It was fascinating for me both to participate in a press briefing sponsored by the American Health Quality Association (AHQA) on January 23, and to then interview Jane Brock, M.D., later that same day. Dr. Brock, the chief medical officer of the Colorado Foundation for Medical Care, the Medicare quality improvement organization (QIO) for that state, was the lead author of a just-published article in the Journal of the American Medical Association (JAMA) that found that community-wide, QIO-led intervention programs could be quite successful in reducing both initial hospitalizations and readmissions.

In fact, the 14 communities participating in the study saw an average 5.7-percent reduction in rehospitalizations, and also a 5.74-percent decrease in initial hospitalizations during the same two-year period. The core innovation involved, Dr. Brock and her colleagues found, was the success of QIOs in working with coalitions of stakeholder groups within individual communities to create consensus-driven interventions to improve care delivery. And at the core of that success was what Dr. Brock calls the “coaching model” of intervention, in which providers and other caregivers help patients to prepare to “take on the burden of self-management.”

And for that to happen, Dr. Brock noted in my interview with her, communications around the transitions of care have to be dramatically improved; but that doesn’t necessarily mean, she points out, that providers have to reinvent the wheel on that front. Asked what she would advise CIOs, CMIOs, and other healthcare IT leaders to do, she told me, “I would urge them to think about creating some version of this electronic bulletin board; it seems to me that there ought to be a way to facilitate that… [A]t least that would allow the person receiving the medical responsibility to be in charge of deciding the level of worry that is appropriate” for a particular patient released with challenges.

What’s compelling here, in my view, is how this quality leader, a physician who heads a Medicare QIO, has been involved in looking at improvements in healthcare delivery across communities, and can clearly see gaps in care transitions whose solutions could be leveraged by information technology—and not even futuristic IT, either.

So here’s the thing: as we as an industry move forward to develop and implement the concepts of accountable care, bundled-payment contracting, the patient-centered medical home, value-based purchasing, avoidable readmissions reduction, and other important ideas, it will be important to consider the learnings coming from leaders like Dr. Brock who have had experience with creating community-wide coalitions and who have thought on a broad scale about healthcare delivery system performance improvement.

And, to quote an old, oft-used phrase, one doesn’t necessarily have to “boil the ocean” to make important advances that can facilitate community-wide care transitions improvements. What’s most important is to create changes that can make advances quickly possible, while of course keeping the big picture in mind overall.

In short, CIOs, CMIOs, and other healthcare IT leaders will be absolutely critical players in these discussions going forward. There’s both challenge and opportunity involved in that, but the opportunity to help steer important initiatives—like the ones that Dr. Brock and her colleagues have been involved in and written about—is considerable. And the “connectivity” part of “community” could well be the critical success factor in this important equation.