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About the series

As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

New models of providing care and getting paid for it have made yesterday's stretch goals for information technology today's basic building blocks. "We've made major investments in the past that are considered table stakes today, just to get going," says Ed Marx, senior vice president and chief information officer of Texas Health Resources, Arlington, which has spent big on clinical IT.

A high-end, high-performing electronic health record like THR's, operating among connected hospitals and integrated with offices of its employed physicians, is a powerful advance in data sharing, says Sean Cassidy, vice president and general manager of the Premier Data Alliance. But despite all that, he tells executives, "The journey is just beginning for you."

To become contractually accountable for the relative health of people against a set of expectations, health care organizations must be able to track and manage those people, individually and as members of defined illness groupings. That requires efficient use of post-acute facilities, home care, and health-promotion options like medical homes and workplace wellness — in short, the continuum of care.

The next challenge after achieving meaningful use of hospital- and physician-based EHRs is to coordinate care for patients outside those settings, says James Walker, M.D., chief health information officer of Geisinger Health System, Danville, Pa. Organizations have to connect all members of the care team "in ways that are simple, process-focused, business-smart and cheap enough" to tie in home health agencies, skilled-nursing operations and other partners that don't have an EHR and won't in the foreseeable future.

For example, Geisinger has engineered a method of extracting information on post-acute patients from standard electronic reports that those entities already are sending to the Centers for Medicare & Medicaid Services, says Walker. [See Cool Tech.] Through a health information exchange rounding into shape in Pennsylvania, those data are becoming available to clinicians in offices and emergency departments who otherwise would not have details from post-acute settings to consider in care decisions.

A continuum strategy has led THR, a 25-hospital system in North Texas, to increase the number of employed physicians, fill geographic gaps in primary care and strengthen working relationships with care providers including independents, says Ferdinand Velasco, M.D., vice president and chief medical information officer. To bridge a gap in post-acute services, THR has forged partnerships with skilled nursing facilities exhibiting measurably good clinical performance as well as "a degree of implementation of technology so that we can comfortably develop HIE connectivity with their system."

A private HIE network, to be operational this month, is a key investment to integrate those nursing facilities and other continuum entities not on the health system's enterprisewide EHR, including physician offices already up and running with their own EHR choices. "We don't want to be disruptive to these physician practices," says Velasco, but "we want to connect them to the enterprise and be able to track their information. So that's the use case for our HIE."

Getting the IT connections between entities in place is necessary but not sufficient to manage risk for care populations, Cassidy says. The second half of the equation involves a capacity to sift through the heterogeneous data to identify the highest-cost conditions, grade the risk from low to high, and marshal resources according to that scoring of severity.

Some health care organizations are spending many millions of dollars on sophisticated evaluation of information from enterprisewide data warehouses, but commercially available population management tools can get health systems started on risk stratification and segmentation of patient populations for a relatively affordable per-member, per-month cost and scale to whatever size needed, Cassidy says. [See Case Study.] They can look at past claims and other data for chronic problems to target, or evaluate factors that give rise to unwanted consequences such as readmissions.

Vendors are racing to invent IT solutions for coordinating the continuum, but Walker cautions that the process has to trump the product. "Start with the care team ... What would the team need to share — to know when it's their turn to do something, if it's already been done, to know what the patient's preferences are. Then start to build information technology that meets those needs."


A patient from a skilled nursing facility lands in the hospital emergency department with an urgent problem that has a long history behind it. The ED doctor does his professional best; however, he has no access to the patient's history, and that makes his efforts more inefficient and clinically risky. In central Pennsylvania, however, a new data-extraction process invented by Geisinger Health System can consume key fields of data from SNF patient reports sent at intervals to CMS, upload to the Keystone Health Information Exchange, or KeyHIE, and be available to any authorized provider.

The new extraction tool, dubbed the Gobbler, is up for approval by the standards development organization Health Level Seven International, says Walker. Tested and in limited production, it costs nothing to the reporting facility except the general cost of HIE connection, and the process happens without their having to do anything else.

To complete the coordination, a process currently being tested uses KeyHIE to alert an ED patient's care providers — a home health nurse, case manager or others — that the visit took place and to follow up.


Edward Hospital in suburban Chicago already could gather pertinent information to show what happened when patients were in the 309-bed inpatient facility or offices of employed physicians. But now providers need to know more about what happens to patients outside that environment, says Brent Smith, D.O., vice president for clinical integration and chief medical officer. Whether filling prescriptions or going for tests, "we didn't necessarily know whether they actually did what we told them to do."

A new tool being implemented first for the hospital's workforce and then its patient population at large will look at what patients did when sent off with their instructions. The self-insured provider's third-party administrator will be sending claims data feeds on individual patients to population-management company Verisk to help discern patient behavior.

The result is a management capacity both immediate and longer-term. If someone at risk for coronary complications is filling a hypertension-control prescription erratically, "you can reach out to that patient and find out what is the barrier," says Smith. Early intervention also lessens the chances of that patient worsening and costing more in a year. The computerized management tool scores patients based on their health risk for special attention.

5 levels of maturation for information management

1 | Achieving meaningful use

Productive use of an EHR across an organization is foundational. Capabilities must include health information exchange to gain standards-based connectivity with other health care entities, and quality and performance measurement and improvement.

2 | Assisting care coordination

Use of, and adherence to, best practices and evidence-based medicine must span providers and the care continuum. IT must help drive the use of clinical decision support, care management and registries, and analysis of demographics to stratify risk and report against benchmarks.

3 | Facilitating clinical integration

Information systems are established to define baseline outcomes (quality, cost, etc.) for episodes of care, coordinate services across the virtual care team, and support the engagement of covered individuals in their care.

4 | Population management

Support systems are built around evidence-based standards with true team-based care collaboration, and they foster accountability in people for their appropriate role in optimizing their own health status.

5 | Supporting accountable care's sustainability

A comprehensive capability is achieved to implement integrated, continuous process improvement, management of financial risk, and advanced analytics that support optimum health of the covered population while controlling care costs and maintain fiscal viability.