Population Health Tools Help Unite California FQHC Network

Oct. 15, 2021
Integrated Health Partners of Southern California helps clinicians from nine community health center organizations gain insights into network’s data

Integrated Health Partners of Southern California (IHP), a clinically integrated network of nine community health center organizations with 81 clinical sites, has begun gathering network-level data to help clinicians understand population health trends and see more complete longitudinal records for their patients.

Three IHP executives recently met (virtually) with Healthcare Innovation to describe some of the challenges involved in implementing a population health platform in a community health center setting as well as some of the benefits they are already seeing.

Located in the San Diego-Riverside area, the network is five years old, although Amanda Simmons, executive vice president, described IHP as still in its infancy because 18 months ago it launched a new three-year strategic plan that includes moving even further into value-based contracts.

“We have always been in capitation arrangements with our medical payers, but we are moving into full professional risk agreements,” Simmons said. “We are 96 percent Medi-Cal [California’s version of Medicaid] with four payers. We have two active negotiations with payers to move into full professional risk, and one should be implemented in January, with others to follow soon after. Our goal is to be in the risk environment. We are partnering with health systems and hospitals to talk about concrete solutions on the shared savings side. We're progressing pretty rapidly in that space.”

On the population health front, IHP has been working to unify data from across the nine organizations, said Sarah Cho, vice president for population health management. “We have nine health center members and they're all on different EHRs,” she said. Unifying all the clinics on the same EHR would be nice, but was seen as more of a long-term strategy, Cho added.

“At the network level, there previously wasn't a way to gauge how we were doing collaboratively in a way that was actionable. That was a big gap. Being on different systems, you can't get a glimpse of the population health perspective of the patient across the care continuum,” Cho said.  

The network began looking for a population health data aggregation and normalization platform with the capability to create longitudinal patient records across the care continuum. “We know that patients, especially in this vulnerable population, are jumping from provider to provider, and we weren't getting the feedback from the health plans either — their data really lagged,” Cho said.

IHP chose a population health tool from Arcadia. The implementation consisted of building data feeds from all the EHRs into Arcadia’s data warehouse. IHP also gets several network-level data feeds, including health plan eligibility data and an ADT (admission, discharge, transfer) data feed from the San Diego Health Connect HIE. “Being on the primary care side, having real-time information about hospitalizations is huge,” Cho said. “Now as soon as the patient is discharged, we can work with the health centers on standardizing timely outreach and follow-up.”

Another new tool is a huddle report that clinics can use to see care gaps of patients coming in that day.  

Creating a business intelligence strategy has required developing data-sharing rules and protections. “We had to develop data governance processes and policies, including having an intake process for ad-hoc data and analytics requests, so that we can help the health centers,” Cho said.

She added that they continue to look for opportunities to build the data warehouse with more feeds such as local and state-level immunization registries.

Kristine Ortwine, manager of population health analytics, said IHP wants to work more on issues of social determinants of health and health equity. Tools within Arcadia can help to quantify how you might be able to impact the patient and how much of those factors are outside of the clinic’s walls. Do they have transportation and food insecurity issues? Is there a language or health literacy barrier? “That's the kind of data that we're hoping to begin to leverage,” she said, adding that it is a work in progress. “One of the problems we have with social determinants of health data in particular is it's not usually collected in a standard way. Teams are putting it in spreadsheets or in separate systems that don't necessarily communicate with the EHR or even with our feed into our Arcadia. Several of our health centers are using templates like PRAPARE to collect that data in a more standardized way.”

Ortwine said she couldn’t overstate the amount of support and communication necessary between each of the health centers and the centralized staff to get the population health platform up and running. This is a unifying project that's required resources and commitment, because we have to meet each of these health centers where they are,” she explained.

Previously, the health centers’ quality reporting was really within the four walls of their own organization, and they saw population health more in terms of how patients move across their health center’s own clinics. “If you had asked them at the inception of this project if their patients really go to other health centers within IHP, they all would have said no. But then when we pull the data, they realize there's quite a bit of transference,” she said. “They are beginning to look at network-level data in order to make network-level decisions, and that is a huge cultural change.”

Also, each of the health centers previously had portions of this data available to them in disparate systems. They could log into the HIE and try to find out if their patients were discharged, or they might receive some care gap lists from the payer. But now they have the ability to do all that in concert at once, with a longitudinal record.

Cho and Ortwine stress that data validation is one key to success. “The first thing people do when the data looks different than what they are used to seeing is they say the data are wrong,” Ortwine said. “We continue to spend time validating and improving the quality of the data. It requires water and sunlight so that it keeps growing and stays healthy. We can’t just say we're done with the implementation. There is lot of strategy and thought that needs to go into ensuring that there's buy-in and that we use the right tool for the right purpose.”

For the health centers, their source of truth has been their EHR, Cho noted. “Now that they have the ability to see what happens to their patients everywhere else in the care continuum, it kind of shook that source of truth. That cultural transformation is definitely a big challenge. Data validation was probably the most important piece. When we're aggregating it and normalizing it from a population health perspective, it looks different from what they're used to seeing. We spend a lot of time training and doing technical support, having conversations to build trust in this data so that it can become something that is actionable and we can use it to make decisions and improve clinical protocols and impact quality measures.”

Cho added anecdotal feedback from clinicians is positive.  “One health center provider said to us that one patient’s risk score was really high and it's because of an event that happened four years ago, and there's no way they would have known about that from the data in their EHR.”

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