How HIE Can Help Identify Vulnerable Patient Populations

When Margaret Wood moved to Colorado to continue a career in nursing as part of the University of Colorado Health System, she had not prepared herself to see what lengths patients coming from rural communities would go to in order to access healthcare or what barriers they face when returning home.

As the nurse manager of Interventional Radiology at Medical Center of the Rockies, Wood sees a diverse patient population but one commonality they all share is their need for aftercare. Something Wood seeks to remedy in her position are the number of patients who fail to seek the follow-up care they require because Social Determinants of Health (SDoH) data points were not collected or communicated between care staff.

These data points include information regarding housing and food security, transportation issues and other sensitive topics that can make the difference between whether a patient receives support services in order to access additional care of if they end up readmitted due to complications.

Once these data points are collected, they need to be stored in a common, accessible repository. This is what motivated Wood to write a graduate paper on SDoH and Health Information Exchange (HIE). In the paper Wood notes, “As leaders in healthcare, our goal should be to improve health outcomes and increase health equity for all of our patients.  We must make evidence-based decisions around patient care that includes socioeconomic screenings of patients in the EHR in order to provide targeted medical care for patients, appropriate public health emergency response and multi-sector collaboration. HIE’s such as CORHIO create a space for a collaborative informatics infrastructure and provides appropriate response time for the dissemination of disease data and shared patient data in order for health systems to collaborate with the community to provide better care and combine resources.”

In using CORHIO, Wood has experienced success intervening with patients who would be considered part of a vulnerable population. “Accessing CORHIO, we are able to get full patient chart, say if they’re coming from Estes Park , and we don’t have to ask all the sensitive questions like ‘are you food insecure?’ because it’s already in their chart. Typically, those are things people are ashamed of and they don’t want to bring it up to several different providers in a care setting.”

This issue is so important to Wood that she has hired a nurse navigator to gather information pertaining to SDoH and to use this information in assisting patients in accessing aftercare and improving health literacy among her patients.

In the near future, Wood hopes to see more health care providers gathering SDoH information within HIEs. “HIE provides transparency. Colorado can create a standard that everyone screens for certain SDoH that will affect a patient’s outcome and services they need going home. There is a space to work on that and I hope we’re moving in the right direction towards improving patient care.”

Wood encourages those wanting to discuss this important topic to reach out to her at Margaret.Wood@uchealth.org.