Community wide, coordinated care delivery is a foundational element of a successful transition to value-based payment models. The future success, in fact the future viability, of all healthcare organizations depends on it. Unfortunately, vendors have not made it easy. With few exceptions, the billions of dollars spent on electronic health records (EHR’s) and health information exchanges (HIE’s) have yet to deliver the clinical integration and collaboration necessary across the continuum of care.
The ability to share information is fundamental to better coordination and improved outcomes. Today, information is often unavailable at the point of care, and when it is shared the primary mechanisms, fax and phone, are highly inefficient and unreliable. In order to address this problem, the primary focus in terms of development and ongoing investment by healthcare organizations has been on interoperability. There are several ways that interoperability is currently being tackled, but for the most part they fall into one of three buckets, each of which has its own challenges. At the highest level though, it is interesting to note that all three strategies emphasize point-to-point connections and data exchange, rather than addressing the fundamental issue of community-wide coordination.
The first strategy, primarily being deployed by large health systems, is to get their hospitals, employed physicians and some community physicians onto their common electronic health record (EHR). The theory of course being that if everyone is on the same system, everyone has all the available information on the patient. Unfortunately, even the largest health systems in the country can only cover a fraction of the providers and venues across the continuum of care. For example, very few health systems are able to cover all types of providers with employed physicians including home health and skilled nursing. Inevitably, the care of the patient ends up outside of the four walls of the system and care coordination breaks down, as does the ability of the primary care provider to maintain visibility and control over the quality and cost of that patient’s care.
Absent a common EHR, many states and organizations nationwide have invested in the development of HIE’s. In addition to data exchange many have focused on creating longitudinal patient records that can be queried on demand. Efforts to achieve adoption have been plagued with challenges such as high cost, lengthy implementations, patient matching, lack of data sharing, governance challenges, and security concerns. HIE’s that have succeeded in overcoming these inherent barriers have typically experienced low usage. Poor usability and cost are often cited as key reasons that HIE’s are not being utilized as envisioned. Users often complain about the complexity to login, the number of clicks it takes to get to the right patient, and the amount of time between clicks. Additionally, if we step back and think pragmatically about the reasons why patient information is exchanged and coordination is necessary in the first place, the workflow challenges may be the bigger reason for low utilization. The need for information almost always starts with a referral or patient visit. When a second provider, like a specialist or other venue of care is engaged in the care of a patient, that provider requires specific, contextually relevant information on the patient in order to provide high quality, efficient care. In the real world of patient care, sorting through fifty or more pages of a longitudinal patient record to pull out what is contextually relevant for today’s visit often isn’t practical. In addition to being time consuming, there is a risk that something important buried within will be missed. The combination of adoption, usability and workflow challenges has kept many HIE’s on the brink of economic viability.
The third area of innovation around interoperability is Direct messaging, which appears to offer the most promise for broad adoption. Since the policy variance issue was resolved several years ago, Direct messaging adoption has accelerated tremendously. The biggest challenge with Direct messaging is that most healthcare providers don’t understand what it is, what it isn’t, and how to use it. Direct messaging is to healthcare what TCP/IP networking is to the internet. It is a transport mechanism, not an application or workflow. However when Direct messaging is used as a transport mechanism within an application, the combination can help bridge both the interoperability and the coordination gap. For example, Infina Connect’s referral coordination system, Intelligent Care Coordinator (ICC), leverages Direct messaging as the underlying transport mechanism. As a result, ICC is able to cost effectively provide interoperability across disparate EHR’s for the management of patient referrals, and coordinate patient care during the referral process without expensive integrations and interfaces.
Dr. Laura Patel, Chief Medical Officer at Transitions Lifecare, recently shared an interesting perspective on this topic with me. Transitions Lifecare is a non-profit 501(c)(3) that provides a variety of services including Home Health, Palliative Care, and Hospice Care to individuals and families in the Raleigh, NC area. According to Dr. Patel, “Providing comprehensive care for our patients requires consistent information exchange and coordination with other caregivers across the community. With Direct messaging through ICC, Transitions is able to share clinical information and process referrals in an efficient way so that our patients can receive our care as quickly as possible. We can provide the best possible experience for patients and families by coordinating more effectively with the entire care team.”
While we tend to think of primary care as the quarterback for coordinating care, Dr. Patel’s comments remind us that just like when a quarterback hands the football off to a running back, the provider who is caring for the patient at the time makes decisions that have long term impact on patient experience, outcomes, and resource utilization. Coordination between providers helps them work better as a team on behalf of the patient.
If we are to successfully replace fax and phone as the primary communication mechanisms between providers and care settings, we need solutions that add real value, are affordable, easy to implement, and easy to use. In competitive markets, it’s highly unlikely that any healthcare organization will be able to deliver the level of community-wide, coordinated care necessary to establish market leadership with a common EHR alone. Similarly, the inherent challenges associated with HIE’s make community-wide adoption unlikely. When embedded within an application with consistent workflow, Direct messaging appears to have the greatest potential to ensure coordinated care delivery, community-wide, without breaking the bank. I believe we will continue to see tremendous innovation around Direct messaging, and that it will emerge as the most successful, cost effective strategy for solving this pressing issue.