Success Stories
We pride ourselves on working closely with our Participant Organizations to meet their unique health information exchange needs.
Read the success stories of our partnerships.
Improving case management using Bronx RHIO alerts with BronxWorks
BronxWorks is a human services organization and settlement house based in the Bronx. The organization joined the Bronx RHIO in January 2012 and integrated their data feeds through Foothold Technology’s AWARDS EHR in 2015, when they also began registering users in the Bronx RHIO portal.
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BronxWorks has integrated Bronx RHIO consent collection into their program intake process. 70% of BronxWorks street homeless clients and >98% of BronxWorks supportive housing program clients have provided “Yes” consents. These consents have allowed authorized BronxWorks staff to receive near-real time alerts on clients direct to the Foothold Technology AWARDS EHR.
Bronx RHIO and BronxWorks staff presented the following use case at the 40th annual ACLAIMH conference in November 2019 to demonstrate the difference Bronx RHIO alerts have made in their services:
Deidentified client Candy Apple (“CA”) is a 59-year-old woman who was enrolled in BronxWorks’ Care Coordination program since 2017, but the program lost contact with her after 1 year. Due to program requirements, program initiated discharge 6 months after losing contact.
CA was admitted to the Montefiore Medical Center Emergency Room 3 months after discharge was initiated, which triggered a real-time alert to BronxWorks Care Coordination staff about the event. Program discharge was stopped and BronxWorks staff went to Montefiore Medical Center to meet with CA and hospital providers.
Over the following six months, BronxWorks staff were able to re-engage CA, establish trust with her, and link her to services. With BronxWorks assistance, CA secured her housing and obtained medical services. She also enrolled in mental health services and substance use treatment. As of this reestablished contact, CA has decreased her substance use, expanded her support network, followed up with medical care, and is attending a local church.
Without BronxWorks’ access to real-time Bronx RHIO alerts, CA would have likely been discharged from the Care Coordination program, lost the support of the team, and been further isolated and de-stabilized in the community.
Learn more about our collaboration with BronxWorks: the BronxWorks Facesheet and Predictive Analytics.
Building a custom analytics dashboard to tackle value-based payment reform
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The Bronx RHIO has years of experience partnering with Performing Provider Systems (PPS) to support the New York State Delivery System Reform Incentive Payment (DSRIP). The partnership between one such PPS and the Bronx RHIO drove analytic priorities as the PPS navigated the transition to operating within a Value Based Payment (VBP) environment. Bronx RHIO currently works with Behavioral Health Care Collaboratives to support their value-based payment reform efforts.
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The Bronx RHIO developed a quality measure dashboard for the PPS which integrates both HIE-wide EHR data and claims data on patients known to the PPS. This tool provides a more complete view than either the PPS’ internal EHR data or their claims data could on their own, as the RHIO integrates clinical data from hospitals and institutions outside the PPS.
The dashboard allows comparison of measure performance, with filters for insurance, comorbidities, and demographic factors. The quality measures were chosen to align with the PPS’ DSRIP and Managed Care Organization (MCO) contracts for performance measurement. The dashboard monitors site performance over time and can identify individuals at a given point in time who would benefit from intervention in order to meet the standards of the quality measure. It also allows data exports so that PPS staff can see where clinical data fills gaps for measures where they lack claims data.
Goals on performance measures are often missed by only a few patients. This tool identifies those patients early, providing the opportunity to achieve performance goals tied to payment.
The Bronx RHIO developed a quality measure dashboard for the PPS which integrates both HIE-wide EHR data and claims data on patients known to the PPS. This tool provides a more complete view than either the PPS’ internal EHR data or their claims data could on their own, as the RHIO integrates clinical data from hospitals and institutions outside the PPS.
The dashboard allows comparison of measure performance, with filters for insurance, comorbidities, and demographic factors. The quality measures were chosen to align with the PPS’ DSRIP and Managed Care Organization (MCO) contracts for performance measurement. The dashboard monitors site performance over time and can identify individuals at a given point in time who would benefit from intervention in order to meet the standards of the quality measure. It also allows data exports so that PPS staff can see where clinical data fills gaps for measures where they lack claims data.