The move toward value-based care involves hospitals tackling community health issues to provide more tailor-made care for patients, and a new collaborative partnership between six East Bay-area hospitals is meeting the needs of its most underserved residents.

The partnership is one of a first of its kind in northern California, using a secure-data sharing platform to share patient health records across participating hospitals in real-time. That means more personalized and cost-effective care for patients whose point of access is often the emergency department.

The six partner hospitals in the collaborative are: Alta Bates Summit Medical Center (Oakland), Alta Bates Summit Medical Center (Berkeley), Sutter Delta Medical Center, Eden Medical Center, Highland Hospital and San Leandro Hospital.

“We’re trying to use technology and available information to make it so no matter what door a patient walks through in Alameda County, we’re all on the same page when it comes to their care plan and information about what support services they need in the community,”says Jim Hickman, CEO of Better Health East Bay, Sutter Health’s philanthropic foundation partner in the East Bay.

Early data collected from the first 60 days online at Alta Bates Summit Medical Center's two campuses registered 16,119 individual patients, nearly 2,000 of which had also been to Highland Hospital since it came online April 29. And of those 16,119 patients, a whopping 4,191 had three or more visits to the ED in the previous 12 months. Of those 2,000 shared patients, 1,448 had three or more visits to the ED in the prior 12 months.

The data, which is maintained on a platform called PreManage ED, will boost the ability to provide coordinated care to patients who frequent the ED, such as one patient who, according to the collaborative, has visited ED’s throughout Oakland 900 times in the past three years.

“This integrates with the electronic health records system of each hospital and extracts information that helps us understand the historical health care utilization patterns of a patient. Push notifications are sent into the pathway of clinical physicians, nurses case managers and health providers to let them know who stepped foot into their hospital,” says Chris Klomp, CEO of Collective Medical Technologies, the makers of PreManage ED.

“This is changing the way we’re looking at how to design care planning. People are self-organizing around patients — which is really the great promise of health IT, to organize around patients,” adds Hickman.