Care coordination in today's healthcare landscape — Opportunities and challenges

Today's health systems are complicated organisms. Clinicians, staff and leaders must manage numerous services ranging from care coordination for patients throughout their healthcare journeys to medication reconciliation and adherence, telemedicine and more. To succeed in this dynamic environment, data and system integration are required.

At Becker's 5th Annual Health IT + Revenue Cycle Conference in Chicago, DrFirst sponsored an executive roundtable to uncover what the "new normal" really looks like for healthcare systems. Linda Fischer, DrFirst's vice president of product strategy, facilitated the discussion.

As the number of healthcare players grow, care coordination becomes more challenging

Although EMRs and other technology platforms have gained a foothold in health systems, faxes are still used to coordinate care across the continuum of providers. Healthcare organizations usually turn to faxes due to a lack of technology interoperability. Providers have many different levels of technology maturity. As one RN based in the South noted, "Our technology can't always talk to theirs. We can't meet in the middle, so we have to communicate by fax."

A governor in the South recently approved a state notification law which requires hospitals to communicate admissions information to patients' primary care physicians. In response, one system has established relationships with community providers who have direct secure messaging. It has also created data interfaces with community physicians to share information electronically. The state, however, sees a huge influx of seasonal residents in the winter. "A patient's PCP may be in Alaska or New York. We have no knowledge of how to communicate with those providers," said the chief health information officer of a health system in the state.

A former chief medical informatics officer and immersion medicine physician observed, "Communication has gotten easier because we know what to communicate, but it's also gotten harder because there are more players."

Health information exchanges have abundant data, but do providers trust it?

Many physicians don't trust the data provided by health information exchanges, so they refuse to read it. Part of their reluctance may stem from concerns about liability. The CMIO of an integrated health network in the Midwest said, "Data flows in on allergies, medications and more. Do I have to reconcile all this data? If I didn't pay attention to every piece of information and something happens to a patient, will a lawyer go after me?"

A participant from an electronic health information exchange on the East Coast offered his perspective, "People want the right data at the right place and the right time. The problem is that this is different for every physician and specialty. It's a struggle to identify how best to present the information." This HIE has developed a general data presentation that satisfies 80 perecent of the provider population and also offers data customization tools. Most physicians, however, don't take advantage of these.

According to the HIE representative, the big things providers want are care summary documentations from PCPs, as well as records for every office visit and graphs of blood pressure over time.

Not surprisingly, data quality is a hot topic. One participant observed, "The number one tool we need for reconciliation is a deduplication tool. We get all this data coming in and there's no way to clean it up. The tools we have in the EMR for reconciliation aren't easy to use."

HIEs also struggle with issues of data quality. The attendee from the HIE said, "One of our largest health systems wants us to give them all the [continuity of care documents] on an ongoing basis and they want us to improve the data quality, but some of the biggest data quality problems are coming from them. We still feel like we are making a difference for treatments and outcomes with our data."

For complex patients, some providers are investing in programs to promote medication adherence

There are many reasons why patients don't take their medications as prescribed. Some can't afford their drugs, while others don't understand why they need certain medications. Social determinants of health are also getting more attention from physicians. The CMIO from the Midwest said, "Some EMRs are adding geospatial locations to patient records so doctors can see whether individuals have access to transportation, a pharmacy and a good grocery store. In reality, food is a form of medication."

For complex patients, one hospital has its pharmacy call within 24 hours after discharge to review their medication list and to confirm they received their prescriptions. Some providers use case managers to encourage patients to take their prescriptions. This labor-intensive approach can't be used for every patient, however. Providers need tools to isolate the patient populations that will generate a positive return on care management investments.

Telemedicine is a promising way to expand access to care

Telemedicine is gaining traction at a variety of healthcare providers. One attendee works at a hospital that launched a telemedicine program in August for urgent care patients. The goal is to reduce traffic to the emergency department. Some ICUs are also using telemedicine so intensivists don't need to be on staff 24/7.

Other organizations are exploring telehealth to connect people in the ED to behavioral health specialists. This is particularly valuable in rural areas. A participant used to work at a rural "micro hospital" which served low acuity cases. He explained, "The hospitalists would conduct a video consultation to determine if a patient needed to be placed on observation or admitted. It cost $45 and someone didn’t have to fly in."

Since telemedicine is a fairly new mode of treatment, some organizations haven't yet integrated telehealth information with their EHR, which affects the integrity of the medical record.

Information security is a concern for many health systems

The Office of the National Coordinator for Health Information recently introduced new interoperability rules that could lead to health information sharing without safeguards. These rules suggest that anyone can access application programming interfaces for systems like EMRs and hospital administrators won't have control over who gets the information. The College of Healthcare Information Management Executives is fighting these rules.

One participant shared his concerns. "Who is liable if data is hacked once it leaves my organization and is in transit? My fear with this ONC rule is that we don't know who controls the data when it's in flight."

Conclusion

Change in healthcare requires visibility into what is happening across the continuum of care and making improvements. The immersion medicine physician said, "Healthcare has to be agile. It has to be immediate, inexpensive, efficient and easy. We need to get to the point where you can automate knowledge transfer about care at discharge." 

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