Santa Cruz Health Information Organization to integrate SDOH data


Along with creating a HIPAA-certified master patient index, the universal identity platform will allow SCHIO to integrate social determinants of health into patient records. 

SCHIO participates in a community information exchange, Together We Care, a platform designed to compile data on SDOH and bridge the gap on care coordination in Santa Cruz. 

The information includes housing, homelessness, mental health and substance abuse disorders, transportation, and food insecurity, according to the announcement. Multiple providers can communicate on the community information exchange, including case managers and social services providers. 

With the patient identity management platform, SCHIO can provide safe and more accurate data to the community information exchange. The data can be shared with patients and healthcare organizations across the Santa Cruz area, and the more robust patient records could help improve care.


Shared platforms can improve the integrity of data and the quality and efficiency of HIEs while shared data on underlying social determinants of health, like a lack of transportation, across clinical and social services can help providers act to ensure access for patients they come into contact with. 

Some equity information exchanges can provide access to millions of patient records. 

But to address population health, analytics are needed to activate the data, experts say. With advanced analytics, cohorts of people with common attributes can be identified, and healthcare organizations can then prioritize action based on urgency, severity or cost of the challenges faced by patient groups, according to Sheila Talton, CEO of Gray Matter Analytics, in a recent Q&A with Healthcare IT News.

“Population data analysis helps providers quickly determine which patients should be targeted for outreach and intervention. Maybe analytics has identified several patients who recently missed their annual wellness visits. Providers then can contact these patients to reschedule appointments or provide other meaningful interventions,” Talton had explained.

When Contra Costa Health System embarked on the whole person care approach and integrated all data into its Epic EHR, there were many success stories. But one of the greatest successes was establishing an automated, scalable system for identifying frequent users of multiple clinical and social systems, saving on hours of case management administration.


“SCHIO is a special organization, and they’ve fostered an incredible relationship of trust within their community. They understand that this relationship of trust is founded on accuracy and consistency, especially when it comes to patient data,” said Clay Ritchey, CEO of Verato. 

Andrea Fox is senior editor of Healthcare IT News.

Healthcare IT News is a HIMSS publication.

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