Clinician Decision Support a Home Run at IL Accountable Care Organization

For Medical Home Network (MHN), clinical decision support needs to look like a baseball card.  Just like a baseball card outlines high-level stats of players, the MHN baseball card summarizes high-level patient health information at the 13 federally qualified health centers (FQHC) and three large hospital systems comprising MHN's Medicaid ACO accountable care organization (ACO).

"The MHN baseball card organizes disparate sources of data externally," Laura Merrick, senior director of eSolutions at MHN, explained to EHRIntelligence in an interview. "This includes admission, discharge, and transfer data, medical and pharmacy claims, care management information, and medication information."

The EHR integration then applies analytics to that information to present the most actionable data to the provider at the time of the patient interaction for clinical decision support.

"Oftentimes, a lot of information is incomplete, scattered, and hard to find," Merrick explained. "We're pushing it in one place, allowing the doctor to begin the right conversation with the patient."

She noted that the baseball card updates as activities occur in near real-time.

"We're trying to capture how the patient is interacting with the rest of the healthcare system, whether it be in a different hospital facility, a pharmacy, or a specialist so that the provider doesn't have to sift through volumes of data," Merrick said.

She emphasized that the organization approached the EHR integration from the provider workflow perspective to ensure the tool would add value to its ACO members.

"At the root of the MHN journey into interoperability, we've had to focus the innovation efforts on solving problems that really affected people," she said. "We focused on eliminating any type of duplicate data entry and ensuring there was clear access to the patient information."

Merrick said that MHN collaborated with providers to develop the integration based on their experiences. For example, providers shared it is difficult to know what prescriptions a patient is filling and when.

The MHN baseball card runs calculations called percent days covered (PDC) which helps support medication management.

"If the medication shows, for example, a PDC of 50 percent, it's implying that the patient fills a medication for only 50 percent of the days in the past year," she said. "The prescription information allows the provider to more deeply have the right conversation with the patient about it or engage with other care managers to facilitate that care coordination."

Merrick said that providers also shared a need to chronologically list the encounters across the care continuum within the EMR.

"The key for us in terms of driving this integration is making sure that we've listed the information in a chronological way that allows a really good understanding of what's happening," she said.

Merrick pointed out that just like patients may not remember all the details of their medications, they may not always remember what specialists they saw or where they accessed care.

Having this information easily accessible at the point of care helps ensure that the provider understands the patient's health status.

"We know that as these conversations can continue to happen, we're going to see better outcomes for the patient," Merrick said. "The baseball card allows the provider to have that information at the right time and place to engage with the patient, ultimately impacting their health status and care coordination."

She also explained that by pushing this information in the EMR, providers will be able to address readmissions and build stronger relationships with patients.

"For me, it's like there's this door that we're opening, and the more and more that we do, we have a wider front door for everybody to come in and to seek exactly what they need," Merrick said. "Sometimes that is with the clinical staff, and sometimes that's in the community. We're trying to open those doors to break down the barriers that we see."

For instance, providers may see a social determinant of health (SDOH) need from a care management assessment within the baseball card, prompting them to ensure that a patient receives services to fulfill that need.

"Often it's really hard on providers when they don't have a lot of time, and they're just trying to find information," she said. "If we can address more streamlined workflows, we can drive more quality and really help people. That's what this is about."

Merrick noted that integrating the EHR tool across the clinically integrated network required an agnostic approach, as organizations leverage health IT from various vendors across the ACO.

"We also needed to work with clinics that didn't have a lot of IT support, so we designed an approach where we could work with everybody," she noted.

Merrick said that MHN began the EHR integration with EHR vendor athenahealth, as many MHN providers leverage the vendor's platforms.

"We partnered with that particular EMR to work with their integration team to push the information in a high-value area that was easy for the providers to see and then interact with at the point of care," she said. "We also have continued the different integrations with other systems such as Centricity/AthenaPractice, NextGen, and Epic."