In May 2016, MHIN published its Population Health Strategic Plan to outline priority areas of population health focus and activities to be pursued over the next three years to improve the health of our local communities. MHIN has spent the past year collecting feedback on what data our stakeholders need to support their organization’s mission and then working with those organizations to formulate a plan to obtain that information in order to establish “baselines” for the region. This baseline information has enabled MHIN to develop mechanisms that encourage residents to actively engage in the management and improvement of their own health and wellness and to support innovation in population health.
This process has not been easy or straightforward, but MHIN is, and continues to be, dedicated to identifying and integrating data contribution from Community and Human Services Organizations as well as State and Local Agencies. The goal of this Interim Report is to update the community on our progress in implementing the Population Health Strategic Plan and to provide insights on any changes to our previously established timelines and deliverables. We are proud of our progress thus far and are excited to continue working with you!
MHIN’s strategic plan aims to leverage the power of research, data, and analytics to address the region’s most immediate health concerns. MHIN works with regional partners to identify the data necessary to develop solutions that bridge the gaps in services in the region and improve outcomes and health equity. For example, we are giving Emergency Medicine Services (EMS) leadership access to the MHIN data repository to review outcomes and improve in-the-field decision support and service delivery. MHIN also partnered with community partner organizations as part of a grant-funded initiative to provide supportive housing for chronically homeless persons who are frequent users of emergency departments. In addition, MHIN is now receiving data from the Indiana State Department of Health’s Division of Vital Records. This data, coupled with behavioral and social factors, will provide a more comprehensive interpretation of the health of population at the county level. Finally, MHIN has been focusing on strengthening relationships with local community and human services organizations to develop a strategy to collect social determinants of health data to shift from a focus on acute care for the individual to improving the health equity for the residents who comprise our regional population.
The Population Health Strategic Plan outlined three regional health priority areas: fetal and infant health, integrated care and behavioral health, and transitions of care. These issues were identified based on findings from research reviews, as well as community health needs assessments from local hospitals and health departments in northern Indiana. MHIN recently completed a study with Saint Mary’s College to document prenatal care data collection workflows how they can be improved through enhanced data exchange. As a result, MHIN is working with prenatal care providers to support improved discrete data contribution of important perinatal health indicators. In behavioral health, MHIN is testing the use of Screening & Referral in acute care settings. Lastly, MHIN is seeking to enhance the data available on long-term and post-acute care facilities. The goal is to leverage HIE infrastructure to notify and/or exchange timely information between providers transferring and receiving patients to allow the receiving provider to effectively care for the patient no matter what type of electronic system they are using, which means that data contribution from these providers is vital.
As of April 2017, MHIN made substantial progress towards its goals and has remained on track with its initial implementation timeline. The remaining 18 months will consist of identifying and onboarding data sources needed to support the emerging data needs to drive our Regional Analytics initiatives, and identifying and developing additional uses case to respond to the improvement of health equity in the region.
We are excited about promising opportunities to support various Community Health use cases, such as Community Paramedicine, Community Health Workers, Public Health Department Outreach, and Emergency and Disaster Responses.
As previously stated, MHIN has a solution available to support remote monitoring by developing the technology necessary to monitor patients following treatment or discharge from a facility.
MHIN completed a special fetal and infant health project with Saint Mary’s College and, as a result, is developing a Prenatal Care Data Collection Solution in anticipation of an eventual accredited standard for a Prenatal Care transitions of care format.
We are also preparing to test an on-demand screening and referral mobile technology to support the virtual integrated care model in clinical settings, as well as the onboarding behavioral health data into our HealtheIntent platform.
MHIN is also proud to be collaborating with the Mike and Josie Harper Cancer Research Institute, The Medical Foundation, and University of Notre Dame’s Department of Applied and Computational Mathematics & Statistics, as part of our new partnership as members of the Indiana Cancer Consortium, to examine mutational profiling on tissue samples from individuals who have lung cancer, colorectal cancer, or melanoma and the factors that influence the incidence of these three types of cancer and their treatment.
One focus of the strategic plan was bio-surveillance: the process of gathering, integrating, and communicating essential information that might relate to disease activity and threats to human health. Over the past year, we have refined our focus to address emergent priority areas, one being opiate use in our region.
Another focus of the strategic plan is remote monitoring, which is the development of secured mobile technology solutions to enable health systems and providers to deploy integrated care coordination, patient monitoring, and engagement. MHIN has successfully implemented technology to support this area and has the capacity to expand to additional use cases.
In other collaborative efforts, MHIN is now part of the Indiana Cancer Consortium, along with the Mike and Josie Harper Cancer Research Institute, The Medical Foundation, University of Notre Dame, and other community partners, who are working to pursue collaborative projects to support the emergent efforts by the National Cancer Institutes, including the Beau Biden Cancer Moonshot to accelerate cancer research. These collaborative efforts will provide clinicians with additional information on which to base treatment decisions to improve patient outcomes. We will also continue to identify demographic, socioeconomic, and geographic distinctions in disease incidence and outcomes, which can be used to influence education and outreach activities and to initiate further research.
- Dr. Matthew Koscielski
- Kari Tarman
Manager, Marketing, Communications & Volunteer Services
- Joyce Simpson, MD
- Daniel A. Nafziger M.D., M.S.