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Health Equity

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Health Equity

Over the last several years, efforts to identify strategies for the successful collection, storage, and use of health equity data sets has advanced across the country. This is a result of increased recognition that the status of an individual’s health is more than just the sum of their clinical encounters. HealthInfoNet’s aim is to further these efforts in Maine by serving as an information conduit among the many medical providers, community-based organizations, and other cross-sector stakeholders working in our communities to improve the health, wellness, and wellbeing of the individuals they serve.

Why Health Equity?

The effort to leverage diverse cross-sector data sets to more effectively and efficiently “tell the story” of an individual’s health, wellness, and wellbeing represents a fundamental shift in the traditional care delivery model. 

Understanding that medical care alone cannot account for what makes an individual sick has shifted the diagnostic focus to simultaneously examine the underlying social circumstances and influences impacting their health. According to the Robert Wood Johnson Foundation, only 20% of health outcomes can be attributed to medical care; upstream factors account for the other 80%, including social and economic factors (40%), physical environment (10%), and health behaviors (30%).

The complexity of interpreting an individual’s health-related risks, conditions, and outcomes casts a light on the many health disparities that exist in our communities, especially within the most vulnerable and underserved populations. But increased information sharing among multidisciplinary providers, who are committed to coordinating access and delivery of care to individuals across clinical and community settings, aims to eliminate these key drivers of health and to move toward health equity — the desired outcome that everyone has a fair and just opportunity to be healthy.


How Do We Define Health Equity?

When it comes to conversations about health equity, semantics matter. For instance, one of the most commonly used terms in the study, “social determinants of health,” is a loaded and misused concept that often creates more confusion than it does clarity. Which is why HealthInfoNet employs the following definitions to more pointedly refer to the specific health equity data sets of priority to health information exchange in Maine.

Expanded Demographics and Personal Characteristics: The various socioeconomic factors that are used to describe populations and their characteristics, such as race, ethnicity, language preferences, veteran status, farmworker status, etc. While “these characteristics are not inherently connected to poor health outcomes… the social and economic conditions affecting patients’ health are deeply rooted in systemic racism, discrimination and inequality” (PRAPARE) that derive from their identities.

Sexual Orientation and Gender Identity (SOGI): The ways in which individuals identify themselves biologically, emotionally, romantically, and/or sexually, and those identities’ relations to health status. The information is inclusive of preferred names, preferred pronouns, legal sex, sex assigned at birth, sexual orientation, gender identity, etc.

Social Health: The upstream social, economic, and political circumstances (e.g., food security, transportation access, housing stability/quality, etc.) impacting the downstream health risks, conditions, and outcomes of persons, communities, and societies. The information is inclusive of social risk factors (person-level), social determinants (community-level), and structural determinants (societal-level).

What Is Our Role in advancing Health Equity?

‘Health Information Exchange’ (HIE) as a concept is an example of the kind of technology system and partner network that could facilitate care management for individuals across clinical and community settings. But because ‘HIE’ is often synonymous with exclusively benefitting the medical field,Community Health Information Exchange’ (CHIE) has been more widely accepted among the community and social stakeholders at the forefront of addressing individuals’ upstream health factors.

In Maine, there are active efforts aimed at identifying the state’s unified approach to designing a CHIE system to benefit cross-sector stakeholders in the value of person-centered care and with the hope of informing community-level planning, policy, and investment efforts to dissolve systemic health disparities in the state over time.

While this statewide vision develops, HealthInfoNet is bettering its own expertise and experience by working with our medical participant community to understand how health equity information stored in clinical data sets can be transmitted and leveraged through the HIE to support providers’ strategies for improving the health, wellness, and wellbeing of the populations they serve both within and beyond their organizations. 

Sometimes the greatest challenge is not the specific social risk identified; it’s how you get the patient connected to the services that can help them – and that process is a social risk in itself.

A Few Of Our Recent Health Equity Projects

Municipal Data Across Sectors for Healthy Aging

An outgrowth of their Maine Blueprint for Action on Healthy Aging (2019), the Maine Council on Aging (MCOA) partnered with the City of South Portland and Age Friendly South Portland in early 2020 for a demonstration project in which a task force of municipal officials, citizens, and cross-sector stakeholders was convened to surface and help address the unmet needs of the city’s older adult residents. Known as the Municipal Data Across Sectors for Healthy Aging project, its goal was to build an integrated system of formal and informal supports and services that prioritize low-cost, high-value interventions. Funded by the Robert Wood Johnson Foundation’s Data Across Sectors for Health (DASH) program, HealthInfoNet served as a technical subject matter expert on the task force for helping to identify solutions that blend diverse data sources to yield invaluable insights and actions.

Dual-Eligible Special Needs Plan (D-SNP) Care Coordination

In order to be approved by the Centers for Medicare and Medicaid Services (CMS), per the Bipartisan Budget Act (2018), Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) must enter into agreements with states’ Medicaid agencies to address greater care coordination for high-risk individuals. In Maine, the Office of MaineCare Services (Maine’s Medicaid agency) enforces this rule by mandating all long-term care facilities and service coordinating agencies contracted with a D-SNP to be connected to HealthInfoNet. As a result of this partnership, HealthInfoNet is now receiving Admission, Discharge, Transfer (ADT) real-time clinical information from all long-term care facilities located in the state and has provisioned viewing access to its health information services to each of the state’s service coordinating agencies.

Social Health Data Action Plan for Maine's Federally Qualified Health Centers

As part of their funding from the Health Resources and Services Administration (HRSA) to provide technical assistance to their Federally Qualified Health Center (FQHC) member organizations, the Maine Primary Care Association (MPCA) partnered with HealthInfoNet to facilitate a 6-month convening process in mid 2021 to inform the creation of a unified set of strategies for successfully collecting, exchanging, and operationalizing social health information among Maine’s FQHCs. What resulted was the creation of the “Social Health Data Action Plan for Maine’s Federally Qualified Health Centers,” a report that provides a series of FQHC-centric recommendations for improved social health data practices.

Community Health Information Exchange Workgroup

In Maine, there are active efforts aimed at identifying the state’s unified approach to designing a Community Health Information Exchange (CHIE) system. A CHIE is an ecosystem comprised of multidisciplinary network partners that use a shared language, resource database, and integrated technology platform to deliver person-centered, clinical-community communication and planning. Though the types of services that a CHIE could offer (e.g., shared client health records, universal social risk screening assessments, closed-loop referral management functions, etc.) may vary based on use case and need, the mission of any CHIE remains the same: to encourage a fundamental shift in the way care is delivered by incorporating the full picture of a person’s health drivers.

To date, the statewide CHIE workgroup has focused on addressing the barriers and challenges required to establish the appropriate data governance, legal and policy, and technical infrastructure requirements. HealthInfoNet serves as a technical advisor, subject matter expert, and invested stakeholder in this process.

Health Equity Data Action Plan

In early 2022, HealthInfoNet began having one-on-one conversations with some of its leading participants to understand how to receive their social health and/or SOGI data sets. What became immediately evident was that while each participant was on its own strategic trajectory, each was also curious as to what others in the space were doing to advance their data collection, storage, and use case efforts. And so our Health Equity Data Action Plan convening series was born. Formally known as our Social Health Data Action Plan (since broadened to be inclusive of additional data sets), the effort was designed to create a forum in which healthcare providers across the state could share lessons learned, best practices, and emerging priorities for collecting, storing, and using the information. 

Other Notable Projects & Activities

National Veterans Affairs Data-Sharing Connection

As part of our participation in the eHealth Exchange, a national HIE network, veteran patients’ health record information sourced from Veterans Affairs locations nationwide can now be obtained by their care teams through the HIE’s Clinical Portal electronic health record system.  

Department of Corrections Data-Sharing Connection

HealthInfoNet partnered with the Maine Department of Corrections (MDOC) to support two critical functions for MDOC residents: (1) improving the quality of healthcare services received while incarcerated by giving MDOC clinical teams access to their statewide HIE records and (2) helping to support care coordination efforts once released from incarceration by sharing their ADT and Vitals information from MDOC locations with their broader care teams.

Expanded Race & Ethnicity Mappings

As part of our evolving Health Analytics Reporting Platform (HARP), we have standardized our approach to transforming and displaying race and ethnicity information within our services. Using the raw values received in participants’ ADT feeds, we translate the local concepts into industry standard terms so that universal understanding, review, and analysis is possible. 

Would your Organization Like To Partner on Health Equity Projects?

Contact our Clinical Education team to learn more about potential collaboration opportunities!

How Can We Help Advance Health Equity Efforts?

Engagement Opportunities

Expand HIE Participation

Enhance HIE Partnerships

Support CHIE Efforts

Service Opportunities

Clinical Portal


Analytics & Reporting

Join The HIE Health Equity Hub!

An actionable request from attendees of our recent Health Equity Data Action Plan convening series was for HealthInfoNet to continue to serve in a role of fostering and facilitating important health equity related conversations among HIE participants and other invested stakeholders throughout the state of Maine.

In that effort, we are beginning to plan the beginning phase of what we are calling our HIE Health Equity Hub  a network designed to enable and empower the sharing of knowledge, best practices, lessons learned, and emerging strategies and next steps for collecting, exchanging, and leveraging health equity information to improve patient care and population health. To stay informed about the creation of this hub, join our distribution list!

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