Electronic Health Reporter

Guest post by LeRoy E. Jones, CEO, GSI Health, LLC.

The health IT revolution is here and 2016 will be the year that actionable data brings it full circle.

Opportunities to achieve meaningful use with electronic health records (EHRs) are available and many healthcare organizations have already realized elevated care coordination with healthcare IT. However, improved care coordination is only a small piece of HIT’s full potential to produce a higher level synthesis of information that delivers actionable data to clinicians. As the healthcare industry transitions to a value-based model in which organizations are compensated not for services performed but for keeping patients and populations well, achieving a higher level of operational efficiency is what patient care requires and what executives expect to receive from their EHR investment.

This approach emphasizes outcomes and value rather than procedures and fees, incentivizing providers to improve efficiency by better managing their populations. Garnering actionable insights for frontline clinicians through an evolved EHR framework is the unified responsibility of EHR providers, IT professionals and care coordination managers – and a task that will monopolize HIT in 2016.

The data void in historical EHR concepts
Traditionally, care has been based on the “inside the four walls” EHR, which means insights are derived from limited data, and next steps are determined by what the patient’s problem is today or what they choose to communicate to their caregiver. If outside information is available from clinical and claims data, it is sparse and often inaccessible to the caregiver. This presents an unavoidable need to make clinical information actionable by readily transforming operational and care data that’s housed in care management tools into usable insights for care delivery and improvement. Likewise, when care management tools are armed with indicators of care gaps, they can do a better job at highlighting those patients during the care process, and feeding care activities to analytics appropriately tagged with metadata or other enhanced information to enrich further analysis.

Filling the gaps to achieve actionable data
To deliver actionable data in a clinical context, HIT platform advancements must integrate and analyze data from across the community—including medical, behavioral and social information—to provide the big picture of patient and population health. Further, the operational information about moving a patient through the care process (e.g., outreach, education, arranging a ride, etc.) is vital to tuning care delivery as a holistic system rather than just optimizing the points of care alone. This innovative approach consolidates diverse and fragmented data in a single comprehensive care plan, with meaningful insights that empowers the full spectrum of care, from clinical providers (e.g., physicians, nurses, behavioral health professionals, staff) to non-clinical providers (e.g., care managers, case managers, social workers), to patients and their caregivers.

Armed with granular patient and population insights that span the continuum, care teams are able to proactively address gaps in patient care, allocate scarce resources, and strategically identify at-risk patients in time for cost-effective interventions. This transition also requires altering the way underlying data concepts are represented by elevating EHR infrastructures and technical standards to accommodate a high-level synthesis of information.

Fostering feedback-loops with complimentary frameworks
Analytics and care management will become mutually reinforcing in ways that foster closed-loop feedback. HIT and care coordination leaders will transition their focus to interdependent and complimentary care frameworks. This structure is emerging in next-generation population-health management systems that focus on “whole person” and “whole population” care through efficient communication and information sharing, workflow within interdisciplinary care teams, robust analytics that stratify the population and identify gaps in care, and real-time reporting on outcomes and operations. These innovations move beyond retroactive reporting to goal-directed and action-oriented predictive capabilities. Stakeholders of leading healthcare organizations must be willing to realize the value in big- and little-data and embrace fundamental shifts to existing care paradigms to achieve their clinical and financial goals.

In 2016 and beyond, leading HIT companies will drive progress toward forging technology bridges between care coordination and analytics that empowers caregivers, reduces risk, and improves overall population health.