HIE inPractice Blog Series: Using Health Information Exchanges to Identify Vulnerable Populations (Part 1)

by: Timothy Butts, BS, MSIS, PMP, Certified Healthcare CIO,  Sharon Davis, CPHIMS, PMP, Sr. Project Manager, and Charles Stewart, MBA, SSBB, CHTS-IM, CHTS-PW, CHTS-TR, CHTS-TS, HIE Executive Director  


Healthcare Information Technology (HIT) is at a unique place in history. For the first time we have the capability to identify vulnerable populations who are at risk for chronic or life-threatening diseases and help mitigate the risk of disease by communication and early intervention. Health Information Exchanges (HIEs) can provide a vital role by gathering pertinent demographic and clinical data regarding these populations and can help curate outreach efforts.

First, we need to identify constitutes a vulnerable population – these are individuals unable to access healthcare as the rest of the population due to one or more of the following factors:

  • Age
    • Children
    • Elderly
  • Gender
  • Ethnicity/Race
  • Residence location (address)
  • Economic Status
  • Employment Status
  • Insurance status
  • Veterans
  • Language
  • Education Status
  • Homelessness
  • Mental Illness
  • Incarceration
  • Chronic Illness (one or more such as HIV)

According to the American Journal of Managed Care, a key identifying characteristic of vulnerable populations is the presence of one or more chronic illness.  The United States spends disproportionally more on healthcare for those with chronic illnesses than for those without. Any incremental advancement achieved from outpatient intervention that improves outcomes may significantly impact healthcare costs.  Vulnerable and marginalized populations are often disconnected from traditional health care settings, receiving episodic and acute-orientated care often late when disease has progressed and outcomes are poor (McHugh, Arnold, Buschman, Medscape 2012).

An important factor in identifying vulnerable populations is determining where in the health information exchange (the verb) data flow will the HIE (the noun) gather these demographic factors.  Many patients’ entry point to the HIE will be through an Electronic Medical Record (EMR) Patient Demographic or Patient Information screen and these demographic fields should be present in this screen, and standardized across all members of the HIE.  Care must be taken with sensitive information such as the last four items from the list above to maintain patient trust and comfort. In addition to direct data entry of patient demographic information into the EMR, other data paths must be considered, such as automated data synchronization with other existing databases, and non-EMR related applications including mobile apps.  Data standardization and data management is especially key when synchronizing and adding data from other databases.

Once the type and source of demographic data has been established, clinical data will need to be captured to help determine the health status of a given population. There are several clinical pieces of data that can be gathered from an EMR or other data source to determine whether a person has or is close to having a chronic illness.  Below are several pieces of clinical data and their commonly associated illness:

  • Blood Pressure (Hypertension)
  • Weight/height/BMI/ (Obesity)
  • Blood Sugar (Diabetes)
  • Asthma
  • Cholesterol

These clinical data points are essential in gathering corresponding information on the health of a given population and would help determine whether and what type of further action would be needed.

In our next blog, we will discuss technical aspects of gathering HIE data for vulnerable populations and how to implement this data gathering activity, and use it to monitor a given population.


Nurses Leading the Response to the Crisis of Palliative Care for Vulnerable Populations

About Mari Greenberger, MPPA

Director of Informatics at HIMSS North America
This entry was posted in HIEs and tagged , , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s