Care Coordination Happens Outside the EHR Kingdom

Care Coordination Happens Outside the EHR Kingdom

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A brilliant insight into the importance of communication and collaboration in the care continuum, leading to the vision behind Hucu.ai. Take a look at what Asif Khan, our CEO, shared in his LinkedIn post

Over the course of a patient’s life, healthcare is like a relay race, with the baton being passed from one provider to the next.  It might start with primary care and when there is a health-related incident the PCP or GP may ask another caregiver outside of the practice such as a specialist to engage in the patient’s care.  That may then result in the patient’s ‘hand-off’ to a hospital for a procedure, and then back again. Not to mention all of the handoffs within a practice during a typical course of care.

In the world of fee-for-service reimbursement, inefficient hand-offs were not much of a concern.  But in the rapidly evolving world of Value Based Care (VBC) there is an accelerating focus on efficient and effective Care Coordination.  And with CMS expecting 100% of Medicare beneficiaries to be enrolled in VBC programs by 2030, that focus is largely concentrated in the collaboration between hospitals and post-acute care organizations such as skilled-nursing facilities (SNFs), home care agencies, hospice, and palliative care.

When a patient is transferred from a SNF to the hospital, it’s crucial for the hospital to know everything they can about the patient’s condition and care, including what medications they are on, whether the patient’s baseline metrics (i.e. blood pressure, blood work, cognition, etc.) are “normal”  and so forth.  This is also true in the reverse when the patient may be transitioned from the hospital to the SNF, or back to home. Based on this it should not be a surprise that the initial effort to drive more efficient “care coordination” has been and continues to be focused on sharing of data between disparate Electronic Health Records (EHRs) used in each participating organization.  While this is certainly critical, data interoperability may not be enough to result in truly efficient coordination of care.

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The Limits of EHR Data

Having all of the data in one place is a major step forward.  But it is still dependent on two (2) key things if it is to lead to effective care coordination:

  • Accessibility
  • Data Quality, Completeness, and Clarity

The electronic health record in any institution is a highly secure data collection, storage, and reporting apparatus.  Gaining access to the system in most institutions requires a formal and complex process of “Credentialing” of each user.  This might include background checks, verification of professional credentials, and other considerations.  It is, in a sense, a guarded kingdom, only allowing trusted individuals inside its walls.

In the context of care occurring across and between independent organizations, the idea of authenticating staff from one organization into another’s kingdom can be quite problematic.  And in many cases, these ‘barriers’ are becoming more complex in light of the increasing threats of ransomware and other security breaches. This is why many approaches to care coordination are instead aimed at sharing the data (rather than the access) between the disparate EHRs.  Sending a ‘discharge summary’ of key data to the ‘next’ organization in the relay race avoids the need to let that organization’s staff into the prior organization’s EHR. But this introduces the second concern…

Learn more: Accelerate Post-Acute Referrals With Real-Time Care Coordination Technology

The quality and completeness of the data in the Electronic Health Record is a byproduct of many factors, including how timely it is entered into the EHR and then made available to others.  In the fast-paced world of a hospital for example, it’s not uncommon that a patient’s orders, lab results, status, etc. are not fully updated in the EHR prior to the patient’s discharge and transfer.  This means the transport team may not have all of the information, nor might the staff at the SNF or other post-acute setting when the patient arrives.  Furthermore, there may be ambiguities in the data such as when or how the blood pressure was taken (i.e. brachial, auscultatory, etc.), or a medication contra-indication that requires clarification.

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Given these 2 challenges to data integration & interoperability, there is another key element required for efficient care coordinated to ensue; communication.  Regardless of the implemented data sharing or interoperability, there will always be a need for the various participants in the patient’s care to communicate efficiently.  It’s this communication that allows one member of the team to seek clarity on ambiguous or incomplete data available to them.

Quality Care Requires Interpretation and Communication of Data

The world of post-acute care communication is exponentially more complex than within a single institution, as the number of organizations (and therefore staff members) may be vast and varied.  It may include a SNF (with its own EHR) but then the medical providers (MDs and NPs) supporting that SNF are from a separate provider organization (with their own EHR), separate again from the internists at the hospital.  For one patient it might include a diabetes team from a 3rd organization with Registered Dietitians, Endocrinologists, and Diabetes Educators.  For another patient at the same SNF, it might include a Physical Therapist from yet another separate organization.  In the end, the coordination of care is all about making sure this variable and dynamic patient-centered team of caregivers not only have access to the information, but are in fact, coordinating their efforts.  And this requires communication in addition to data integration.

We want to avoid, for example, the Physical Therapist from booking a session with the patient at the same time the physician is rounding.  Or we want to make sure when the physician, who is employed by a Provider Group independent from the hospital and the SNF, changes a prescription that the Dietitian – in yet another independent group – changes the patient’s diet to support the new medication, and that in turn is communicated to the dietary (kitchen) staff in the SNF.  Not all of this information may be readily available in an integrated data set of information shared between disparate EHRs.

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The Future Requires Real Time Access to a Large and Disparate Care Team

This need for almost real-time communication is why providers have answering services or in rare cases give out their personal phone numbers, and various caregivers use things like text or WhatsApp (despite their lack of security or HIPAA compliance).  Email and fax are also used.  And of course there’s the option to use any communication or messaging inherent in the EHR itself.  But again, this runs into issues of pre-defining who ‘the users’ are and authenticating them which requires them to take additional time and effort to login in order to see any such messages.

This is why we built Hucu as a secure, multimodal communication platform. By making it easy to communicate securely and seamlessly, Hucu negates the complexities of authenticating users, and easily & cost-effectively allows a variety of individuals to form each patient’s unique care team.  Hucu was designed specifically for the unique attributes of post-acute care (although it has been applied elsewhere) where not all caregivers are known at any given time, and will change over the course of a patient’s health and wellness journey.  It allows those members of the team to communicate effectively in context about each patient.  Hucu uniquely applies rules and AI to optimize the signal-to-noise ratio of alerts and notifications, so only those members of the team that need to know about a new message, are bothered with it.  And Hucu ultimately complements the interoperable data that is being shared so that those using the data have the ability to fill-in gaps, and add clarity to what that data indicates for quality patient care.

The end results are powerful, over 90% of Hucu users are able to save up to 2 hours per staff per shift. Additionally, 89% users feel more engaged and satisfied with their work because they experience less burnout. Most importantly, in many cases the hospitalizations have dropped significantly.

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