Table 4 Facilitators of developing information infrastructure used to coordinate care and address quality
Technological Factors | Facilitators | Quotes |
|---|---|---|
SDOH Data Infrastructure and Standards | IT use supported SDOH data integration, care management, and quality improvement | “We can see the chart, whether that particular need had been addressed or if there’s additional follow-up and work that needs to be done.” Care Manager |
“Z-code encounter reasons provide data necessary to enhance quality improvement initiatives.” Quality Director | ||
“Risk stratification is made possible through the EHR system, using data such vital health indicators, patient lifestyle, and medical history.” Care Manager | ||
Data Policies, Rules, and Procedures | EHR system use helped with implementation of internal data policies and activities | “Some notes can be marked sensitive, and then there’s some patients that you’re not able to access. You have to request access.” Social Worker |
“Our internal data protections prevent sharing patient information without first receiving patient consent.” Practice Manager | ||
Existing Information Infrastructure | Local IT infrastructure provided access to shared patients | “We have access to EHRs of all the local hospitals in our area, so the care connectors will actually go in and pull reports of patients that have in the ED there, and they do outreach calls. See if they need follow-up and try to decrease ED utilization.” Quality Manager |
“We exchange data with the health department… providing biometric information on patients with chronic disease.” Program Manager | ||
External Policies and Regulations | Quality measures supported new care management and monitoring activities | “We always work with the health plans on HEDIS required reporting of that information that helps drive revenue back to us. And it helps us to hire additional people to monitor for quality.” Executive Director |
New Technology | Cell phones and telehealth connected patients to care | “Most people can follow a link on their phones. And we learned this during the pandemic when people were doing medical visits.” Care Manager |
“Patients can just snap a picture with their phone and upload requested documentation right into their case.” Care Manager |