull up someone’s record and see that they are in the middle of a six-month treatment plan for behavioral issues, and you can see all the contact information for the person providing that care.”
For the next step, San Mateo is planning to make it possible to push some of that information from the HIE back into the electronic medical record.
“I think of this HIE as a stepping stone to being what a truly interoperable organization looks like, especially when we’re touching directly on social determinants of health,” Raffin says.
The benefits of the HIE are greatest for parts of the organization that were paper-driven or information-starved, Raffin says. Other departments may have had more access to data, but even then, they might have had to pull up several different screens of information in order to get a complete picture of one patient’s situation, he says.
“It’s still a challenge, because change can be hard when you are accustomed to doing work a certain way,” Raffin says.
“I think the medical community is hungry for this kind of information and will be far more engaged when the external information from outside the county is made available.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.