Individuals with chronic and complex health conditions are a large and growing segment of the population today, and account for a disproportionately large portion of healthcare utilization and costs. For that reason, improving the efficiency and effectiveness of chronic care management has been an important area of focus in ongoing efforts to increase the cost-efficiency, quality and consistency of care through value based healthcare models. Here, we'll look at the role healthcare information technology can play in promoting those improvements.
Today's healthcare IT plays a number of crucial roles in supporting chronic care management. Among the most important of these is capturing, aggregating, analyzing and reporting data on healthcare clients through each step of their healthcare journey. This allows clinicians and care managers to efficiently 'group' chronic care clients for the best review and analysis of best practice and its outcomes for the clients in that group. These clients may initially be grouped by specific health condition and then more focused profiling can tease out the individual variants that may help in the best practice approach for them: accurately identify their care needs, and devise efficient, coordinated care paths and even set an expectation of goals for that group to work towards. This process works to eliminate any 'missing elements' that are very real in chronic health conditions, areas that are individual and become the unseen gaps in care even when following the established or evidence based practices. The readily identifiable profile for any one person within a defined chronic condition population is needed for this to be possible; using an IT platform that is truly patient focused and truly values the data collected along the patient journey can slice and dice the data with great results. This can have an immediate impact on reducing unnecessary or ineffective care planning for that individual and show up any duplication of services; overall promoting better health outcomes at lower costs. This is the bottom-line principles of value based healthcare.
Efficient data sharing is another key way that a full-featured, fully integrated healthcare IT system can work to improve the efficiency and quality of chronic care management. Better data sharing across the continuum of care helps to address a key problem in chronic care management - too many silos and lack of common data in view for all in the care team.
Gaps in care that often occur as chronic care clients transition between healthcare providers and settings – is a real problem in providing effective care- seen as escalating costs and poorer health outcomes. And a lack of effective follow-up care after hospital discharge, can increase risk for avoidable readmissions. The ability to seamlessly continue care is important in this day and age of internet savvy patients; they go home with the task of looking after themselves! There is a real need to use an IT platform that keeps the patient in the care team. Then the clinical data is accessible - ensuring relevant information follows the client through the continuum of care, avoiding these gaps in care.
The important role that healthcare IT can play in achieving the goals of the value based healthcare model is in improving patient outcomes and satisfaction- tools of self- activation and self-management are key to improving functional health status and overall health outcomes for that person when at home. A patient portal software fully integrated within your EHR will be able to help motivate and engage your sufferers of chronic illness, outside the practice setting.
Via a patient portal, healthcare clients have access to their own health information, including test results, treatment plans, progress data and more. Portals can also improve communication by providing clients with the means for secure, online interaction with clinicians between appointments. Clients can also be provided with the ability to upload self-monitoring information for their clinicians via the portal, such as blood glucose readings in diabetes management or daily weight and eating habits. Set goals online with these sufferers that they know you can see online too! So you start to use your EHR as an assistant in managing your clients- you can then easily send them helpful encouragement; diet or exercise tips for those working to manage congestive heart failure. Patient portals can also provide access to personalized health information and education to empower chronic care clients in taking more responsibility in their own health management, adding efficiency and accuracy to appointment management, allowing for online prescription and sending their referrals with these many online management tools.
To Recap: Use of a high-quality, comprehensive healthcare IT platform in chronic healthcare management gives providers the means to collect, store, track, share and analyze data for each healthcare client - at every step of their healthcare journey. The power of data is there to improve care quality, coordination and efficiency in your daily practices. Present clients with the tools they need to be active participants in their care, increasing their capability for effective self-management.
A high-quality, comprehensive healthcare IT platform helps a clinic team make great strides towards fulfilling the goals of the value based care model: Improved care pathways with better health outcomes measured over time and delivered at lower cost.