Five health systems in Dane County, Wisconsin, are working alongside community partners to embed a social needs referral tool into Epic.
The Connect Rx Wisconsin team, from the University of Wisconsin, Madison, earlier this month won $1 million from Schmidt Futures to create an integrated network of healthcare and social service systems across Dane County, building on existing electronic healthcare technology.
As proposed, the community resource solution will be embedded directly in Epic so that providers don’t need to change to a different portal.
“Connect Rx is the gold-standard solution for integrating multiple healthcare and social service systems within the electronic health record to increase income and improve health for families,” said the team in an informational video published this past week.
WHY IT MATTERS
Dane County has some of the worst racial disparities in the country in terms of median household income, poverty rate, unemployment rate and birth outcomes, according to Connect Rx.
“Connect Rx will turn the tide of economic instability and racial disparities in Wisconsin. With our health systems burdened by the COVID-19 pandemic and growing social unrest, never has a project been more imperative to invest in than right now,” said the team.
The organization’s health system partners include SSM Health, Access Community Health Centers, Group Health Cooperative of South Central Wisconsin, UW Health and UnityPoint Health – which provide care for 95% of county residents.
“Instead of purchasing a platform that operates outside of the health record, our chief medical information officers told us to work directly with Epic systems to leverage their existing software and create a comprehensive care coordination model in the electronic health record itself,” said the Connect Rx team.
The team’s combination of screening tools, resource directory and decision support will all be embedded in clinician workflow – without alt-tabs or hyperlinks required. After screener questions, Connect Rx will automatically code patients’ risk for unmet social needs on a social determinants of health wheel. Patients can then be linked to community resources digitally pulled from UnitedWay’s directory and listed in their EHRs.
“This will empower frontline staff to have direct access to Dane County’s most robust resource directory right at their fingertips,” said the team.
Families with more risk factors will be connected with more individualized needs.
The initial focus will be prenatal care, with the rollout starting by next year.
Connect Rx is also working with community partners such as the Foundation for Black Women’s Wellness, United Way of Dane County, Public Health Madison and Dane County, and Madison Metropolitan School District, along with Epic.
THE LARGER TREND
Integrating social determinants of health data into patients’ medical records, and linking them with community resources, has been a growing priority among the healthcare providers and population health researchers.
A new article this month in the Journal of the American Informatics Association describes the emergence of social informatics as an IT subspecialty, noting that social data is infrequently captured in EHRs in a structured format.
“As the availability of social data rapidly increases in response to new policy and payment models that incentivize these different awareness strategies, there will be new opportunities to integrate these data into EHRs and implement social care interventions that address identified risks,” wrote researchers at University of California, San Francisco.
In Idaho, the statewide health information exchange partnered with Aunt Bertha this summer to allow users to access thousands of social service organizations as they work in an EHR.
“This partnership will provide support for a more complete, well-coordinated service through a single access point to an individual’s medical record for referral capabilities,” said Idaho Health Data Exchange Executive Director Hans Kastensmith in a statement this July.
ON THE RECORD
As for the new Epic integrations in Wisconsin, the model will “revolutionize the way that families experience care delivery,” said members of the ConnectRX team, helping them “access resources … that increase their income, reduce their financial stress [and] realize a lifetime of savings for themselves and for their children.”