Using FHIR Hubs to Drive Social Service, Health Data Interoperability

Organizations are looking to connect social service and health data to support patient-centered care. However, this level of interoperability is easier said than done, according to Paul Sorenson, director of the St. Louis Regional Data Alliance at the University of Missouri, St. Louis.

“This isn't really a simple pairing of sectors,” Sorenson said during an ONC Social Determinants of Health (SDOH) Information Exchange Learning Forum. “It's not like you have a thing called healthcare and you have a thing called social services and we just need to put them together.”

The technical infrastructure for health data exchange includes the use of EHRs and the almost ubiquitous use of data standards like FHIR, Sorenson noted. Then, health information exchanges (HIEs) or health information networks (HINs) facilitate the flow of patient information across EHRs and health systems.

For social services, this picture becomes a lot more complicated, he explained.

“Instead of a person going to a provider at a clinic, you have programs that serve a whole family or a whole community,” Sorenson said. “There's an aging network, a disability network, a foster care network, and a behavioral health network that are all part of social services and have their own communities and constraints.”

“What we see is that there is a gulf between the incentive structures, the level of connectivity, the funding streams, and the funding that is invested in data systems,” he continued.

Over the past couple of years, the St. Louis Regional Data Alliance, which serves as the data backbone for the St. Louis Community Information Exchange (CIE), has joined ongoing conversations with the aging services community about data connectivity.

“We started to think about what it really will take to connect health and social care using aging services as an anchor point,” Sorenson said. “We recognized that this needed to be grounded specifically in the context of aging services, while not reinforcing an additional silo. The concept that we came up with was to build an interoperability hub for aging services in Missouri.”

The interoperability platform is grounded in the aging services sector but can be pieced together with components of existing healthcare data exchange infrastructure such as HIEs, he explained.

The hub, built in partnership with health IT vendor Long Term Care Innovation, is called Cumulus. The system leverages an open data standard that builds upon FHIR, eLTSS, and the Gravity Project to incorporate missing pieces of aging services data.

Having one central location for aging services data is a vast improvement for providers, Sorenson said. Prior to the hub, almost every aging services provider used at least two client data management systems, including the statewide Aging IS platform that connects 10 area agencies on aging.

“Instead of having DHSS and Adult Protective Services have to enter data into multiple platforms and try to navigate a confusing array of different providers depending on which area of the state they were in and eligibility criteria, they're using Cumulus,” Sorenson said.

“It's used like a survey tool that helps determine social need,” he continued. “Then Cumulus is integrated on the backend directly with Aging IS to help facilitate data exchange to the appropriate area agency on aging.”

The project is in partnership with Adult Protective Services and the Missouri Association of Area Agencies on Aging.

Sorenson said that the organizations will continue to build out the interoperability hub by supporting connectivity to home and community-based service providers through FHIR data exchange.

“What we think is promising about this approach from a technical infrastructure standpoint is how it may connect to other social service sub-sectors, as well as to health information exchanges,” Sorenson said.

The St. Louis Regional Data Alliance is exploring connecting the hub to additional referral platforms like Unite Us, as well as the Missouri Hospital Association healthcare data infrastructure and local HIEs.

“In St. Louis, we made a decision to make this social service-centered and community-centered first and then bring in healthcare over time,” Sorenson said. “We are just starting to do that now. The HIE landscape in Missouri is complex. We are trying to figure out the best way to approach it, but there's a lot of work to do.”

He noted that some local HIEs don't have a preference for which referral platforms to connect to, while others have selected a specific vendor platform.

“There are a lot of political dynamics in terms of where those dots connect,” Sorenson added. “Hence, the focus on standards and community governance and making sure that social service providers and community-based organizations feel comfortable diving into the system because without their participation, there really isn't anything; you’re making referrals into the void.”

Sorenson said that the CIE is not looking for every provider to use the same screening tools or referral platforms. Instead, setting forth a technical infrastructure that allows disparate tools and platforms to interoperate will be key.

“The pursuit of one screening tool to rule them all misses the complexity of people, their social context, and condition, so it may require different screening tools in different circumstances to really make sure that you are most responsive to an individual need,” Sorenson said.

State and philanthropic funders mandate the use of certain screening tools, so making yet another screening tool obligatory could add to clinician burden, he added.

However, that doesn’t mean screening tools and screening domains cannot connect across the board, Sorenson pointed out.

“Decentralization is sometimes good because you have different tools built for different purposes based on different community priorities, but we have to figure out a way to make sure that they can talk to each other,” he said. “Interoperability, if done right, can enable a high level of coordination regardless of decentralization.”