Beyond Buzzwords: Care Coordination, Operationalization Save Lives

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Terms like population health management, interoperability and care coordination are more than just buzzwords

Many people in the healthcare business tend to toss phrases such as population health management, operationalizing care, interoperability and patient-centered care around like a good game of buzzword catch. But, for me, these words represent something deeply personal.

As healthcare systems gather an ever-increasing amount of patient data to operationalize the continuum of care, that plethora of information remains surprisingly disconnected. Complete care coordination seems like common sense, but it is anything but common in today’s climate of rules, regulations and new requirements. And that too frequently puts patients at risk.

Unfortunately, I experienced such risk up close and personal.

A week before his 70th birthday, my father passed away in large part due to a lack of care coordination. His risk factors were high and his care provider had all his health records and history documented in his chart. Over the course of 15 years, my father had been admitted and treated six times at the same hospital. He was an open heart surgery patient, had multiple coronary artery stents placed 10 years post surgery, and he was diagnosed with cancer eight years before his death.

Then nine years ago, his primary care physician admitted him to the emergency room after finding a lump on his leg. Later that evening, we learned he had Stage 4 non-Hodgkin’s Lymphoma. The coordination care breakdown started with his oncologist who, although equipped with most of my father’s health information, missed one critical piece of the puzzle. Our family later learned the physician never reached out to my father’s interventional cardiologist to better understand his percent of heart function. If he had, they would have learned his left ventricular function was only 45-percent.

Because of this lack of care coordination, the wrong drug cocktail was prescribed to treat his cancer, ultimately resulting in heart failure. He was gone in six weeks.

On a Mission

I made it my mission to do what I could to prevent other families from experiencing this heartbreaking journey.

It made no sense to me that space travel, iPhones and the internet are commonplace, but when I or any of my colleagues went for a routine health appointment or procedure we were asked the same questions over and over and over. How is it that someone can’t figure out a way to connect secure, compliant, accurate data in real time so entire systems can make informed and actionable decisions? Not only to increase patient satisfaction, but to actually save lives.

So when I saw an opportunity with a company developing a cutting edge IT solution moving toward this elusive concept of health interoperability, I jumped at the chance to champion such a product to address this exact industry-wide conundrum: lack of connectivity, complete visibility and actionable data.

Baby Steps for Giant Results

So began this nearly two-year journey to develop a new product that expanded a data solution from merely addressing reduced readmissions and increased patient satisfaction to making data visible along the complete continuum of care, thus operationalizing care coordination and population health management.

CertaInly, EHR technology adoption and compliance certifications around Meaningful Use have been driving improvement for quality, safety, efficiency, and reduced health disparities. I believe these efforts to enhance care coordination are resulting in improved population and public health so that fewer and fewer families will experience what mine did. Yet, while progress has been made over the years, I believe more work is necessary to improve care coordination, so we began taking baby steps toward that lofty goal.

To be fair, enormous demands have been placed on healthcare systems for profitability, efficiency, compliance, safety and overall excellence. However, excellent quality healthcare is inextricably connected to a patient-centered strategy to operationalize care coordination. Our current systems must get back to a root focus on the patient through improved communication and sharing data transparently across all facets of the patient’s health spectrum. The key was finding a user-friendly solution to collect and analyze the right data, and warehouse and share all this data in a compliant way.

A Connected Roadmap

Sharing all of that data sounds like a tall order and the technicalities of exactly how it gets accomplished seem daunting. We must follow patients from their first office visit to hospitalization, to discharge, to outpatient care, to patient-centered medical home (PCMH) care, and even at-home care. Lives depend on it. The rub for patients and providers comes when collecting information becomes cumbersome, time-consuming and inefficient. And everyone doesn’t speak in the same vernacular.

Recent advances portend smoother sailing ahead. Powerful data tools are now available to collect, connect, communicate and share information from inside and outside a hospital’s four walls, directing real-time, actionable health decisions to operationalize across the continuum of care. Optimal tools collect data from the patient’s complete health history and the best solutions can synthesize that data across all platforms and providers. This connected data roadmap then acts as a support and monitoring tool, as well as a yardstick to measure business intelligence goals.

Collect –  and Share – Complete Data to Save Lives

Operationalizing data must be a partnership among systems, practitioners, patients and their families (when appropriate) to ensure that decisions respect the wants, needs, and preferences of patients.

Providers need to do their part to make sure the discharge plan is appropriate for that patient and that they have every significant piece of health data: demographic information, medication, past and present, family health history, personal health history, diet and surgeries, allergies, home and family situation, and cognitive ability.

They must also ask critical questions throughout the discharge process like are they involved in a PCMH or some other type of accountable care organization (ACO)? Is the patient’s health status relative and appropriate to the plan of care? Is the patient actively participating in decisions about their care and treatment options? Are there other symptoms that present themselves post discharge that would cause them to readmitted to the hospital?  Are they filling medications and if not, why not? Is there a language barrier? Are their transportation challenges? And how is the system measuring and monitoring compliance to head off challenges before they become problems and improve care across the entire continuum?

In short, when patients discharge from the hospital, care – and capturing the data – can’t stop.

While typical EMR documentation, fax, image and some voice/phone information now gets captured, tools need to also accommodate less structured data like paper files, face-to-face conversations and web/internet visits from in- and out-patient settings. By synthesizing absolutely all communication into a manageable dashboard, providers and systems get a complete view of patient data across the continuum of care.

I’m certain providers who develop this capacity for interoperable data will consistently report improved trust, compliance and business success across all platforms. Patients will be more satisfied, more enabled, less symptomatic, and have lower readmission rates. And we’ll all be able to share more stories of lowered risk and saved lives.

Jennifer Holmes is a 30-year health IT veteran, president, CEO and board chair of Central Logic, which launched Central Patient Connect in August. This new IT tool gives visibility to data from inside as well as outside a hospital’s four walls, offering a comprehensive patient data dashboard to centralize, see, use and share key data and so systems can make decisions in real time and improve patient care. 

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Jennifer Holmes
Jennifer Holmes

Jennifer Holmes is a 30-year health IT veteran, president, CEO and board chair of Central Logic, which launched Central Patient Connect in August. This new IT tool gives visibility to data from inside as well as outside a hospital’s four walls, offering a comprehensive patient data dashboard to centralize, see, use and share key data and so systems can make decisions in real time and improve patient care.

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