Next year, Alameda County, Calif., will launch a social health information exchange (SHIE) and community health record (CHR), focused initially on high utilizers of medical, behavioral, housing and emergency services.
Alameda County, whose county seat is Oakland, has approximately 240,000 residents who are on Medicaid or uninsured. It also has a public hospital and nine Federally Qualified Health Centers (FQHCs). The data-sharing infrastructure project is being funded by a Medicaid waiver project.
“Like other California cities, we are struggling with homelessness, so we are trying to figure out how to hook in the healthcare network with housing and mental and behavioral health,” said Kathleen Clanon, M.D., agency medical director at Health Care Services of Alameda County. The county began piloting the SHIE by linking emergency departments together. It now includes mental health treatment encounters and claims data from the two managed care Medi-Cal plans as well as EMS transports.
To build the technology platform, Alameda County Care Connect put out an RFP and got nine submissions. It is in negotiations with a vendor on a $9 million contract. They expect to go live in April 2019. The goal is to integrate the social data into the EHRs of the medical providers.
Clanon said her primitive metaphor for the SHIE and CHR is that the SHIE is like a bank, with multiple streams of data coming in from lots of locations. The data is held there securely and de-duplicated and cleaned, and that is where credentialing is determined. The CHR is like an ATM machine, she said. “If you have the right credentials, you can go to the ATM and get out data about a particular individual for the purpose of care. At that point, there is a consent event that has to occur.”
Clanon described some of the value Alameda County Care Connect is already starting to see with its prototype CHR, using some anecdotal examples. “The first few things we have been able to do is to connect medical and housing,” she said. For instance, the county has 111 permanent supported housing spaces available through HUD.
“With 111 of those slots, we had 3,000 people assessed, but only 25 had complete document sets,” she explained. If you are homeless, what you need to get into HUD housing is a driver’s license, a Social Security card, proof of income and a few other things if you have special circumstances. If you are homeless and living on the street, it is hard to keep those documents together, she noted. “But the healthcare system mostly had all that information because when people come in we take images and scan their ID. So hooking together the homeless management information system with our healthcare system, we are able to figure out where we have those documents already, and enable people to take advantage of these HUD slots.”
The initial effort is focused around high utilizers of multiple systems, about 20,000 people. They might use multiple systems at a high level and no one system knows what is happening in the others. “Someone might be going to psych emergency a few times a year, medical emergency departments a few times a year, and jail a few times a year,” Clanon said. “It is described differently, but it is for the same problem such as an uncontrolled addiction or an untreated psychiatric condition. We don’t see all that utilization until we put all the puzzle pieces together of the different data systems.”
Here is another real-life anecdote she shared about someone she called “Fred,” who is severely disabled as a result of schizophrenia. Homeless and living outside, Fred got matched to a housing spot after waiting several months. His case worker found a place for him, but couldn’t find him anywhere. “As soon as we hooked our system together, we saw that Fred was in a skilled nursing facility because he had jumped off a building and had terrible trauma,” Clanon said. He ended up with a colostomy because he had a ruptured spleen and had been in and out of the hospital several times and then back to living on the street. The emergency department had hospitalized him because they had no idea how to get him into housing. “As soon as we hooked the systems up, we were able the same day to call the case manager and say Fred is at the skilled nursing facility, and he was able to go over there and get the documents together for a discharge plan.”
Clanon said one model for its work is the City and County of San Francisco, which has a homebuilt system it built 20 years ago that links together city and county clinics and hospitals and EMS. “That showed us what is possible to do, how to get consent from people for their data to be used and the limits on consents to disclose to multiple users,” she said. “Our challenge is we need to put together a bunch of people who aren’t under the same organizational roof. That adds to the complexity. The technical part is really not that hard. It is the permissions and the culture and work flow issues.”
Of the nine FQHCs in the county, two are already feeding their data into the SHIE. Clanon said that as they try to coax organizations in, they have to overcome a little bit of reluctance. “There are individuals in every organization who say this is going to be great and are so happy the county is doing this, but there is some reflexive concern about the government getting data and why we need it.” There is some discussion about moving the governance outside the county to a semi-independent structure in the future.
Some clinics, she said, are healthcare-centric and don’t see how knowing what is happening with housing is going to help them with medical care. “We are trying to get them to re-frame that — their patients are getting care in these other parts of the system, and these other parts of the system can’t see the primary care,” Clanon said. “Someone is being seen in the specialty mental health system for being severely bipolar, and the mental health providers can’t see who is taking care of someone in primary care, so that hampers the ability to coordinate care. Clinics tend to be focused within their own walls, so it is a little bit of a task to get them to see they are part of a larger system, and that the client is touching a lot of other touchpoints they need to know something about.”