Health care providers need access to comprehensive health data in order to provide appropriate care to their patients. But specific data about individual patients isn’t enough; information about health and environmental risks in a patient’s community, for example, can determine or guide treatment options and even let physicians recommend preventive health measures by providing additional information that might not be in a patient’s medical record.
As a professor at the University of Michigan Department of Family Medicine, a physician at Briarwood Family Medicine in Ann Arbor, and consulting medical director for cross-sector data sharing at the Michigan Health Information Network, Dr. Michael Klinkman relies on electronic health records (EHRs), as well as additional health information from a variety of sources, to do his job.
This interview with Klinkman has been edited for clarity and length.
In my everyday clinical work at Briarwood, I use an EHR to help care for my patients. Among other things, we get immunization records or notifications of cases of diseases that have a public health impact, such as COVID-19 or tuberculosis.
There may be other feeds that we get data from, but we don’t always know the source. For example, a report from another provider of another clinical encounter or medical procedure with a patient might come in, but I may not know it’s there until I actively access it when I’m working with the patient. Or I might get an alert if there’s an emergency with a patient, such as being admitted to a hospital or emergency room, but I may not initially know the source of the data.
Aside from traditional medical data, I also receive results of social care screenings, such as information on social determinants of health like housing or food insecurity. I can get a risk assessment score for a patient—a numerical value that lets me know if they’re facing major inequities that could affect their health—but again, I’m not always sure what the underlying data is.
All physicians, whether primary care or specialists, work together with public health. But we have to sift through so much data to find the nuggets that are truly meaningful for patients. There are more data feeds than I would like to have, but I don’t have a way to access the ones I need in any given situation. Many practicing physicians feel like we’re feeding the monster; we’re adding in data, such as reports of laboratory tests around conditions that need to be shared with public health agencies—sexually transmitted diseases, to give just one example—but receiving useful data is harder.
During the height of the pandemic, for example, I would have loved for the EHR to let me access data about my populations.
Most clinicians live in everyday work like checkups and screenings, which are essential for primary care. But I also need data on social problems or environmental risks that could alert me to the need to connect a patient with resources or treatment.
There are moves in that direction here in Michigan; the state Department of Health and Human Services has been trying to develop clinical-community linkages between health care and social care providers in several regions. Ideally, that would mean a community could collect and use nontraditional public health information—such as food insecurity—that could help providers improve the quality of care they provide by screening for and addressing a broad range of problems instead of just reacting to the problems.
A few years ago, the American Board of Family Medicine started to work with the American Academy of Family Physicians’ Robert Graham Center and the data organization Health Landscape to get census-type data to clinicians. The goal was for clinicians to better understand which regions might be facing inequities—for example, whether a region is a “food desert” with few grocery stores available. Ideally, we would pair that information with our knowledge of individuals’ health conditions to plan for their needs. For example, someone with diabetes living in a food desert might need help getting nutritious food.
It’s hard for clinicians to find the time to do things like find out if there’s a higher lead exposure risk or too few walking paths in a community. So the lack of quality data isn’t the only issue we face; our time as clinicians is limited. We need time in order to be able to step back from individual patient care and start thinking about the population, including social and environmental factors, and how to help people facing those challenges. It has to be more user-friendly.
To address this, the University of Michigan Family Medicine Department is trying to “buy out” clinicians’ time, by essentially asking them to set aside an hour to think about population-level challenges for every three to seven hours of patient-focused work. That would be the ideal time to use this public health data to identify people who might be at risk.
I would like clinicians to start receiving a certain subset of public health data. We often think about this narrowly, such as focusing on information on diseases. But what about the current prevalence of COVID or flu in my community, or whether we’re living in a food desert? I would love to know those things, but my EHR can’t help me do it seamlessly.
Above all, I would like to have a robust public health data infrastructure, such as a dashboard that looks at issues beyond the prevalence of COVID and gives us a better sense of any issues that are significant in the community. Is there an outbreak of a certain disease? Being able to see that in my EHR, and then connect with at-risk patients to plan further interventions, would be terrific.
The reporting structures I deal with are good. The EHR makes it easier for me to report information public health agencies need. I spend a lot less time on the phone with patients who have a reportable condition than before, and I’m confident that will continue to improve.
What I don’t have is the feedback loop: We’re feeding information into the system, but not necessarily getting a reply from public health agencies. Sometimes I’ll have to call my patients to ask them if a follow-up was done. Similarly, while I know who our public health officials are, there isn’t always an easy way to connect with them. As a clinician, I need to know how to get in touch with them and be confident that I’ll get a quick response.
Despite all this, in my experience, the issue is never that the public health system doesn’t want to participate. Public health officials always want to do more to help the people in their communities. That’s what they’re there for. But people working in public health are understaffed and underfunded, and most of what’s on my wish list are things they don’t have the resources to do. If they can get those resources, it could be transformational for our communities and the patients we serve.