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Unite Us Accelerates Population Health Impact Through its Integration with EHRs


Clinical providers often go above and beyond to address people’s social needs, even when they are not properly trained to do so. Clinical providers are typically a trusted resource to their patients, but are not always equipped to respond to housing, transportation, food, or legal concerns. What happens when they have instant access to a coordinated network of social service providers?

In order to support true interoperability, we knew that we needed to be able to integrate with electronic health records. We developed a seamless experience for our healthcare partners so that they didn’t have to use more software tools than necessary.

We’re simplifying holistic care delivery.

Unite Us has the capacity to exist within EHRs, which means that EHR users can experience the functionalities of Unite Us that are most useful to them within the framework of a tool they are already using. This means healthcare partners within our networks can send referrals for social needs, track their patients’ interactions with community providers, and measure specific outcomes for every intervention—all from within their EHR.

ehr app desktop

Clinical partnerscan now send electronic social service referrals directly to community partners straight from the EHR.

Health and social care providers use a variety of digital and non-digital tools today to help with research, intake, screening, referral, follow-up, and numerous other processes. We knew we could save our clinical partners time if we could integrate with their EHR and allow them to send instant electronic referrals to their partners in the community. This approach is picking up momentum rapidly in NCCARE360, our statewide network in North Carolina.

Cone Health was the first healthcare partner to join NCCARE360 leveraging our Epic integration—and they’re already flourishing in the network. Between April and August, their usage of the tool—as defined by the number of API calls—grew at an average monthly rate of over 50%.

cone health referrals

This chart depicts the number of EHR API calls from Cone Health in NCCARE360 during April–August 2019.

This success would not have been possible without our integration with their EHR.

“We are bringing the best of our human capabilities to build a stronger network of care using an extraordinary technological tool,” said Kathy Colville, Healthy Communities Director at Cone Health. “For the first time in the country, you can launch a closed-loop referral system from an electronic medical record.”

By working with standard interfaces, we’ve created a solution that only took two months to get up and running with Cone Health. We look forward to watching this integration continue to help streamline our healthcare partners’ workflows as our networks grow.

Connecting health and social care—actually.

Being available in-line within our partners’ EHRs allows them to refer their patients to community resources in a way that’s never been done before. With this integration, all members of a person’s care team are given visibility into referrals and service outcomes. This way, communities can measure which programs are effective and why. The data we’re capturing will allow care providers to improve their services and transform the community’s conditions for health from all angles. It also has the power to drive funding for community partners with limited resources.

We’ve connected with Kaiser Permanente’s EHR, as well. Thrive Local, our network in partnership with Kaiser Permanente, is the perfect example of a group of clinical providers looking for a simplified way to refer their patients for social services such as housing, transportation, and food and nutrition resources. Referred to as the “most comprehensive, far-reaching social health network of its kind,” Thrive Local is working community by community to give providers across sectors the tools they need to collaborate around shared patients.

“This tool will accelerate our evolution as a sector to next-generation care delivery—a community-integrated model that connects physicians, our patients and health care systems to community resources that address our patients’ socioeconomic needs.” – Imelda Dacones, MD, president and chief executive officer, Northwest Permanente.

Thrive Local is expected to be available to all of Kaiser Permanente’s 12.3 million members and the 68 million people in the communities Kaiser Permanente serves within the next three years.

Why is this integration essential?

We’re committed to ensuring that every partner in our networks is empowered by Unite Us and given all the tools they need to connect people to the right services at the right time—saving time and effort for both patients and care providers. However, the reason our solution is so revolutionary is because of the outcomes we track. Providers need to be able to follow referrals and their outcomes—on both individual and population levels—to measure the extent to which people’s needs are being met. Granting access to all partners involved is the first step to truly being able to work together to improve health.

This integration is an essential step toward whole-person, coordinated care that’s replacing today’s fragmented system. We’re honored to be a part of it.

Discover how Unite Us is building healthier communities:

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About Unite Us

Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. Through Unite Us’ national network and software, community-based organizations, government agencies, and healthcare organizations are all connected to better collaborate to meet the needs of the individuals in their communities.

Topics: DataHealthcare