by Dr. Peter Edeltein, Chief Medical Officer
In the US, health care is moving irreversibly toward clinical integration, in part in response to federal legislation, but also because of new care models that are focusing on improved patient care. To remain financially viable and healthy in the current regulatory environment, hospitals and health care providers must reduce readmissions, improve patient outcomes, increase patient satisfaction with care, improve resource utilization, and reduce operating costs. These outcomes rely on the integration of clinical information among primary care physicians, surgeons, emergency department staff, nurses, caregivers, and even payers.
Historically, health care in the United States was local. One primary care physician provided care to a person from birth to old age. That model is no longer current. Today, an obstetrician delivers our children, a pediatrician cares for them when they are young, a primary care provider takes over in their adolescence, and a geriatrician may assume their care in old age. Across the lifespan there will be specialists, surgeons, and emergency department physicians who touch them for finite treatments or for ongoing care of specific, chronic conditions.
Because of changing way in which health care is delivered, the primary care physician has lost his or her role as captain of the health care ship, and the ship has been on an unchartered course in which care has become fragmented, repetitive, and overly expensive. Outcomes are harder to predict and manage, and patients suffer.
Models such as accountable care organizations and patient-centered medical homes are attempts to put the primary care physician back in the pilot’s seat, but those attempts can only be successful if there is a means to integrate the clinical care of the patient across multiple settings and a variety of providers. Improved care outcomes is the carrot that is enticing health care providers, hospitals, and payers to integrate clinical data.
Where there’s a carrot, often there is also a stick. This is true for health care and the stick is a big one wielded by the government. Federal regulations are shifting risk from payers to hospitals, and hospitals, in turn, are shifting risk onto individual providers. The government’s huge stick, in the form of reimbursement penalties and other reforms, will help to drive clinical integration because failure to integrate will be the demise of hospitals and providers alike.
Against this background, providers and payers alike are looking for ways to analyze care outcomes and efficiencies, and to predict those patients who can best be helped with disease management programs, careful adherence to treatment guidelines, or encouragement in patient self-management of health.
Elsevier MEDai has been at the forefront of efforts to integrate clinical data, analyze risks and gaps in optimal care, and predict future use of health care resources, with tools such as its flagship Risk Navigator, which manages populations and stratifies high-risk members.
In the first quarter of 2013, Elsevier MEDai will introduce a new Physician Portal for Risk Navigator. The portal will give physicians a big-picture view of “whole” patients under their care. Physicians will be able to see all the touch points a patient has had with health care providers over several years. Prescription fills and refills, surgeries and procedures, and office visits across all providers of care will be integrated in the patient’s electronic data file. Physicians will be able to identify care that has not met the standards of clinical practice guidelines and patients who have not been adherent to treatment. They will be able to compare care for different patients with the same types of diagnoses to determine if costs or outcomes are superior with one intervention vs another. This information, coupled with a motivation index that stratifies patients according to their motivation to change behavior or adhere to treatments, will help physicians determine the best use of resources and investment of time to improve patient care outcomes for those at high risk.
Only by having a full view of patients’ encounters with the health care system—hospitals, outpatient care services, pharmacists, physicians, case managers, and more—can meaningful programs be implemented to improve health, drive down costs, and help to prevent admissions or readmissions to hospitals. On an individual patient level, disease can be better managed when gaps in care are identified and then mended. On a hospital and provider level, costs and resources can be better managed, penalties can be avoided, and the financial health of the health care system improved. And individual physicians may find they can retake the captain’s wheel and steer the patient’s care toward better health.