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Epic’s EHR Optimization Mitigates SDOH, Promotes Care Coordination

Health IT services can aid providers in addressing social determinants of health and fostering care coordination across the healthcare continuum.

Epic’s EHR optimization services boost care coordination and help providers address social determinants of health, according to a recent health equity presentation for Workgroup for Electronic Data Interchange (WEDI)’s annual conference.

Led by Seth Howard, a product development lead at Epic, the presentation outlined the EHR vendor’s advances to help healthcare organizations deliver high-quality, patient-centered care.

According to Howard, about half of all the data exchanged in practice is within the Epic network, while the other half comes from non-Epic systems including specialty groups, dental providers, and post-acute care providers.

The Epic ecosystem continues to expand in pursuit of increasing administrative efficiency and providing higher quality, coordinated care, Howard noted.

“It's been our goal over the past many years to weave together health and social factors into a more patient centric comprehensive health record so we can really start shifting more focus to the social factors,” Howard said.

Howard explained that many groups use Epic’s comprehensive care coordination application, called the Compass Rose Module, to assess patient social determinants of health, enroll patients in community-based programs, and track patient outcomes. The application outlines social determinants of health in patient records just like vital signs or lab results.

“These factors, like access to healthy food and transportation, describe the wider set of the social forces that really influence patient outcomes,” Howard said.

For example, Trinity Health uses the application to recognize patients experiencing food insecurity. Then, the health system connects these patients with nutritious food programs.

Epic also recently worked with Lyft to add rideshare services into appointment scheduling to mitigate transportation as a social determinant of health.

“In some cases, this is driven by agreements between the health system and Lyft,” Howard said. “We've also seen some payers have direct relationships with Lyft. We're working to incorporate that into the system as well. For example, Humana is working with us to incorporate ride costs as part of the reimbursement.”

Epic’s Compass Rose Module is based on the eight standard domains published by the National Academy of Medicine to help provide industry consistency and aid interoperability.

“We also, when needed, like to build on these standards and expand the standards where possible,” Howard said. “Based on feedback from our users, we also introduced additional specificity and variation by age to really tailor the content based on patient specific needs.”

The EHR vendor also branched out from the National Academy of Medicine’s eight domains by adding details regarding transportation access, housing stability, and postpartum depression to ensure providers have information regarding specific social determinants of health.

While this application is a major part of the Epic implementation processes, there is still room to grow in terms of standardizing information collection and ensuring providers use the data to improve care coordination, Howard said.

He noted that one of the vendor’s main goals is to make sure data collection is possible wherever it is needed, such as during an office visit, in the hospital, or during home care visits. Additionally, patients can enter information regarding social determinants of health through Epic’s MyChart patient portal.

“Community organizations can access records through Healthy Planet Link and that allows them to both see and contribute to the record, including social determinants of health,” Howard added. “Interoperability is an important aspect of this. Payer Platform is a bit newer and that allows providers and payers to connect and exchange data much more richly across the network.”

In addition to EHR optimization, Howard emphasized the importance of looking outside of the realm of traditional EHR data to help inform patient care needs and population health initiatives. For instance, some health groups use the CDC Social Vulnerability Index to prioritize community-level patient engagement initiatives.

“One very concrete example of this is in the deployment of the COVID-19 vaccine,” Howard explained. “Health systems are using the Social Vulnerability Index to help target initiatives at a neighborhood level and also make sure that they have equitable distribution of vaccine based on these different types of factors.”

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