Interoperability 2.0 – Creating a Holistic Model of Care

Published on
Monday, April 2nd, 2018

AUTHORS: Eric Crawford, Director of Product Management, and Adam Bell, Senior Director, Advisory Services Department

Introduction to Blog Series

“Interoperability” has historically been used by industry professionals to describe the technical details of connecting disparate systems together.  For many years, hospitals, providers, and ancillary services have built advanced networks that remove barriers to sharing healthcare data.  These networks have become increasingly complex and adept at assembling a valuable data asset.  At the same time, the cost of care has dramatically outpaced improvements in healthcare outcomes (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863949/).

Many now recognize that interoperability alone, while necessary, is not enough.  In this blog series, we will focus on a specific use case that applies principles of interoperability (Interoperability 2.0) to clinical and community contexts, driving a holistic model of care.

This series will include 3 parts:

  • Part 1: A Holistic Model of Care
  • Part 2: Contextualized Population Profiles
  • Part 3: Innovating by Workflow Integration

We invite you to participate in the conversation throughout the blog series by commenting below.

Part 1: A Holistic Model of Care

A holistic model of care is the focus of an interdisciplinary care team that considers the physical, emotional, social, economic, and spiritual needs of the person; his or her response to illness; and the effect of the illness on their ability to meet self-care needs. Researchers and clinicians are now fully recognizing the importance of incorporating social determinants of health into a holistic plan of care. Social determinants of health (SDoH) are generally defined as a broad set of “health promoting factors found in one’s living and working conditions, rather than individual risk factors that influence the risk for a disease, or vulnerability to disease or injury. (Simandan, 2018)” These include topics such as:

  • Transportation
  • Employment
  • Housing
  • Support systems
  • Income
  • Health coverage

Social determinants of health can account for more than 30% of health outcomes

(Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/) however these are often not consistently addressed in traditional clinical workflows.

Consider this scenario:  A single mother is suffering from diabetes.  She works two part time jobs and is the sole bread-winner for her family of three elementary-aged children.  The last thing she has time or resources to do is manage her HgbA1c when there is no food in the pantry, electricity is about to be shut-off, and it is dangerous to even walk to the bus stop.

Studies have found that people that don’t feel understood are less likely to trust their care team recommendations, such as taking their prescription medications as directed (Source: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170988).  This has important implications for health care quality, outcomes, and costs. Trust begins with understanding the patient’s social context and help them overcome, not only clinical, but also life challenges. Building trust is both a pre-requisite and an outcome when patients are treated using a holistic model of care by incorporating social determinants of health.

Hear Aetna’s CEO and Chairman, Mark Bertolini, discuss how your health and life expectancy is driven by your zip code.

Top 5 healthiest places to live in the US: Aetna CEO from CNBC.

Where You Live Impacts How You Live; Aetna and U.S. News have collaborated to create Healthiest Communities, a powerful tool for change. By Mark Bertolini Contributor March 26, 2018

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