Lori Evans Bernstein, President of GSI Health

December 6, 2013

Hospital systems and accountable care organizations are demanding tools to better manage population health.  A major challenge healthcare organizations face is choosing health information technology solutions that place clinical value, care coordination and patient outcomes first.

A traditional health information exchange (HIE) assembles clinical data from a variety of disparate sources and presents it to users. These traditional systems are necessary but not sufficient to support care coordination and population health.  Care Coordination software is essential to realizing the value of health information exchange.  Here’s why:

• Data overload: An HIE summary may contain too much data and, paradoxically, not enough information. There are plenty of relevant details, but the information must be actionable and intelligently organized in order to support clinical programs and workflow among care team partners.
• Lack of meaningful context: A traditional HIE system may not provide the clinical workflow context to the information to appropriately guide the next steps in care coordination. Care teams need this context applied to the information via workflow friendly applications provided by care coordination software.

Care coordination software can make HIE more valuable, giving it more currency to help providers track and manage patients as they move through the delivery system, including: dynamic management of care transitions, care planning, referral management, clinical decision support and medication reconciliation. Here’s how:

1. It applies clinical relevance and workflow context to the information: Care coordination software condenses and reconciles the data from different sources and formats into customized summaries that each provider sets up, presenting the details most relevant to their role as a care manager, primary care physician, specialist and other team members. Behind the scenes, the platform automatically applies logic to the information and feeds it to the relevant applications and users in support of care coordination. For example, a primary care physician is alerted to hospital discharge and can immediately view/update a care plan, manage referrals, reconcile medication list and initiate additional services or communications with other providers.
2. Puts the power in the hands of the user: A care coordination software platform helps manage population health through efficient clinical decision support.  For example, according to established clinical protocols, upon hospital discharge a patient is required to visit the primary care physician within seven days. The care providers would be prompted if the patient has not followed the care instructions. The clinical protocols or care steps operate behind the scenes while the platform watches for any deviation from the protocols.
3. Uses collaborative tools to reconcile information and streamline communication: Care coordination software can increase the efficiency of processes such as medication reconciliation as patients receive care among multiple settings. For example, the care manager can survey the patient’s full medication record in order to create a care coordination summary of medications excluding old information that’s no longer relevant and including new information in real-time providing timely updates. This helps the care team to be able to quickly know the top line issues facing their sickest and most costly patients.  The physician can quickly review the care manager’s actions and click to confirm the medication reconciliation.

Care coordination software is essential to realizing the value of health information exchange. Organizations and delivery systems need data presented in more actionable and more valuable formats through workflow friendly applications to improve care coordination and manage population health to improve patient outcomes.