BOSTON—Healthcare is motivated to improve care coordination due to changing payment systems that are shifting the risk to providers, said Gilad Kuperman, MD, PhD, director for interoperability informatics at New York Presbyterian Hospital, speaking at the AMDIS Fall Symposium.
Kuperman cited several approaches to care coordination such as improving efficiency within a particular setting, managing a population by segment, improving the referral process or a combination. “It’s important to have a broad view,” he said.
Several IT features are needed to support patient-centered medical homes (PCMHs), including personal health records, registries, support for team care and clinical decision support. “The majority are not in the current generation of EHRs,” he said.
Kuperman’s facility focused on improving care coordination on patients with both diabetes and depression. The effort included IT, workflow redesign and data collection and feedback. Building on the PCMH model, the initiative standardized care for depressed diabetics through screening and monitoring symptoms. “A lot of this education of primary care providers (PCPs) about depressed diabetics and the best way to care for these patients.” He pointed out that IT was part of the program, but not the only part. IT features included structured documentation screens in EHRs, alerts and reminders, patient summary screens, registry, analytics, personal health records, EHRs for community providers and interoperability.
The evaluation framework for the study considered demographics, inpatient utilization, ambulatory utilization, screening and monitoring effectiveness and team-based measures. The project was implemented early this year so Kuperman did not yet have any results.
There are many opportunities to improve the efficiency and effectiveness of care, he said. “The key challenges are knitting together the IT capabilities that exist, integrating them with the desired workflow and creating new IT to support the institium. Certified EHRs are not enough.”