Advanced Health Models: Healthcare’s Future?

05-11-16  by Richard Taylor, Director of Business Development for eTransX Inc.

Recently,  the Advanced Health Model workgroup of the ONC’s Health IT Policy Committee issued their initial findings and recommendations*.  This workgroup, chaired by Paul Tang, MD, the chief innovation and technology officer at Sutter Health’s Palo Alto Medical Foundation, is charged with finding ways to facilitate the effective use of health IT to support and scale advanced health models.

Their findings and recommendations can be summarized as follows:

1.  Recognizing the significant impact of the social determinants of health

Providers seeking to improve individual health outcomes are increasingly acknowledging the reality that an individual’s health is shaped largely by life circumstances that fall outside the traditional health care system. An extensive body of research has shown that social, psychological, and behavioral factors, such as family support systems, stress, housing, nutrition, income, and education explain far more about an individual’s health outcomes than the results of medical care.

2. Expanding the traditional medical “continuum of care”

The Advanced Health Platform (AHP) Workgroup recognizes that improving health will require a broad expansion of the traditional medical “continuum of care” to encompass all of the entities and individuals within a community that influence an individual’s health. The IT solutions and systems that are used to support a holistic approach across all of these entities must evolve as well to enable truly seamless services to the right individual at the right time.

3. Defining a new  “Advanced Health Model”

The AHM workgroup has sought to describe a range of emerging, community-level interventions that strive to bring together clinical, social, psychological, and behavioral data to improve and to coordinate health across settings for individuals. In many cases, these Advanced Health Models start within the medical system but seek to bridge gaps with a wider set of relevant services. In other cases, these models may be driven by community-based organizations seeking to incorporate clinical services to meet individuals in their preferred setting, such as where the individual lives, or another community setting. Rather than prioritizing clinical outcomes dictated by the medical system, these models seek to drive sustainable health improvements by focusing on person-centered goals and priorities that matter most to the individual.

4.  Utilizing technology to support Advanced Health Models

Selecting and implementing technology to support AHM models requires recognizing a wider  ecosystem of technology solutions beyond the traditional electronic health records system used in clinical care. In the clinical setting, these include technology applications that may exist outside the traditional EHR, such as care management modules and population health management and analytics applications,  as well as third-party services, such as those offered by health information exchange organizations. Meanwhile, organizations such as schools, food banks, and social services agencies that are focused on supports that are non-clinical in nature may have a wide range of software solutions that support case management. At the community level, technology platforms that link human-services information and deliver consumer education are also integral to improving health.

Advanced Health Models that bring together these disparate systems frequently rely on an additional layer of information management that can match, normalize and aggregate data to support individuals and inform targeted service provider decision-making.

An Ideal IT Platform for supporting Advanced Health Models

eTransX offers a robust IT Platform to support Advanced Health Models.  This platform is the XCare Community system a hosted software as a service application.   This platform was designed from the ground up to support a fully integrated care coordination solution that connects healthcare providers with community based social service providers.

For any organization seeking to implement an Advanced Health Model, the eTransX XCare Community system provides a robust IT platform that can be integrated with existing healthcare delivery systems already in place.

* Source:  Advanced Health Model Workgroup June 2, 2015 Hearing summary,  6/21/15