Social Determinants of Health and the EHR: One HIMSS Presenter’s Story

Feb. 10, 2019
Jitendra Barmecha, M.D., vice president and CIO at SBH Health System in the Bronx, will speak at HIMSS about his organization’s journey around social determinants of health data and the EHR

The journey around the electronic health record is inevitably complex and challenging or any U.S. patient care organization. What’s more, every provider organization is navigating its own operational landscape. In the case of the Bronx, New York-based SBH Health System, incorporating data on the social determinants of health (SDH) has become increasingly important. That topic will be addressed by the organization’s vice president and CIO, Jitendra Barmecha, M.D., in a presentation at HIMSS19 on Tuesday at 2:00 PM local time, in the Allscripts Theater, Booth 3501, entitled “EHR Journey: Transforming Care in the Underserved Community.”

As the session’s description notes, “With limited investments (speed to value), learn how a community health system rolled out the Sunrise™ EHR from ambulatory care into ED and acute care as well as expanded its use to help drive outcomes. The presentation will also cover how we built and refined the EHR especially for mental health and substance use orders service lines and how we have leveraged our IT governance to manage on-going optimization and transformation of EHR usage to provide safer and value-based care in the community.”

Before departing for Orlando, Dr. Barmecha—who is both SBH Health System’s CIO, and a practicing internal medicine physician—spoke with Healthcare Innovation Editor-in-Chief Mark Hagland about his organization’s journey in this area. Below are excerpts from that interview.

Tell me about the overall thrust of your presentation Tuesday.

So, first of all, I will be mentioning about our organization and our underserved community and the types of pathology we have. In our patient population we don’t necessarily have just individual chronic diseases like asthma or CHF; we also have behavioral health issues, and mood disorders, and all that makes it even more complex. The purely medical aspects are straightforward, but tackling the social determinants of health are another thing. And the EHR is a support in that. We started our journey in 2006, with the implementation of Sunrise in ambulatory. We were the first to implement what was then Eclipsys for ambulatory, at that time. We did not want it to be an electronic typewriter for our physicians; we wanted it to be smart and sophisticated, and to see if we could reengineer our workflows.

And we had incentives under HITECH, which provided some federal and state funding for the implementation of the EHR, which aligned well with our mission, to expand the use of our record into the emergency room and clinic sites; but the monies weren’t enough to implement altogether in ER and pharmacy. So we through a process with Allscripts, in order to implement across our health system on a single platform, and to do it in a way that we called “speed to value.” So it’s a shorter timeframe to implementing the EHR in a cost-effective way, at the same time not jeopardizing patient care quality. And so in 2011, we did a big-bang implementation, upgrading the ambulatory, and implementing inpatient and EHR. We had started in 2010, because it took several months to get going.

Tell me about the practical connection that you and your colleagues wanted to make, between social determinants data and the EHR?

We realized in 2011 that our several behavioral healthcare programs, including substance abuse disorders—we were having some shortfalls. And we were seeking grants to implement, because it was very important for us to have a single healthcare record between primary care and behavioral health we wanted to do full integration. And we received a HEAL grant from New York state, to help us create full integration, not only the implementation of a behavioral health record, but also full integration between primary care and behavioral health. That was in 2013.

And between 2011 and 2013, obviously, we knew that through this implementation, we’d meet the regulatory requirements of meaningful use as well; so our implementation was very successful both on the hospital side and the eligible-professionals side in 2013. And we felt that integrating the social determinants of health would be essential in our community. And it was very important for us to document these gaps, whether housing gaps, food-desert gaps, gaps in the chain of community organization connections; so we started using our EHR to document those non-traditional data points. So from primary care to emergency care to inpatient care to behavioral health, now we’re able to tackle all of those elements, including by community organizations, into our behavioral health record.

It’s a work in progress. We’re not 100-percent yet. But we realized during these evaluations that it’s not only access to housing, food, pharmacy, but also things like lacking broadband service or text-messaging services; those can have severe impact on the patient engagement side. So we have a patient portal to our EHR, and we’ve tried to optimize that particular solution of Allscripts, to push some data elements into the electronic health record, so that the patients become more engaged. And we need their email addresses for that. And to that end, we had to reengineer our workflows at all the touchpoints, whether through emergency room visits, hospital admissions, or clinic appointments. We had to reengineer processes to include documenting the email addresses. And we’ve had good success obtaining the email addresses, but also in pushing out appropriate health education through the portals and email.

And we came to feel that we needed some patients to be more involved in their care, so we adopted OpenNotes last year. So we have more than 80 types of clinical notes in the OpenNotes program, where the patients are seeing what’s explained to them, and they can make changes.

What have the biggest learnings been so far in this overall journey?

There many, but I would highlight two things. First, there are two sides to the electronic health record, the clinical and the financial sides. It’s about engaging the clinicians who will use the EHR. It’s extremely important during the design, development, testing, and training, clinicians need to be involved, we need to hear what they’re requesting, and the adoption will be higher when the clinicians are making the decisions. That is number one. And number two is training and retraining. A single instance of training is not enough. We have to constantly retrain; some need hands-on training, some need retraining. And what I’ve realized in the past several years, is that clinician input and training of clinicians, is incredibly important.

So, engagement, and retraining have emerged as the key elements in success in this area, so far?

Yes, that’s correct.

After laying these foundations, have your organization’s clinicians and care managers now been able to make better decisions, using social-determinants data?

Yes, they have. Some of these SDH data points are coded and some are not. And we find that there are some challenges that aren’t typical challenges involved in providing care in our community. And, regarding lessons learned, another one is around governance, both at the executive and clinical levels. So the governance aligning the mission and vision of this, is very important. It was important for us to have good governance in place, to make sure that the highest priorities were given to patient safety, to clinical quality, and then financial quality, in that order.

How do you see things moving forward in the next couple of years?

This is a journey. Any implementation involves a journey. I think we’ve come very far along. And we are going to move into EHRs 2.0, which means smart EHRs. For example, we now have data from the past 10 to 20 years; and there are so many ways we can make our clinicians more efficient, through giving them the right information at the right time. And the use of clinical decision support and machine learning and AI tools will help. And we are doing some innovative pilots that aren’t commercial yet; and we’re very hopeful that they’ll improve patient outcomes, as well as decreasing clicks and screen time, so that they’ll be spending more time with the patients rather than looking at a screen.

Is there anything you’d like to add?

We still face challenges around interoperability. For example, when we have to exchange information with certain providers or health systems, because of federal policies, and because of the politics inside different healthcare organizations, and because of the nature of consolidation of healthcare organizations in markets, and because of patients not understanding issues around consent, and because of technological shortcomings, we still lack a considerable amount of interoperability. But I remain very optimistic that these systems will one day talk to each other in a much more meaningful way.

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