Patient-Centered Care Needs Engaged Communication through Shared Data

Guest post by Jennifer Holmes, chief executive officer, Central Logic.

Jennifer Holmes
Jennifer Holmes

Healthcare systems gather a lot of patient data as care providers, but a surprising lack of coordination too often puts patients at risk.

Tragically, that is exactly what happened to my father nine years ago.  A week before his 70th birthday, he passed away due to the 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.

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 armed with most of my father’s health information, he missed one critical piece to 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. Due to 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.

Finding the Good in the Bad

The good news is that EHR technology adoption and compliance certifications around Meaningful Use is driving improvement for quality, safety, efficiency, and reduced health disparities. I believe these efforts to enhance care coordination will result in improved population and public health so that fewer and fewer families will experience what mine did.

According to the Health and Human Service’s Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine identifies patient centeredness as “a core component of quality health care.”  The agency tracks and analyzes the number of incidences of avoidable hospital-acquired conditions along with adverse events.  While progress has been made over the years, more work is necessary to improve care coordination.

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 care centered strategy. Our current systems must get back to that root focus through improved communication and sharing data transparently across all facets of the patient’s health spectrum. The key is finding user-friendly solutions to collect and analyze the right data, and warehouse and share all this data in a compliant way.

How to Engage – Transparently

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 can depend on it. The rub for patients and providers comes when collecting information becomes cumbersome, time-consuming and inefficient.

Recent tech and software solution advances portend smoother sailing ahead. Powerful tools are now available to collect, connect, communicate and share data from inside and outside a hospital’s four walls, directing real-time, actionable health decisions to improve patient-centered care. Providers realize efficiencies of scale when they use systems and software solutions that aggregate a patient’s total record. 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.

What to Engage – Complete Data for Excellence

Patient-centeredness must then be a partnership among systems, practitioners, patients, and their families (when appropriate) to ensure that decisions respect the wants, needs, and preferences of patients.  Such partnerships ensure patients have the education and support they need to make decisions and participate in their own care.

Providers need to do their part to make sure the discharge plan is appropriate for that patient. 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? How is the system measuring and monitoring compliance?

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

Systems must move toward engaging with absolutely every significant piece of health data. Demographic information. Medication, past and present. Family health history. Personal health history and surgeries. Allergies. Home and family situation. Cognitive ability. Does the patient fill their medications? Are they monitoring their diet?  Are there other symptoms that present themselves post discharge that would cause them to readmitted to the hospital?

While typical EHR documentation, fax, image and some voice/phone information now gets captured, tools need to also reel in 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.

Providers who have this capacity to follow patient data consistently report improved trust and overall patient satisfaction scores, improved compliance across all platforms – including outpatient care and reduced hospital readmission rates. Patients are more satisfied, more enabled, less symptomatic, and have lower referral rates.  In short, improved patient-centeredness produces not only an improved return on investment, but fewer tragic stories of lives that could have been saved.

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