The most rewarding aspect of our job working with Beacon Communities is the opportunity to meet with leaders on the front lines of health care to discover how they are using health IT to design concrete improvements in care delivery. Of course, much innovation is underway and progress is being made throughout the country beyond ONC’s network of programs. Our Beacon Communities and other ONC awardees can learn from these efforts, and vice versa. Last week, for instance, we visited Parkland Health and Hospital System in Dallas, Texas, an 800-bed urban public safety-net hospital system delivering care for thousands of uninsured and underinsured persons in the Dallas “Metroplex.”  Like many health care systems, Parkland augments direct acute and chronic care with a range of supportive services to help patients manage their own health once they leave the hospital. This includes intensive patient coaching and discharge planning by nurse practitioners, pharmacists, nutritionists, and case managers; and careful outpatient case management for 30 days, including visits to patients’ home environments.

The problem is, delivering high-intensity supportive services to older, frail, or high-risk patients with complex health or social needs is costly and often unreimbursed. It is too costly to send a nurse out to every patient’s home after they have been discharged from the hospital. Yet as Atul Gawande’s latest article in the New Yorker illustrates, scarcity often inspires innovation.

To identify the best ways to concentrate high-intensity supportive services to the highest-cost, highest-risk patients most likely to benefit, the Parkland’s Center for Clinical Innovation, under the leadership of Dr. Ruben Amarasingham, has developed a system that carefully tracks patients with conditions like congestive heart failure starting when they enter the emergency department and throughout their stay in the hospital.

Amarasingham’s system takes into account real-time clinical and utilization data available in patients’ medical records (depicting, for example, acuity of illness) along with non-medical social or behavioral factors (e.g., whether the patient is homeless or without transportation).

Together, these factors can predict with impressive accuracy which patients are most likely to experience subsequent medical complications or avoidable hospital readmissions. Parkland uses this system to concentrate its supply of specialized supportive services to the patients with the greatest risk of complications.

Patients receive more personalized care. Clinicians gain access to the kinds of “wrap around” support that their sickest patients need without having to devote a considerable amount of time away from other patients. And patients’ health is carefully monitored even after they have left the hospital to find areas for improvement and avoid complications. Early results appear promising.

The team’s next project will be to establish the means by which Parkland health care providers can exchange critical health and case management information securely and effectively at the point of care with social services providers (e.g., the Salvation Army and Catholic Charities) delivering social services to the same patients outside of the hospital.

Securely exchanging relevant information, such as when a patient is discharged from the hospital or when a social worker first evaluates a client, will lay the groundwork for an innovative system of care delivery for uninsured or underinsured patients by allowing health and social interventions to occur away from traditional care settings. Amarasingham’s goal is to use this system to reduce avoidable hospitalization readmissions for patients with diabetes and heart failure by preventing complications before they arise.

The work is still in formative stages, and Amarasingham and his team are engaging a large group of Dallas stakeholders to carefully design the system before deciding which technologies are most relevant. They are grappling with the necessary security protocols to ensure that patient privacy is protected at all stages. They are mapping out the kinds of processes that would need to be in place at both the hospital and social service settings to make the best use of newly available data to coordinate care most effectively.

These are examples of how a modernized health care system, with health IT as a critical foundation, will support new and innovative ways of delivering better care, with better health, a better care experience, and lower costs as the ultimate goals.