1. Community Wellness Health & Medical Essay
A publication made possible by How understanding social determinants can deliver
community wellness A system approach to community health August 2019 In This Issue In
2017, former-U.S. Surgeon General Vivek H. Murthy wrote in the Harvard Business Review
that loneliness is becoming a serious healthcare problem. Then, in early 2018, the U.K.
appointed a Minister of Loneliness to address an epidemic that some say is worse for your
health than smoking 15 cigarettes a day. And loneliness, some research found, is more
accurate in predicting early death than obesity. What has all of this got to do with the
treatment of conditions such as diabetes? Well, quite a lot as you’ll see in this issue of Next
Now, an electronic magazine made possible by Allscripts. According to the Robert Wood
Johnson Foundation, “80 percent of clinical outcomes are attributable to the social
determinants of health.” And, according to a July 2017 JAMA article, the average life
expectancy is 15 to 20 years shorter in low-income communities than in more affluent
communities. In this issue of Next Now, we explore factors that contribute to a person’s
health, do a deep dive into the social determinants of health, then look at policy implications
affecting a comprehensive approach to improve community health and well-being. 2
Tomorrow’s ideas, today. 4 What determines health and why should we care? The United
States consistently ranks poorly on measures of health status. Why is that? What can we do
to improve? Goeff Caplea, MD, MBA 6 8 When would a 50-year-old woman with diabetes
most likely have a poor health outcome? As explained in the Social Determinants report
issued by HHS last year, the dearth of standards to address the capture and exchange of
social determinant data is a significant issue for the industry and is one that is limiting
research and analytics opportunities. What does a patient’s neighborhood have to do with
her diabetes? Geoff Caplea, MD, MBA A look at the policy side of social determinants of
health Leigh Burchell, Vice President, Allscripts Government Affairs 10 5 considerations for
overcoming obstacles in the shift to value Here are the 5 considerations (and the Allscripts
contributions) for overcoming the 15 impediments to taking on risk. Catherine Costa, RN,
MTM Next Now | August 2019 3 5% Environmental exposures 40% Individual behaviors
10% Medical care 15% Social circumstances 30% Genetics What determines health and
why should we care? Geoff Caplea, MD, MBA 4 The United States consistently ranks poorly
on measures of health status. Why is that? What can we do to improve? As we continue our
quest to achieve healthcare’s Triple Aim, it is essential we take a systematic look at the
factors that impact health and the best solutions to achieve our goals. The determinants of
health As outlined in the New England Journal of Medicine (NEJM) by Dr. Steven Schroeder

2. in “We Can Do Better— Improving the Health of the American People,” there are 5
determinants that contribute to an individual’s overall health—genetics, social
circumstances, individual behaviors, environmental exposures and medical care.
Importantly, the determinants of health do not contribute equally to a person’s overall
health and better health is not merely achieved with better medical care. In fact, medical
care plays only a small role in what makes a person—and a population—healthy. While
medical care is the determinant that receives the greatest share of resources and attention,
it contributes to only 10% of the factors that make a person healthy. The most influential
determinant to improve health and reduce premature deaths lies in changing unhealthy
individual behaviors (e.g., smoking, alcohol abuse). The chart on the previous page
illustrates the contribution of each determinant to overall health status. Individual
behaviors account for 40% of premature deaths in the U.S. influenced by factors such as
obesity, physical inactivity and smoking. Genetics, or the traits we inherit from our parents,
is another determinant with significant impact on a person’s overall health and well-being.
While historically less modifiable than other determinants, there is now great potential to
use genomics to better understand ourselves and for doctors to utilize this information to
tailor preventative and treatment therapies. The environment refers to the neighborhood or
built environment in which we live. Not only does this include environmental conditions
such as allergens, air quality and water quality, but also factors like access to healthy foods,
places to exercise, adequate public transportation, educational and job opportunity, and
safety from crime and violence. Although a smaller contributing factor to health overall, the
environment plays a critical role in the health (or sickness) of people with highly sensitive
chronic conditions like asthma. Poor social circumstances have significant impact on people
and negatively impact the health and wellbeing of both individuals and communities. The
final determinant of health, social circumstances, represents the social conditions in which
we live and develop. These factors include support networks, education, job opportunity,
income and social status. Poor social circumstances have significant impact on people and
negatively impact the health and well-being of both individuals and communities. To learn
more about the 5 determinants of health, read “We Can Do Better— Improving the Health of
the American People” (New England Journal of Medicine) by Dr. Steven Schroeder.
REFERENCES: Schroeder, S. A. (2007). “We Can Do Better — Improving the Health of the
American People.” New England Journal of Medicine, vol. 357, no. 12, 2007, pp. 1221–1228.
“Goinvo Determinants of Health.” (n.d.). Retrieved May 1, 2019: https://www.goinvo.
com/vision/determinants-of-health “NCHHSTP Social Determinants of Health.” (2014).
Retrieved May 1, 2019: http://www.cdc. gov/nchhstp/socialdeterminants/definitions. html
“The determinants of health.” (n.d.). Retrieved March 14, 2016: http://www.who.int/hia/
evidence/doh/en/ “Social Determinants of Health.” (n.d.). Retrieved May 1, 2019:
https://www. healthypeople.gov/2020/topics-objectives/ topic/social-determinants-of-
health “Beyond Health Care: The Role of Social Determinants in Promoting Health and
Health Equity.” (n.d.). Retrieved May 1, 2019: http:// kff.org/disparities-policy/issue-
brief/beyondhealth-care-the-role-of-social-determinants-inpromoting-health-and-health-
equity/ To learn more about the 5 determinants of health, read We Can Do Better—
Improving the Health of the American People (New England Journal of Medicine) by Dr.

3. Steven Schroeder. In my next article, I will discuss the social determinants of health in depth
and why a holistic approach by doctors, hospitals and communities is necessary to elevate
health and quality-of-life. Next Now | August 2019 5 What does a patient’s neighborhood
have to do with her diabetes? Geoff Caplea, MD, MBA W hen would a 50-year-old woman
with diabetes most likely have a poor health outcome? When she lives in an area (urban,
suburban or rural) that lacks access to healthy food, a safe place to exercise, or convenient
access to medical care. organizations seek innovative, holistic solutions to costeffectively
deliver care and provide better health outcomes, they must identify and address health
literacy, financial instability, food insecurity and other social circumstances to meet the
demands of our U.S. value-based care transformation. What do these things have to do with
diabetes? A lot, as research has shown that these and other factors, known as the social
determinants of health, play a significant role in the health (or sickness) of people and
communities. The example on the next page illustrates how social and economic factors can
significantly impact a patient’s needs and alter what interventions are required in her care.
What are Social Determinants of Health? According to the World Health Organization
(WHO), social determinants of health are “the conditions in which people are born, grow,
work, live and age, and the wider set of forces and systems shaping the conditions of daily
life. These forces and systems include economic policies and systems, development agendas,
social norms, social policies and political systems.” …social and economic factors are far
stronger determinants of health outcomes than medical care. As indicated by Dr. Steven
Schroeder and others, social and economic factors are far stronger determinants of health
outcomes than medical care. The contribution of social, economic and environmental
circumstances is so strong in determining health that the WHO states “blaming individuals
for having poor health or crediting them for good health is inappropriate. Individuals are
unlikely to be able to directly control many of the determinants of health.” With this
understanding that the context of people’s lives is what most significantly determines their
health, we must take a comprehensive and systematic approach to address social
determinants to improve individual and community health. Addressing Social Determinants
of Health to achieve the Triple Aim As we continue in pursuit of healthcare’s Triple Aim—
better care, smarter spending and healthier people—the social determinants of health take
on even greater importance. As healthcare 6 Although the social determinants are clear in
this illustration, they may not be as apparent in practice and steps must be taken to ensure
clinicians and healthcare organizations assess patients for these factors as part of routine
care. Even more important than identification, however, clinicians must be supported with
appropriate resources to effectively adjust the care plan to address socioeconomic factors
which may limit or prevent Nicole from achieving her health goals. To this end, stakeholders
across the country are evaluating new and innovative approaches to identify and address
the healthrelated social and economic needs of patients and communities. Some examples
include: • Early childhood education and development programs • Safe access to green
space for physical activity • Healthy grocery options • Nutrition services • Transportation •
Workforce development • Medical neighborhoods So far, we have discussed the wide range
of factors that contribute to health and have taken a deeper dive into the social
determinants. Next, we’ll examine the policy implications. Diabetes High Blood Pressure

4. Diabetes Working Poor High Blood Pressure Food Desert High-Crime Neighborhood R I S K
S T R AT I F I C AT I O N R I S K S T R AT I F I C AT I O N Medium Priority High Priority Next
Now | August 2019 7 A look at the policy side of social determinants of health Leigh
Burchell, Vice President, Allscripts Government Affairs 8 I t is generally accepted that there
is a correlation between social determinants of health and patient outcomes. As far back as
2003, the National Academies of Medicine (NAM) studied and reported on the relationship
between the rates of medical procedures and the race of the patient. In the last several
years, as EHRs and other health information technologies— such as population health
solutions— gained wider use, data related to the social determinants of health (SDoH) have
been increasingly captured and available to clinicians. In particular, the Meaningful Use
incentives, the MACRAresponsive requirements and the CPC programs have—as a
byproduct—helped expand the volume and types of nonmedical determinative information
on file about patients. Beginnings of policy I recently met with representatives from across
CMS for a discussion on SDoH. I was heartened to learn about the breadth of the agency’s
focus on this topic, spanning the Center for Medicare to the Office of Minority Health; Center
for Clinical Standards and Quality (CCSQ) to the CMMI. However, while a few CMS programs
have started piloting work in this area, such as the Accountable Health Communities model,
it is clear that HHS is nowhere near a comprehensive strategy, with the health IT
intersection one area in need of real focus. Capturing social determinant data As explained
in the Social Determinants report issued by HHS last year, the dearth of standards to
address the capture and exchange of social determinant data is a significant issue for the
industry and is one that is limiting research and analytics opportunities. Policy makers are
also weighing the inadvertent consequences that could negatively affect the groups most in
need of assistance if social determinant data were to be misused. The challenge is described
in a recent eHealth Initiative report. “Organizations must consider the potential impact of
the use of SDoH data on vulnerable populations and ensure the data is collected and used in
a fair, unbiased and scientific manner… It is also important that choices made about
modeling and analyzing data elements are free from bias. Standardization may be a means
to help eliminate potential bias and discrimination.” Additional standards complexity The
issue of standards is even more complex than the norm when addressing social determinant
information because the sources of data that would be useful are so variant. Everyone from
housing programs to transit authorities to Meals on Wheels have information on patients
that could be clinically relevant. Unfortunately, there is currently no widely-available
mechanism to convert the information they have on their clients into discrete forms that
can be absorbed by an EHR. Further, there is still no industry agreement addressing where
such data should be stored…should healthcare providers be responsible for asking about
and digitally capturing that information? If so, where would it be saved? Or does it make
more sense for the health plans and payers to gather and store this intelligence, making it
available via application programming interfaces (APIs) to the whole team of clinicians who
see that member? Clinician drivers to act on SDoH The industry will need to come to
agreement on performance metrics associated with SDoH and map those measures to
claims codes. It will also be imperative that payment models rolled If a physician has no way
to help a patient who lives in a food desert zip code, or doesn’t have an air conditioner as a

5. congestive heart failure (CHF) patient, there are questions whether it is a good use of their
time to have that conversation. out from the CMMI start to financially incite consideration of
SDoH factors in the care process. Additionally, we cannot overlook that providers are
concerned about being asked to spend valuable time during a patient encounter gathering
and documenting non-medical data without any real ability to act on what they learn. If a
physician has no way to help a patient who lives in a food desert zip code, or doesn’t have
an air conditioner as a congestive heart failure (CHF) patient, there are questions whether it
is a good use of their time to have that conversation. Given the ongoing focus on reducing
clinician frustration throughout their work day, this is an important question to answer. My
final thoughts There is much more to be done to bring comprehensive social determinant
data into the provider’s EHR workflow in a userfriendly, trusted and actionable fashion. And
it is clear that it may be some time until policies from regulators and payers settle into any
type of consistent framework. Allscripts is pleased to be taking a leadership role in the
conversation and is excited that the health IT industry has yet another way to contribute to
the betterment of patient care. Read more on determinants of health here. Next Now |
August 2019 9 T he journey to a value-based healthcare payment model is further away
than we think. The AMGA’s recently released Fourth Annual Survey, Taking Risk, 4.0:
Clearing a Pathway to Value-Based Care, lists many obstacles. 5 considerations for
overcoming obstacles in the shift to value Catherine Costa, RN, MTM 10 Even after a decade
of programs, incentives and infrastructure investments, the federal payment plans are
tipping the scales with 56% of healthcare revenue aligned with care delivered via fee-
forvalue programs. The commercial plans are woefully behind that, with a whopping 72%
of revenue still based on fee-for-service programs. Similar to results from the past three
years’ surveys, AMGA members noted ongoing obstacles in moving to value. Here are the 5
considerations (and the Allscripts contributions) for overcoming the 15 impediments to
taking on risk. 1. Attribution methodology Providers are paid based on the list of patients
that are attributed to them by the healthcare plan. Healthcare plans “attribute” their
members (the patients) to specific providers. When these lists don’t align, providers don’t
get credit for the care (and reporting) they delivered to the patient (i.e. member) and
therefore will score lower in value-based care models. An exception to the attribution
problem is the Medicare Advantage participants. Because members (patients) enroll in an
MA plan, attribution to the provider is clear. This is perhaps one reason why MA is the most
prevalent risk-payment model for federal plans. Allscripts helps with payer systems
partnership and integration to create custom attribution reconciliation reports and
recommended data governance needed to manage these lists. 2. Access to full claims
information As a provider, you are constantly solving a puzzle. Information from various
sources is pulled together to give the full picture of health or risk. The single source of truth
for all this information lives within the claims data. Without full access to claims data,
providers can be left with blind spots that impact diagnoses, treatment and even care
management. Ultimately, patients don’t receive the care they deserve and providers are left
“under delivering” within the metrics of the value-based care program. Providers are left to
send and receive data to different payers in different formats, causing large data integration
needs. Pulse8, part of the Allscripts Veradigm™ business unit, provides granular analytics

6. (output files, chase lists, dashboards and reports) at both the member-centric and provider-
centric levels. Member-centric analytics are available within Qualit8 and Calcul8, whereas
provider-centric analytics are also contained within Collabor8. Together, Pulse8 pairs the
most piercingly accurate Risk Adjustment and Quality Management analytics with the most
pragmatic interventions and provider-engagement approach available on the market. 3.
Standardize data submission We all know the importance of interoperability. There are
degrees of interoperability. Simply providing access to a consolidated clinical document
architecture (CCDA) is hardly the level of interoperability needed to support the shift to
value. True value from the healthcare data (clinical and claims) comes when a clean, nimble,
unified patient record is made available at point of care and within managed population
reporting. The Allscripts CareInMotion™ suite can submit data across fragmented sites and
integrate discrete patient data from diverse care settings, regardless of IT supplier, into a
single patient record. dbMotion provides a longitudinal patient record with semantically
normalized data, point-of-care tools and an analytics gateway. 4. Lack of commercial “risk
arrangements” and cost/quality feedback In what industry besides healthcare are
commercial plans far behind federal plans? There are little to no incentives for the
commercial plans to provide risk-based payment models. Providers spend thousands of
dollars on IT investments and care management teams not knowing the full potential or
return of the risk-based models. Allscripts partners with Quality and Analytics teams to de-
code what plans are available to you in your region and that best align with your
capabilities. Together we will create a plan in alignment with your values and strategic
goals that will maximize the plan’s performance. 5. Problems with the data (Medicare and
health plans) Not all data are created equal, clean or good. The best technology will not
work on bad data. CareInMotion employs semantic grouping technology, making dbMotion
the leader in complex medical ontologies. We also leverage a data source analysis tool to
determine source data deficits and identify gaps in data integrity. On the topic of data, the
report correctly calls out the point that we are, at times, spending tremendous resources
collecting quality measures that have little impact on improving quality. Models that focus
on prevention, appropriate utilization, patient experience and meaningful outcomes are in
line with a move toward value. Value lies with the patient, especially because caring for the
patients was the reason respondents entered the healthcare field. Risk-based payment
models should allow providers the flexibility to participate in programs that matter to their
local population. As plans evolve and non-clinical factors needs are considered (such as
social determinants of health), program and IT flexibility will be even more critical. Risk-
based or not, the three categories of investment highlighted in this report resonate: care
process redesign, IT solutions and care management personnel. These are all pillars for
better care and better collaboration between providers and payers. To read the full report,
click here. Thank you to the AMGA for conducting this survey for the fourth consecutive
year. I leave you with this final question and truly would like to hear your thoughts: Are
risk-based payment models really the pathway to value-based healthcare? Next Now |
August 2019 11 The story of possible. When you’re dealing with people on the best or worst
days of their lives, you can’t overprepare. You are tasked with offsetting the needs of a
business full of financial and competitive pressures, without compromising the care of a

7. human life. That’s why we offer flexible solutions rather than abiding by the oh-so-common
“one-size-fits-all” mentality—not just for patients and families but for the doctors and staff
taking care of them. With abundant humility, we offer that our role is a noble one. We use
technology to help you provide care, and we believe the hardest part of healthcare shouldn’t
be gathering the information to provide it properly. We enable amazing teams that beat
cancer, deliver babies, and make people walk again. We are the support system with lifelong
consequences. It’s a massive balancing act: between integration, privacy, and practicality.
And it all needs to be handled with grace and understanding, and be permeated with hope.
When you change what is possible, you change everything. 12