A central challenge to a CCO system is the limitation around the sharing of patient data. The Health Commons Project is a set of interventions that could potentially touch all providers in the region, yet without a logical method for data-sharing providers might never be aware that an intervention has touched their patients. Similarly, because many of the Health Commons Grant interventions are targeted at high-utilizing patients, it is important to track patient utilization across the community—yet as of now, different providers across the community are not linked.
As a solution, the Health Commons Project is developing PopIntel, a regional care coordination registry. PopIntel allows the interventions to be informed of patients who are suitable for the program, keep track of the patients who are enrolled, record patient touches and care plans, and collect program data. A version of PopIntel is already in use by the ICCT workers.
We have been hard at work on several next steps. First, PopIntel must be customized to serve the needs of all the Health Commons Project interventions. During the past three months, the PopIntel development team has been working with project leads to customize elements of PopIntel in order to ensure that the system will be useful and efficient. Second, PopIntel must be built for an external secure web server. The current version is accessible only by CareOregon employees; the next version will be web-based so that outreach workers from all partner organizations can use it and so that it can be used in the community as well as at a desk. This development is in process; specifications for ensuring that the next version will be fully HIPAA-compliant were completed in November.
By January, CareOregon outreach workers will be using the external version of PopIntel. By March, we expect to add non-CareOregon users. PopIntel and its improved, customized functionality is a crucial piece of our self-monitoring system, providing data on each program and allowing us to track progress.
Debra Read, who has been leading the development of PopIntel, describes this as “invisible work.” It is work that goes on behind the scenes. Its products, if they are crafted well, will never be noticed by the patient because technology will not intrude on the patient experience. Nevertheless, despite the “invisibility” of the work, this homegrown system is the only means we have of tracking our population across providers and of mapping overlap between interventions. The CCO structure aims to integrate all partners, including physicians, health plans, public health, and the safety net, and as Ms. Read puts it, “Integration doesn’t happen without technology.”