West County Health Centers
West County Health Centers (WCHC) is a federally qualified health center that serves 12,000 patients in upper West Sonoma County, California. It does not operate in the same way most medical facilities operate, on a transactional basis. WCHC focuses on whole-person health in addition to addressing patients’ individual medical needs. To do so requires looking at all of the social determinants of health including living conditions, educational attainment, belief systems, racial bias, even crime data alongside patients’ medical records. This requires accessing many public datasets as well as medical records data. This information is combined to see trends and factors that have a significant impact on a patient’s medical condition and other anomalies that may not be immediately evident by only looking at a person’s medical records or current state of health. In this way, cerebral healthcare is hard to measure in terms of dollars and cents. It’s not about efficiencies in a supply chain or patient billing, it’s about changing the entire health of communities of people.
WCHC has been serving patients with this care team model for the past 40 years and is deeply embedded in the community it serves. The challenge that WCHC faced was being able to access all of its eClinicalWorks EMR data and publicly available data which resides in many different systems and locations, and then combine that information for clinical analysis while also ensuring data privacy, compliance and governance requirements were met. For Jason Cunningham, the Chief Medical Officer for WCHC, and his team, it wasn’t the volume of data that was the problem; it was finding the relevant existing data and then having the right tools in place so that staff could quickly and easily access the medical insights delivered by the data.
Jason Cunningham, Chief Medical Officer at WCHC, describes their how using data helps them deliver value-based care
During the Northern California wild fires in 2017, WCHC used their EMR data combined in Unifi with NOAA data to find effected patients.
A culture of self-service data empowers everyone to be a hero
By implementing the right tools to build a culture of self-service analytics, everyone from front office staff, to doctors, to nurses are now affecting significant change. In fact, during the wildfires that raged at the end of 2017, WCHC did what no other patient care facility in the local area could do during that crisis—they were able to, within hours of the wildfires starting and spreading, gain access to patient records; identify which patients were at the greatest risk of serious injury from the smoke or those that had heart issues; transpose that information into longitude and latitude points; map that data and overlay it with public information from the National Oceanic and Atmospheric Administration (NOAA) on the real-time spread of the fires in order to reach out to impacted patients and ensure their medical needs were met.
WCHC extended its capability to do this to three other care centers that didn’t have the benefit of self-service data and visualization tools in place, allowing them to reach many more patients. As an example of what is possible under this data-driven business, patients whose houses had been lost to the fires were proactively contacted via cell phone and email to ensure that they were able to leave home with their prescribed medication, and in cases where that was not possible, a new prescription could be called in to their nearest pharmacy. Because the patients were geo-identified during this initial phase of the crisis and labelled within the health record, the patient’s care team have been able to provide ongoing care management support and connect patients to available resources such as mental health services, housing support, legal services or other benefits on an ongoing basis and will be able to trend clinical outcomes over time.
West County Health Centers
Accessing a vast array of publicly available datasets and combining that information with medical records data for analysis to deliver value-based care to treat patients and affect change at the community level.
WCHC deployed the Unifi Data Platform to give its entire staff of 230 employees the visibility they needed to discover, view, and join a multitude of disparate datasets—both public and private—to more effectively treat patients and gauge clinical outcomes while maintaining data privacy, governance and compliance standards.
All 230 staff members including doctors, nurses, front office and community staff use a combination of visualization tools alongside the Unifi Data Platform to discover, access and use data on a daily basis to help patients and their families. They were first responders for patients during the Northern California wildfires in 2017 and today are finding ways to fight and combat the opioid epidemic at a community level.
Jason Cunningham, Chief Medical Officer, West County Health Centers