A FHIR-side Chat: How MEDITECH Is Enabling Organizations to Advance Community Care with Unite Us

Hi, everyone, and welcome to the first session of our fireside chat series where we sit down with leaders across the health care ecosystem to talk about the role of interoperability, EHR integration, and community collaboration, empowering more connected person centered care. I’m Katie Keating from Unite Us, and today, I’m joined by Janet Desroches, the associate vice president at MEDITECH, a long time leader in the EHR space and one of our key integration partners.

We’re also joined by Casey Piergan, community health equity coordinator at Citizens Memorial Hospital, a comprehensive rural health care system in Southwest, Missouri. Citizens Memorial Hospital was the first hospital to go live with the NIDAS MEDITECH integration, and we’re so excited to have you both join us today. Welcome, Janet and Casey.

Thank you, Katie. Hi.

So, it’s great to see you both live today. I had a great time getting to know you before as we prepared for this discussion. And we’re gonna start off nice and easy today with talking about why it is so important for health care organizations to focus on what’s going on outside of the walls of the doctor’s office, such as a patient’s ability to even get to an appointment or refrigerate a medication.

And how have you seen the recent changes and approach to these nonmedical or SDOH needs get updated in recent years? Janet, let’s start with you.

Sure. Thank you, Katie. And it’s an absolute privilege to be doing this with you and Casey today. You’re doing such meaningful work and thank you for what you do.

In answer to your question, what we know is it is important for healthcare organizations to put attention on what happens outside traditional clinical settings because social determinants of health such as what you mentioned, as well as financial strain, transportation barriers, and food insecurity, really profoundly influence an individual’s health outcomes.

For example, we know that studies link housing insecurity to higher rates of chronic disease like hypertension and diabetes as well as mental health issues. In fact, there was a recent study done in the UK and France that proved that food insecurity is directly linked to increased risks of depression, anxiety, as well as suicidal ideation.

So the industry’s approach to these nonmedical needs has evolved significantly. Traditionally, we know clinical data systems and social services platforms operated in silos making it challenging to get a comprehensive view of the patient’s health.

Now there’s a clear shift towards a more connected whole-person approach to care, and that’s facilitated by what we’re gonna learn about more—the FHIR resources and standardization around interoperability—which have been transformative in bridging this gap. They allow for standardized, secure, real time exchange of data.

This enables care teams to better access and act on social needs directly within their clinical workflows and provide better coordination of holistic care. And Casey, I know you’re gonna talk about this in more detail from a real life perspective.

Yeah. That was such a really good answer. That was so good. For someone who works in a clinic, I think it’s definitely very important that we provide SDOH screenings and focus on social drivers of health because if we don’t ask the questions, patients often won’t give you that information.

They’re not going to the doctors to talk about how they don’t have transportation to go to the grocery store or go apply for WIC if needed. So I think it’s really important that clinics focus on doing these screenings and asking these questions, just because there’s so much more to a patient’s health care than just going to the doctors to get a diagnosis and leave, then try to figure it out on their own.

Thanks. I know screening is sort of top of mind for everyone these days. There are so many initiatives. And I think for me, the question is always: so what? If I’m gonna be vulnerable with you and I’m gonna share this information, what action are you gonna take to support that?

Yeah. I feel that’s a—oops. Sorry.

No, go ahead.

That’s a big question that people always ask when they go to the clinic: well, do I have to answer these questions? What are you actually gonna do for me if I answer these?

Exactly. I think when we think about how EHRs have traditionally worked, it’s been really around the documentation and the review of clinicians providing care. When you think about MEDITECH’s approach going forward and taking a more proactive role in identifying or acting on some of those screening results and nonmedical needs, how do you all think about that?

It’s a great question. And when you look at it from a macro level, what we’ve been seeing is that things have been evolving and the role of the EHR has become more important in terms of delivering technology and solutions that actively support population health and care of the community at large.

One of the interesting things that we’ve seen is alignment with these initiatives in community health needs assessments. Many of us know community health needs assessment is a requirement of health care organizations, not-for-profit health care organizations to put together, and that includes a health care provider as well as community-based services.

The goal is to look at what is the prevalence of chronic disease in the community, what is the prevalence of newly diagnosed mental health problems, and then also understand what the social drivers of health are. What are some of those areas such as food insecurity, housing insecurity, even environmental concerns that are in the community?

Then make a correlation between those things, because one drives the other. When you talk to an organization, this has largely been a driver when they start thinking about their strategy around how they’re gonna use technology as an enabler, taking a look at what their initiatives are and aligning with the community health needs assessment.

So they’re creating implementation strategies to address the identified needs and often partnering with community organizations to design and fund targeted interventions.

Casey really hit on a key point, and that is in order to embed integration with such a powerful service as Unite Us, you need to look at organizationally what you need to do. It really is about identifying nonmedical needs in a discreet way upfront and then being able to understand the workflow and connect those patients to those community services.

The beauty of the FHIR-based interoperability is you can do that in workflow and bring that into your EHR. At the end of the day, what we’re supporting is really a holistic person-centered approach.

Thanks. I think so much of that really comes to life when you start to think about a community health needs assessment and how you actually act on that.

From a day-to-day perspective, that’s what you’re doing—really connecting those resources in the community with the needs that people have. When you think about some of the challenges in that work, why was it so important for you all to integrate your MEDITECH environment with Unite Us? And what are some of the challenges it solves in your workflow that Janet was just talking about?

Yeah. So I actually started working at CMH after the partnership with Unite Us and the integration took place. So all I know is sending referrals through MEDITECH and Unite Us, which is great because it’s so helpful.

However, when I talked to other community resource specialists in the past, they say that some of the big challenges were you spend all this time calling agencies and hope that they would actually respond and reach out to the patient if they had time. Or you spend all this time printing off information to provide patients in hopes that they actually contact the people that you give them the information for.

So a lot of the issues stemmed from just having hope that people would actually do what you’re trying to get them to do, because there’s a difference between asking someone for help and then actually taking the steps to get the help you need.

That was definitely one of the bigger roadblocks to getting people the assistance they needed after doing the SDOH screens prior to the Unite Us MEDITECH integration.

Yeah. I think that it’s always one of the things we talked about, the ability to see what’s happened. And to be able to know when you go and have that next conversation, what really happened between the last time we talked and what’s going on now.

Yes. I know that you are often also challenged by lack of resources in a rural community. Are there any ways that tools or technology can help you with that that you’ve found impactful?

Yeah. Once our community started talking about utilizing Unite Us, a lot of the different community agencies were really interested in getting onboarded because one thing we always have in common is we’re trying to help the same people in the community. But I don’t know if they actually went to Calm to get food pantry benefits, and Calm doesn’t know if this patient went to OCAP to get utility assistance.

What’s nice with utilizing Unite Us is I can see where the patients have gone and if they’ve actually reached out for help. If not, I can follow up with the patient to talk about maybe doing a new referral and bridging that gap between what they said they were going to do versus what’s actually happening.

I think it’s so important to be able to see that. From our perspective here at Unite Us, it’s really important for us to be integrated with some of our EHR partners because of the way it smooths out that workflow for clinicians and community health workers. When you think about MEDITECH’s strategy to deliver really connected holistic care, how does this fit into your overall strategy?

Thank you for asking. This has been so powerful and I love talking to Casey because she validates some of the past challenges as well as the current challenges around that 360 referral loop. I’m sure we’re going to talk about that in more detail. I’ve been so appreciative of what Unite Us does.

Now, with some of these FHIR standards, we’ve been able to integrate it into workflow. The core lies in the seamless integration of Unite Us with MEDITECH Expanse EHR. That is the game changer here. It allows us to bridge data silos—like Casey was talking about—so that if we know what’s in Unite Us and what that key data is, we can put it in workflow. That’s powerful.

This kind of integration facilitates actionable insights. You don’t know what you don’t know, but if you’ve got a registry of patients that you’re tracking, you know they’ve been referred out. You can easily, one click away, see whether or not they actually followed up and took advantage of those services. That’s really important information and it supports population health management. Are the patients being screened? Are they being referred? Are they taking advantage of those services? And are we seeing improved outcomes as a result?

The integration with Unite Us has been a game changer, accelerated by FHIR interoperability and standardization. Ultimately, Unite Us solutions have helped MEDITECH deliver on its vision for a more connected, person-centered ecosystem where critical data follows the individual, empowers the care team, and allows them to collaborate more effectively.

I think that is so important—being able to follow the data no matter where it is so that you’re able to have the right information in the right place at the right time to take the right action. From your perspective, what makes Unite Us a strong partner to you, and how does the integration reflect on your bigger vision of what might be possible in the future?

Unite Us is such a strong partner because they truly listen and care about how the platform works for us. A good personal example is that sometimes I just can’t figure things out on the platform. Out of frustration, I’ll email my Unite Us representatives, and they always take the time to hop on a quick Zoom meeting to walk through the confusion with me. That’s so helpful and personable.

That makes them such a good partner: the platform truly cares about how the system works for your community.

I’ve got to say, I’m not going to complain about that. I think our team members really do make magic happen for folks at times, and it’s really good to hear that the partnership is strong and that it supports everything from silly gooseness to technology integration.

Yes. To talk about the technology a little, we are really excited about the integration with MEDITECH because it expands the number of our customers that we’re able to provide that streamlined workflow with. And when we start talking about FHIR standards, they’re expanding across the ecosystem.

They started with moving clinical information from place to place, but now also account for things like social needs. For example, if you’re doing a prepare screening, you can share that information between systems as well. The standardization of data and the ability to share it across systems helps follow the person as well.

When we’re talking about this, what role do you see FHIR and other interoperability standards playing in improving how organizations are able to share, track, and act on this information?

Thanks for asking. Now I’m officially going to be using the term silly business—I love that. But to get a little techie: FHIR is the transport methodology, the way that we share data. The standards that have been evolving are also key, like USCDI and CCD, which help codify data and make it meaningful.

This has reached an apex where we can leverage FHIR interoperability standards as well as nomenclature standards to exchange data in a meaningful way. From a social care standpoint, we can share, track, and act on the drivers of health across the broader ecosystem.

Traditionally, clinical data systems and social service platforms operated in silos. This is changing with FHIR and Unite Us. It allows a comprehensive view of the patient across the continuum of care, including community services.

Specifically, FHIR has enabled us to standardize secure real-time data exchange. Within the MEDITECH EHR, we can link out via one click to Unite Us. In the background, the FHIR API brings up a view of the patient and key data like history and pregnancy status, without having to re-identify the patient.

This can happen when you’re referring out, but also later when managing that patient. It’s integrated into clinical workflows, which means care teams can access crucial social needs directly within the EHR for better coordination, fewer duplicate referrals, and holistic care.

Beyond individuals, this interoperability also lets us look at things in aggregate and identify trends. From a health equity standpoint, you can look at populations, identify needs, track referrals and services, and see outcomes. That’s the game changer and ties back to the community health needs assessment.

As FHIR adoption grows across healthcare, we’re going to see more connected person-centered care, and that is a real game changer.

I really appreciate that perspective. You said so many things that I felt like you and I could have been in a meeting together any day of the week this week. But I think what you said about population health is really important.

Some of the power of Unite Us data tied with clinical data is really showing the impact on outcomes and being able to see how many social interventions it takes to improve a patient’s outcomes or to get a patient to a more stable place. Being able to see that in a single longitudinal record or to sort through your patient panel for the day means that you’re always on top of that information.

The codification of that data is important as well. Unite Us has been working with the Gravity Project to ensure it’s represented in USCDI and FHIR API standards, so that as we continue to expand, interventions and outcomes are measured consistently across the ecosystem.

Casey, turning back to you, I know you said that you’ve only existed in a world post-integration, which is fantastic. But as you are an early adopter, are there any initial results or learnings shared from your team in this integrated environment that you’d like other people to know about?

Yeah. Initially when we first went live with the integration, there was hesitation from the clinic because it was new. We had just gotten everyone to learn how to utilize Unite Us alone, and suddenly it was like, hey, we’re actually going to start doing it through MEDITECH now, which is going to be so much more helpful.

So in the beginning, there were little road bumps. But once we got those taken care of, the process became super smooth for resource specialists, social workers, providers—anyone could go into the patient’s chart, click the Unite Us button, and be able to create the profile, send the referral, and do everything needed.

Since the integration took place, we’ve had a lot of positive feedback. People have said that it makes sending referrals so much simpler and less time consuming. When you’re in the clinic with a patient, if sending a referral takes a long time, patients don’t want to sit around and wait. But now with the MEDITECH integration, it’s really just an easy click of the button, and you can send the referral before the patient even walks out the door.

With the process so simple, our referrals on the platform have increased. We have a goal of around 50 to 80 referrals a month, and we’ve been really close to hitting or meeting those goals consistently since the integration.

That’s phenomenal. I love when people can say they’ve hit a goal. I talk about that on my team all the time. I love what you said about before a patient walks out the door. There’s something powerful about having your clinician’s full attention when you’re right there, and the fact that you’re both clear on what next steps are.

I know that from Unite Us, we also send an additional notification to the patient, but it’s great knowing everyone’s on the same page about what’s going to happen next.

From your perspective, what sort of interest or feedback have you heard from your customers who are considering this sort of integration? What brought you to Unite Us to start this discussion, and any early lessons you’re seeing?

I’ve been working for years now in the population health, health equity, and social drivers space. I was introduced to Unite Us many years ago before we were integrated. Unite Us is a game changer and provides a service that is so robust and patient-centered.

If we can get our clients to see the value of that and then bring the integration, that’s huge. There’s been significant interest, even with some of the pullback from reporting requirements on social drivers of health. There’s still huge interest from a population health perspective in interoperability and tying in the community health services piece.

It not only stems from the community health needs assessment, but it ties into value-based care as well. Certain Medicare Advantage and Medicaid plans want you to treat patients holistically, and that goes beyond medical care. Organizations want this, and they want us to help them implement it in a streamlined, efficient way.

In the coming years, I envision this becoming more common out of the gate. We just need to continue to partner and assist health care organizations with planning and execution, using these technology enablers to get them to a more integrated state.

That’s so important to remember—that no matter the administration or reporting requirements, people still have to do their jobs day to day. Systems and programs are already in place, focused on whole person health. It’s important to give folks tools that support those programs and support reporting.

Especially in value-based care arrangements, there are studies showing how impactful it is to support additional needs to drive down costs and improve outcomes. The more data we can provide to support those studies, the better.

So I want to thank you both again for spending so much time with us today. My wrap-up question is always my favorite: what advice do you have for health systems that are just beginning to look at this, or maybe pivoting to population health or incorporating nonmedical drivers of health into care planning? What’s one takeaway you want everyone thinking about from today?

Actually, that’s good because I’m curious what Casey says after me. My experience has been that if an organization is looking at doing this work, they really need to understand and assess what the workflow is, what the roles are, and what the data needs are at different points. Where will the triggers exist?

Casey was talking about primary care, but this also has a role in the emergency department. So who are all my customers, who are the roles relative to identifying social needs? Think in three areas: screening, follow-up, and outcomes.

For screening, who are the roles—community health workers, providers, social workers? What do they need, what is the process, where are the triggers? For follow-up, the same thing. And for outcomes, what kind of data do we need and how are we going to track it?

My advice is that it’s really important to start there. We can’t lose sight of the people and process piece alongside the technology.

You speak so elegantly, I don’t know how I could possibly top that. The advice I’d give to health systems looking to expand their EHR capabilities is that it’s scary at first to take on a new system. But if you’re really in the business of health care, it’s important to look at pieces outside of just going to the doctor.

As we’ve said many times today, there’s so much more to health care than treatment. It’s about transportation, food, housing—things that impact people’s day to day lives.

If your community is invested in providing community support, I think that’s something all hospitals and clinics should pay attention to and think about offering this type of referral system. For a rural community, it’s essential, but I think any community invested in its people will see a big impact.

That might mean something as simple as driving someone to their SNAP appointment or helping them fill out an application for low-income housing. It makes a difference in everyday lives.

I love that. Very diverse perspectives that definitely align. That’s a good reminder about change management: the first time you do anything, it’s scary. But if everyone around you has done it before, it’s a little less scary to get started.

So I want to thank you both for joining us and sharing your perspectives. MEDITECH and Citizens Memorial Hospital are certainly leading the charge in helping providers deliver more connected, community-centered care, and we really appreciate you sharing with us.

I also want to thank everyone watching and who joined us today. If you’re interested in learning more about how Unite Us can integrate with your EHR workflows to connect patients to care in the community, please connect with our team at uniteus.com to continue the conversation.

This is one in a series of fireside chats we’ll be having, so hopefully you’ll stay tuned for next time.