HEALTH

INFORMATICS
Final Project

Author: Fran Sánchez Cascos

Date: 05-2020
TABLE OF
CONTENTS
Introduction.................................................3
1. Executive Summary.............................4
2. Analysis of the current situation...........6
3. Why addressing health-related social
needs is important....................................10
4. Intervention Proposal.........................13
5. Appendix 1: Communicating the
Vision........................................................18
Culminating Project in Health InformaticsCapstone: ImprovingHealth

INTRODUCTION

Hello, I am Fran Sánchez, Telecommunications Engineer born in Spain and resident

in Barcelona.
I am passionate about healths informatics and telemedicine and currently develop
my professional career within the department of information systems of a large European
health group.
I decided to pursue this specialization because of its contents and to be able to
progress within my organization. These courses have certainly met expectations and I have
learned to approach certain problems from a different point of view.
Below I present the final project of this specialization in Health Informatics. My
solution for implementing a CDS in the organization. I hope you like it.

Thank you.

3
Culminating Project in Health InformaticsCapstone: ImprovingHealth

1. EXECUTIVE SUMMARY

Currently, most healthcare organizations are focused on providing healthcare in the

most efficient way possible in order to reduce its costs. They are focusing their efforts on
medical factors without going any further. Recent studies show that only 20% of health
outcomes are determined by medical factors, while those social factors are responsible for
80% of health outcomes. Some studies have even shown that these determinants social
health (SDOH) have associated mortality rates similar to myocardial infarctions or lung
cancer. Therefore, it seems clear that health organizations must work, detect and improve
these social determinants (together to the social agents of their communities) in order to
improve medical care for patients and avoid future problems that lead to costly healthcare
interventions.

In this regard, ImpovingHealth is firmly convinced of this fact and has implemented
the needs detection tool-related social networks of responsible health communities (HRSN).
This tool evaluates 5 domains of action: housing, food, utilities, safety, transportation.
Through its scoring system, it allows to identify the social needs of patients so that they can
act clearly (together with the community social agents) directly on said needs.

6 months ago, ImpovingHealth started evaluating patients in its 4 clinics, but today,
the adoption of this new mandate It was not what was expected. Of a total of 860 patients
eligible to perform the assessment, only 59 patients have completed it, which means an
adoption rate of approximately 6.8%.

After studying the current situation, several clear causes have been identified that
have caused this poor adoption rate. Among them fits highlight a low initial training of the
personnel involved in the workflow that will support the tool for detecting social needs
(HRSN form), lack of motivation of the clinic staff for not understanding the reason for this
new mandate (lack of explanation and leadership by ImpovingHealth) and an excessive
added workload due to not having an automated tool integrated with the current information
of the organization.

4
Culminating Project in Health InformaticsCapstone: ImprovingHealth

In the following document, an exhaustive analysis of these causes has been carried
out, the current workflow has been analyzed and it is proposed to Extensive improvements
to address initial adoption issues. The proposed improvements include very specific
aspects. Aspects like creation of a leadership and monitoring committee for the
implementation and adoption of the HRSN tool, the modification of the current workflow for
such to increase its efficiency and reduce the workload of the affected health professionals
and a full integration of the tool within of the organization's EHR. This computer integration
will allow to have correctly identified all the patients that make the form and will allow an
exhaustive study of the results (dashboard of the aggregated data) by the management of
ImpovingHealth.

It is certainly not an easy task and we will find difficult barriers to overcome. A good
motivation of the staff will help us to tackle the problem and a correct integration Computing
will enable reliable results without high additional workloads. Evaluating the success of this
intervention will not be an easy task to tackle either. But one of the first goals we want to
achieve is to increase the rate of adoption or completion of HRSN forms. An adoption rate
of 30%. In the first 3 months from the implementation of the proposed changes, it would be
a success for the objectives of this mandate.

5
Culminating Project in Health InformaticsCapstone: ImprovingHealth

2. ANALYSIS OF THE CURRENT SITUATION

The first task carried out has been to analyze the current situation in order to detect
the existing problems that have caused such a low adoption rate of the organization's
mandate.

To understand the problem first hand and to find out its causes, visits have been
made to the different centers of ImprovingHealth and interviews have been held with the
different roles involved: doctors and administrative staff.

In this way, we have been able, firstly, to describe the specific problem we are facing,
secondly, to detect the main causes of this problem (Ishikawa diagram), thirdly, perform an
analysis of the computer stack of the current scenario and finally, know the workflow of the
process that is currently running for the realization of the HRSN form.

A. Informatics Problem Statement

ImprovingHealth is a non-profit health service provider that has the firm purpose of
addressing the social needs of its beneficiaries to improve their health (social factors are
responsible for 80% of health outcomes). It has implemented the HRSN visualization tool in
all its clinics in order to identify social needs and thus improve health. After 6 months, its
implementation is evaluated, observing the low rate of forms completed and the poor
adherence to the mandate of ImprovingHealth's management.

The observed causes of the malfunction are mainly 3: insufficient training of the
personnel to carry out the task, the forms are made on paper and the results are sent to the
plant every two months, collected manually by an administrator (there is no process
automation or integration with the organization's EHR) and lastly a lack of leadership on the
part of ImprovingHealth that has not explained the benefits and why of this mandate to the
employees of its organization.

6
Culminating Project in Health InformaticsCapstone: ImprovingHealth

B. Identify Potential Causes (Ishikawa Diagram)

Training Technology

Delayed reporting

No secure file
transfer

No explanation of Manual report in

workflow Excel

No integration
No support tools
with EHR
Problem Statement
I nsufficient Paper
training questionnaires

I ncomplete Screenings

Benefits not Workflow only for

explained physician

No application
No project leader
support

No follow up Time consuming

Without explicit
Uninvolved staff
procedure

Environment Workflow

7
Culminating Project in Health InformaticsCapstone: ImprovingHealth

C. Stack Analysis

I have made a study of the computer stack to better understand the process as it is
currently developing.

This is:

Stack Level As-Is Comments

World Health System Health System of the reference

population that includes our health
organization.

Organization Non-profit medical organization ImproveHealth is a healthcare

organization with 4 clinics.
 Physician
Role The physician implements the
 Administrative staff
HRSN form as part of the medical
care they provide to the patient.
Administrative staff support this
process by collecting data and
submitting it for aggregation.
 Physician: medical care and
Function Currently, the physician performs
implementation of the HRSN
form the HRSN form and the
 Administrative staff: support in administrative staff collects the
collecting data from HRSN forms data and sends it to central.
and sending data to central.

Workflow The physician performs the HRSN The study of the population's
form as part of the medical care for health through the HRSN tool is
the patient and the administrative based on data collection by the
staff collects the data afterwards physician as part of the patient's
and sends them to the central. medical care.

Information Paper forms Currently, data collection is done

System on paper and there is no
integration with the organization's
EHR.

8
Culminating Project in Health InformaticsCapstone: ImprovingHealth

Module HRSN form for the detection of This form or module is integrated
social needs related to community into the medical care that the
health. physician provides to patients.
 Data: HRSN formulations
DIKW
responses
 Information: scores obtained in
the HRSN form domains
 Knowledge: From the
information obtained, the social
factors of the population that put
their health at risk are known.
 Wisdom: Knowing the risk
factors, corrective actions can be
applied with the social agents to
improve the health of the
population.

Technology Paper forms and Excel. Currently, the only technology

used in the procedure is the
collection of data in Excel and
sending it by mail.

D. Workflow

9
Culminating Project in Health InformaticsCapstone: ImprovingHealth

3. WHY ADDRESSING HEALTH-

RELATED SOCIAL NEEDS IS IMPORTANT

As we have commented at the beginning of this document, social factors are

responsible for 80% of health outcomes. Why is it important to address these social factors
from a clinical setting like our organization.

Simple, all social factors are directly or indirectly associated with rates and health
indicators that directly affect in people's health. These social factors normally directly index
mortality or morbidity rates in the population, increases in diseases that involve direct
medical attention (cancer, severe acute infections, etc.). Therefore, lead an improvement in
the social factors of the community in which our organization provides its service (together
with the community social organizations) will directly involve a reduction in direct clinical
care. And not only that, but will allow ImprovingHealth to optimally offer its care, knowing in
advance the health problems that most affect to the community.

Now, to address the social needs related to the health of the members of our
community, we need to screen for health related social needs. Since there are questions
about whether or not these non-medical determinants of health are a problem in the region
with the zip code of: 90001 (One of 102 Los Angeles ZIP Codes), I’d like to provide some
data that underscores the importance of this issue. Data from County Health Rankings and
Roadmaps ([Link] ) in the timeframe of 2011-2015 shows
that the health-related social need of housing impacted in 34% of the population of Los
Angeles according to the indicator “Severe housing problems” (Percentage of households
with at least 1 of 4 housing problems: overcrowding, high housing costs, lack of kitchen
facilities, or lack of plumbing facilities).

Furthermore, data from AARP livability index ([Link] in the

timeframe of 2018 shows that the health-related social need of food impacted directly on
the health of the population, since according to the indicator “Obesity prevalence”, the 18.7
% of people are obese.

10
Culminating Project in Health InformaticsCapstone: ImprovingHealth

NOTE: The indicators presented above can be easily obtained by following the
instructions

To get the indicator “Severe housing problems” we access the page

[Link] we click on the option Explore Health Rankings and
in the collection of Find County Rankings we introduce Los Angeles. We will access the
data from Los Angeles, California and we will choose the year 2019
To get the indicator “Obesity prevalence”, we access the page
[Link] we choose Los Angeles as community and we directly
access the report. In the health section we can find the indicator used on obesity.

There are many public data sources at the state and local levels that contain
variables related to population health factors (SDOH data sources). These data sources
provide us with infinite variables that will allow us to evaluate the factors on which we want
to focus our attention. Some examples of these data sources and variables are the
following:

Dataset Variables

Kids Count Data Center Analysis of variables by county (for example

Los Angeles, LO
[Link]
 Children in low-income working families
by family nativity
 Children living below the poverty
threshold by family nativity
 Median family income among households
with children by family nativity

County Health Rankings and Analysis of variables by county (for example

Roadmaps Los Angeles, LO)
http://  Adult obesity
[Link]/  Severe housing problems
 Drinking water violations
11
Culminating Project in Health InformaticsCapstone: ImprovingHealth

AARP livability index Analysis of variables by county (for example

Los Angeles, LO)
[Link]

 Housing affordability (Housing cost

burden)
 Healthy behaviors (Smoking prevalence)
 Healthy behaviors (Obesity prevalence)
 Convenient transportation options
(Frecuency of local transit service)

12
Culminating Project in Health InformaticsCapstone: ImprovingHealth

4. INTERVENTION PROPOSAL

The improvement proposal to be implemented completely modifies the current

workflow with the aim of improving the adoption and completion rate of HRSN forms. The
proposed new workflow focuses on three basic aspects:
First, put the patient at the center of healthcare, so that he or she can fill out the form
automatically. Second, decrease the workload on practitioners and administrative staff by
automating almost all tasks. And thirdly and lastly, integrate the entire process with the
organization's EHR in order to have each patient correctly identified with their social needs
and to obtain reliable, high-quality aggregated data.
Below is the new flow diagram that is intended to be established as well as the
analysis of the computing stack of this new scenario.

A. New Workflow

13
Culminating Project in Health InformaticsCapstone: ImprovingHealth

B. Stack Analysis

Stack Level To-Be Comments

World Health System Health System of the reference

population that includes our health
organization.

Organization Non-profit medical organization ImproveHealth is a healthcare

organization with 4 clinics.
 Physician
Role The proposed solution focuses on
 Administrative staff
 Pacient the role of the patient since he will
 Clinic Social worker be in charge of filling out the HRSN
form from the patient portal. The
other main role will be that of the
physician and he will receive the
alert in consultation when the
patient has not filled out the form.
In this solution, the secondary
roles are Administrative staff, and
the Clinic social worker.
 Physician: medical care and
Function Despite the fact that the main roles
implementation of the HRSN
form if the patient has not in the proposed solution are the
completed it patient and the physician, they all
 Administrative staff: Review the have an important role in the
list of patients with future visits workflow.
and mark those patients who are
eligible to fill out the HRSN form Especially Administrative staff who
 Pacient: Fill out the HRSN form will be in charge of deciding which
from home. patients will fill out the HRSN form.
 Clinic Social worker: It will study
the available resources to offer It is important that all these roles
to the patients that the system receive excellent initial training as
considers vulnerable and will well as an overview of how the
contact them to coordinate the
problem of social factors affects
intervention.
health and your organization can
improve this.

14
Culminating Project in Health InformaticsCapstone: ImprovingHealth

Workflow The new workflow to be See attached workflow.

implemented begins with
administrative staff reviewing the
patient list for the following week
and marking patients who are
eligible to fill out the HRSN form.
For the patients chosen in the EHR,
the form to be filled is automatically
posted on the patient portal and an
automatic email is sent explaining
why and a link to the form to be
completed.
If the patient completes the form at
home, the results are processed by
the EHR, calculates the final results,
and sends the aggregated data to
the scorecard that will be viewed at
the organization's headquarters to
track implementation.
In turn, if the results indicate that the
patient needs help, send an alert to
the clinic social worker to analyze
the actions to be carried out and
subsequently contact the patient.
When the patient comes to the visit,
the physician searches his history
on the computer. If the patient has
not filled out the form, a hard stop
alert appears (does not allow to
continue) warning that the patient
has not filled out the HRSN form.
At that time, the physician urges the
patient to fill out the form online with
their help. Once completed, the
EHR processes the results,
calculates the final values and
sends the added data back to the
scorecard that will be displayed in
the central offices of the

15
Culminating Project in Health InformaticsCapstone: ImprovingHealth

organization. If the patient needs

help, the workflow continues as
explained above.
The physician continues with his
medical visit and finally the patient
goes home.

Information CDS of logical conditions (IF .. Implemented CDS contains

System THEN). various logical rules throughout the
workflow that cause various effects
in parallel depending on whether
the condition is met or not.

Module HRSN form for the detection of This form or module is integrated
social needs related to community into the medical care that the
health. physician provides to patients.

DIKW It is not feasible to accept the

 IF the administrative staff marks
the patient as eligible in the results of the form as correct until
EHR, THEN the HRSN form is the patient is contacted. Problems
posted on the patient portal and with the patient's native language
email is sent or problems with understanding the
automatically to the patient with form may arise.
the explanation of the form and
the link. Therefore, the form responses
should be reviewed with the patient
 IF the patient fills out the form in to ensure that the results are
the patient portal, THEN the consistent.
results are saved in their patient
In addition, the patient will have to
file, the EHR automatically
calculates be monitored since his personal
the results of the form and save conditions may change over time
the results in the [Link] so that (loss of job, change in home
they can be consulted by the conditions, etc.).
organization. ELSE, an alert will
appear to the doctor in the
patient's file indicating that the
form has not been completed.

16
Culminating Project in Health InformaticsCapstone: ImprovingHealth

 IF the results of the HRSN form

indicate that the patient needs
help, THEN the social worker is
alerted so that they contact the
patient and offer the different
alternatives and solutions.

 EHR
Technology The implemented CDS is based on
 Patien portal
integration with the organization's
EHR and the patient portal.

17
Culminating Project in Health InformaticsCapstone: ImprovingHealth

5. APPENDIX 1: COMMUNICATING
THE VISION

The reason for this meeting is to present the improvement proposal that we are
going to make in the implementation of the HRSN form within the organization's clinical
practice. As you know, only 20% of health results are determined by medical factors,
and that social factors are responsible for 80% of health results. And our organization,
ImprovingHealth, is firmly convinced of this fact and of the mandate to address the social
needs of our community and lead the improvement of these needs together with the rest
of the social agents involved.

To address this leadership, it is necessary to know these needs firsthand. There

are many quantitative variables that help us get an idea of these. And ImprovingHealth
knows these variables and their results in our community perfectly. To give you an idea,
social needs have been shown to affect mortality at a rate like heart attacks, strokes, or
lung cancer.

As you know, the initial implementation of the project did not have the expected
reception and the completion rate of the HRSN forms was very low. It is our obligation
as part of ImprovingHealth to participate in the vision of the organization and work
together to improve the health of our patients. For ethics, vocation, and pride. All staff,
from physicians to administrative staff to IT, must work together to offer the best possible
care to our patients.

We have detected all the causes of the bad result obtained during these first 6
months of implementation and we clearly know that we as an organization have not
been able to actively explain the mission and vision of this project, we have not made
you participate in the implementation and we have not known to adapt the workflow to
the new process thus increasing your workload.

Precisely, taking these causes into account, we have redesigned the entire
process and have adapted the workflow to: on the one hand, put the patient at the
center of our medical care, and on the other, automate the entire process so that we can
obtain reliable results with full traceability and lower the workload you currently have.

18
Culminating Project in Health InformaticsCapstone: ImprovingHealth

For this we have integrated the HRSN form with our EHR and with the patient
portal so that the patient will have the online form prior to their visit and will be able to fill
it out easily from home. When the patient visits our clinic, the physician will already have
the results of the form so that he can discuss the situation with the patient and take the
necessary measures with our social worker if he deems it necessary.

At the same time, ImprovingHealth will have all the data in real time, without the
need to send data or secondary work without added value.

From the IT department, we are committed to monitoring the entire workflow and
the correct operation of the system, acting quickly in the event of failures or
improvements that you think are necessary.

The organization will lead in the first person the implementation and control of the
mandate and to this end will create an interdisciplinary control group in which you are
invited to participate.

Your support and involvement are very important to us.

Thanks for that.

19