How a Texas innovation hub is eliminating socioeconomic disparities in health

Will integrating data on social determinants of health into clinical workflows improve patient outcomes? One Dallas research hub is determined to find out.

The Parkland Center for Clinical Innovation, a health IT research and development think tank created by Dallas-based Parkland Health & Hospital System, in 2015 launched a local health information exchange, called the Dallas Information Exchange Portal. The Dallas IEP connects Parkland Health & Hospital System to social services organizations across the area — such as food pantries and homeless shelters — to help physicians and case managers streamline care coordination.

To date, the Dallas IEP has exchanged information related to a quarter million patient encounters.

"Up to 50 percent of clinical outcomes are driven by social, economic or environmental factors, and not necessarily related to the direct care the individual received," says PCCI President and CEO Steve Miff, PhD. "That has basically set the stage and created the need for this solution to connect communities, and through that, to drive personalized medicine."

Laying the groundwork

Although the Dallas IEP went live two years ago, Dr. Miff traces its history back to 2010, when PCCI Founder Ruben Amarasingham, MD — who now serves as president and CEO of PCCI's sister company, Pieces Technologies — honed in on an under-discussed predictor of readmissions for congestive heart failure patients: homelessness. Dr. Amarasingham sought to develop an innovative way to improve chronic condition management for these disadvantaged patients, with an emphasis on social determinants of health like unstable housing.

For Dr. Amarasingham, the solution came in the form of a community HIE. That year, the W. W. Caruth Jr. Foundation — a Dallas-based endowment of the Communities Foundation of Texas — awarded PCCI a $980,000 grant to develop plans for an HIE that would connect Parkland Health & Hospital System to nearby social services organizations. With funding under its belt, PCCI hoped to better facilitate patient care transitions, improve disease management and reduce hospital readmissions.

The PCCI team constructed a five-year blueprint to build the Dallas IEP. Upon evaluating the business plan in 2014, the Caruth Jr. Foundation issued the team a second grant — totaling up to $12 million — to build and deploy the system by 2019. Monica Egert Smith, chief relationship officer of Communities Foundation of Texas, says the endowment was drawn to the Dallas IEP's potential to "transform" the healthcare landscape.

"These are exactly the types of investments we want to be making," she says. "We're looking for things that are really game-changing. We're not interested in small, incremental changes. We're looking for things that would benefit potentially hundreds, or even thousands, of people, and getting to some of the most challenging issues facing our world today."

Building the infrastructure

The Dallas IEP's mission is to map individuals who visit health- and community-based organizations in the region alongside their social services needs, such as food or housing assistance. However, it is not an automatic process — patients opt into the system based on their willingness to share information, and community-based organizations work one-on-one with PCCI to implement data-exchange capabilities.

However, after a review of the social services landscape during the project's initial design and planning phase in 2011, the PCCI team realized they needed to start at square one. "There was an obvious, desperate need for infrastructure," says Donna Persaud, MD, senior medical director at PCCI, noting most of the community-based organizations lacked the necessary software setup. "So we developed a case management software system."

Through a collaboration with Pieces Technologies, the PCCI team developed Pieces Iris, a case management system that standardizes patient data to facilitate meaningful exchange among participating organizations. However, the PCCI team emphasizes that's just the back-end. The front-end, user-facing section of the system is customized based on the organization, enabling each group to run their own business operations, whether providing food, housing or job assistance services.

"That was a key milestone we didn't anticipate, but that really facilitated broad adoption," Dr. Miff said of the front-end, which enables organizations to manage their daily activities while collecting data in the background. "It wasn't enough for us to just create connections and provide smart referral, even at no cost. In order for them to adopt this system, they needed something that could run their operations."

Engaging community support

Today, the Dallas IEP connects two umbrella organizations in Texas: the Metro Dallas Homeless Alliance, which comprises more than 30 partner agencies, and the North Texas Food Bank, which boasts more than 200 partner agencies. But for Dr. Miff, the project's potential has only just begun.

"It's a huge community, with a huge social need … You don't tend to see an immediate commercial application," he explains. "The value becomes exponentially greater when more participants are part of the ecosystem, and we've finally reached that tipping point."

Mesquite, Texas-based Sharing Life Community Outreach, a faith-based nonprofit that provides hunger and poverty alleviation services to low-income families in the region, was the first social services organization to join the Dallas IEP in 2015. The Dallas IEP has helped Sharing Life open up informed dialogues with its clients, driven by information on individuals' food choices and medication adherence, for example.

"The minute I heard about it, I wanted to be involved," Teresa Jackson, CEO and executive director of Sharing Life, says of her decision to join the Dallas IEP. "The IEP is only as good and as strong as the number of people who are sharing their data. We need every social services provider who does similar work to be involved so we can share data and make sure our clients' safety net is very strong."

Next steps for the Dallas IEP

So far, the Dallas IEP encompasses 100,000 individuals, including information from roughly 250,000 encounters. In one successful project, PCCI deployed a predictive risk score that illustrates how homelessness affects adverse clinical outcomes, and implemented integrated care management and coordination services to intervene. Since the start of this initiative, Parkland Health & Hospital System has experienced a 26 percent relative reduction in readmissions for Medicare patients.

The PCCI team's immediate next steps involve targeting a few select clinical populations to further personalize referrals. The team has identified diabetic and hypertension patients who don't have access to healthy food, for example, and developed workflows to help clinicians direct these patients from Parkland Health & Hospital System to two nearby food pantries. Future subgroups might include the geriatric population or those affected by behavioral health or substance abuse issues, according to Dr. Miff.

Beyond this year, Dr. Miff notes more than 600 additional health systems and social services organizations have expressed interest in adopting Pieces Iris. To build on the initial success of the project, he also expects to integrate groups like skilled nursing facilities and home health agencies into the network. And, as the Dallas IEP continues to establish itself in the Texas market, Dr. Miff is considering a pilot for similar projects in other cities and states.

"We can really bring these connections beyond Dallas and make them national, as well," he says.

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