Empowering New State Health IT Leaders: Sharing Expertise Through State Health Technology Commons

By Kate Ricker and Amy Zimmerman 

In 2009, when the American Recovery and Reinvestment Act (ARRA) Health Information Technology for Economic and Clinical Health (HITECH) was introduced, many of us were deeply immersed in state efforts to advance health information exchange (HIE). The Office of the National Coordinator for Health Information Technology (ONC) (now the Assistant Secretary for Technology Policy (ASTP)), announced the State Health Information Exchange Cooperative Agreement Program, offering states federal funding to expand HIE efforts. This funding presented a unique opportunity to bridge data and technology gaps across health systems.  

Along with this funding came new responsibilities for states, including the State IT Coordinator role. Each state applying for funding was required to have a State Health IT Coordinator providing, “health IT leadership and coordination across the federally funded state programs, including supporting the efforts of the State Medicaid Directors (SMDs) in developing the state’s Medicaid Electronic Health Record Meaningful Use Incentive Program (now known as Promoting Interoperability.” In addition, State Health IT Coordinators coordinated health IT activities across Medicaid, behavioral health, public health, departments of aging, and other federally funded state programs. The role held responsibilities beyond the State HIE Program, including directing health technology policy, strategies, and activities across federal and state-funded programs advancing health data, interoperability, and technical capabilities. 

Serving as State Health IT Coordinators in Colorado and Rhode Island, we took on this new and broader role as State Health IT Coordinators and became extremely busy focusing on our individual state efforts. It was challenging to keep up with national efforts and emerging health technology priorities. There were limited opportunities to engage the other State Health IT Coordinators for knowledge sharing beyond the initial State HIE Program.  Almost 15 years later, states are no longer required to have a State Health IT Coordinator, but many states kept the role and expanded the role and teams responsible for this work. State governments still play a significant role in effectively and efficiently modernizing the overall health data ecosystem inclusive of health care delivery, public health, behavioral health, social care, and health insurance by having interoperable data networks.   

Transitions and Evolution of Health Technology  

The health technology landscape has undergone significant transformation over the past few decades, primarily driven by the increasing need for secure, efficient data sharing across the public and private health sectors. Since leaving our state government roles, we have witnessed the transition from CMS HITECH Federal Financial Participation (FFP) funding to Medicaid Enterprise Systems (MES) modular certification funding for HIE, a global pandemic emphasizing the need for standardized data reporting and robust data exchange, and the evolution of multi-sector data needs for behavioral health and social needs data.  

The state health IT and informatics leaders today can be in different state agencies with a broad range of responsibilities, technology portfolios, and influence.  This, in turn, requires a wide range of subject matter expertise. Stepping into the role of a state health IT leader can be both an exciting and overwhelming challenge with a steep learning curve.  

State Health IT Leader example responsibilities: The complexities associated with establishing health IT strategies that promote interoperability among health information systems, navigating the federal and state regulatory landscape, aligning privacy laws and policies, leveraging existing infrastructure,  harmonizing the implementation of data standards, securing and sustaining funding and driving innovation to support the use data  for data driven decision making in a timely manner, requires a unique blend of relationship building and community engagement, collaboration, strategic visioning, general management and  technical understanding.

We are committed to supporting new and existing state health IT leaders and providing them with specific opportunities to support and learn from each other. This is why we have partnered with Civitas Networks for Health to develop The State Health Technology Commons (the Commons).  The Commons offers new and existing state health IT leaders an opportunity to build the expertise necessary for success and to continue expanding that knowledge throughout their careers. 

The Journey to Becoming a State Health IT Leader 

State health IT leaders are tasked with modernizing health information ecosystems to ensure that they are efficient, secure, and align with state and federal health care goals such as improving individual health and social outcomes, protecting public health, and ensuring equitable access to care. For those new to the role, topics such as understanding the intersection of policy and technology, maximizing the technology funding process and opportunities, leveraging HIEs and Health Data Utilities (HDUs) to increase interoperability, and assessing the impact of federal regulations can be intimidating.   

This is where the State Health Technology Commons comes into play. Designed as a collaborative, open learning community, the Commons provides new as well as existing leaders with access to a wealth of resources, expert insights and experiences, and a supportive network of peers. 

Michael Pancook has been serving as Maine’s Health Information Technology Coordinator for Maine’s Department of Health and Human Service since May 2023.  Although Michael   trained federally qualified health centers in the use of health it and data analysis, he found his new role a bit daunting. Michael, as a new state health IT leader has stated that participating in this learning community has “provided access to expertise and resources to manage the stream of new information and offered a safe venue to ask questions and share challenges.”  

The journey for state health IT leaders is not typically a straight path. It is often a long and winding road with many twists and turns, and crossroads where decisions must be made. Today, we all use GPS to help us get to where we are going. The Commons is a tool, like GPS, that aids State Health IT Leaders in helping to navigate and drive efforts to meet state health IT needs in the following ways:  

• Accelerating the Learning Curve - New state health IT leaders need to quickly get up to speed on a wide range of topics beyond technology such as community governance and partnerships, state and federal legal, regulatory and policy considerations, data and interoperability standards, and funding and sustainability to mention a few. The Commons provides an environment where newer leaders can promptly identify their peers in other states, talk with more experienced leaders and subject matter experts to better understand lessons learned and best practices, and ask questions to gain knowledge and obtain support, as needed. Accelerating the learning process can help new leaders avoid common pitfalls, build confidence, become educated and gain access to current resources to guide them in their work.    

• Obtaining Mentorship and Peer Support - One of the most valuable aspects of the Commons is the opportunity for new leaders to connect with experienced mentors and peers.  This often occurs during facilitated monthly calls. The relationships, built through the Commons, create a peer network where state leaders feel comfortable reaching out to others on their own to ask pressing questions, obtain guidance, and use each other as a sounding board or vent as needed.  For many leaders, a peer support network is an essential resource that helps to reduce the feeling of job-related isolation and provides a safe and supportive environment.  Collaboration and mentorship is not a one-way street. It fosters a culture of continuous learning and collaboration, where both new and season leaders benefit from the exchange of knowledge and perspectives.  

• Enhancing Expertise Over Time - Health IT policies and tools are dynamic, ever-changing, and rapidly evolving. For state health IT leaders, staying current is a necessity. The Commons supports professional development and knowledge sharing by creating an environment that enables leaders to continuously expand their expertise. This includes the ability to stay current on new and emerging health IT topics (e.g., the use of AI), in addition to federal priorities and new initiatives.   

• Creating a neutral and safe space in support of building ongoing state health IT leadership - The Commons strength is in facilitating a highly collaborative environment encouraging active and open participation. New and existing state leaders can engage in meaningful and honest conversations and learn from each other’s diverse perspectives and constraints. Creating a neutral and safe community with a shared purpose allows new leaders to comfortably ask questions, explore new concepts, gain feedback on their approaches, and create a common voice. For seasoned leaders, it offers the opportunity to contribute their knowledge and learn from the fresh perspectives of new leaders.  

Looking Forward  

The Commons serves as an investment in the future of state health IT leadership. As leaders continue to increase their understanding of state health IT needs and solutions, the overall capacity of state health ecosystems across the country will continue to expand and improve. The Commons offers a unique opportunity for state health IT leaders to obtain familiarity with their role and for all leaders, new or old, to expand their expertise in a caring and supportive, collaborative environment. We encourage all state health IT leaders to join the Commons.  Together, we can build a stronger, more knowledgeable community of state health IT leaders prepared to address the rapidly evolving health IT needs of states and align with national efforts.   

Kate Ricker, B.A., M.A., is a transformative leader in health policy, strategy, technology, and program integration with nineteen years of experience providing vision and successful execution of multi-stakeholder projects. She has advised thirty-two states leveraging a unique capacity to conceptualize and develop creative solutions to complex health initiatives in the public and private sectors.

Amy Zimmerman, MPH,  is a health Information technology and exchange specialist focusing on state and federal strategy, policy, and operations.

We encourage you to get in touch with our team at Civitas to hear more about our work, our partners, and answer any questions you might have.

If you are interested in participating in the State Health Technology Commons, please reach out to     

by Civitas Admin

Learning the language of Health Information Exchange: Insights from Ohio Health Information Partnership’s Henry Vynalek

Bridging the gaps between technology, research, and patient care has been an invaluable translation skill for Henry Vynalek, Senior Director of Health Information Exchange (HIE) and IT Operations and Security Officer for CliniSync, of Ohio Health Information Partnership (OHIP). Henry’s decade-long journey with OHIP and his extensive background in health care provides a unique perspective on the evolving landscape of HIEs.

His journey from pharmacy technician to a key player in health care IT showcases a diverse skill set and an ability to adapt and thrive in various roles.

Speaking the Right Language

Henry’s roots in health care IT run deep but it’s his background that gave him the language he needed to blend his experience and expertise for success.

After working in various health care settings, including a pharmacy, a research lab, and the Ohio State Medical Center and Nationwide Children’s Hospital, Henry decided to try something new and find an intersection between his interests in health and computers.

What he developed was a deep understanding of how health data is collected, processed, and shared along with the skill set to address the technology-related barriers health care workers face when providing patient care and addressing health-related issues. With this backbone, Henry has been able to effectively communicate with end-users about their needs and translate those insights into product developments that make data processes more seamless with OHIP’s CliniSync.

OHIP operates on a stakeholder-driven model, engaging over 150 hospitals across Ohio. Recognizing the diversity of needs among acute care facilities, specialty hospitals, ACOs, ambulatory facilities, reference labs, state departments, and payers, OHIP fosters regional collaborations that bring together various health care providers to address common challenges and streamline data exchange processes.

One challenge where Henry’s translational skills were put to the test was the varying preferences among providers for accessing patient data. While a comprehensive continuity of care document (CCD) seemed like the best solution for CliniSync’s upgrade on paper, the emergency care providers Henry worked with expressed a need for more granular, on-demand access to specific data points. With this insight, OHIP reassessed CliniSync’s Community Health Record (CHR) offering, providing a new use case that allowed providers to choose the method that best suited their workflow, whether it's a comprehensive document via CCD query or detailed individual results via the CHR.

Collaborative Efforts for Forward-Looking, Accurate, Unified Data 

OHIP’s success is built on collaboration. The organization works closely with a diverse range of stakeholders across Ohio to address common challenges and improve interoperability. Henry’s approach emphasizes cooperation over competition, recognizing that shared goals lead to better outcomes for all.

One critical focus for Henry is ensuring data quality at the lowest level. The accuracy of data input, especially concerning social determinants of health data, is necessary and mistakes/incorrect information can significantly impact the integrity of the entire dataset.

OHIP's strategy involves creating a stakeholder-led data committee to put shared robust systems and operations in place to facilitate correct data entry, minimize human error, and enhance data reliability.

This collaborative effort aims to ensure that the data driving health care decisions is reliable and comprehensive to ultimately enhance the quality and accessibility of patient data across Ohio.

As CliniSync continues to grow, plans are underway to transition to a more scalable, next-generation platform. Moving some components to the cloud will further enhance scalability, ensuring that OHIP can handle increasing data volumes and maintain high-performance levels.

Engaging with Civitas in Meaningful Ways

Henry’s forward-thinking approaches and commitment to continuous improvement are sure to support this next phase for OHIP and CliniSync. Rising leaders like Henry are critical to the overall success of Civitas’ work as well, where networking, professional development, and leadership growth is helping transform the field of health information technology and health improvement.

As an active member of Civitas participating in the Emerging Leaders Forum, Henry benefits from the collective knowledge and experience of HIEs across the country, which provides opportunities to influence industry standards and collaborate with peers, recognizing the diverse needs and priorities of different states.

This October, hundreds of health IT and health improvement leaders will join Civitas for its 2024 Annual Conference centered on, “Bridging Data and Doing,” in Detroit. “The Civitas conference grants HIEs a unique opportunity for collaboration and engagement, as well as providing a forum for all members to discuss and strategize the future of health care informatics,” says Henry. Along with other OHIP team members, Henry will be joining us in Detroit—Be sure to catch up with him in person!

Henry Vynalek is a seasoned health care technology leader with more than 15 years of experience connecting and analyzing health care data for major hospitals and health care facilities across Ohio. Henry serves as the Senior Director of Health Information Exchange (HIE) and IT Operations and Security Officer for CliniSync, of Ohio Health Information Partnership (OHIP). He is known for his structured yet innovative approach to problem-solving and effectively bridging technical and clinical gaps to deliver practical solutions that enhance data interoperability. 

We encourage you to get in touch with our team at Civitas to hear more about our work, our partners, and answer any questions you might have.

by Civitas Admin

Why CMS' Proposed New Advanced Primary Care Management Codes are a Big Deal: A Real Movement Forward for Whole-Person Health

By Diane Marriott and Alan Katz 

Each July, CMS releases a proposed Physician Fee Schedule (PFS) that previews proposed changes to physician payment and other Medicare B services for the upcoming year.  Last year, for example, CMS introduced the Community Health Integration and social determinants of health (SDoH) Risk Assessment codes and previewed them in the 2024 proposed rule.  We are hopeful about the positive impact these changes can foster in our health system, promoting positive health outcomes and advancing whole-person health while simultaneously reducing barriers for service providers. 

For Civitas members, one of the most interesting aspects of the 2025 PFS proposed rule is CMS’ introduction of three advanced primary care management (APCM) codes, which represent a first-of-its-kind attempt to “bundle” several different billable care coordination activities into single G-codes for use by Medicare primary care providers at large. The three proposed APCM codes vary by patient complexity and pay practices for advanced care management on a monthly basis, instead of paying piecemeal on a fee-for-service basis. This is a big move forward in providing practices with reliable revenue to meet the care coordination needs of their patients.  

When Medicare introduces new codes, commercial plans, and Medicaid plans, other payers take note and often introduce them as billable codes, making it possible for practices to apply them across the range of payers they may work with.  

Whether your organization interacts with primary care practices; helps to engage community resources to address social drivers of health; promotes the uses of patient-reported outcome tools; provides data; facilitates gaps in care reporting; or serves people with health and social needs, it helps to have strong primary care partners. Let’s look at the requirements for the proposed new APCM codes: 

• Patient Consent: Inform the patient about the service, obtain consent, and document it in the medical record. 
• Initiating Visit: Engage new patients or those not seen within three years. 
• 24/7 Access: Provide patients with urgent care access to the care team/practitioner at all times. 
• Continuity of Care: Ensure continuity with a designated team member for successive routine appointments. 
• Alternative Care Delivery: Offer care through methods beyond traditional office visits, such as home visits and extended hours. 
• Comprehensive Care Management:
  • Conduct systematic needs assessments. 
  • Ensure receipt of preventive services. 
  • Manage medication reconciliation and oversight of self-management. 

• Electronic Care Plan: Develop and maintain a comprehensive care plan accessible to the care team and patient. 
• Care Transitions Coordination: Facilitate transitions between health care settings and providers, ensuring timely follow-up communication. 
• Ongoing Communication: Coordinate with various service providers and document communications about the patient’s needs and preferences. 
• Enhanced Communication Methods: Enable communication through secure messaging, email, patient portals, and other digital means. 
• Population Data Analysis: Identify care gaps and offer additional interventions. 
• Risk Stratification: Use data to identify and target services to high-risk patients. 
• Performance Measurement: Assess quality of care, total cost of care, and use of Certified EHR Technology (CEHRT). 

Practices need strong, inter-connected data systems to make this happen, and the APCM codes: 

• Require the use of certified electronic health record (EHR) technology (CEHRT) and remote access to the care plan, a helpful step to ease the path to interoperability.  In the proposed rule, CMS notes that CEHRT is, “fundamental to providing the APCM service elements of 24/7 Access to Care, Continuity of Care, and Management of Care Transitions under an advanced primary care delivery model.” By requiring CEHRT, CMS is encouraging practices to electronically report clinical quality, support data exchange with other providers and health systems, and connect to their regional health information exchange (HIE).  
• Provide practices with resources to support patient care optimization and prevent things from slipping through the cracks in transitions of care from an emergency department (ED) or hospital to make sure that patient needs are met. This includes medications being reconciled and following up with patients —either virtually or in-person—in the prescribed timeframes. You can’t do this without information and data exchange about patients seen in an ED or admitted to/discharged from a hospital (for example, via HIE, hospital portal, hospital-generated report, EHR, or additional health IT system); and
• Put practices on track to Medicare Value Pathway reporting and electronic clinical quality measures (eCQMs). 

What could these new codes mean for population health? Looking at states like Michigan that have had experience with CMMI multi-payer models, including APCM-like payments (e.g., multi-payer advanced primary care practice (MAPCP) and Primary Care First (PCF)), might give us a glimpse. Until now, to receive this kind of monthly advanced primary care management funding for their Medicare patients, a primary care practice had to be fortunate enough to qualify for a spot in a Center for Medicare and Medicaid Innovation (CMMI) advanced primary care innovation model with enough other participating payers to cover most of the patients in their panel. When the innovation model ceased, so did the Medicare per member per month (PMPM) funding for advanced primary care management. Even if the commercial payers were able to continue funding, the loss of Medicare and Medicaid funding was often so significant that it was a non-starter for many. It’s margin versus mission, again. The introduction of APCM codes will be a game-changer for these practices.  

Introducing APCM codes, however, is not a silver bullet. There are some aspects of the proposed APCM rule that are less than ideal (the payment rate, the potential for the 10% of Traditional Medicare beneficiaries who do not have Medigap to face the statutory 20% cost share, etc.). CMS would probably have addressed these if it had the authority to do so.  

Let’s not let the perfect be the enemy of the good. There is much that CMS has enabled in the new APCM codes that can unveil a new age of true care integration and coordination.  

In the proposed 2025 PFS rule, CMS has included an extensive RFI section focused on the new APCM code set and future value-based reimbursement models more broadly. Civitas Networks for Health, a national nonprofit collaborative representing over 170 member organizations that are advancing health data exchange and health improvement throughout the U.S. has the ability to bring forward critical perspectives from implementers using data-led multi-stakeholder approaches to both payment and deliver reform. Civitas will speak to the challenges and opportunities created for many of its members’ public comments on the proposed rule, as well as in ongoing communications with regulatory bodies and policymakers to ensure that they understand our perspectives. Civitas will also continue to highlight the technical and operational aspects of value-based care approaches and share best practices among members through its workgroups, collaborative sessions and other forums, such as the Government Relations and Advocacy Council (GRAC).

Our field is ready to move forward with these opportunities CMS is offering to provide better care and promote better health outcomes. We look forward to the next steps and working with fellow Civitas members to implement these critical changes! 

Diane Bechel Marriott, DrPH, MHSA, directs Michigan Multipayer Initiatives (MMI), a group that catalyzes health care payer and plan alignment on common, evidence-based policy to improve health equity, quality of care, patient experience, affordability of care, and the health of the populations served. 

Based at the University of Michigan and hosted by the Center for Healthcare Research and Transformation, MMI also works with providers, practices, physician organizations, social care organizations, national groups, and patients to ensure that community voice is incorporated. 

Diane has served as Statewide Convener for several large-scale CMMI primary care practice demonstrations to improve value, quality, and patient/provider experience outcomes including Comprehensive Primary Care Plus (CPC+), Michigan Primary Care Transformation (MiPCT), and the Patient-Centered Medical Home (PCMH) Initiatives of Michigan’s State Innovation Model (SIM). She is also a member of the Milbank Fund’s Multipayer Primary Care Network Advisory Group and has served on committees for the National Quality Forum, U.S. Preventive Task Force, National Business Group on Health, and E-Health Initiative.  

Alan Katz is Associate Director of Advocacy and Public Policy at Civitas Networks for Health, working to continue shaping the future of health improvement and information exchange through government relations in Washington D.C., and beyond. Alan brings over a decade of experience representing public and private entities before policymakers, including acute and specialty health care providers ranging from Fortune 500 systems to Critical Access Hospitals that have successfully leveraged data partnerships to improve access and efficiency in some of the nation’s most underserved communities. 

We encourage you to get in touch with our team at Civitas to hear more about our work, our partners, and answer any questions you might have.

by Civitas Admin

Advancing Health-Related Social Needs Screening through Health Information Exchange Infrastructure and Data Standardization

By Jolie Ritzo and Jessica Little 

Addressing health-related social needs (HRSNs) is crucial to ensure the best health outcomes, improve treatment, and increase care coordination between community and health care settings. Data derived from HRSN screening also informs health care and public health processes such as payment, quality, and population health, and can also influence policies and programs to support the health of communities and individuals.

By leveraging existing data infrastructure from health information exchanges (HIEs) and standardizing how data is coded and exchanged we can transform data derived from HRSN screening into a meaningful resource that benefits patients, providers, and communities, which ultimately supports whole-person health.

Standardizing Data Collection and Exchange

Collecting HRSN screening data within various care settings—social services, community-based organizations, and health care—is the first step toward progress. However, to ensure the best patient experience and lack of duplication, it is important that this data can be shared across settings. This critical aspect lies in standardizing this data for interoperable use and integration into existing processes and tools.

Health-related social needs (HRSNs) refer to individual-level factors, whereas social determinants of health (SDOH) refer to community-level factors, both of which impact an individual’s health and well-being, according to HHS.gov.

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, according to health.gov.

Computers cannot interpret responses to HRSN screening questions without a standardized coding system. Data standards can allow for the seamless exchange of electronic codes between unaffiliated providers and disconnected care settings to enable whole-person care. That’s where the Gravity Project ® comes in. 

The Gravity Project is a consensus-driven collaborative that leads the development and implementation of SDOH data standards. Gravity supports four clinical activities: screenings, assessment and diagnosis, goal setting, and treatment interventions. Information can be accurately captured and exchanged to advance interoperability by using validated screening tools and standardized coding for HRSN screening data, such as those found in different code sets utilized for clinical activities.

Civitas Networks for Health – A Gravity Implementation Partner 

The Gravity Project operates three work streams: terminology, technology, and implementation. Terminology develops languages and codes created through an evidence-based consensus-building process designed to make data publicly available for exchange. The technical workstream addresses how these codes are exchanged, aiming for advancements like Fast Healthcare Interoperability Resources (FHIR) ®. And the implementation workstream advances the adoption of SDOH data standards by meeting communities where they are and providing forums and resources supporting implementation activities. 

Civitas Networks for Health (Civitas) is a national nonprofit member and mission-driven organization focused on health data exchange and health improvement; it acts as a bridge between data and doing. As a member and partner of Gravity, Civitas works to support implementation of Gravity data standards in communities throughout states and regions by engaging its members and their partners, connecting them with Gravity experts and resources. Through convening partners, experts, and community members, Civitas supports pilots and peer-to-peer learning forums where implementers can learn from the successes and challenges of others implementing HRSN screenings and standardizing data exchange, allowing members to build upon progress generated by others. 

At Civitas’ recent May Collaboratives in Action event, we heard directly from members of the Civitas network leading implementation efforts to embed HRSN screening data in clinical settings within the contexts of their unique state, local, and community perspectives. They shared successes, barriers, and outcomes of their work to provide highly relevant insights that allow others to learn from their journeys.  

MyHealth Access Network (MyHealth) 

MyHealth Access Network, a nonprofit HIE in Oklahoma, has been addressing SDOH by integrating HRSN screening and referrals into clinical care settings. Having been awarded an Accountable Health Communities (AHC) model grant in 2016, MyHealth embarked on an innovative journey to bridge clinical data with social services, recognizing the fragmented nature of both clinical and HRSN data. The effort led to the creation of the Route 66 Consortium, which united competing communities and established the governance and relationship-building essential for collaboration. Through its role as a state-designated HIE, MyHealth leveraged its data infrastructure to implement a comprehensive social needs screening process, seamlessly integrating HRSN data into clinical workflows and facilitating timely referrals to community resources. 

MyHealth developed a workflow that utilized mobile technology to conduct screenings and deliver referral information in real-time, effectively automating the process. This modern approach ensured high screening and response rates while also showing significant reductions in health care costs and provider burden. By May 2024, MyHealth had offered more than 4.5 million screenings, identified and addressed nearly a million social needs, and saved an estimated 250,000 hours of staff effort, roughly equating to $4.5 million in savings. This model showcases the role HIEs can provide in integrating SDOH considerations into clinical care, ultimately improving patient outcomes and enhancing the efficiency of health care delivery. 

North Carolina Health Information Exchange Authority (NC HealthConnex) and North Carolina Department of Health and Human Services  

North Carolina's Department of Health and Human Services (NCDHHS) partnered with their state-wide HIE, NC HealthConnex, to improve the exchange of data related to HRSNs within its Medicaid program. NCDHHS aimed to create interoperable data systems that provide necessary, relevant patient data to inform clinical decision-making and provide the best care. By implementing pilots under the 1115 waiver, NCDHHS pioneered a program that allowed community-based organizations to invoice for non-medical interventions and ensure that HRSN screening data was collected. These pilots were geographically limited but aimed to provide valuable insights into the effectiveness of addressing HRSNs through community-based efforts.  

To advance similar goals, North Carolina began integrating HRSN screening data from various health systems into NC HealthConnex, creating a unified system that facilitates data sharing. The initial pilot phase involved collaboration with the NCDHHS and selected health care organizations to standardize data collection using LOINC codes and CCD-10 codes. The first phase of this work successfully identified commonalities and variations in screening questions, paving the way for standardized data entry. Moving forward, the state plans to expand the pilot to include primary care practices and Medicaid health plans, aiming to ensure comprehensive data flow from providers' electronic health records into NC HealthConnex. The goal is to use this data for improved clinical decision-making, policy development, and program evaluation, with a future focus on incorporating referral and intervention data to address identified needs more effectively. 

Challenges and the Path Forward 

By identifying the needs of individuals and communities, and where there are unmet HRSNs, we can better inform and shape programs and policies that address needs, thereby promoting health equity and overall well-being.  

Despite many successes with HRSN screening and standardized data exchange, challenges remain, such as variability in screening tools as well as the associated time and financial costs of standardization. Resources are needed to develop consistent, interoperable rules for validated screening tools and to support the iterative process of building, implementing, learning, and refining these standards. There is also a tremendous need for education and furthering the adoption of existing resources, standards, and tools.  

Clarity and appropriate funding for entities responsible for collecting, coding, and exchanging this data are also critical. Different states have varying responsibilities and resources for these tasks, necessitating a collaborative and localized approach to ensure efficiency and effectiveness.  

Advancing HRSN screening, data capture and exchange through use of existing HIE infrastructure, and adopted standards is a collaborative and continuous effort that Civitas is supporting through multiple fronts. Civitas is also closely tracking partnerships between CIEs and HIEs, which brings great promise in having more connected and streamlined data across sectors. By utilizing tools, such as those from the Gravity Project, and supporting local implementation, we can improve data exchange, reduce provider and patient burdens, and ultimately enhance health outcomes. This process not only supports whole-person health but also strengthens the foundation for a more equitable and effective health care system. 

Jolie Ritzo is Vice President of Strategy and Network Engagement at Civitas Networks for Health. She leads communications and marketing, government relations and advocacy, event strategy, and strategic planning. Jolie previously served as the Director of Partnerships and Programs at the Network for Regional Healthcare Improvement (NRHI). Jolie also serves as President of the Crossroads Board of Directors, a nonprofit organization serving patients and families in Maine with addiction and behavioral health treatment. 

Jessica Little is Vice President of Business Development and Programs at Civitas Networks for Health. Jessica oversees Civitas’ portfolio of grant-funded programs and contracts and leads the development of strategic partnerships with funders and program partners. Jessica also serves on the Gravity Project Operating Committee and a variety of other national workgroups aimed at improving health and social care data interoperability.

We encourage you to get in touch with our team at Civitas to hear more about our work, our partners, and answer any questions you might have.

by Civitas Admin