TriHealth-Informatics finalists

The Health Collaborative is pleased to recognize TriHealth’s Ambulatory Care Coordination team as a finalist for the 2017 Informatics Solutions Award. The award will be given as part of the Inspire | Healthcare dinner and awards celebration, planned for November 1 at the Renaissance hotel in downtown Cincinnati. The Informatics Solutions Award recognizes an individual, team, or organization that has applied products from the HealthBridge technology suite – either data services, notification products, or business intelligence – to create an innovative solution to an ongoing challenge.

Inpatient care, out-of-network information
TriHealth’s Ambulatory Care Coordination team was nominated for the award for integrating care management notifications directly into their clinical workflows utilizing Epic electronic health record system software, as well as into their data warehouse for analysis purposes. These notifications happen even when a TriHealth patient arrives at a non-TriHealth hospital. What does this mean, exactly? This service allows TriHealth to stay within the Epic environment for management of these patients, regardless of whether that is real-time action or data analysis efforts. In other words, this gives healthcare professionals peace of mind by granting them access to the medical history of each and every patient, even from out-of-network sources.

Support means success
The Ambulatory Care Coordination department supports TriHealth primary care physician practices. At TriHealth an Emergency Department (ED)/Inpatient (IP) discharge report is run daily for the supported practices. This report contains discharge information from an inpatient, observation, or emergency department visit for the practice panel and provider’s attributed patients. The Health Collaborative’s hb/notify alerts provide visibility for patients who have received care outside of TriHealth facilities, which is invaluable in the management of care for the at-risk population.

Healthcare that genuinely cares
A notification from The Health Collaborative alerts a patient’s Care Coordinator that the patient has had a recent ED/IP admission. These notifications are essential to the TriHealth RN Care Coordinator during their outreach with the appropriate patient or patients. The RN Care Coordinator provides a follow-up call to the inpatient discharges within two business days, and the high-risk emergency discharges within seven days.

Ensuring follow-ups keeps readmissions down
As the RN Care Coordinator completes tasks associated with the admission alerts, they are able to create an encounter within Epic to request the records through Care Everywhere, ensuring timely follow up with patients, and addressing any discharge-related barriers or gaps in care with the patient. In addition, the alert and associated tasks allow the TriHealth Care Team the opportunity to schedule a follow-up appointment with their provider within 14 days. Providing and scheduling a timely office visit after an initial hospitalization decreases an individual’s risk of readmission.

Without the alerts from The Health Collaborative regarding the discharges from outlying facilities, TriHealth Care Coordinators would be unable to ensure a smooth transition from one care setting to the next for the associated patients. TriHealth’s goal is to provide care across the continuum, and with these notifications, TriHealth can provide timely follow up and decrease the likelihood of an adverse outcome.

More about the Informatics Solutions Award
Informatics Solutions Award finalists have been chosen by tech-knowledgeable members of The Health Collaborative’s Informatics team. Nominees must have demonstrated measurable improvements through use of one of The Health Collaborative’s hb/suite of technologies to address patient outcomes, cost savings, and/or work flow efficiency. The award also seeks to recognize the most compelling new ideas for using technology to deliver on the Triple Aim of healthier people, better care, and lower costs. The innovation must measurably improve significant business and/or clinical processes that positively impact health and/or patient care.

Meet the team

  • Beth Berter, Executive Director of Ambulatory Medical Management
  • Mufaddal Frosh, Manager Data Warehouse
  • Tom Hammergren, System Executive Analytics
  • Holli Klepak, Solution Leader Data Warehouse
  • Donna Peters, Director Application Solution Center

The Health Collaborative’s Executive Team, Informatics experts, and staff hope the community will join them in congratulating the TriHealth Ambulatory Care Coordination team for their innovative approach to excellence in care.

About Inspire | Healthcare:
Inspire | Healthcare is the Greater Cincinnati and Northern Kentucky region’s premier annual healthcare event and awards celebration. The awards seek to recognize innovations by individuals, teams, and/or organizations in the areas of informatics, quality improvement, and population health. Other awards given annually include the Inspire Champion Award and the Hoxworth Blood Drive Awards, with separate nomination and judging processes. For more information about Inspire | Healthcare, visit

About The Health Collaborative:
The Health Collaborative strives to lead data-driven improvement initiatives that result in healthier people, better care, and smarter spending. Based in Cincinnati, we work with those who provide care, pay for care, and receive care, to find mutual solutions to healthcare’s most challenging problems. For more information about The Health Collaborative, visit