Care Coordination as Enterprise System: A Truly EPIC Opportunity

Posted by Gary Winzenread

December 3, 2015 at 12:08 PM


In healthcare circles today, the word “system” comes up a lot. A number of years ago, large healthcare organizations and hospitals began calling themselves “systems,” because they treated diverse patients in a range of settings and environments. That name continues to make perfect sense today because it accurately reflects how healthcare works today. And if we are to achieve everybody’s “holy grail” goals of better outcomes, a better patient experience and increased cost-effectiveness, only a systemic approach will do.

That’s why healthcare organizations must “think big” in terms of their capabilities regarding care coordination and start viewing it as an enterprise-level capability. In the eyes of many in our industry, care coordination is misunderstood as a simple or administrative process for nurses and social workers to point patients in the right direction. Lots of sticky notes and spreadsheets were once the main tools of the trade. Some technology is in place, but they are often “point solutions,” that lack integration with electronic medical records (EMR) systems or other key software platforms.

In our view, care coordination can be – should be – so much more. In fact, we see the broad-based adoption of care coordination as an “EPIC” opportunity (pun intended) for large hospitals. Yes, it can help improve outcomes, increase efficiencies and boost patient engagement. But there is also a gathering of forces in support of care coordination that reminds me of the early days of EMRs. New reimbursement codes that CMS has defined for care coordination are likely to prompt broader adoption of the practice, just as meaningful use regulations led many hospitals to invest in and implement EMRs. Regulatory actions like these serve as effective endorsements or even “tipping points” for certain technologies or practices. There is clear reason to believe that care coordination has reached such a tipping point.

The bottom line is that care coordination must become an enterprise-level capability because it can help address the complexities and challenges faced at typical challenges – where too many patients fall out of their recommended treatment plans. Consider patients with complex care needs. Low back pain is one of the most common of modern ailments. The big idea is to prevent complex cases from becoming chronic conditions, which drive up healthcare costs for everyone, including patients and payers. After an initial visit to a primary care physician or urgent care clinic, the patient might be referred to an orthopedist or back specialist for consultation. X-rays may be taken at an imaging center or pain treatments may follow. Then come pain treatments, either at the physiatrist’s office or perhaps at an ambulatory surgery center (ASC).

A round of physical therapy may come next, lasting anywhere from six to 12 weeks. If the pain management injections or PT prove ineffective, surgery may be a last resort, whether inpatient or outpatient. That procedure will dictate follow-up appointments and perhaps additional PT. Conceivably, each visit could occur at a different facility, only some of which may be in-network. All of these events or episodes of care are important, but none of them are endpoints. Each must be seen in relationship to the other events and in the broader context of treatment that may last six, 12 or even 18 months.

In such a complex treatment path, the responsible parties (hospitals) must be able to track and monitor patients carefully, lest they face the risk and financial consequences of poor outcomes. In an accountable care world of bundled payments, health systems will be highly motivated to track this patient all the way through and ensure he/she is complying with the recommended treatments and actually getting better. To do that effectively and proactively, they will need strong processes, people and tools. Now multiply that one back pain patient by a larger population, whose health you may be trying to manage on a macro scale, and the challenge becomes exponentially more difficult.

These are huge challenges, but now look at how care coordination mitigates them. Outcomes can be improved primarily by recognizing and prioritizing urgent patients, promoting better adherence to screening, diagnostic and clinical treatment paths. In terms of capturing revenue, decreasing missed appointments can save the average hospital up to $15 million per year. (And don’t forget that CMS now offers billing codes for care coordination.)

And then there’s patient satisfaction. Patient satisfaction for coordinated patients is 78% compared to 43% for non-coordinated. With patient satisfaction becoming a key component of value-based payments, the impact is potentially significant on billings for key services.

So what will it take for care coordination to achieve enterprise scale so that it can support multiple disease types and conditions? The first step to seizing the EPIC opportunity is likely to be linking EMR and other foundational systems with powerful and easy-to-use tools for care coordination. Focusing on interoperability and data sharing will enable ready availability of standard data by the people who need it to treat patients. Plus, the organization will be able to generate insights regarding timeliness of care and proven protocols. You can learn more about our view of the history and role of EMRs and their limitations in supporting care coordination.

As you can see, this is very much a strategic approach to enhancing systems of care, a topic I’ll delve into a subsequent post.


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