One of the most impactful developments in healthcare today is the movement towards coordinated care. It’s essential as more healthcare organizations engage in population health management and participate in a broader health network with a variety of partner providers. Many providers have recognized that the care of a high-risk patient is a team-based activity that requires the coordination of a variety of clinicians and care givers serving different roles. It also involves a series of processes – intake, screening, assessment, developing a plan of care, reviewing a plan of care, making contact with care givers, reviewing medications, etc. To deliver the best patient outcomes possible, providers need to ensure that these processes are being completed efficiently and consistently across the team.

The idea of coordinated care is not new, but being able to deliver it effectively is starting to become a reality as new health IT emerges to help enable it. A care team is made up of a diverse group of clinicians and family members that can include primary care physicians, specialists, a lead case manager, an in-patient case manager, a field coordinator that works on non-clinical tasks, a pharmacist, community organizations, and family and friends that may be providing support such as transportation or helping pick up medications. That’s a lot of people and a lot of information that is needed to properly care for just a single patient. Multiply that by potentially thousands of patients in a care management program, and it becomes clear why coordination and efficiency can be challenging.

Here’s how health IT can innovate care coordination. First, it brings together all the data and information needed to care for a patient from all systems across the health network. All care givers have a 360 degree view of the patient that includes the plan of care, medications, lab results, vitals, documents, immunizations etc. When an update is made, all care givers have that update in real-time. With a full 360 degree view of patients, the care team can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient-centered care by incorporating patient personalized goals.

Second, it transforms the efficiency of clinician workflows, which leads to increased productivity and consistency of care. Physicians can see care gaps and close them while still in the presence of a patient. Care plans, task lists and interventions can be automatically generated from the patient’s clinical information and assessment responses. Complete medication histories can be brought into single patient views that display order and fill history for easier review. Patients that may need immediate attention can also be tracked across the continuum through event-based alerts (e.g. admissions, discharges or Bluetooth device alerts). Lastly, all of the needed tasks are being assigned to the right team members assuring “top of license” activity.

From the patients’ perspective, they’re on a better path to become healthier as they receive care focused on wellness and preventive measures. They’ll also receive a better patient experience as they don’t have to repeat answers and all care givers are up-to-date on their information. Care coordination is one of the foundational strategies healthcare organizations must employ to achieve the Institute for Healthcare (IHI) Triple Aim of 1) Improving the patient experience 2) Improving the health of populations and 3) Lowering the per capita cost of care. With a little help from innovative new health IT, coordinated care can become a reality.