How Can Data Integration Promote Personalization, Availability of Health Care?

With the coronavirus disease 2019 (COVID-19) pandemic continuing to expose health care delivery gaps, data has emerged as a vital tool to delineate those at greatest risk of poor clinical and social outcomes. When it comes to managing patients, Paul Grundy, MD, chief transformation officer at Innovaccer, explains that the social aspect serves as a crucial, if not equal, need to consider since social determinants of health can have a significant impact on the risk of readmissions, hospitalizations, and risk of adverse events.

Recently, Innovaccer, a health care data activation company, partnered with Emtiro Health, a population health company, to employ their FHIR-enabled Data Activation Platform that works to provide a comprehensive, full-scope view of a population down to the individual level. “It's really thinking about integrating social support, strong community-based support, but having the data to understand exactly what's happening down to every person in the community. That's the vision, that's the dream we have,” said Grundy.

In a recent interview with The American Journal of Managed Care®, Grundy, along with Kelly Garrison, CEO at Emtiro Health, spoke abou the details of the partnership, as well as the opportunity to further expand personalized health care and availability of care.

“Through data, utilizing our care management and work workflows and protocols, we can identify those patients early enough and empower them to be active in their health care and if not, connect them to those resources that we're going to end up in a much better place than where we were pre-pandemic,” said Garrison.

AJMC®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care® is pleased to welcome Kelly Garrison, CEO at Emtiro Health, and Dr Paul Grundy, chief transformation officer at Innovaccer. Can you both just introduce yourself and tell us a little bit about your work?

Garrison: Sure, I'll gladly go first. Thank you for the opportunity, Matthew. My name is Kelly Garrison, I'm the president and CEO of Emtiro Health, which is a population health management company located with a home base in Winston Salem, North Carolina, but rapidly expanding beyond that.

We're excited to be here today to talk with you a little bit more about Emtiro, but certainly our partnership with Innovaccer as we strive to really make some leaps in terms of changing the health care landscape and how health care is delivered, which we think we'll be able to do far more successfully with Innovaccer supporting us.

Grundy: Thank you, I'm Dr. Paul Grundy, and I'm the chief transformation officer for Innovaccer. Prior to that, I was the chief medical officer for IBM’s Health Care and Life Sciences industry for many years, and in that role, I was the founding president of an organization called the Patient-Centered Primary Care Collaborative that led the medical home transformation, known as a patient-centered medical home.

I got a title called the godfather of the medical home from that, but in part of that, I was with our Foreign Service, the State Department, interfacing health and foreign policy.

AJMC®: Paul, to get us started off, can you explain what is Innovaccer’s FHIR-enabled data activation platform and how it operates?

Grundy: A data activation platform, simply put, is a way to get at a comprehensive 360 degree view of your population down to the individual level. So, we're beginning to get at the technology for the first time to do that. We're moving away from the age of information to an age of intelligence where we can much more readily understand what's going on in a broad way.

So, in order to really understand how to manage somebody like Matthew, and their family, we really need to know about all of their clinical data. We also need to know about their social data. So, it's really putting together a comprehensive view so you can really have a plan for every patient in a population.

AJMC®: Kelly, Emtiro Health’s partnership with Innovaccer to employ their FHIR system comes at a time when many employers and health care purchasers are scrambling to provide preventive and affordable care amid the pandemic. How can this partnership optimize this transition for those supported by your organization?

Garrison: Absolutely. So, I think what's interesting is that the pandemic that we're experiencing right now, is uncharted territory for everyone. So, one, I think it has brought together the right people to have conversations at the right time to drive needed change in our health care system as a whole, but what we know is that we need information to do that. We don't want to just make educated guesses because we do have the technology and data available to us now to make educated and informed decisions that can be tested and evaluated.

So, we believe that by having a partnership with Innovaccer that we are able to bring together all of those data sectors. So, ADT [admission, discharge, and transfer] data along with social data along with clinical data along with data that is being captured in a real time manner, a real time way from our care management and clinical teams to ultimately put together a comprehensive plan for the patient, but that is also shared with the provider.

So, what we don't want to have happen is that we have the provider working in one silo and we have the patient that is sitting outside of that. We have a care manager who is then working with the patient without any of those parties talking to each other, and then you throw in community-based or health services organizations into that mix as well and we are just introducing more complexity into the system. So, we have to have a unified data platform so that if a change is made in one place, it is carried throughout that entire longitudinal record, so that everybody is reinforcing those same messages with patients so that we get an actual difference in the outcomes that we see with patients.

AJMC®: In addition to the pandemic, social determinants of health such as race, location, and access to care have become growing factors in health care plan design. Kelly, can you explain how Emtiro Health have addressed systemic barriers to well-being in the past and how it will continue to do so through this novel platform?

Garrison: Definitely. So, we just like everyone knows that social determinants of health are definitely a key contributor to the health and well being of populations. Again, the pandemic has only heightened those things. So, I love to hear directly from our care managers with some of the challenges that they are facing and we do a lot of work of addressing those barriers, social determinants of health issues in a one-on-one manner. While that work absolutely has to continue, and that's something that we will never get away from, through our partnership with Innovaccer, we are also able to come at it from from a bottom up, meaning patient level up and top down approach to say, what are the broader systemic changes that need to be made?

When we're looking at a particular zip code, what trends can we identify to then create an impact in that community, and again, leveraging data to do that, because we're able to look at geo maps and we're able to look at the social vulnerability index. That's one of the things that we were probably most excited about our partnership with Innovaccer is that we have to get away from only looking at high risk patients based on cost and utilization. Health care is in a time and place where we have to start looking upstream, and not being so reactive, but really proactive in how we manage a population of people.

The social vulnerability index is just yet another risk indicator that we can capitalize on as we're evaluating an entire patient population to work with a community. So, again, I think in health care, we spend a lot of time identifying a need, thinking we know what the solution is, and therefore implementing it and telling people what they need to do rather than doing things along with them.

We're really excited to identify those areas and then address them along with the communities that we serve and the patients that we have the opportunity to serve.

Grundy: We began looking at the data of one of our clients a year or so ago, and what we were seeing was really interesting. We were seeing a spike in hospitalization for type 2 diabetics with hypoglycemic events. We were seeing that spike in just a few zip codes and we were seeing that spike in just a few days. Those few days that we were seeing that spike was the end of a pay period.

What we began to understand was that these folks were running out of food, right? If you're at risk, if you're a system at risk for a person in a bed versus a profit for a person in a bed, all of a sudden that becomes important to you. So, you know, what we saw in Emtiro, what we saw was what their name means, which is to inspire and support at the community level. Strong individual families and communities to really empower, making a difference with a scenario that I just described.

So, in communities where you have integrated social services, support activity–as a community I visited in St. Johnsbury, Vermont, where you have a plan that's broader than just I'm going to give you medicine because you’re a person with metabolic syndrome, you're going to develop diabetes, but you have a way to integrate them into the diabetic hiking club, into the nutritionist at the grocery store. You have all 37 social activities, sport community activities that are prepared to make sure that they have a coat, that makes sure that they have housing.

It's that kind of concept, right? It's really thinking about integrating social support, strong community-based support, but having the data to understand exactly what's happening down to every person in the community. That's the vision, that's the dream we have.

Garrison: I think to even take that a step further, it's about utilizing that to predict and take action in advance of. So, before we hit that spike or before a patient has landed in the emergency room or in the hospital and therefore are needing care management or transitional care services, we’re identifying those trends early enough to work with food banks to say, we know that we're going to see a spike at the end of this month, how do we make sure that we have enough for patients at that time.

Then utilizing care managers or care coordinators to work with patients who are at risk of running out of food at the end of the month or running out of nutritious food. For our diabetic patients, going into a food bank and getting a load of macaroni and cheese and pasta is not going to be the best thing for them, but being able to then identify where the right places for them to go so that we can keep them out of the hospital to begin with or experiencing, another delay of treatment, so to speak, which I think we've seen a lot during the pandemic, especially to kind of pull all of it back together is patients that were scared to seek treatment, which I think heightens the need for care management, care coordination services that are empowered through really good data and technology.

Knowing that if we expect the patient to self quarantine at home for 14 days, while that seems like a novel and appropriate idea, that is not a feasible idea for everyone, and until we can pull together their social risks, along with their health risk, in light of a pandemic type of situation. There's no way that we can truly address and or expect patients to take those proactive steps if they don't have the resources needed.

Grundy: Where there's communities that have actually done this– I mentioned one, the Blueprint for Health in Vermont, we have seen a 30% to 40% reduction in the need for hospitalization for ambulatory sensitive conditions like diabetes. We've seen a 60% reduction in the complication, ie, amputations, end stage renal disease, blindness. That's the vision, that's the view.

AJMC®: To build off this conversation on technology, Paul, for organizations or employers who are working to better implement data and analytics in their care delivery, what factors warrant consideration?

Grundy: I think that the basic concept of the medical home that we defined all those years ago, is a concept that if you have data, where does it reside, who's accountable for managing that data? That's the core concept of the medical home. Our core belief system and Emtiro did a really good white paper about this just a few days ago, our core belief system is that data belongs in a trusting relationship with the healer, and their team.

So, it's getting a healer and their team, and their team from our perspective is anybody who interacts with that patient. It could be prescribing a medication, it could be behavioral management, but it also could be a coat. It's that concept.

Does that make sense? That’s our core belief system. Identifying that core, now how do you do that? So, on key and when I was with IBM, we focused on first dollar primary care. So, we tried to get all of our patients in a medical home with no cost and if you don't do that–I was at a meeting of the school boards in western Colorado, and there were 3 examples that were brought up. It was a high deductible benefit plan, right? An $11 an hour cafeteria worker has to pay a bunch of money out of pocket to make sure that they don't have hypertension. So, this school teacher has a stroke at age 47 with 3 kids. I mean, that's a human tragedy, right? This was somebody who was delivering huge value to your community and all of a sudden, you know, is paralyzed and has a difficult time speaking and is now in Medicaid. That happens, you know, once every 3 minutes.

AJMC®: As a question for both of you, what are the next steps your respective organizations are considering or currently implementing to address implications of the pandemic and beyond? Kelly, you can go first.

Garrison: We definitely know that the pandemic has magnified the health inequities and injustices that we all experience in our communities. Our focus remains on the health and well being and addressing those barriers, whether they're pandemic related or not for the betterment of patients. When we talk about purpose and drive, it really is about seeing patients being empowered in the delivery of their own health care and feeling like they have a voice and how to manage those things and supporting them when they don't know where to go for help.

I think, certainly our organization will continue to work with providers. Providers are tapped out and maxed out right now, in really just feeling like they have to keep their nose to the grind. How can we, one, be the interstitial space for them to help be an extension of their care team. I know Innovaccer uses the phrase, care as 1, but I think that's a common theme that we share is that we know that all members of the care team need to have access to information.

We're leveraging technology to be able to seamlessly share that information across so that, again, we're all reiterating the same messages with patients so that they don't feel like they're getting conflicting information and really leveraging us. I talked a little bit about this earlier, but leveraging data and analytics tools available to us through our partnership with Innovaccer to target the right patients.

Again, I think gone is the time of only looking at the high cost, high utilizing patients. We can't take our focus completely off of them, but we know that there are risk factors outside of medical costs that are such key contributors to the overall health and well being of patients and a population. Through data, utilizing our care management and work workflows and protocols, we can identify those patients early enough and empower them to be active in their health care and if not, connect them to those resources that we're going to end up in a much better place than where we were pre-pandemic. I just think the pandemic has put the spark underneath a lot of health care organizations to make very needed and timely changes.

Grundy: I look at this as never waste a crisis. What I see happening is an opportunity we are moving to the ability to much better engage our patients because they are now forced to really engage us synchronously and remotely in ways that I think can make a big difference in their lives. I think we're going to be able to much better monitor, we're going to be able to much better deal with care at home.

It's becoming much clearer to communities all over the country that the weakest among us can carry a disease process into our schools, into our children, and into our community. It's going to be really important that we care for the comprehensive. I mean, without a healthy community, you do not have a healthy workforce–that basic concept.

For Innovaccer, it's all about how do we provide the tools for other organizations to really be able to connect the support that's needed with community resources with primary care, and integrate that into secondary care. I mean, really make it possible to have a comprehensive plan for every citizen in a community with the support they need around them in a way that's really going to fundamentally shift our disease burden, our need for hospital beds, and I think thank god we left the information age and we’re in the age of intelligence because I think for the first time, we're going to be able to do for the community resources minds, for the doctors minds, for the patients minds, what we were able to do for the vision of us in health care with x rays and imaging.

That technology gave us an anatomy textbook to look at versus scratchy images. I think the same thing is going to happen with creating a database and a platform that's actionable at the point of the individual human being, their family, and their community. That's our goal.

AJMC®: To learn more, visit our website at ajmc.com. I’m Matthew Gavidia, thanks for joining us!