Care Beyond the Clinic: Public Health Lessons from Electronic Health Record Data
Up to 80 percent of family physicians are expected to use electronic health records (EHRs) by the end of this year, and experts across the country are talking about ways to leverage this influx of data to inform better health. A pre-conference workshop at the National Association of County and City Health Officials (NACCHO) Annual Meeting focused on Beacon Communities, which are part of a pilot to demonstrate how meaningful use of EHRs can lead to better health and better health care at a lower cost. The HHS Office of the National Coordinator for Health IT is providing $250 million over three years to 17 selected communities throughout the United States where numerous institutions are sharing data to inform quality improvement and other data-informed efforts.
The NACCHO meeting highlighted Beacon communities that are partnering with public health in different ways to forge data-informed population health activities.
Health departments in North Carolina have been required to do community assessments since 2002 as part of a statewide health department accreditation program and are very experienced with working with this data, whereas hospitals are just now beginning to be required to do similar assessments under the affordable care act, according to John Graham, PhD, PMP, Senior Investigator for the NC Institute for Public Health at the Gillings School for Global Public Health, which plays an integral role in the Southern Piedmont Beacon Community.
“Health assessment planning and communication are tools that can be leveraged to foster more collaboration,” said Graham. “We really try to coordinate public health prevention and health care. We can do a lot with clinical interventions, looking at it from a population health perspective.”
And the assessment data is richer when fed by clinical data through EHRs. This data lets health officials track health status changes longitudinally and by community. “The more effectively we can geographically target an intervention, the better we can use our limited funds,” Graham said.
The North Carolina health assessment paired a look at population health data, including County Health Rankings and Healthy People 2020, with clinical data from across area hospitals and clinics. With this aggregation of data, they were able to map indicators like number of emergency department visits by Medicaid recipient by county and identify areas of need.
As a result, the health department helped to develop and implement the ANNA module, an interactive digital kiosk that offers a virtual discussion with an “avatar”—an onscreen fellow mother who asks the participant questions and provides them with custom answers on a variety of topics, including help with using complex WIC vouchers, healthy eating, breastfeeding and more. Not only is the health education experience highly customized, but it also captures important data that can be fed to WIC staff so they can provide more in-depth help where it’s needed. Anna is also bilingual and introduces herself as a fellow WIC participant, and the conversation is delivered in a way that it feels more like a chat with a peer who is modeling very healthy behaviors.
>>Watch a video demo of the ANNA program [MP4].
>>Read more about ANNA on NACCHO's ePublic Health blog.
In the Southest Minnesota Beacon Program, among other efforts is a program to help provide real-time access to pediatrician-prescribed action plans to school nurses by linking data systems. The technology was not the only factor in implementing this effort, though. A community assessment revealed that out of 47 school districts, fewer than 100 asthma action plans were in the hands of school nurses. “That was unacceptable,” said Daniel Jensen, MPH, Associate Director of the Olmsted County Public Health Department.
There were major perceptual and logistical barriers on the part of schools, nurses and pediatricians alike. Through a community assessment process, the health department revealed that school nurses felt very disenfranchised—they were un-empowered by the schools and felt that trying to secure health in a place where the focus is education was very difficult. They also weren’t connected to the clinical world. Physicians for their part didn’t want to use asthma action plans because they thought no one used them, and it was extra busy work on top of already overworked caseloads. The health department worked hard to engage all of the stakeholders as a community. They helped the school nurses to create a newsletter, which led to them feeling more empowered and connected, and doctors started to realize the critical need for asthma action plans. They also helped tell the story that healthy students are better learners, and many school days are lost because of uncontrolled, preventable asthma events, which got school administrators on board with the project.
Once the community was on board, the health department began a laborious effort to get the number of asthma action plans in school nurses’ offices into the thousands —but at the start it was a manual and inefficient process. Technology was challenging, when there was a vast range of technological capabilities and data systems across schools in different districts. Through the Beacon Program, the group helped to create the Kids eHealth Portal, which led to a much more rapid deployment of the system.
Finally, Terrisca Des Jardins, Director of the Southeast Michigan Beacon Community, shared her community’s experience linking public health and clinical care. They piloted a spin on a community health worker program that embedded the lay navigators as part of the care team in the clinic itself, instead of out in the community, to help diabetic patients address anything standing in the way of self-management—from childcare to securing an affordable refrigerator for medications. The group opened the three-week training for community health worker positions to the community, and as a result were even able to work with the health department to help trainees that didn’t make it into the Beacon program to find positions in other community health worker positions throughout the city. Community health workers were also, critically, paid a living wage.
Outcomes for patients after participating in the program included improved medication adherence, healthier food choices and more physical activity, and checking blood sugar appropriately.
“We’re trying to see how public health can effectively become a part of accountable care models—and to do that, we have to demonstrate our value in the equation,” said Graham.