Leveraging User-Centered

Technology to Improve

Health Outcomes

July 13, 20173:30 p.m. – 4:30 p.m. ET

All In Project Showcase Webinar

We are All In!

COMMUNITY HEALTH PEER LEARNING PROGRAM

NPO: AcademyHealth, Washington DC

Funded by the federal Office of the National Coordinator

15 former grantees

BUILD HEALTH CHALLENGE

Funded by 10 national & local funders (including Advisory Board, de Beaumont

Foundation, the Colorado Health Foundation, The Kresge Foundation and

Robert Wood Johnson Foundation)

18 implementation and planning grantees

DATA ACROSS SECTORS FOR HEALTH

NPO: Illinois Public Health Institute in partnership with the Michigan Public Health

Institute

Funded by the Robert Wood Johnson Foundation

10 grantees

THE COLORADO HEALTH FOUNDATION: CONNECTING

COMMUNITIES AND CARE

Funded by the Colorado Health Foundation

14 grantees

All In: Data for Community Health

1. Support a movement acknowledging the social determinants of health

2. Build an evidence base for the field of multi-sector data integration to improve health

3. Utilize the power of peer learning and collaboration

Speakers

Breione St. Claire

Project Director,

Essential Access Health

Karen DeSalvo, MD, MPH, MSc

Former Acting Assistant

Secretary for Health and National

Coordinator for Health IT, HHS

Katie Sendze, MBA

Director of Client Services,

HealthInfoNet

Starting the ConversationJuly 13, 2017

Breione St. Claire, MPH

Project Director

Project Background

This opportunity is made possible by Grant Number TP2AH000023-01-00 from the HHSOffice of Adolescent Health

Selected by the National Campaign to Prevent Teen and Unplanned Pregnancy in partnership with IDEO, an international design company

Innovation Next

Phase I: Use Design Thinking to create an innovative product to

help reduce teen pregnancy

Initial Concept: Custom EHR templates to help pediatric

providers have more comfortable conversations about sex with

their teen patients

Intro to Design Thinking

Design Research

▪ Interviews

▪ Pediatricians (5)

▪ Adolescent Health Specialists

▪ General Pediatrics

▪ Child Abuse Pediatrics

▪ Teens (5)

▪ 14-18 y/o males and females

▪ Peer educators

▪ Non-family planning users

▪ Analogous (2)

▪ Retail sales manager

▪ Real estate agent

Insights - Pediatricians

“If you have three partners before

your spouse, your spouse is not number one.”

“I don’t want parents to feel like

their rights are being taken away.”

“It takes a goodbit of practiceand time for

clinicians to getcomfortable

talking about sex.”

“[EHR] systemauto- populates sex

info into otherpatient visits.”

privacyloopholes

providerbias

comforttakes time

patientvs

parent

Insights - Teens

“Doctors don’t ask these questions!”

“I was slut shamed by my doctor.”

“My peers ask personal questions

via text, not in person.”

“I’m not going to be completely

honest in front of my mom, or if I know she’ll find

out.”

discuss confidentiality

explainwhy

electronicspreferred

fear ofjudgment

How Might We…

…help pediatric providers to have more comfortable conversations with their teen patients?

How can we make doctor visits a more comfortable

experience for clinicians and teens?

What needs to be said/done to elicit honest responses

from teens about their behavior?

Key Product Principles

• Value proposition: This product helps pediatric providers by

increasing their comfort talking about sex with their teen patients.

• Flexibility of use

• Keeps info confidential

• Doesn’t add more work

• Integrates with other systems

Prototyping

Provider Interface Mockup

Patient Interface Mockup

Patient Interface Mockup

SMART on FHIR ( )

SMART – Substitutable Medical Apps, Reusable Technology

FHIR – Fast Healthcare Interoperability Resources

“pluggable apps” that can extend systems with new capabilities

Next Steps

Continue Software and Content Development

Identify pilot testing sites

Questions?

Feel free to contact me directly…

Breione St. Claire, MPH

Project Director

(213) 386-5614 ext. 4620

bstclaire@essentialaccess.org

HealthInfoNet

Maine’s Health

Information Exchange

July 13, 2017

HealthInfoNet Timeline

2004 A statewide study establishes a need and support for an exchange in Maine

2006 HealthInfoNet incorporated with statewide collaboration

2010 Statewide HIE Portal rolled-out to Healthcare Providers

2012 Predictive Analytics & Reporting Tool introduced

2013 Initial Behavioral Health Organizations & Medicaid Claims connect to the HIE

2015 Veterans Administration connected to the HIE

2017 Social Determinant of Health Data available in the HIE

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HIN Proprietary – Not for Redistribution

• All Maine hospitals

• 57 FQHC sites

• 500+ ambulatory sites

- physician practices,

behavioral health and

long term care

facilities

• VA bidirectional

exchange

• All Medicaid Claims

Key HIE Connections- 2017

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• Community Action Agencies (CAA)

• Maine Department of Health and Human Services (i.e. Medicaid)

– Non-emergent transportation services data

– Behavioral health prior authorization & certification data

• FQHC “UDS” social data:

– Housing/migrant worker status

– Use of new SDoH ICD-10 coding available (Z Codes)

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Active SDoH Data Partners

HIE Portal - Community Services

Data Upgrade

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Medicaid Behavioral Health Data

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Examples of new data contributions include:

• Medicaid Health Home (Stage B) Encounters

• State Mental Health Hospital Encounters

• Employment status

Patient HistoryPatient Risk of Event or

Outcome

Risk Model Development

1000s of Patient Features

• Age

• Gender

• Geography

• Income (Census)

• Education (Census)

• Race (Census)

• Diagnoses

• Procedures

• Chronic conditions

• Visit and admission history

• Outpatient medications

• Vital signs

• Lab orders and results

• Radiology orders

Multivariate Statistical Modeling –

Decision Tree Analysis

Machine Learning

Available Risk Models

Population Risk Models

(predicts future 12 months)

• Predicted Future Cost

• Risk of Inpatient Admission

• Risk of ED Visit

• Risk of AMI

• Risk of Asthma

• Risk of CHF

• Risk of COPD

• Risk of CVA

• Risk of Diabetes

• Risk of Hypertension

• Risk of Mortality

Event Based Risk Models

(predicts future 30 days)

• Risk of 30 day Readmission

• Risk of 30 day ED Return

HIE Analytic Predictive Model Design

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Readmission/ED Return Management

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Shows the timing of

each encounter along

with the risk scores

increasing over time.

Risk Score Profile Details

Shows the timing of the

actual cost with predicted

future cost increasing.

Clinical

information and

factors that are

driving the risk

scores.

Individual Patient Risk Summary

Patient Risk Care Management

• 3 Primary Care RN Care Managers responsible for 24,000 patients

• Assess real-time risk scores daily, including risk for readmission, ED visit, disease,

high cost and mortality.

• Practice sets thresholds for each risk category to flag high-risk patients.

• Care managers proactively reach out to high-risk patients to provide education and

manage care gaps.

Low Risk

Med Risk

High Risk

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(HIN) – All Rights

Reserved HIN Proprietary

– Not for Redistribution

31

Future Opportunities for SDoH Data

• HIE Connection with Maine’s HMIS- Homeless

Management Information System

• Combine State Services & HIE EMPI

• Opt-In Structure for “non-covered entity” SDoH

data (example: CAA data)

• EHR use of new ICD-10 Z codes for “Factors

influencing health status and contact with health

services (Z00-Z99)”

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Maine HIE- What works well

1. HIE Interface standards: HL7 v2 discrete data

– Robust standardization process

2. HIE Data Aggregation Model

3. HIE State Designation & Consent Framework

4. Statewide EMPI (MRN’s linked with

demographics/claims etc.)

5. Data flexibility for SDoH (use flat files with

EMPI)

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Strength- Collaboration Framework

1. State law enables consent/trust framework

2. Standard HIE “Participant Agreement”

(includes BAA)

3. Community stakeholders are entrenched

4. State agencies are partners in moving the

needle forward

5. Data “use case” development includes the

customer team

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Connect with Us!

▪ Visit our website: allindata.org

▪ Sign up for news from All In

▪ Follow #AllInData4Health on Twitter

▪ Contact information for speakers

▪ Breione St. Claire: BStclaire@essentialaccess.org

▪ Katie Sendze: ksendze@hinfonet.org

Next Steps

▪ Share Your Feedback

Please complete the evaluation survey following the webinar

▪ Save the Date for the Next Project Showcase Webinar

Wednesday, August 30 from 2:00 - 3:00 pm ET