In a recent post, I explored the promising nature of clinically integrated networks (CINs) and outlined how this model differs from previous efforts to “fix” health care. Now let’s look more closely at the technological underpinnings critical to success for organizations participating in CINs.

Data sharing criteria require HIT interoperability

One key attribute of the current CIN model is a focus on information sharing among members—and an acknowledgement that success is highly dependent upon the use of interoperable health information technology (HIT). In other words, CINs require that members be able to share data, aggregate data and analyze data.

Let’s look at what this means in practical terms: how interoperable technology is essential as a CIN focuses on reducing hospital readmissions.

– When a patient is discharged, providers in the community must be informed about the treatment delivered in the hospital, instructions given to the patient and follow-up care that needs to be provided by the broader care team.

– All clinicians then need visibility into the comprehensive patient record. This level access allows them to monitor not only the care delivered by their own organization, but by all others in the community as well, to ensure the care plan is followed and eliminate gaps.

– Analytics performed on comprehensive, aggregated data enables the CIN—and participating members—to identify patients presenting the greatest risk and pinpoint providers whose readmission rates need to improve.

Access to information that improves care

Interoperable HIT systems enable providers to answer critical questions:

1. Are patients getting the care they need from their various providers to recover and remain healthy?

2. Are these patients complying with their care plans?

3. Are we able to identify when an immediate intervention is needed to prevent a readmission?

dbMotion harmonizes data from disparate systems

The focus on HIT promoted by the CIN movement fortunately coincides with the availability of highly effective interoperability solutions like the Allscripts dbMotion™ platform.

dbMotion sits on top of EHRs and other clinical information systems, aggregating data from disparate technologies and harmonizing it into a longitudinal patient record. This actionable information is then delivered directly into the provider’s native EHR and workflow, to support point-of-care clinical decisions.

Because it draws data from virtually any EHR used across a CIN (as well as radiology and laboratory information systems), dbMotion delivers a truly comprehensive view of the patient and allows data to be shared seamlessly. The result? Better care coordination and management, and real-time clinical decision support.

Opportunities for patient engagement

CINs also recognize the importance of engaging patients more directly in their care—asking them to be more accountable for their health and encouraging regular communication with the care team outside of scheduled visits.

Patient engagement, too, is highly dependent upon technology. Patient portals are not a new concept, but the industry increasingly demands a more sophisticated approach to engagement. Existing portals too often are tethered to a single EHR, requiring patients to log in and out of multiple solutions.

Patients are accustomed to and expect a more consumer-friendly approach, and CINs will find that a “multiple vendor/multiple portal” strategy simply doesn’t work.

Alternatives are available, however. Allscripts FollowMyHealth® is vendor-agnostic and integrates seamlessly with all systems across the enterprise. This means patients have a single point of access regardless of the individual provider’s software.

In addition, patient-generated data flows directly from FollowMyHealth back to the EHR, automatically populating the medical record so critical information is readily available to the care team. Plus, FollowMyHealth can integrate consumer wireless devices—like scales, blood glucose monitors and blood pressure monitors—so patient status can be monitored remotely (and caregivers can be automatically alerted when potential concerns arise).

CINs offer a promising approach to the challenges that face health care today. Supported by interoperable technologies, participants are equipped to effectively coordinate and manage care for better outcomes and lower costs.

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About the author

Joel Diamond, MD, serves as Chief Medical Officer for Allscripts dbMotion Solution. Previously, he held positions as Chief Medical Information Officer and Chairman of the Physician Advisory Board at UPMC/St. Margaret Memorial Hospital, where he helped achieve 100% adoption of CPOE. Dr. Diamond graduated from medical school at the State University of New York, Health Science Center at Syracuse in 1988, and completed his residency in Family Medicine at UPMC/St. Margaret Memorial Hospital in 1991. In addition to his position with Allscripts, Dr. Diamond is an active partner at Handelsman Family Practice in Pittsburgh, PA.

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