Creating and operationalizing processes and in-system workflows that integrate Social Determinants of Health throughout clinical workflows at [Redacted Organization].
Company:
Role:
Team:
Project Duration:
Epic Systems, Whole Health System
Healthy Planet (Population Health & Care Management software) Project Manager
Core workgroup consisted of 14 Epic, Whole Health System IT and operational leads; 78 Epic and Whole Health SystemSubject Matter Experts engaged
7/16/2020 - 4/10/2021
Project Background
I helped Whole Health System implement a suite of Epic applications for their entire organization. Whole Health System is one of the larger enterprise organizations in recent Epic history to go live with our latest install methodology, with a patient population of over 6 million and over 80,000 clinicians and employees. Most Epic projects require legacy data collection and conversions, in addition to Epic-focused decision-making, workflow design, system configuration, and end-user training. Decision-making and workflow design is meant to encompass all facilities, no matter how disparate their systems, processes, and resources are today. I oversee the configuration and implementation of the software that the care managers, social workers, quality reporting leads, and population health supervisors use in Epic.
One key functionality my team owns on this project is Social Determinants of Health. Think of SDoH as the underlying reasons or causes that may produce more evident health issues. The graphic shows how SDoH risks are listed, and which 'domains' are asked about in an assessment with more than 15 questions.
Problems & Risks
Previous attempts to standardize SDoH workflows at Whole Health System failed
Competing Epic project priorities and timelines that stifle creativity and analysis
Disparate staffing, technology, and interest across the 50 hospital campuses
First Epic project to utilize cross-clinical approach for exhaustive strategy formation
My Contributions
Led weekly core workgroup and SME attendees through clinical workflow design
Evaluated operational resources, priorities, and goals to determine feasibility of SDoH adoption
Presented strategy and decisions to Advisory Council of over 200 Whole Health System clinicians
Advised IT analysts on system configuration, troubleshooting, and training
Coordinated project timeline, SME involvement, and follow-up questions/tasks
Demoed Epic functionality to inspire SMEs' ideas and goals per specialty
Liaised with Epic R&D and internal workgroup to influence development roadmap and update install recommendations
The 'SDoH wheel' which displays system-calculated risks based off of evidence-based assessments; each SDoH 'domain' listed starting at the top of the wheel, continuing clockwise
Project Research
Research has shown that these factors, when left unaddressed, will result in worsened health, regardless of whether the patient has chronic conditions. Social risks are tied to more frequent ER readmissions and inequitable healthcare access and outcomes, amongst other impacts. Currently, the majority of clinicians are not trained to seek out this social information, and healthcare organizations do not always have the resources or insight to provide care specific to SDoH.
Epic’s SDoH tools were first introduced in 2018, and organizations are having varied success in installing and operationalizing all SDoH tools and concepts. As a member of our Install Success Council, which internally reviews every active project for Population Health/Care Management, I have seen multiple organizations limit themselves to a gradual rollout of the ten domains by focusing on one critical domain or just one patient population. Whole Health System wants to collect information for all ten domains across the entire patient population, which has not been executed successfully at this scale in Epic history.
Even if Epic customers are successful in screening patients for SDoH, actually acting upon these risks required further thought. Patients need to be connected with resources to help with the identified risks, and they must be followed up with to ensure services were coordinated or the risk is no longer present. This creates a convoluted web of possibilities for any one patient's journey throughout the Whole Health System which complicates how to ensure no patient's risks go unidentified or unaddressed.
Research Impact
Whole Health System is quite passionate about caring for every single aspect of the patient, so operational and IT buy-in was immediate. Proper change management and communication starts at the top of hierarchical structures, so I quickly asked for volunteers to staff a core workgroup of Care Management IT and operations who would help set the organizational strategy for SDoH across the entire enterprise. For specialties where SDoH would be quite new, our workgroup would analyze the standard protocols and training of end-users to determine how SDoH could fit in; see the ER Nurse sample below to understand how the workgroup first determined the feasibility of SDoH adoption by defining one archetype of each specialty:
Given all of this, our Emergency session of the workgroup determined to display SDoH information to ER Nurses, but they would not be required to leverage the full SDoH toolkit. Instead, the ER Nurses were given a shortened assessment, and the system would automatically order a consult to a Social Worker if a high risk was identified, without any intervention/thought needed from the ER Nurse, to ensure someone followed up with the patient's needs.
An overview of the entire IT and operational process for SDoH, including the specialties consulted in the SDoH workgroup
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Starting with the most acute contexts of care, the SDoH workgroup would then work ‘backwards’ to ensure that the most acute patient populations were most likely to have needs addressed. The workgroup met with over 15 clinical specialties to tailor the decision-making strategy to their context of care. Each week, after decisions were made, the IT Care Management team and I would help advise and oversee the system configuration other teams would complete on their own applications. I created a Decision Matrix that served as a dual reference of decisions made and a tracker for IT to sign off on their application team's progress in decision approval and system configuration. This served as a focal point when presenting to the Epic project's Cross-Clinical Advisory Council where clinical governance approved of each strategic decision made.
Whole Health System will go live on Epic for their first wave of facilities on October 24, 2021. We currently are in the Change Management and Testing phase, so I am unable to report on the success of our work at Whole Health System in relation to their strategic aims or the different metrics set in each workgroup session.
A sample agenda of the SDoH workgroup - the Core workgroup would meet before to prep discussion questions and topics to guide the full workgroup
Despite not yet going live, the process that I created for installing SDoH drew interest from internal Epic Care Management and Social Determinants of Health leadership. An internal workgroup is following along with my process as I go, updating install materials and customer-facing documentation, so that every organization can start with a stronger chance of creating Social Determinants of Health workflows that will can improve the lives of millions.
