Michigan is, for better or worse, at the leading edge of a lot of work regarding social-related health needs and SDOH interoperability, according to Lisa Nicolaou, Michigan Health Information Network's (MiHIN) social determinants of health (SDOH) program director.
Although it is hardly ideal that a state's population has numerous social and welfare needs, Michigan has responded in kind by making it easier for healthcare providers to identify those needs, refer patients to social services, and track patient data.
This is in part because the state has been well-funded in the health information exchange (HIE) space.
"The state has engaged in some advanced work in cross-sector data sharing that led to some pitfalls along the way, but it really puts us out front," Nicolaou told EHRIntelligence in an interview. "We're experiencing a lot of those bigger issues related to cross-sector data sharing that may not be experienced in other areas for a few more years."
In 2015, CMS awarded Michigan $70 million over four years to test and implement an innovative model for delivering and paying for healthcare. The award was based on a plan submitted by the state called "Reinventing Michigan's Health Care System: Blueprint for Health Innovation."
"The Blueprint for Health Innovation talked about the idea of bringing together health-related social needs and social care providers in the community that could help meet those needs," Nicolaou explained." For better or worse, it took a very healthcare-centric focus, and that was the learning curve."
The lack of infrastructure for sharing social care data in the state innovation model gave rise to a handful of social care referral vendors in the area.
"There is a plethora of these social care referral vendors and the way they work is very similar to the way electronic medical records first started up 40 years ago," Nicolaou said. "They are very siloed and the data stays within that silo."
This has left many community-based organizations caught in the middle.
"With so many vendors in that space, the community-based organizations oftentimes have to connect to two or three different platforms to service their population, plus deal with all the people who walk through their doors or call them," Nicolaou pointed out.
She emphasized that having so many social care platforms is, in many ways, doing the opposite of what all those vendors set out to do: make it easier to provide social care.
A 2020 report published in Health Affairs showed that many accountable care organizations (ACOs) lacked data on both their patients'social needs and the capabilities of their potential community partners.
SDOH referral and data exchange platforms might seek to provide that data to ACOs and other health systems, but the siloes present a challenge.
To support a more interoperable social care infrastructure, MiHIN convened vendors CareAdvisors, findhelp, PCE Systems, RiverStar, Unite Us, and WellSky. Together, they created an Interoperable Referrals Pledge.
In signing the pledge, the vendors have taken responsibility to enable a more interoperable social care environment through collaboration.
The pledge has five core principles:
- Service providers should be able to work within their chosen systems of record
- Consumers should have access to their own data with full transparency into who will have access to their data if they consent to a service; and service providers commit to not blocking electronic health information (defined as knowingly and unreasonably interfering with information sharing)
- Service providers commit to the use of open APIs and national standards like the HL7 FHIR Gravity Accelerator
- Service providers recognize the need for data aggregation from multiple systems to quantify demand and utilization for services to inform policymakers and ensure service quality
- Service providers support the state-designated entity, statewide HIE, or health data utility to serve as the trusted health data exchange broker to ensure an interoperable ecosystem among the medical, public health, and social care communities
Joanne Jarvi, senior director of outreach and market communications at MiHIN, said that the pledge outlines basic principles that the vendors have in common, including the obvious: wanting to have some marketshare in Michigan.
"What they all need to also have in common is to start to figure out what data is important to what parties, what that data means to each of the parties, and how they are going to get it there," Jarvi added. "What we got with this pledge was a pledge to see that technical infrastructure is supposed to support human infrastructure."
The vendors have varying focuses on social care referrals. For instance, some of the platforms are focused on behavioral health, while others work on homelessness case management. However, the organizations have a shared line of sight, Jarvi said.
"We work with Gravity and the CARIN Alliance, and most of those partners do, too," she said. "Nobody's coming in and suggesting anything crazy. It's just sort of like, "Can we keep taking these baby steps and opening up to let the data flow to support work capacity to serve human beings?'"
Nicolaou said that the term MiHIN chose for this collection of vendors is a "community of practice."
"It's ultimately up to that community of practice to dictate how we move forward," Nicolaou said. "People are passionate about the idea of helping individuals. They're all there for that reason. They all recognize the problems that are starting to surface by all of them being in a single space. Interoperability of the data between platforms is critical."
"So far, things have gone well," she continued. "We haven't hit the bumpy spots yet, and there's going to be bumpy spots. These systems were designed proprietarily, and they were designed to be siloed, so now we're trying to open those up and use standards to be able to exchange data. It's going to take some work."
For instance, Nicolaou expects it'll be hard to reach on consensus on certain contentious issues, such as consent and secondary use processes.
However, she noted that the interoperable referrals pledge helps define how the organizations will work together.
Additionally, Nicolaou said that there are lessons to be learned from healthcare's steps to a more interoperable environment amongst vendors.
"That willingness to work together and exchange health data really did not happen for many moons, but we saw the impact that it had both on patients and care teams in the end," Nicolaou said. "I think the fact that we're able to engage these vendors in a different way, much earlier in the process, bodes well for the end result."
She said that improving the interoperability of social care data will help drive health equity by addressing social determinants of health.
Researchers have found that social determinants of health can have serious implications for wellness, ranging from exacerbating an existing chronic illness to leading to the development of illness.
"Social determinants of health are conditions in the environments," Nicolaou said. "Data doesn't change conditions; what changes conditions is the distribution of power and wealth. We need data to drive better quality decisions about where to spend scarce human and financial resources to get the greatest outcome."
Jarvi emphasized that MiHIN cannot solve for social determinants of health.
"What we can do is bring attention and learning to cross-sector data sharing so that the right sectors can take what they see as meaningful data and move towards wellness," she asserted.
The MiHIN officials pointed out that the initiative is in its infancy.
"These problems were not created over a two-to-three-year period, so they're certainly not going to be solved over two to three years," said Nicolaou. "This is like a 50-year process change that we have to go through to really right the ship of where we invest our money that is way beyond MiHIN."
Jarvi said that change management works with awareness first. The pledge helps outline the community of practice's principles and common goals.
"Everybody wants to get to the knowledge and the how and the codes, but the truth is you have to start with like the why," she said. "Why are we all here? Let's agree on five reasons and a common purpose."