Home > Achieve Coordinated Healthcare Services through Enhanced Technology
Last Update: 6/11/2021

Achieve Coordinated Healthcare Services through Enhanced Technology

This coordinated care intervention is focused on utilizing health information exchange to improve accuracy and efficiency for patients with multiple medical providers. Patients will have access to their own personal health information across all platforms and sources through a regional data-sharing network. Partnerships with organizations like the Michigan Health Information Network (MiHIN), GENE-5, Great Lakes Health Connect (GLHC), TavHealth, Collective Medical and Conduent will work to improve efficiency, data security, patient safety, and a patient treatment plan ownership. As we move along the continuum of strong coordination of care, we intend to expand by implementing evidence-based interventions.

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Data Snapshot for Region: MiHIA

Compared to MI Counties, MiHIA has a value of 84.4% which is in the 2nd worst quartile of regions. Regions in the best 50% have a value higher than 84.8% while regions in the worst 25% have a value lower than 82.1%. Households with an Internet Subscription
(Compared to MI Counties)

Up to Date Progress

We believe that monitoring the progress of our interventions is a essential process that comes into play between setting and attaining a desired end. Continuous, up-to-date progress-tracking is the best way to ensure that the objectives are translated into action.  Each intervention follows a process of stages moving from implementation to expansion, then to scaling, and in the long run, sustainability.

The progress-tracking graphic above is a handy visual aid designed for a "quick glance" update. The graphic color will update as we continue towards a path of successful completion of this intervention.

                             

        Implementation Stage                                Expansion Stage                                       Scaling Stage                                    Sustainability Stage

Key
  • Red: Signifies no work has been completed
  • Orange: Signifies a plan has been created to begin work on the intervention
  • Yellow: Signifies action has been created for the intervention
  • Light Green: Signifies action has begun towards executing all of the objectives and some strategies are completed
  • Dark Green: Signifies significant progress towards completion of all objectives

Intervention Progress per Objective and Strategy

Learn more by exploring the objectives below

Objective 1: Explore available technology assets to be leveraged to as data analytic partners to assist THRIVE Portfolio

  • Strategy 1.1 - Meet with MiHIN, GENE-5, Great Lakes Health Connect, TAVHealth, Collective Medical and Conduent to explore their approach to improve existing use cases and in depth dialogue to determine capabilities

    • Responsible Party: MiHIA
    • Data: All meetings occurred by the Winter of 2019
    • Target Completion Date: Winter 2019
    • Program Highlights and Significance: Exploring available technology assets allowed for MiHIA to match capabilities of partners to THRIVE portfolio to harness and capitalize on potential partners

Objective 2: Explore available technology assets to be leveraged as innovative science partners to assist THRIVE Portfolio

  • Strategy 2.1 - Meet with DayTwo to explore their approach to studying microbiomes and how they impact clinical outcomes

    • Responsible Party: MiHIA
    • Data: Completed
    • Target Completion Date: August 2019
    • Program Highlights and Significance: Exploring available technology lead to a pilot with DayTWO and regional health systems. Once the pilot is completed, it will help determine the potential impact after applying enhance technology to health outcomes

  • Strategy 2.2 - Pilot a regional test with DayTwo and regional health systems to determine impact potential

    • Responsible Party: MiHIA
    • Data: Pilot is underway with regional partners such as McLaren Caro & Bay, Ascension St Mary’s, Delta College, Morley, City and County of Saginaw, Central Michigan University, CMU Health, Garber, Covenant Healthcare and outcome data to be provided by DayTwo. The pilots have concluded in several businesses and are still underway in others; some of those who completed the pilot have signed contracts to maintain the work; a current Medicaid client study is underway with financial support from United Healthcare; Results of all pilots have been outstanding and are achieving as good or better outcomes than the published clinical trials.  Click the following link for a DayTwo One Page Summary.
    • Target Completion Date: January 2020
    • Program Highlights and Significance: Exploring available technology lead to a pilot with DayTWO and regional health systems. Once the pilot is completed, it will help determine the potential impact after applying enhance technology to health outcomes
    • Covenant HealthCare Member Stories
    • Morley Companies Member Stories
    • Ascension St. Mary's Member Stories

Objective 3: Understand National strategies underway to advance tech and care coordination across clinical and social service systems

  • Strategy 3.1 - Explore national best practices to inform our regional work

    • Responsible Party:  MiHIA
    • Data: Participated in NASDOH; Work is currently underway where the THRIVE Patient Safety Taskforce is partnering with two regional systems to jointly learn through participation with the Primary Care First initiative. Ascension and MidMichigan have opted into cohorts 1 and 2, respectively, and will work with THRIVE in shared learnings and opportunities. This process will inform the region about how to use upcoming capitated, risk-stratified, value-based payment models to drive primary care reform and to improve care coordination across multiple healthcare system domains.
    • Target Completion Date: Ongoing
    • Progress Highlights and Significance: It is a best practice for the region to study and explore the state of affairs and priorities nationally to determine what partners can contribute and match to THRIVE portfolio

  • Strategy 3.2 - Explore national purveyors to support community based organizations via technical assets

    • Responsible Party: MiHIA
    • Data: Social determinants of health data available to support community based organizations on the MiHIA 4.0 Dashboard. A review of a new start up company Limber Health is underway with its online physical therapy services; The plan is to pilot with a set of regional primary care offices; It contributes to several portfolio interventions such as a preventive component of the opioid strategy, a piece of the future of primary care and care coordination with integration of effective primary care into the care team model and to regional attractiveness as a cost control action.
    • Target Completion Date: Ongoing
    • Progress Highlights and Significance: It is a best practice for the region to study and explore the state of affairs and priorities nationally to determine what partners can contribute and match to THRIVE portfolio

  • Strategy 3.3 - Explore national initiatives underway to advanced technology and care coordination across clinical and social services systems

    • Responsible Party:  MiHIA
    • Data: Convened system reviews with TAVHealth, Signify, Aunt Bertha, the Conversation Project, Respecting Choices model and embedded assessments within EPIC; We continue to monitor closely the advances in systems and technology for connecting clinical and social services to address SDOH and the policy and technology aspects of care coordination and electronic health records; Practices who will implement Limber Health for the trial are identified and the trial will be starting soon
    • Target Completion Date: Ongoing
    • Progress Highlights and Significance: It is a best practice for the region to study and explore the state of affairs and priorities nationally to determine what partners can contribute and match to THRIVE portfolio

  • Strategy 3.4 - Distribute survey of health systems and physician providers to determine greatest needs and interests, what exploration work already done

    • Responsible Party: MiHIA
    • Data: This has been done through the Patient Safety Taskforce, with feedback collated and used to drive upcoming learning sessions during monthly meetings
    • Target Completion Date: November 2019
    • Progress Highlights and Significance: It is a best practice for the region to study and explore the state of affairs and priorities nationally to determine what partners can contribute and match to THRIVE portfolio

  • Strategy 3.5 - Provider resources and references to explain everything can access as explore technology for themselves in the health systems

    • Responsible Party: MiHIA
    • Data: Created a library, webinar and survey to explain everything can access as explore technology for themselves in the health systems
    • Target Completion Date: Ongoing
    • Progress Highlights and Significance: It is a best practice for the region to study and explore the state of affairs and priorities nationally to determine what partners can contribute and match to THRIVE portfolio

Objective 4: Pilot a case to use technology to reduce admissions and clinical improvement

  • Strategy 4.1 - Supported GENE-5 in technology pilot to reduce readmission for CABG

    • Responsible Party: MiHIA & GENE-5
    • Data: Documented value case and sent to other health systems for review
    • Target Completion Date: May 2020
    • Progress Highlights and Significance: May potentially positively impact individual well-being, health care systems and the economy with advanced technology to achieve coordinated healthcare services

  • Strategy 4.2 - Explore new capabilities for a regional shared data network (RSDN)

    • Responsible Party: MiHIA
    • Data: Mapped pros and cons for best case scenario and business case is in review to share with health systems
    • Target Completion Date: May 2020
    • Progress Highlights and Significance: May potentially positively impact individual well-being, health care systems and the economy with advanced technology to achieve coordinated healthcare services

  • Strategy 4.3 - Explore combination of GENE-5 and MiHIN technology to improve patient safety

    • Responsible Party: MiHIA & GENE-5
    • Data: At this time Care Journey and direct EHR extracts offer the most complete and time sensitive capabilities
    • Target Completion Date: Spring 2020
    • Progress Highlights and Significance: May potentially positively impact individual well-being, health care systems and the economy with advanced technology to achieve coordinated healthcare services

Objective 5: Advancing Cancer Genomics Best Practices from Research into Public Health Applications through Education, Surveillance and Policy in Michigan

  • Strategy 1 - Participate in Steering Committee meetings and conference calls

    Responsible Party: MiHIA / Tina Swanton
    Data:
    Target Completion Date: September 30, 2021
    Program Highlights and Significance: 

  • Strategy 2: Assess provider education and training on the use of family history screening tools to identify at-risk individuals, and about tumor testing for newly diagnosed colorectal and endometrial cancer patients. Identify system barriers and areas where a change in policy could be implemented to increase referral and genetic testing in rural and underserved areas

    Responsible Party: Tina Swanton and CMU Health
    Data:
    Target Completion Rate: September 30, 2021
    Program Highlights and Significance: 

  • Strategy 3 - Increase provider education on risk assessment and appropriate referrals to genetic services in rural and underserved areas

    Responsible Party: Tina Swanton and CMU Health
    Data:
    Target Completion Rate: September 30, 2021
    Program Highlights and Significance: 

Michigan Health Improvement Alliance