The ‘Three D’s’ Of Health Care: How Determinants And Data Are Creating Delivery Improvements
As our field converges on the nation’s capital for its annual gathering to present, debate, and learn about the changes in health care and health policy, the time is right to reflect on if and how this year’s conversations will be different than those of prior years. Health services research (HSR) is still focused on what works, for whom, and at what cost, but the context and specificity of the questions has evolved to leverage today’s opportunities and respond to new and persistent challenges. The needs of federal and state policymakers continue to be a prime focus for the field’s work while three dimensions have grown significantly: grappling with social determinants, exploiting new sources of data, and responding more effectively to health system leaders’ questions as they struggle to respond to myriad policy and market demands.
I’ve been calling these the “three D’s” of health care; determinants, data and delivery. These dimensions are also reflected in the membership of AcademyHealth and the content of our other events (the National Health Policy Conference and the Health Datapalooza, among others). Nearly half our members work outside of academic settings, many embedded within health care systems or in one of the many data analytics and consulting organizations that support care delivery.
In response to these overall trends, AcademyHealth has expanded our portfolio of programs and services for individuals working to support health care delivery system improvement and implementation science, including the Health Data and Leadership Institute, a recently announced collaboration agreement with the Network for Regional Healthcare Improvement and the launch of a members-only Learning Health System Interest Group. These efforts join the existing work with the National Institutes of Health for Dissemination and Implementation Science annual meeting and our Delivery System Science Fellowship and Methods and Data Council.
It is therefore not surprising that the agenda of our Annual Research Meeting (ARM), is full of abstracts, posters and podium presentations focused on these three D’s: determinants, data, and delivery.
A Shift In The Focus On Social Determinants Of Health
We’ve been learning for decades about how where we live, work, and play affects our health. However, it appears that many more health care delivery systems are now paying attention to this evidence base as they prioritize outcomes and population health in response to new payment and market pressures. It is no longer enough for health systems to understand how social determinants affect care; they are now grappling with the questions of if, when, and how they should tackle patients’ social needs and the upstream drivers of those needs.
However, taking social determinants of health into account at the health system level requires a shift of focus in what is measured to chart progress. Health services researchers are using research on social disparities to identify strategies for fostering health equity among populations serviced by a range of health care systems.
Mental health research to be featured at this year’s ARM shows racial, ethnic, geographic, and sociodemographic disparities in childhood ADHD diagnosis and treatment, as well as in mental health care utilization of transgender and gender non-binary adults. The impact of one’s economic status on mental health is also examined with research on the association between debt burden and suicide risk.
Even beyond the now well-accepted fact that non-clinical factors such as minimum wage levels affect health outcomes, research shows how abstract factors such as trust in the health care system are mediated by income. Further upstream, health services researchers are also examining how structural discrimination has compromised the home care workforce in terms of recruitment, retention, and working relationships.
In addition to considering social factors’ impact on health, health systems must consider their own policies’ effect on socio-demographic gaps in medical outcomes. Understanding the role of upstream health system factors – from payment policies to market allocation – is an important step towards mitigating health disparities. But in the same way factors outside the clinical setting affect health, policies outside the health care sector also affect health outcomes. For example, research to be presented at ARM examines the relationships between handgun purchase policies and adolescent suicides; incarceration rates and population health at the county level; and several dimensions of housing policy and health and well-being.
From tracking disparities to developing and testing effective (and financially sustainable) responses to them, the ever-growing list of considerations for health systems can be dizzying. Here again, health services research can help by listening to health systems priorities and assisting with the implementation and evaluation of interventions.
New Data Sources And Methods For Health Care Transformation
Despite this growing emphasis on social determinants of health, data on them are still not routinely or systematically collected. The ARM program includes several bright spots on collecting and using social determinants of health data and will feature perspectives and experiences from both policy makers and providers. In addition to social determinant data, health systems are applying digital technologies to capture other data such as patient-reported outcomes beyond those tracked in clinical visits. For example, advances in digital technology make it easy for primary care patients to screen for depression, for dental patients to assess their pain, and for patients with rheumatoid arthritis to measure their functional status. Others are looking at the use of portals, digital badges, and user centered design to improve patient engagement in their own care.
When it comes to the use of data within the traditional clinical setting, the ability to share data between organizations is a critical aspect of effective decision-making. Hospitals, community health organizations, skilled nursing facilities are all engaged in meaningful use of electronic health records as well as methods to facilitate data exchange to support direct care delivery. Research also reveals the impact of event notification to drive health information exchange (HIE) use and the limitations of HIEs to support effective post-acute care transitions. Other presented research highlights the use of electronic clinical decision support tools leveraging data to improve the accuracy of medication selection.
As our field begins to grapple with the tremendous potential of the growing volume, variety, velocity and veracity of data, a deeper sophistication in the methods, management and governance of data is needed to appropriately access, manage, analyze and report on these data, all topics covered in various methods workshops. And yes, artificial intelligence and machine learning – the buzzwords “du jour” are also featured in the titles of over 20 presentations, such as how the VA is applying machine learning to assess disparities in health-related quality of life.
Health systems are not the only ones innovating with data - Medicaid policy researchers will present on the Medicaid Outcomes Distributed Research Network (MoDRN) built to compare opioid addiction treatment access and quality across states, and evaluate major changes in state Medicaid policy.
Delivery System Innovations Driving Cost And Quality Improvement
The volume of abstracts for this year’s ARM focused on various care delivery innovations reflects just how widespread these efforts are in response to market and policy demands. In primary care, experts examine its role in caring for people with complex needs, and integration of primary care with the larger health system, public health, and human services. Opportunities to improve primary care at the organizational level, are also showcased – particularly around models of community care and integration of behavioral health among others.
The growing tailoring of care improvement efforts to diverse contexts and populations also will be reflected at the ARM. From efforts to enhance the organization and delivery of perinatal care to improve maternal and neonatal outcomes to work focused on care delivery innovations for high cost, high need populations with presentations on the impact of complex care management programs, patient-centered medical homes, and social work programs. Indeed, the ability to improve the value of health care will be a much discussed topic at this year’s meeting with presented data about the prevalence of a range of low value services across the U.S. and Canada. Experts will examine the drivers of low value services and discuss their implications on costs of care, downstream care utilization, and patient health.
When taken together, all these care improvement efforts are part of the journey to achieving a learning health system. The concept of a learning health systems was first articulated by the Institute of Medicine in 2007 and is taking hold across many settings. One example has been the Veterans Health Administration’s delivery reorganization under the Veterans Choice Act in 2014 and the more recent MISSION Act in 2018. A panel at ARM will highlight the details of the shift and its implications for other large learning health systems.
A critical component of effective learning health systems are effective collaborations between researchers and decision makers from both inside and outside the care delivery system. Bringing together the world of research with the pragmatic realities of real-world settings can be challenging. ARM attendees will hear from those on the front lines and what they’ve learned are the key facilitators and barriers to collaboration between business coalitions, employers and researchers. Other experts will discuss best practices for delivery system embedded research including how to organize, fund, undertake and use health services research capacity within delivery systems.
Join The Conversation
With an expanded focus on social determinants and new data sources and methods, delivery systems are increasingly turning to a variety of sources of evidence and analysis to help them develop, test and evaluate care delivery improvements. As a snapshot of the work of the field, the ARM program demonstrates that health services researchers are responding; it also underscores the range of unmet needs the field should address. I hope you’ll consider joining us next week and adding your perspective to the conversation.