Great Lakes Health Connect, a health information exchange covering much of  Michigan, is upgrading its referral capabilities by incorporating information about social determinants of health into its available data.

More and more recently, the healthcare industry is recognizing that tackling those complex geographic, socioeconomic and behavioral factors are a key component to making population health management work.

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To make some of that data available for some of the 9 million patients at the 129 hospitals and 4,000-plus ambulatory sites that connect to it, GLHC has enlisted Alpharetta, Georgia-based startup Holon Solutions, which develops patent-pending data exchange and decision support technology.

The aim is to provide more effective care while also meeting the goals set by Michigan's State Innovation Model, which has established a series of standards for providers managing Medicaid patients, officials say.

Holon says its CollaborNet technology will help integrate clinical and social determinant data, present information in via intelligent alerts within clinicians' existing EHR the workflow. The tool will also allow care providers more easily refer patients to community groups that could help them address social health issues such as transportation or housing.

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When a patient's electronic health record is opened, the Holon tool senses it and begins searching other data sources for supplementary data associated with that patient, company officials say. The analytics tools examines the records and relays pertinent data with an appropriate alert in the top right corner of the clinician's workflow.

The alert can be clicked away or opened for further information and potential intervention. The tool can show coding or risk-adjustment opportunities, reveal gaps in care and identify members of specially-managed populations, officials say.

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"Holon takes the sea of data and makes it very relevant to a specific patient and his or her needs," said Doug Dietzman, executive director at GLHC, in a statement. "This is critical because our users are looking to us to help them solve their very local problems. We want to constantly anticipate answers to, 'How do we advance the care and experience for this patient in front of us today?' and 'How can we be more intuitive and make providers' lives easier?'"

"We've tailored our product's referral functionality for GLHC's mass deployment, to allow physicians to refer patients seamlessly not just to other physicians, but to community organizations that assist with social health needs," added Holon CEO Bryant Castleton. "We're looking forward helping make Michigan a healthier state."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com