HLTH 6443 Module 1 Public Health Information System Analysis Example

Did the Family Ever Get the Food? Analyzing a County's Closed-Loop Community Referral Platform With the Sociotechnical Model

Student Name

American College of Education

HLTH6443: Systems, Policy, and Leadership in Health Informatics

Module 1 Assignment

Instructor Name

June 1, 2026

Introduction

For years, the health department in a composite county of about 180,000 people in western Michigan referred families to food pantries, housing programs and utility assistance by handing them a printed list. Staff rarely learned whether a family called, whether the agency had room or whether the need was met. Eighteen months ago, the department became the lead agency for a closed-loop community referral platform, a web-based system in which clinics, school nurses, the health department and community agencies send referrals electronically, accept or decline them and record whether services were provided. The system now has 64 participating agencies. As the department's health education and informatics lead, I was asked to analyze how the platform works, what it does well and where it falls short. This paper uses Sittig and Singh's (2010) sociotechnical model to organize that analysis.

The System and Its Purpose

The platform's purpose is to turn referrals for social needs into completed connections and to give the county data on unmet needs. Its core functions match those found across the market. A review of nine referral platforms and interviews with representatives of 35 early-adopter health care organizations found that nearly all offered screening for social risks, a resource directory, referral management, care coordination, privacy protection, systems integration, and reporting and analytics, and that early adopters struggled most with engaging community partners, managing internal change and complying with privacy rules (Cartier et al., 2020). The county's platform includes all seven functions, though integration with clinical records is limited.

Why a Sociotechnical Model

Information systems in health rarely succeed or fail on technology alone. Sittig and Singh (2010) proposed eight interacting dimensions for studying health information technology: the hardware and software that run a system; its clinical content; the user interface; the staff and volunteers involved; workflow and the way messages pass between people; internal organizational policies, procedures and culture; external rules, regulations and pressures; and system measurement and monitoring. The model was built for clinical systems, but its dimensions apply well to a platform shared by agencies with very different missions and capacities. Using all eight dimensions keeps the analysis from treating a social problem, such as an overloaded food pantry, as a software problem.

Infrastructure and Content

The platform is a cloud-hosted service licensed by the health department, accessed through a browser on any device. Agencies need no special hardware, which matters for small organizations with old computers. The content consists of a resource directory of about 900 programs, a screening questionnaire covering food, housing, utilities, transportation, child care and interpersonal safety, and structured referral records with status codes: sent, accepted, declined, services provided, unable to contact and closed. The directory is maintained by a part-time resource specialist, and about a fifth of entries were found out of date in a spring review, a common weakness in such directories.

Interface and People

Clinic and school users find the interface straightforward; a referral takes about three minutes once a family has consented. Agency staff find it harder, because they must log in to a separate system, check an inbox and update each referral's status, adding work that is not part of their own case management software. The people involved range from nurses and community health workers to volunteers at small pantries. Their digital skills vary widely, and turnover at agencies means that trained users leave often. Families themselves do not log in; they receive text messages when a referral is sent and when an agency accepts it.

Workflow and Communication

The intended workflow runs from screening to consent, referral, agency acceptance, contact with the family, service and closure. In practice, the loop often breaks after acceptance. In the platform's first year, 4,812 referrals were sent. Of these, 78% were accepted or declined within three business days, but only 41% reached a final status showing that services were provided, and 29% remained open after 30 days with no update. Interviews with agency staff suggested that many families were helped but never recorded as helped, because updating the platform competed with serving the next person in line.

Organizational and External Factors

Inside the health department, leadership support is strong, but responsibility is split: the informatics lead manages the platform, program staff send referrals and no one owns agency engagement. Participating agencies have signed a network agreement, but its expectations for response times and status updates are not enforced. Externally, the platform must satisfy several sets of rules: HIPAA applies to clinics and the health department's clinical programs, while many community agencies are not covered entities; school nurses work under education privacy law; and domestic violence programs and substance use treatment programs have their own confidentiality requirements. Funding comes from a two-year grant, which creates pressure to show results quickly.

Measurement and Monitoring

The platform generates reports on referrals by need, agency and status, and a dashboard shows response times. Its data are only as good as agencies' updates, so the 41% closure rate may understate success. The county has not yet linked referral outcomes to any health measure. Evidence that such links are worth pursuing exists: in a trial at two safety-net pediatric settings with 1,809 families, caregivers who received in-person navigation to services reported a greater reduction in social needs at four months than those given written information, along with greater improvement in their child's health (Gottlieb et al., 2016). The county's platform could eventually support similar evaluation, but only if closure data become reliable.

Equity in the Platform's Reach

An analysis of a public health system should also ask who it reaches and who it misses. Screening happens mainly at the health department's clinics, two federally qualified health center sites and the schools with nurses, so families who use none of these services rarely enter the platform. The screening form and text messages are available in English and Spanish, but not yet in Arabic or Swahili, languages spoken by refugee families resettled in the county in recent years. Families without a working phone cannot receive status updates. Agencies in the county's rural townships joined later and in smaller numbers than those in the city, so a rural family's referral is more likely to go to an agency thirty miles away. The data can show some of these gaps, since referrals are recorded by ZIP code and language, and the county should examine them before expanding.

Strengths and Weaknesses

The platform's strengths are its breadth, 64 agencies in 18 months; its ease for referring staff; its text updates to families; and its data on need, which have already shown that housing referrals are declined far more often than any other type, mostly for lack of capacity. Its weaknesses are the broken loop after acceptance, an outdated share of the directory, the burden on agencies, the lack of integration with clinic records and unclear governance of privacy across very different organizations.

Priorities for the Course

The analysis sets the agenda for the remaining modules. Module 2 will examine the policy and compliance requirements, especially consent and the different rules that apply to different participants. Module 3 will develop a training plan aimed at agency staff, where the loop breaks. Module 4 will write protocols for data use and security. Module 5 will evaluate interoperability, since double entry is a main reason agencies do not update. Module 6 will set out a leadership plan for the platform's second phase.

Conclusion

The county's referral platform has succeeded in bringing agencies onto one system and making referrals easy to send. It has not yet succeeded in its central purpose, closing the loop so the county knows whether families received help. The sociotechnical analysis shows that the reasons are mostly human, organizational and regulatory rather than technical, which is where the rest of this course will focus.

References

Cartier, Y., Fichtenberg, C., & Gottlieb, L. M. (2020). Implementing community resource referral technology: Facilitators and barriers described by early adopters. Health Affairs, 39(4), 662-669. https://doi.org/10.1377/hlthaff.2019.01588

Gottlieb, L. M., Hessler, D., Long, D., Laves, E., Burns, A. R., Amaya, A., Sweeney, P., Schudel, C., & Adler, N. E. (2016). Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatrics, 170(11), Article e162521. https://doi.org/10.1001/jamapediatrics.2016.2521

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085