5 stages of maturity in care coordination and patient collaboration regarding health information exchanges w/ John Smith, Director of Communications at ICA
Care coordination is rapidly becoming the watch-word for improving outcomes and reducing costs. One in four Americans has multiple chronic conditions that require coordinated care in order for care to be effective. That number increases to 66% for patients over 65, a growing segment of the population as baby boomers reach maturity. According to a new report issued by the Centers for Medicare and Medicaid Services (CMS), Medicare beneficiaries with multiple chronic conditions account for 93% of Medicare fee-for-service expenditures. These patients usually receive care from multiple physicians. A failure to coordinate care can often lead to patients not getting the care they need, receiving duplicate care or being at increased risk of medical errors. Each year, one in seven Medicare patients admitted to a hospital have been subject to a harmful medical mistake in the course of their care. And, nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – a readmission many patients could have avoided if their care outside of the hospital had been aggressive and better coordinated. Improving coordination and communication among physicians, other providers and suppliers will help improve the care Medicare beneficiaries receive, while also helping lower costs.[1]
As patient populations age and become more mobile and geographically far-flung, informal care coordination will become almost impossible, without some IT-based care coordination solution. The National eHealth Collaborative polled their membership in February of this year and 73% of its members said that care coordination was the single highest benefit of health information exchange.[2]
Fortunately, health information technology has been rapidly advancing toward integrating, aggregating and communicating clinical information, becoming both more robust and supple at the same time. The ability to transfer, or communicate, clinical information across multiple care settings, whether in an integrated delivery network (IDN) or across a community, is now available through interoperability platforms which enable health information exchange (HIE). These HIEs provide a framework for the secure exchange of medical data stored in a patient’s electronic medical record (EMR) between their team members. Consequently, the wide spread adoption of EMRs is critical as inputs for the exchange of clinical information that HIE provides.
The Five Stages
As the evolution of care coordination continues, stages of maturation have been identified to help providers and vendors get organized around this important theme in care delivery. The model was developed by Shahid Shah, software IT analyst and blogger at The Healthcare IT Guy. He argues that EMRs, in order to succeed in the future, need to enable care coordination and patient collaboration, or risk being dis-intermediated by platforms that do. He says it’s about more than just record sharing and messaging. It is increasingly about digital biology and chemistry (genomics) and customizing treatments for best outcomes.[3]
The five stages of care coordination and patient collaboration are as follows:
Independent care is just what it sounds like. It involves situations where individuals or separate organizations provide most of the patient care with the bulk of the responsibility of care falling on the patient. This stage is where most institutions and most care delivery are today. It involves very little care coordination. It requires that patients look after themselves, comply with their medication regimen, and see a doctor or go to hospital when there are issues that need attending to.
Connected care increases the level of collaboration by including the sharing of charts among providers, or sending messages about patient care between organizations or providers, such as those facilitated by The Direct Project. In this stage, organizations move from paper to digital, but typically lab information is not included. This is the first stage where glimpses of collaboration and coordination can be seen, requiring some form of data exchange at a minimum, and perhaps some clinical communications in order for care to be connected. Basic HIE may come into play here by enabling some interoperability and even some clinical communications. But the main ingredient in this connected care phase is data exchange mostly facilitated by Direct.
In Coordinated Care, we see more coordination taking place requiring a more robust HIE-oriented solution. Chances are in this phase, multiple systems may be engaged by multiple facilities so that interoperability will be 
required, as well as an HIE infrastructure that enables the passing of clinical information quickly from source system to source system for use at the point of care. In this stage, clinical communications may be robust and a day-to-day reality within the facilities, or at least approaching that reality. Data exchange will be mandatory and should be flowing from physician office to ED to specialist to hospital, although this scenario may be played out more completely in the next stage. But at the coordinated care level, lab and radiology results are shared and the patient begins to feel that his or her care is finally being coordinated and that some of the burden of care has been lifted from the patient’s shoulders. This is the first maturity level where patients begin to feel they are not leading their care team but are at the center of their care team.
Integrated care is the stage where data is now being shared between organizations with increased rapidity and fluidity. This stage is where the walls really seem to be coming down. Clinical data and information is shuttled effectively across facilities through systems that had not been able to integrate or communicate with each other, from provider to provider, across town, across county, across state and even from state to state. This advanced stage of care is the critical step before true accountable care can occur. The HIE systems needed here include a high degree of interoperability; robust clinical communications to transfer patient information between and among providers and facilities as well as to smooth transitions of care; a standards-based exchange feature; data aggregation and a longitudinal patient record to expand meaningful use; consolidated lab, radiology and flow sheets; comprehensive analytics including bio-surveillance and dashboards; and care management tools for advanced claims and financial reporting.
Finally, in the accountable care stage, through improved IT which enables more seamless clinical communications, organizations can now become accountable for patient outcomes and costs leading to constructive therapy based on clinical information and personalized prescriptions based on patient behavior. Accountable care, whether so-named or not, will ultimately be the end-goal of institutional-based patient care. We are moving 
inexorably toward measuring patient outcomes and holding providers and provider organizations accountable for patient outcomes. What has been missing so far are the financial incentives and a technology ample enough to provide the support necessary to achieve the level of care coordination needed to improve outcomes and reduce costs. Accountable care provides the financial incentives, and health information exchange provides the technology infrastructure to make this happen.[4]
Ultimately, healthcare is heading toward more accountability. It will seek to improve patient outcomes efficiently while reducing the ever expanding costs that have vexed so many for so long. Some form of comprehensive HIE will be the tool that enables the conclusion of this journey and this fundamental change, whether that be in a rural hospital setting or a multi-state, multi-teaching hospital complex. HIEs will continue to improve and be more effective in a multitude of settings, and, at the moment, serve as the only viable interoperability solution.
About ICA:
ICA offers a cost effective, proven solution that leverages complete data across clinical settings to aid decision-making and improve patient outcomes.
Our technology:
- Is based on physician-developed technology evolved for more than 17 years at Vanderbilt Medical Center
- Offers clinical interoperability that gives physicians an easy way of accessing and acting on complete patient information across treatment settings
- Enables organizations to better leverage existing systems and aggregated information to improve outcomes
