Health IT

Healthcare needs to adopt the Care Coordination Record

Care Coordination Records have the power to connect these elements in a cloud-based, mobile-friendly platform.

A Care Coordination Record bridges the gap between an in-person visit and everything else that needs to happen across the care continuum and in-between visits. It’s all about managing complexity.

For most families, the beginning of September means a new school year. As a father of six children spanning three different schools – elementary, middle and high school – the prep and coordination for the first day of school is no small job. In fact, it’s overwhelming. Fortunately, this isn’t our first rodeo as parents and there are practices and tools that have been put in place to facilitate these transitions and define the plan:

  • Technology: online, web- and app-based tools for communication.
  • Course Teaching Team: accessible teaching teams and course material plans.
  • Teaching Plan: semester schedule including weekly homework plans, test dates, and tasks that comprise the require coursework.
  • Communication: contact information (phone, email, and study hours) for each teacher to facilitate parent/teacher communication and provide multiple channels for discussion.
  • Real-Time Updates: progress reports to share student performance as well as distribute any changes or adjustments to teaching plans.

My wife and I are critical team members who help drive the teaching plans for our kids. After all, most of the work happens at our kitchen table – away from school and the structure of the classroom. Being able to engage the teams of professionals working with our kids around the various teaching plans and course activities is powerful, as is having defined channels for communicating changes and updates.

In my professional life working to provide solutions to manage complex patient care, I’ve seen how many of these same components and themes are critical for successful care management.

Just as the majority of education happens outside the classroom, a majority of care happens when the patient isn’t in front of the doctor.

We hear from healthcare providers and support staff that there just isn’t enough capacity to manage everything coming at them each day. Think about your last appointment with your PCP. If it was anything like the average, it was about 15 minutes long. This isn’t your PCP’s fault; the system was set up to incentivize your provider to see as many patients as possible. After your office visit is over, there is often significant communication and activity that still needs to happen with you, the patient, your caregiver, and any community resources required to support you through care. This between-visit workload is more time consuming and resource-intensive than your actual office visit. We have a lot of sympathy for provider teams struggling to manage and execute this volume of work.

Patients with complex needs endure a special version of this mania as they attempt to coordinate their care between multiple providers and care settings. For many patients, the sheer volume of information, appointments and self-care tasks to manage is daunting enough; for high-needs patients, the challenge often includes behavioral, social and functional needs which amplify the complexity. Ultimately, our success in reducing costs and improving outcomes hinges on our ability to improve communication and care coordination for the most complex patients.

To succeed, we need a better tool – the Care Coordination Record.

We know that an Electronic Medical Record guides a physician through an
encounter with a patient and facilitates the required documentation to bill appropriately for the visit. These are essential tasks for any healthcare practice, yet they don’t actively support true care coordination.

A Care Coordination Record bridges the gap between an in-person visit (as recorded in the Electronic Medical Record) and everything else that needs to happen across the care continuum and in-between visits. Care Coordination Records are distinct from EMR-based summary care records, continuity of care documents, and continuity of care records, which are temporary snapshots of patient data in the EMR.

What comprises the Care Coordination Record?

  • Team: list or map of everyone involved in the care of the patient, including patients and their family members, clinicians and their support staff, behavioral/mental health professionals, occupational and social services, community supports and the payer’s support staff if available.
  • Plan: a single, comprehensive, up-to-date Care Plan reflecting patient priorities
  • Activities: defined tasks associated with the coordination of care – clear roles and responsibilities, reliable hand-offs, and documentation of completed tasks.
  • Communications: mechanisms for tracking care team communications with all team members, internal and external.

Care Coordination Records have the power to connect these elements in a cloud-based, mobile-friendly platform. All members of a care team, including external providers, community supports, and family caregivers, can use Care Coordination Records to engage in collaborative care planning, efficiently manage in-between visit care, and make safe, reliable handoffs across the care continuum.

With this tool, everyone knows who’s on the team, who is responsible for each activity associated with the shared care plan, and the real-time state of play. The parallel here is the project management platforms used in education and other industries to replace phones, faxes, emails, spreadsheets and sticky notes. Multi-step processes, such as care transitions and referrals, can be readily assigned and managed, while real-time communications and analytics monitor the cross-continuum care process and care team interactions.

A new quest for efficiency is driving Care Coordination Record adoption.

In his August 19 blog post, John Halamka, MD, CIO at Beth Israel Deaconess Medical Center, wrote that his IT group is focused on “projects that could be innovative breakthroughs” for clinical efficiency in FY16. After years of responding to Meaningful Use, quality measures, and population health needs, they will seek to replace “human work with a next generation of technology and workflow.” Beth Israel Deaconess Medical Center’s experience is not unique. At UPMC in Pittsburgh, PA, Rasu Shrestha, MD, Chief Innovation Officer, shared, “The systems that we have today are not geared toward clinical efficiency”.

The problem is exacerbated by the fact that close to 90 percent of a physician’s work with patients is conducted in the informal region outside of the EMR. Though that number is self-reported by physicians, Kent Gale at industry research group KLAS suggests it is accurate and “it’s going to get bigger.” With performance-based contracts becoming the new norm, providers are on the hook to coordinate care and need better tools beyond the EMR to do so. All signs point to the Care Coordination Record as the dominant HIT innovation in years to come.

DISCLOSURE: John Halamka, MD, is on my company’s Board of Advisors.

Photo: BigStock Photo


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Ted Quinn

Ted Quinn is the CEO and Co-founder of ACT.md, a digital health company helping everybody engaged in the healthcare system - clinicians, patients, families, and communities - act together to make health happen, wherever they are.

ACT.md’s Care Coordination Record(TM) promises a better, safer, less expensive, and more flexible approach to managing healthcare’s complex tasks and achieving your organization’s goals. Headquartered in Boston, Mass., ACT.md is privately held and venture funded by the disruptive innovation investment firm, Rose Park Advisors. Learn more at http://www.act.md.

Ted has 20 years of experience leading healthcare IT and technology companies. Prior to ACT.md, Ted served as COO of Vecna Medical, driving revenue growth and new market penetration. Before Vecna, Ted served as President & General Manager of a Taylor Corporation Company, as a Business Manager and Product Manager for the FLEX platform at Teradyne Corporation, and as a management consultant at Accenture.

Ted holds a BS in Economics from Brigham Young University, an MBA from the Harvard Business School, and an unflinching loyalty to the Boston Red Sox.

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