We had a great conversation with Interop Hero, Matt Bishop, CEO of Open City Labs, where we talked about the role of interoperability to address social determinants of health (SDOH), and the pioneering work his team is doing around that idea.

Open City Labs provides leading technology that connects patients to the full ecosystem of care. This spectrum includes healthcare, human services and government benefits. Their technology also connects providers across that spectrum of services. Matt and his team deliver on this by streamlining closed loop referrals, and automating eligibility enrollment and programs, and government benefits. They discovered that artificial intelligence can help aggregate information about programs so they can recommend specific programs patients are eligible for — or, programs that a patient might have a need for based on a clinical or social needs assessment.

Matt’s approach is focused on bridging the gap across systems with the goal of being able to refer to other systems with other electronic health records.

“Our software also enables clinical and human service providers…[It’s] a care management model while offering functionality to kind of provide a 360 degree view of the patient, so that providers can understand [their] life circumstances — households, family members, [and] things like housing, food insecurity and financial insecurity.”

Matt has an impressive track record of experience in his field, starting his journey with a master’s in public administration at Cornell University. Then, right out of grad school, he went to the Manhattan Psychiatric Center where he was part of a management training program. Matt later moved on to Volunteers of America-Greater New York where he managed close to $100 million in government contracts that funded social services. Each of these positions gave him a front row seat for observing when certain programs worked, when they didn’t and why.

Matt eventually taught himself to code and landed work for a few big firms, like PricewaterhouseCoopers and Hearst Corporation. At the same time, he continued his work in the healthcare space. And that work paid off, as it landed him the title of youngest person appointed to the Governor’s Health Care Reform Advisory Council back in 2007 where he supported the implementation of the Affordable Care Act. It was after all those career stops that he decided to start Open City Labs.

We wanted to learn more about Matt’s perspective on SDOH and why it’s such an important focus area today, specifically.

“The pandemic has revealed stark inequalities in health outcomes. Frontline workers oftentimes are in lower paying jobs where there’s greater risk. But even before that, you could just take a subway ride from the Upper East Side to South Bronx, and then in a few subway stops you could see a difference in life expectancy as great as 15 years in big cities like New York or Chicago. So, health equity is certainly central to what is going on in healthcare today. And then from a purely financial perspective, addressing the social determinants of health in itself is good business.”

Matt goes on to describe just how costly health disparities can be, not only to the patient but the provider a well. We learn that managed care organizations are investing hundreds of millions of dollars for housing homeless patients who are frequent flyers in the emergency room because it’s cheaper to pay their rent than it is to pay one, or two or three emergency room visits.

For example, if a diabetic doesn’t have a place to refrigerate their insulin, they simply can’t store it. As a result, they’re more likely to have a life-threatening situation related to managing their condition that lands them in the emergency room.

Luckily, the Centers for Medicare & Medicaid Services (CMS) has recently started to invest in initiatives that focus on addressing social determinants. Matt shares, for the first time, that Open City Labs will be partnering with Children’s Health Ventures as part of a CMS Innovation Center grant.

One of these initiatives is a kids program focused on integrated care, which is a value-based care model based on improving the quality of care and reducing the cost of care for children under the age of 21. Matt and his company are partnering with Children’s Health Ventures on this program, and leveraging the statewide data of community resources from New Jersey 2-1-1 (the United Way-funded statewide information and referral service provider). Open City Labs is excited to be the official referral eligibility and enrollment software to help these young patients address their clinical and social needs through customized community resources.

This is a big opportunity to potentially address social determinants of health nationwide with these types of models. In 2020, 2-1-1 services across the country received 18.5 million phone calls for non-emergency services and 1.5 million texts. It’s clear by the volume of users that there’s a need for data-driven recommendations to provide the personalized support each person’s needs.

“There are a lot of really exciting resources that, with the right technological infrastructure, you can marry that expertise and really connect healthcare to social care in a big way.”

Matt goes on to shed light on some of the obstacles related to information exchange within SDOH scenarios. In his first example, he explains that standards for this data are not fully mature yet. That said, the Gravity Project has done a lot of really great work in this area. They focus on defining social risk factors, creating available SDOH data for interoperability, and accelerating standards-based information exchange.

Matt has been a member of the Gravity Project since it started in 2018. Many of the recommendations the Gravity Project has made on defining things like food insecurity, housing insecurity, and education needs are based in their research, and have been proven to impact health outcomes. It’s these recommendations that have informed the codes that are now in the United States Core Data for Interoperability (USCDI) version 2, a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.

Moving on to his second example, Matt describes the barrier of not yet having a common secure mechanism for exchanging data. He believes there’s opportunity for Direct Secure Messaging to serve as a mechanism for the transmission of SDOH data.

He emphasizes the large opportunity that lies in future trust frameworks for different intersections of interoperability.

“Not all human services organizations…may have the resources to invest in [Direct messaging] but we still need to provide mechanisms for secure information transmission. By developing and offering these standards, we make it easier for these partnerships to take place. We make it easier for human service providers to find grant opportunities to address the clinical needs and coordinate care with the clinical providers.”

Knowing the obstacles that currently exist, we were curious to know what Matt’s ideal state looks like for information exchange among healthcare, human services and government agency organizations.

He starts by emphasizing the importance of government agencies, describing how many programs that human services agencies are implementing are government-funded. These agencies are helping people enroll in government benefits, like the Supplemental Nutrition Assistance Program (SNAP) or subsidized housing. That said, an ideal state would offer the comprehensive ability to exchange highly standardized data among all these key players to improve care coordination, and streamline referral, eligibility, enrollments, and programs — all while giving patients control of consent to share their data. (Sounds like a perfect world to us, Matt.)

“Imagine [some]where you can see all the places you’ve consented to share your data across your care team and across various entities…Ideally, we need to get [there] by using things like artificial intelligence and machine learning to be able to move between structured and unstructured data. Because it becomes burdensome for providers to be always looking for that right code.”

Matt continues to describe his information exchange nirvana, recognizing an opportunity for organizations to consider how their programs can integrate into the broader ecosystem of care, rather than creating siloes. His vision is that such an integration would allow for information to be sent proactively to people about programs and services they’re eligible for, and let those people use their own data to enroll themselves in those programs and services.

The Child Tax Credit program is an example of this, where people are automatically enrolled in a benefit based on information they’ve already provided to the Internal Revenue Service (IRS). This approach uses a model that leverages existing information, rather than asking people to re-enter the same information multiple times. It’s a model that improves access to programs and services, and can be used in other areas of healthcare interoperability.

Thank you Matt Bishop at Open City Labs for sharing your experience and perspective with us!

Learn more about the Interoperability Hero Initiative and check out our first class of Interoperability Heroes.

This post was contributed by Alyssa Foggia-Hamm.