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Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care (Part Four)

October 23, 2013
by Joseph M. Taylor
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Part four of a five-part series addresses the topic, "Tools to empower the Care Coordinator and track patient progress between visits"

In part four of a five-part series on creating the IT foundation for accountable care, Joseph M. Taylor, vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm, addresses the topic of “Tools to empower the Care Coordinator and track patient progress between visits.”

In the previous three parts of the series, Taylor addressed  the topics “The key elements needed to identify and stratify patient populations”; “The office and patient workflow, including integrating the role of care coordinators”; and “The expanded collaboration role between different members of the broader care team.”

Tools to empower the Care Coordinator and track patient progress between visits

A practical observation prior to going into a more detailed discussion on “tools and vendors”: For years I have attended and spoke at industry events such as AHIP, HIMSS, CCA, ACO, Care Management, and Predictive Modeling National Summits.  These events are funded in part by vendors who show off their latest products.  Their mission is to tell you about all the great things they can do, get you to consider their product and hopefully to buy from them.  Each sales cycle they show you the latest and greatest and talk about their new partnerships.  However, when you ask about what they were selling last year and what traction it got in the market, the comments I most often hear are “well, we are focused and 100% committed to this new product” or “we have a new strategic direction that I would love to talk to you about.”  One has to wonder if last year’s latest and greatest didn’t materialize, will this year’s?

Some of this “space” is new and leading edge.  There are emerging vendors with new and exciting concepts and products which have an intriguing value proposition.  Evaluating which tool(s) and vendor(s) could potentially be leveraged by your ACO/PCMH, how they fit into your strategic plan and how they can help you improve your market position and meet your strategic goals is paramount.

Remember to venture into these waters carefully; there is some “vapor ware” out there!  Conducting a well thought out vendor selection process including detailed due diligence can help met your goals save a lot of headaches later on.  Understanding what is really available and when “it” can be delivered, and who has a successful implementation either in place or underway is critical. 

The Needed Tool to Empower the Care Coordination Process


So, you hired the perfect Care Coordinator. You updated the office visit workflow to support your care coordination process and your EMR is able to meet Stage 2 Meaningful Use requirements.  The check-in, check-out and back office staff are all on board and supporting the new process.  The Care Coordinator is trained on and has logins for the EMR system.  You believe you are ready to deliver the best care coordination in the industry.  Well, not quite yet.  Successful coordination needs to be empowered by the appropriate tools designed to integrate data, identity patients, develop patient specific care plans which engage and educate the patient, track their progress, and report the needed outcomes.  Broadly the tools fall into five (5) categories:

  • Data Integration Tools
  • Patient Identification and Stratification Tools
  • Care Planning and Coordination Tools
  • Patient Engagement Tools
  • Reporting Tools

Tool 1 – Data Integration Tools

Not many ACO’s / PCMH’s have fully integrated the data from their own EMR’s, the various payers they are contracted with, the local or statewide HIE and patient preference data.  In many cases today, two or more of the needed data sources are not connected as part of an ACO’s/PCMH’s toolset.  There are other data integration points as well.  There is a need to integrate data and meaningful information to and from the selected Care Coordination tool and all patient engagement tools and apps that are used.


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