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/lp/ou_press/information-technologies-that-facilitate-care-coordination-provider-NmXXo5FAbm
- Copyright
- Copyright © 2022 Society of Behavioural Medicine
- ISSN
- 1869-6716
- eISSN
- 1613-9860
- DOI
- 10.1093/tbm/ibx086
- Publisher site
- See Article on Publisher Site
Abstract
reported poor communication with VHA col- Health information technology is a core infrastructure for the leagues, and their interactions were perceived to be chronic care model, integrated care, and other organized care with a “system” rather than a colleague. From the delivery models. From the provider perspective, health infor- Department of Epidemiology, patient perspective, respondents from the USA in mation exchange (HIE) helps aggregate and share information Indiana University, Richard a care coordination survey reported that their test M. Fairbanks School of Public about a patient or population from several sources. HIE tech- Health, Indianapolis, IN 46202, results were not available, or that duplicate tests nologies include direct messages, transfer of care, and event USA were ordered during a medical appointment, and 17 notification services. From the patient perspective, personal Regenstrief Institute, Inc., health records, secure messaging, text messages, and other per cent reported that information was not shared Indianapolis, IN 46202, USA mHealth applications may coordinate patients and providers. among their multiple care providers [6]. A quarter Center for Health Information and Patient-reported outcomes and social media technologies of Canadian and a fifth of Australian, French, Dutch, Communication, Department of enable patients to share health information with many stake- Veterans Affairs, Veterans Health and Norwegian respondents indicated similar gaps holders, including providers, caregivers, and other patients. An Administration, Health Services in the availability of test results, or duplicate testing information architecture that integrates personal health record Research and Development during a medical appointment [6]. Service, IN 46202, USA and mHealth applications, with HIEs that combine the electronic Department of Medicine, Indiana health records of multiple healthcare systems will create a rich, To facilitate and enhance care coordination, pro- University School of Medicine, dynamic ecosystem for patient collaboration. viders and patients seek to leverage health informa- Indianapolis, IN 46202, USA tion technologies, including the electronic health record (EHR) and patient-centered technologies. Keywords Correspondence to: David Health information technology (IT) systems are Informatics, Public health A. Haggstrom, dahaggst@iupui. designed to provide access, manage, and share infor- edu mation about individuals and populations. Health Cite this as: TBM 2018;8:522–525 IT components are conceived as a core infrastruc- INTRODUCTION doi: 10.1093/tbm/ibx086 ture for the chronic care model [7], integrated care Coordination of care for individuals and populations Published by Oxford University Press [8], and other organized care delivery models [9, 10]. is an imperative for modern medicine. This is espe- on behalf of the Society of Behavioral The promise of health IT applications to improve Medicine 2018. This work is written by cially important in the U.S. healthcare system that, care coordination depends upon providers adopting (a) US Government employees(s) and relative to international comparisons, is character- is in the public domain in the US. them into their practices and patients using the appli- ized by high subspecialization [1] so that the need for cations. With respect to providers, more than 80 per coordination among many different types and levels cent of hospitals [11] and more than 70 per cent of of provider services is substantial. Evidence shows physician offices [12] have at least a basic EHR sys- that patients seek care from a variety of providers, tem. With respect to patients, one-third of patients whether or not those providers are part of the same were offered access to, and just under 30 per cent organized network [2]. For example, the Veterans accessed, online health information according to the Health Administration (VHA) spends 10 per cent Health Information National Trends Survey [13]. of its total health care dollars on care delivered to In this commentary, we describe the progress Veterans outside of the VHA’s network of providers made, and remaining challenges, with respect to how [3]. Moreover, many individuals now manage their health information technologies are used to facilitate health using a growing array of interventions in their care coordination for individuals and populations. homes or non-traditional “care” settings such as the We examine the perspectives of both providers and Internet [4]. Given the mobility of individuals and patients, because both groups play essential roles in populations, delivering high quality care requires generating, storing, managing, and sharing health that providers be able to access, manage, and share information. information efficiently. Retrieving, managing, and sharing health infor- PROVIDER PERSPECTIVES mation for care coordination, however, are chal- lenging for both providers and patients. In a survey There exist a range of health IT applications avail- of non-VHA providers who were participants in a able to providers to facilitate care coordination. practice-based research network [5], respondents Emphasis in recent years focused on EHR systems, page 522 to 525 TBM Downloaded from https://academic.oup.com/tbm/article/8/3/522/5001944 by DeepDyve user on 16 July 2022 COMMENTARY/POSITION PAPER primarily because the federal government incen- clinics, payers, or health systems. Moreover, few tivized their adoption and use in practice [14]. Yet, best practices for how to implement these technolo- EHR systems serve as a mechanism to generate, gies in various settings exist. manage, and access information within a provider’s Another challenge with HIE technologies is the practice or hospital system. Access to information lack of a robust evidence base demonstrating impact beyond one’s own network requires health informa- on health outcomes, the cost of care, or efficiency tion exchange (HIE) technologies that interoperate of care delivery. A recent study by Unruh et al. with a provider’s EHR and connect the provider’s [16] examined ENS using a longitudinal panel EHR to other health IT applications. (N = 2,259) of Medicare patients who lived in The HIE technologies help gather, aggregate, and Bronx. Having an active ENS alert during a hospital share information about a patient or population admission was associated with a 2.9 per cent reduc- from multiple sources. For example, some HIE tion in the probability of readmission. While encour- technologies enable providers to send “e-mail like” aging, more studies in multiple health systems are messages in the context of a referral or consult. For needed to examine the impact of ENS on a broader example, Direct Secure Messaging is a technology set of outcomes. Similarly, studies are needed to that can enable Dr. Jones, a primary care provider examine the impact of Direct messaging and TOC (PCP), to submit a consult request to Dr. Landry, services on care coordination. a dermatologist, for a patient with suspicious skin PATIENT PERSPECTIVES lesions. After examining the patient, Dr. Landry can send some photos and his expert opinion back to Patient-centered health IT applications also offer Dr. Jones. This conversation might continue through several ways to facilitate care coordination, both additional messages clarifying questions or develop- inside and outside of the traditional healthcare ing a care plan for the patient. context. The field of consumer health informatics Another promising HIE technology is Event (CHI), the study of consumer information needs and Notification Services (ENS). An ENS is typically healthcare technologies as well as the implementa- a subscription service that alerts a provider, care tion of methods to make information accessible to coordinator, or payer when an event occurs involv- consumers, organizes a significant and growing vol- ing a patient or population. For example, if Mrs. ume of scholarship [4, 17]. Smith were to be admitted to a hospital, her PCP One key technology is the personal health record can receive an ENS alert with details on the admis- (PHR), which can be considered an extension of the sion. The alert might prompt the provider to contact patient health record, or its contemporary equiva- the hospital and coordinate follow-up care as part lent, the EHR. But unlike the EHR, the PHR is a of the discharge planning process. Similarly, a care patient-facing record of care that can archive, for coordinator might receive information about 20 view by the patient, encounters with the healthcare people who recently visited the emergency depart- system, such as physician visits; medications pre- ment as part of an effort to manage “high utilizers.” scribed and ordered; allergies; immunizations; and A final class of HIE technologies can be referred test results, including laboratory, radiology, and pro- to as Transfer of Care (TOC) services. These ser- cedures. The terms personal health records (PHRs) vices gather information about the care provided and patient portals are commonly used interchange- to a patient at one provider and transfer them to ably, with a portal being defined as “a secure online the next provider as a summary document. For website that gives patients convenient 24-hour example, when Mr. Doe is discharged from an emer- access to personal health information from any- gency department visit for exacerbation of asthma, where with an Internet connection” [18]. PHRs or the information about that visit is summarized for portals can be tethered or linked to a patient’s elec- electronic transfer to his PCP’s EHR system. The tronic health record; this configuration is of greater PCP may then view the document or incorporate coordination value to the patient than stand-alone information from it into the patient’s EHR. systems wherein patients need to self-enter informa- Direct messages and TOC services most readily fit tion about their own medical care [19]. with a practice’s meaningful use strategy in compli- Like HIE, patient-controlled data are a compo- ance with the EHR incentive program sponsored by nent of Stage 2 Meaningful Use criteria, as part of the federal government. Stage 2 meaningful use cri- a requirement that patients be able to view online teria, for example, require that providers generate or download their health information [20]. Based and send a TOC document for at least 10 per cent on a population-based survey, less than 20 per cent of transitions in care [15]. Health systems are further of patients access their personal health information interested in ENS as a mechanism to learn about online [21]. A systematic literature review of the patients and populations that access providers out- impact of patients’ requests for additional informa- side of a given accountable care organization (ACO) tion via patient portals found improved medication network. However, little data exist on the adoption adherence, disease awareness, self-management of rates of these HIE technologies. Therefore, it is dif- disease, an increase in preventive care, a decrease ficult to assess how pervasive they are in hospitals, in office visits, and an increase in extended office TBM page 523 of 525 Downloaded from https://academic.oup.com/tbm/article/8/3/522/5001944 by DeepDyve user on 16 July 2022 COMMENTARY/POSITION PAPER visits. The results also showed an increase in quality and medical providers. Another wide range of in terms of patient satisfaction, but relatively little opportunities opens up when one considers how was reported about medical outcomes [22]. patients may not only receive information from the Sharing healthcare data directly with the patient healthcare provider, but deliver patient-reported clearly facilitate the coordination of medical infor- outcomes to the provider, including information mation and may serve as the foundation for other about symptoms and quality-of-life [25]. Innovative coordination activities. Additional functions can technologies may also be used to connect patients ideally be layered upon PHRs, or operate as with their caregivers, and with one another. For free-standing applications, including evidence-based example, the CaringBridge application has con- disease management and monitoring, nonurgent nected hospitalized patients with their families, and appointment scheduling (linking patients with clinic new computerized platforms have considered how front-offices), prescription refills (linking patients elderly patients living with dementia can be better with pharmacies), and secure messaging (linking cared for at home through remote technologies [26]. patients with their provider team). Other emerging Social media forums can serve as virtual support applications may rarely be integrated with PHR or groups that provide both information and emo- EHR platforms, including activity trackers or other tional support for patients [27]. Research in the area remote monitoring devices that can capture observa- of patient-centered health IT may include better tions of daily living; challenges of these rapidly pro- defining the healthcare and community participants liferating technologies include how, or even if, the who are best to include in online social networks, data may be shared with the healthcare providers or as well as how to optimally implement and spread systems caring for patients. effective interventions. Patient secure messaging refers to an e-mail pro- CONCLUSIONS gram embedded within the electronic, online plat- form offered to the patients seen within a health Health IT holds obvious promise in promoting care practice or system. For example, Mr. Howard coordination. The adoption of provider-centered may communicate with his PCP Dr. Welby about EHR systems is fairly well-progressed; remaining a bothersome side effect that he believes a new strategies need to target late adopters [28], as well as medication is causing; Dr. Welby could then pro- how best to facilitate EHR sharing across healthcare vide guidance about steps to take right away and systems through HIE [29]. Uptake of patient-cen- arrange appropriate follow-up if needed. Of course, tered technologies, and patient portals in particular, it is possible for healthcare providers to exchange is lower. Approaches to more widely disseminate and e-mail with patients through other platforms (e.g., promote the use of PHRs and mHealth should be a Microsoft, Google), texts, or even instant messaging. focus of future evaluation and research. Although But privacy and security concerns may discourage free-standing approaches may offer many benefits routine use of these ubiquitous utilities, even though in terms of self-monitoring and self-management, missed coordination opportunities may arise from coordination will not be complete without integra- avoiding the use of technologies through which tion with the healthcare system. patients most commonly communicate. In a position Consumer health approaches may offer the great- statement, the American College of Physicians rec- est opportunities for innovation [30]. A rapidly ommended that providers establish guidelines with multiplying set of devices and technologies can be patients about what issues are appropriate for digital interconnected to facilitate the identification, track- communication and reserve such communication for ing, and management of a broad range of health and patients who maintain face-to-face relationships [23]. clinical goals. As they evolve, new technologies must Less controversy accompanies the delivery of account for multiple potential users beyond the phy- automatically generated, tailored text messages sician and patient. At the provider level, healthcare to patients for disease management or health pro- teams may function at a higher level when not only motion. A systematic review of reviews found that physicians, but nurses, medical assistants, social the majority of text-messaging interventions were workers, and other nonmedical professionals are effective when addressing diabetes self-manage- connected effectively through EHRs. Similarly, ment, weight loss, physical activity, smoking cessa- patients with chronic and serious illnesses may have tion, and medication adherence for antiretroviral an extensive social network with the need to know therapy [24]. Text messaging for health can be con- at least some of their health information—including sidered part of the larger strategy of mobile health formal and informal caregivers, and patient commu- (mHealth), which may be defined as the application nities with shared healthcare needs or goals. of mobile technologies, including phones, tablets, Imagining the future, an information architec- telemonitoring, and tracking devices, to support the ture that integrates PHR and mHealth applications delivery of healthcare. directed toward patients, with HIEs that combine Most of the information technologies discussed the EHRs of multiple healthcare systems will create so far have considered how patients can coordin- a rich, dynamic ecosystem for collaboration at the ate in new ways with their healthcare information patient, provider, and community levels. 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Journal
Translational Behavioral Medicine – Oxford University Press
Published: May 23, 2018