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Care Coordination's Game Plan

A shared health information platform makes for effective teamwork

Professional football coaches spend many hours on offensive, defensive and special- team strategies, wrapped into an overall game plan that accounts for every contingency. Military leaders coordinate battle plans across multiple fronts and forces and consult intelligence to help them deploy resources most effectively. Directors, conductors and choreographers take performers through endless rehearsals to ensure a flawless, coordinated presentation.

Yet the management of care for complex, long-term health conditions is typically delegated to the patient, who is often already overwhelmed by disease challenges. That care is delivered piecemeal by individual providers with limited visibility to one another. The result: inefficiency, poor outcomes, unsustainable costs, and frustrated patients, providers and families.

Today's value-based care model under the Patient Protection and Affordable Care Act is changing that approach. With compensation tied to patient outcomes, primary care physicians and specialists are more motivated to manage care collaboratively, which has been shown to produce positive patient outcomes.

These providers are shifting healthcare from an individual to a team sport; creating a game plan in which everyone is well informed, understands their roles, and can leverage available resources and react quickly to deviations.

This kind of shift isn't easy. It takes vision, tenacity, commitment, and some trial and error. It also takes an underlying IT foundation to bolster plans and the care teams behind them.

Care models from a simpler time

One of the reasons modern collaborative- care models are challenging to adopt is because today's care teams need to be diverse and distributed. "Most electronic health records (EHRs) and computer systems are still designed on a traditional model where there's one user – usually a physician – rather than multiple users and interactions for the same patient," said Qi Li, MD, director of product innovation for InterSystems. The company provides the information engine that powers some of the healthcare industry's most important applications.

Single-user, physician-oriented information systems are inadequate when patients need support from family members, community-service agencies, mental health providers, specialists or home-care nurses. These patients may be in and out of hospitals, nursing or rehab facilities, and outpatient treatment centers. They may need assistance with transportation, housing and finances.

Similarly, care may be directed by specialists in a center of excellence located far away, and delivered locally, or as a telehealth visit. Care team members may include providers, payers, family members and patients themselves.

These distributed care communities make coordination and common care plans both critical and difficult to achieve. Health records are widely scattered, in multiple formats, and in information systems that are not interoperable. And most team members are also members of virtual care teams for other patients. It is simply impractical to assume that every team member can adopt a single common EHR or even care management application from which to manage care.

Team-based care technology

In a distributed care environment, the shared health information platform is the most critical technology enabler to move from a fragmented, individual provider model to a collaborative, team- based care model. That foundational platform makes teamwork possible in a consistent, scalable way by bringing together information from across all care teams and building out care planning across the platform. "Social networking-based collaboration platforms have been adopted widely in many industries; healthcare should be able to do the same," said Li.

Teamwork unites many perspectives to create a comprehensive set of knowledge and skills. The shared health information platform brings together all health information assets for a patient, a patient cohort or an entire community, to create the basis for optimal care decisions. Those assets include treatment and billing records, goals, device data, images, outcomes and preferences, brought together in real time as each new information element is created.

Roles that relate to patients – and one another

In a good performance, roles are clearly defined. It's even more important to know the members of the care team and how they relate to one another: patient, patient's representatives, clinical providers, social care providers, payers, care facilities and care managers. A platform should make it possible to define and manage care team roles, both clinical and non-clinical.

Non-clinical providers are critical in identifying and treating patients who require more intensive care coordination and follow-up care. "Providers need to know what services are available to the patient, but may have limited knowledge to help a patient find those resources," said Li. "After all, what good is a prescription if the patient doesn't have a means of getting to the pharmacy to fulfill it or lacks the financial assistance to pay for it?"

Winning teams understand how to leverage their own strengths and bring in experts where needed. Care managers can apply analytics to their health information assets to identify gaps in care for individuals, at-risk cohorts that would benefit most from interventions and treatment strategies that have been most effective in the past.

"When the health system is already strained for resources," Li said, "the care team needs to carefully allocate its efforts to those patients who are not necessarily the sickest, but the most likely to avoid high costs and unnecessary care."

From extemporaneous to well-executed care plans

Improvisation may work well for jazz musicians but not for a precision-dance company. Care plans fall somewhere in the middle, balancing standards of care with individual needs. A shared care plan developed in the context of a health information platform will reflect the goals of the patient, the composition of the care team, the condition(s) in question, available treatment options and the best scientific evidence. A shared care plan starts with agreed- upon best practices, is populated by the shared record, is co-curated and is available to team members within their workflow.

A shared information platform also facilitates ongoing management by presenting the relevant information to each team member in an appropriate format. For patients, this may be a social media-like portal highlighting self- management opportunities. For care managers, it may be a task-oriented worklist automatically updated as new information becomes available. For behavioral health providers, it may be a notification that a patient has been admitted to emergency care. For population-health managers, it may be a monthly update to a performance management dashboard.

Know when it's time for change or new tactics

Teams are always changing. New treatments emerge, new technologies become available, disease patterns shift. The shared health information platform supports continuous change not only through dynamic, real-time health information sharing, but through technical flexibility to manage new information types, messaging standards, terminologies, workflows and clinical guidelines.

The shift to collaborative care is as transformative to healthcare as any new drug therapy. With a platform design taking cues from social networking and crowdsourcing, we can create a care management process that enables the entire team -- patients, clinicians and care coordinators -- to creatively design new processes and collaborate for better outcomes.

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