How an HIE Tool Helped an FQHC Boost Care Coordination

Organizations have access to more patient data than ever through health information exchange (HIE), but finding specific data for care coordination amidst the HIE sea can be like looking for a needle in a haystack.

Information overload can contribute to burnout, which is an increasing concern for the healthcare industry. In a 2021 American Medical Association (AMA) national survey, nearly half of healthcare professionals reported at least one symptom of burnout.

"I don't care what field you're in in healthcare; burnout is real, whether you're a registration person, a provider, or a care coordinator," Mike Pease, CEO of New York-based The Chautauqua Center, told EHRIntelligence in an interview. "Part of that burnout is feeling overwhelmed by the volume of information available to them.”

That was a big problem for the care coordinators at Chautauqua, a federally qualified health center (FQHC), who usually carry a case load of about 2,000 attributed patients. In terms of closing care gaps, these care coordinators are in charge of manually mining an HIE to find patients who’d completed their recommended screenings and those who had not.

It’s a difficult and time-consuming task that can serve as a significant hurdle for already-burdened providers.

"If you can imagine trying to look through all of the data that's available, running a query on quality metrics significantly helps with what their duties are during the day," said Pease.

However, an innovative HIE tool is helping the care coordination department at The Chautauqua Center more easily find the data they need to close care gaps.

HEALTHeLINK, the regional HIE for Western New York, developed the tool, HEALTHeQUALITY, through a grant it received as a phase two winner of a Health Resources & Services Administration (HRSA) challenge. The “Bridges to Better Health” challenge aims to enhance care coordination, achieve better health outcomes, and reduce disparities through technical assistance solutions.

HEALTHeQUALITY allows care coordinators to query the HIE for care gaps across all their attributed patients at once.

The tool, which leverages the Health Level Seven (HL7) SMART app on Fast Healthcare Interoperability Resources (FHIR) standard, is populated by the HIE’s population health module used to calculate quality measures.

During the pilot phase of the HRSA challenge, the Chautauqua care coordination team queried the system for colorectal, cervical, and breast cancer screening gaps.

For patients who had completed their recommended screenings, the system automatically pulled up the test result. From there, the care coordinator could upload the result to the EHR for quality reporting.

For patients with care gaps, the system added a comment in the EHR to signal the need for follow-up.

The results go far beyond streamlining workflows for care coordination staff. Compared to 2021, The Chautauqua Center increased its breast cancer screenings by 19 percent, colorectal cancer screenings by 21 percent, and cervical cancer screenings by 23 percent.

"HEALTHeQUALITY made it much easier for us to track and upload procedures and tests that have been done to meet quality indicators for different insurance companies and just the patients in general," Pease said. "Unfortunately, that's the way healthcare has kind of gone; it's all about checking boxes to make sure you get reimbursed."

"That reimbursement, frankly, is what allows us to have a care coordination department," he noted.

Pease emphasized that while improved quality performance has monetary rewards, advancing patient care is paramount.

FQHCs usually treat low-income patients who face various social determinants of health (SDOH), such as environmental factors where they live and work, that may reduce care access and increase the risk of poor outcomes.

"The system significantly improved our outcomes," said Pease. "There is a money part of that, but the important part of that is making sure the patients are getting what they need. Running a report and having it at your fingertips almost immediately speeds up the amount of time that you can reach out to somebody who might need some extra assistance."

"A lot of folks need that extra handholding," Pease acknowledged. "There's nothing wrong with that, but we can't give that to them if we don't have an accurate picture of where they're at."

Pease noted that HEALTHeLINK's overall focus on connecting a network of local healthcare providers and payers has benefited the FQHC's quality improvement efforts.

"To me, the regional focus that HEALTHeLINK has makes their platform more valuable than a platform that's nationwide but isn't necessarily connected to all of the local folks that might have the information to meet some of these quality metrics," he said. "I'm a big believer in building the capacity locally."The HIE said it plans to add three more quality metrics to HEALTHeQUALITY for the third phase of the HRSA challenge: diabetes, hypertension, and adult access to ambulatory and preventive services.

HEALTHeLINK is also building out the system further to support health equity. While The Chautauqua Center piloted the “gaps in care” tab, the HIE is building out connections for two additional tabs: social needs and social services.

For the social needs tab, the HIE will aggregate SDOH data from participating providers for each patient. For the social services tab, HEALTHeLINK will connect to various social service referral platforms, including findhelp.