Electronic Health Reporter

Guest post by Mark Hefner, CEO, Infina Connect Healthcare Systems.

Various forms of payment reform are in play throughout US healthcare today, and with good reason as we search for the right combination of incentives, alignment and engagement that produce systemically better health outcomes at lower overall cost.

As an example, providers are paying much more attention to the small percentage of patients with the highest costs, including patients with chronic conditions. As a result, they are identifying these patients, establishing care plans and engaging care coordinators and patients to improve outcomes. Less attention, however, is being focused on the powerful capability to better connect, communicate and coordinate care among the multiple providers that care for a patient. This caliber of care coordination has the potential to improve outcomes across the entire patient population and is rooted in results that suggest a coordinated network of providers, each capable of high quality and cost effective care, with appropriate information about the patient available to them, can deliver improved outcomes across large patient populations.

Patient populations may be systemically managed under various forms of accountable care, commercial shared savings, Medicare Advantage and full risk – or managed by episodes of care, bundled payments, etc. The shift from fee-for-service to “fee-for-value” incentivizes preventive care, best practice care, and high-value delivery of care and it puts a premium on the ability to coordinate care.

Therein lies a very significant challenge: The collective group of providers that interact with a large patient population are invariably part of different organizations, with different technology platforms or no platform at all and are dependent upon fax machines, phones, and paper to exchange documents and communicate. The provider groups also possess differing incentives: the “at-risk” provider attempts to influence improved health and financial outcomes while other providers may still be receiving fee-for-service payments.

Reconciling these challenges and harnessing the power of care coordination is now possible via referral coordination. One of the most powerful mechanisms for coordinating care are the hundreds of thousands of patient referrals made every day between various providers, with Primary Care Providers (PCP) being the largest initiator of consulting and diagnostic referrals on behalf of their patients. Providers need to communicate with each other when they are treating the same patient, and these patient transitions between providers represent a significant opportunity to realize high value care.

The referral itself is equivalent to a PCP or patient making a decision on which provider to “hire” to provide the needed care. This referral decision and the coordination of the referral are critical to the delivery of better health at lower cost, but improving the overall referral process requires key elements to be implemented consistently:

• Guide patient referrals to appropriate, high-value, accessible providers who are committed to coordinating care with each other;
• Ensure the referral is appropriate for the patient and relevant prerequisites (e.g. lab tests or screening) are in place;
• Communicate relevant clinical information and the reason for referral to all referral recipients who provide care to the patient population;
• Make sure that referral status is coordinated between providers and that referrals are not overlooked;
• Facilitate secure communications between providers regarding any questions that arise;
• Enable new forms of referrals including provider-to-provider e-consult and telehealth; and
• Ensure that the referral recipient provides relevant information about the patient visit back to the referring provider in order to “close the loop” and complete the referral cycle

As we define what we need to achieve in this transition of care, it becomes clear that new tools are necessary. Very few complete continuums of care will be within a single organization and HIE connectivity is not broad enough nor is it supportive of referral management functionality.

Additionally, keeping up with all the health plans, provider networks and managed populations within just one practice is becoming very complex. Also, as more patients experience high-deductible health plans their intense interest in the cost of healthcare (incurred personally) means providers must be prepared to partner with them to guide them to high value care.

Fortunately, a new generation of referral management solutions is presently being deployed to address these challenges and opportunities. Typically cloud-based for universal access by all providers and care team members, they accommodate the exchange of clinical documents and other relevant information about the patient and the referral. Some solutions have progressed to the point of coordinating “closed loop” referrals across the continuum of care providers, and are better described as referral coordination solutions. What’s more, the immediate potential of such systems to enable high-value, coordinated care is now being recognized.

As the shift to fee-for-value continues, increasingly more organizations are recognizing that referral management and care coordination are crucial for their success. Accordingly, referral coordination is quickly emerging as a highly effective means to achieving and optimizing coordinated care. Further, the proven potential of such solutions to produce rapid, significant results is sure to spur broader application and thus, extraordinary progress in the mission to achieve improved care and better outcomes at lower overall cost.