Rethinking the Business of Healthcare

Post by Brad Miller

Vice-President of Clinical Solutions, Caradigm

“What businesses are we in?” ask Michael Porter and Thomas Lee of the healthcare industry in their New England Journal of Medicine Perspective article entitled “Why Strategy Matters Now[.”[1]  As the entire healthcare spectrum transitions from a fee-for-service (FFS) paradigm to a more risk-based system, Porter and Lee contend that healthcare has entered a new era of strategic thinking and must employ new business approaches. I wholeheartedly agree that we need to start focusing on value in healthcare versus maximizing revenue.  

This new era in healthcare is marked for its focus on population health and patient-centric care to drive high value outcomes.  Porter and Lee believe that healthcare organizations should adopt new care concepts like the Integrated Practice Unit (IPU). Their IPU concept is based around specific diseases and comorbidities – like diabetes or asthma – rather than the traditional model of being department or provider-specialty centric.  This means that provider systems can truly focus on delivering disease and condition specific care across a population to achieve high value care. This concept would bring high quality practice and refinement to some of our sickest and highest utilizers, while also driving preventive care for those who have not converted to a full disease state. 

As the healthcare economy evolves in this risk-based direction, the IPU model (or a similar concept – patient-centric care across specific populations) will help break from the FFS “one size fits all” era.  It allows providers to focus not only on what they do well, but to provide a care environment for continual learning, discovery and refinement of care models and methodologies for their specific populations. There is also the possibility that IPUs can reduce large amounts of medical waste by standardizing best practices and reducing unnecessary or redundant tests and procedures. 

Simultaneously, there is a manifestation resulting from the physician and nurse education models that aligns with this disruption in the traditional healthcare business model. Predominantly, in the late 1980s and 1990s many medical schools switched to systemic-based curricula vs organ and departmental approaches.  I know this was the case at Weill Cornell, where I went, and at many of the other medical schools where my colleagues went with whom I have discussed their curricula.  From a learning standpoint, our generation of physicians were taught to view the body more as a system, rather than isolated organs. This generation of physicians are now in leadership roles at healthcare entities, ready to bring a more holistic perspective to the practice of medicine and healthcare.

It reminds me of the Apple Computer strategy of focusing on the educational market in the 80s and 90s – seeds planted a decade or two ago that helped create Apple brand loyalty and the foundation for making computing so central to our lives today. 

We are in an era of transformation as evidenced by the Affordable Care Act (ACA), the removal of Sustainable Growth Rate (SGR) for Medicare, Centers for Medicare and Medicaid Services (CMS’) rapid focus on risk-based payment models, and private businesses directly contracting for care with health systems in growing numbers (private ACOs, bundled payments, etc.). While we might not know exactly where the future will move healthcare, many signs point to it being risk-based and an era of rapid evolution and adaptation. In my experience with ONC’s Beacon Program and various providers under the CMS Innovation program, creating a clinical care environment that can easily adapt on top of a solid data and IT infrastructure is critical to supporting providers in this new and changing world.  Deep intelligence into a provider’s patient population, financial and clinical risk among other information and technical requirements will become central in this healthcare evolution.  I’ll tackle that technical aspect in my next blog post. In the meantime, check out Porter and Lee’s piece on the rapidly shifting sands of healthcare business strategy.

[1] Porter, Michael E and Lee, Thomas H. “Why Strategy Matters Now” New England Journal of Medicine. April 30, 2015.Publsihed from

How Population Health Enriches the Patient Record

Post by Sameer Bade, MD

Vice President of Clinical Solutions, Caradigm

As providers seek new capabilities to help them in their journey to population health, one of the first items they usually target is analytics. Analytics are undoubtedly an important piece of a population health strategy, however, this is just one of a number of important capabilities providers must obtain. In my experience collaborating with providers, a sometimes overlooked capability is creating and sharing a comprehensive, enriched longitudinal patient record. With the shift from physician-focused, episodic-care to team-based care involving multiple clinicians and care givers, it has become essential to have a real-time, 360 degree view of the patient that is shared among the entire team. With that enriched view, a care team can more effectively and efficiently deliver coordinated and proactive patient-centered care that drives improved outcomes. Let’s explore this issue in greater detail.

The reality is that clinical information from a single electronic health record (EHR) provides only a small portion of the information needed for population health management. If there are multiple EHR’s in a clinically integrated network, clinical data for patients may be siloed in disparate EHRs. Also absent from patient records are numerous other key pieces of information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Care plans
  • Lab results
  • Patient outreach information
  • Patient submitted / supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Analytics that measure medication compliance
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

Enriching the patient record with this information enables a depth of patient understanding required to support the transformation to value-based care. Here are a few examples of how the enriched patient record can have an impact.

Scenario 1

With pharmacy benefits claims data automatically augmenting the patient record, a care manager can quickly see which prescriptions have been filled without having to log into multiple systems. They can complete a medication review faster and more accurately and can share this with the care team. It is well known that improper or inadequate medication management can  play a major factor in readmissions and complications (shown to cause as much as 20 percent of hospital readmissions[1]). However, having just EHR based medications (list or prescriptions) and pharmacy benefit / fill data is not enough. Being able to capture what the patient is actually taking can provide enhanced insight.  After medication review, a care manager can determine that a pharmacist needs to be added to the care team to help manage dosing regimens and timing of medications. The care manager can then assign a task to the appropriate care team member working at top of license to make arrangements with the pharmacist and add a note to the patient record that is shared with all other care team members. 

While completing medication review, a care manager may also discover life events that are barriers to medication compliance such as an inability to pay for medications, not having transportation to pick them up, or patterns such as sharing/splitting doses with a spouse. The care manager can then assign a task to an appropriate care team member to make transportation services arrangements for the patient or enroll them in an financial assistance program, and add another note to the patient record that is shared with all other care team members. 

Scenario 2

The same high-risk patient described above goes to see a primary care physician who is part of a clinically integrated network. When the physician looks up the patient’s record in their own EHR, the enriched longitudinal information and actions taken in Scenario 1 are carried forward to the point of care. In this scenario, the physician or nurse can have a deeper and more informed conversation with the patient about medication compliance. Furthermore, easy access to a  comprehensive, validated medication review as part of the enriched longitudinal record, can help speed up the medication reconciliation process in the clinic. With full context on the patient that also includes all care programs they are enrolled in, lab results, visits history, readmissions risk score and relevant patient documents such as a care plan, the provider is better equipped to evaluate and direct additional care. Simultaneously, the provider can also see gaps in care and quality measures (e.g. need for a depression screening) that can be closed while the patient is still in the clinic. From a patient perspective, the provider’s enhanced understanding of issues and plan of care can improve the overall experience. The physician can even see what motivates the patient (perhaps the care manager noted that the patient has a goal to be able to attend their grand daughter’s college graduation) and encourage continued participation.

In the big picture, successful population health management requires addressing a population of patients as individuals. An enriched longitudinal patient record as described here can help providers gain a better understanding of their patients and enable the care team to be more effective, efficient, coordinated and patient-centered.

To learn more about how your organization can obtain and share a longitudinal patient record across a care team, send us a note here to schedule a discussion. 

[1] Guitierrez, David. “Drug Side Effects Blamed for 20 Percent of Hospital Readmissions.” Posted from 1.4.10.



HIMSS15 Day 3 Recap

Post by Azam Husain

Senior Product Manager, Caradigm

After three jam packed days of activity inside and outside our booth, HIMSS15 came to a close. Our final panel presentation of the week focused on the important topic of healthcare data privacy and security. Marianne Kolbasuk McGee, Executive Editor of Information Security Media Group (ISMG) moderated and shared information from ISMG’s annual information security study. Also on the panel were Steve Shihadeh, Senior Vice President of North America Sales Caradigm, Mac McMillan, Chief Executive Officer CynergisTek, and Shane Whitlatch, Executive Vice President FairWarning. The survey results that Marianne shared were really interesting because they showed that despite the high profile breaches that have occurred over the past couple of years, there’s still plenty of room for healthcare organizations to give information security greater focus. Some of the statistics shared were:

  • Only about half of organizations indicated that preventing and detecting breaches is a top priority in 2015.
  • Just 31 percent of healthcare organizations have “high” or “somewhat high” confidence in the security controls of their business associates and subcontractors.
  • Nearly 80 percent of organizations rely on usernames and passwords as the dominant method of authentication used for on-site and remote access to clinical data with use of more advanced forms of authentication still rare.
  • 51 percent of organizations reported having no breaches of any size in 2014 compared to 37 percent in 2013.

The panelists advised that healthcare organizations need to guard against complacency in order to stay ahead of security risks. Everyone should be doing more because of the continuous presence of insider threats and increasing hacking threats that are targeting healthcare heavily because of the value of the data and intellectual property. The panel also stressed the importance of tools to help control identity and access management and ongoing workforce training that needs to be put into greater context for how employees do their jobs.

Another very cool event that took place today was that patient rights advocate and renowned artist, Regina Holliday was in the Caradigm booth painting a mural on population health to raise awareness for the Society for Participatory Medicine. The mural is inspired by the idea that healthcare needs powerful and disruptive change and was completed in a single day. To learn more about Regina’s patient advocacy, I recommend reading her blog and following her on Twitter.


Regina HIMSS


HIMSS15 Day 2 Recap

Post by Vicki Harter

Clinical Product Manager, Caradigm

I value my time spent at HIMSS. It allows me to reconnect with long-time colleagues, meet new people, and check the pulse of the industry in a few short days. This year, I’ve noticed a shift in the types of conversations I’m having on population health management. Healthcare organizations have a more mature interest in discussing the opportunities and challenges of value-based care and the IT solutions that can help. An increasing number of providers are looking to take the next step with population health, scaling programs they have implemented over the last couple of years. It’s exciting to hear that the question has shifted from “should we make the shift?” to “how can we do it more efficiently and effectively?”

Caradigm had another superb day of educational presentations in our booth. I participated on the panel entitled “DSRIP Program – Enabling Participation for Performing Provider Systems.” The panel included several other experts on the program: Todd Ellis, Managing Director KPMG, Wendy Vincent, National Practice Director Beacon Partners, and Paul Contino, Chief Technology Officer NYC Health & Hospitals Corporation.

Todd Ellis kicked things off by providing an overview of the Delivery System Reform Incentive Payment (DSRIP) program. DSRIP aims to improve the Medicaid program, improving the quality of care for the underserved while better managing the more cost of that care. He claimed that the goal can be reached through an increased focus on primary care, preventive measures and patient engagement; together they can reduce the need for high-cost hospital services. Given the billions of dollars that are available to participants in the program, DSRIP represents a significant opportunity to build the systems needed to truly transform care delivery, and implement the IT solutions that can make it happen. 

Succeeding within the DSRIP program, however, does present some significant challenges. Paul Contino shared his perspective of a provider that is leading a large Perform­ing Provider System (PPS). Paul outlined two of the most important things to get right: 1) gathering and sharing data across a large number of providers using a variety of different systems and 2) developing standardized and integrated workflows. He reminded the audience that this change won’t happen overnight as it takes a significant, long-term investment of time and resources. 

As one who has helped clients structure and prioritize their DSRIP programs, Wendy Vincent added a consultant’s perspective. She stressed that a PPS needs clear transparency and communication among all its partners.  They need to agree on goals and processes before implementation. As providers often participate in several population health initiatives, she recommends that they take a step back and take a holistic view of all their programs to find areas of improvement and synergies that cut across multiple activities.   

Lastly, the panel also talked about solutions that are needed to ensure success with DSRIP initiatives. I believe that providers must take a long-term view as they try to improve the health of a population. They need tools that are both flexible and extensible. As Paul stated, transformation will not happen overnight. Programs will change and evolve over time, and what works for one provider may not work for another. As opposed to point solutions not intended to scale beyond a narrow focus, end-to-end enterprise population health solutions give providers the flexibility and extensibility they need.

If you’re at HIMSS15 and would like to talk more about your DSRIP or other state funded strategies, then please stop by our booth #7307. You can also drop us a note here to schedule a conversation at another time. 


 Tuesday Panel 3PM


HIMSS15 Day 1 Recap

Post by Scott McLeod

Director of Product Marketing, Caradigm

It’s always enjoyable to be at the Health Information Management Systems Society (HIMSS) Annual Conference, which kicked off today in Chicago. The sheer volume of people (around 38,000+) who come from all over the world to learn about and discuss innovation in healthcare is amazing, and makes HIMSS the industry gathering.  

Caradigm had a bustling opening day in the exhibition hall as we hosted the first two of a series of outstanding interactive panel sessions to be held in our booth this week. Here are the highlights from today’s panels:

Population Health Trends and Insights Panel

Panelists were Ken Kleinberg, Senior IT Analyst from The Advisory Board Company, Dr. Peter Edelstein, Author and Patient Advocate, Brian Drozdowicz, Caradigm SVP of Global Population Health and Patty Enrado, Senior Editor, HIMSS Media who served as the moderator. To initiate discussion among the panelists, Patty shared preliminary results from a HIMSS Analytics population health research study and asked the panelists to respond. It was a lively discussion centered around where organizations are today with population health and where they are headed in the future. Some of the key points that came up in the discussion were:

  • 22 out of 25 respondents said population health would be a high organizational priority by next year. The panelists agreed that we have reached the tipping point for organizational awareness of population health, but are not there yet on execution because population health is complicated and requires new tools.
  • Respondents indicated that the top challenges providers are having are related to data aggregation, change management, and budget constraints. While the panel agreed that budget and resource constraints are common, providers can mitigate the challenge by honing in on programs and tools that can help them achieve quick wins such as data aggregation.  
  • Initial successes in population health are coming from a variety of different areas such as patient engagement and outreach, building IT infrastructure and care and case management. The panelists commented that experimentation with different population health programs is an effective approach until a provider learns what strategies are working for them. Aligning on goals and how to measure success is important to establish before implementing a program.
  • To further mature population health strategies, respondents indicated that they need to keep bolstering their IT infrastructure, form more partnerships and affiliations to expand coverage, and be adaptable. The panelists talked about how providers should take the long view and build infrastructure that can scale. An ACO that manages a few thousand lives today needs a clear technology and strategy path forward to grow to hundreds of thousand lives managed.

Succeeding In Accountable Care Panel

Panelists were Wendy Vincent, National Practice Director Beacon Partners, Sameer Bade, Caradigm VP of Clinical Solutions and myself as the moderator.  This panel was an excellent follow up to our earlier pop health session as the conversation centered on specific foundational strategies ACOs should be considering to drive quality and lower costs. Some of the recommendations discussed included:

  • Start by obtaining a deep understanding of your population, and use predictive modeling to identify patients who are most likely to become high risk in the coming year in order to prioritize interventions.  
  • Build a strong foundation of primary care and patient centered medical homes (PCMH) that can help improve outcomes for a targeted population.     
  • Establish strong physician leadership in the ACO and also restructure physician compensation to align provider incentives with value-based care.
  • Remember that you can’t manage population health with an EHR alone. As providers scale programs and form clinical networks, the amount of data that needs to be aggregated from disparate systems multiplies very quickly. Providers also need a higher class of population health analytics and workflow tools to help them drive results.

If you’d like to receive the complete research reports from the panels today, send us a note here. Also, check back tomorrow for a recap of Tuesday’s activities as Caradigm will be hosting three more panel presentations in booth #7307.


 Caradigm HIMSS

Advisory Board National Meeting Day 2: Redefining the Value Proposition

Post by Scott McLeod

Director of Product Marketing, Caradigm

I recently had the opportunity to attend the second half of the Advisory Board’s two-day national meeting in Seattle where the presentations went deeper on the central theme of how health systems must adapt to the shift in how they are paid. These systems face four imperatives necessary for success in the new world—competitive unit prices, total-cost control, geographic reach and clinical scope, and clinical and service quality.  These are the attributes necessary for providers to succeed by, as noted in David Lee’s blog, winning at two distinct points-of-sale:

1) They must be the network chosen in risk-based agreements with payers and employers 

2) They must be chosen by patients who need healthcare services

One requirement to winning the first point is assembling a low-cost, high-quality network. Recruiting the appropriate providers is dependent on the evaluation of clinical performance data, e.g. mortality rate, complication rate and readmission rate, making sure that providers included in the network can deliver the high-quality care expected by payers and employers.  Other factors for evaluation include their per-capita cost of care, efficiency of care utilization and care experience—helping to make sure that the providers included also can deliver low-cost care.

Assembling the appropriate network is also critical to building the geographic reach and clinical scope to provide healthcare access that meets the demands of patients.  In addition to competing on price (driven by increased price transparency) and convenience (offering services that meet diverse patient demands), health systems can differentiate themselves from their competitors by offering enhanced management. Increasingly, employers are purchasing health management solutions for their workforce, and patients are opting for direct primary care and concierge services. Successful networks need providers who can deliver services such as preventive screening, disease treatment and lifestyle management. 

Once assembled, it is important to continuously monitor and manage the network. Quality analytics are required to identify gaps in care or measures and surface them to providers so the gaps can be closed. Performance analytics are necessary to measure the behavior of providers and evaluate patterns of activity for areas of improvement. Utilization analytics are needed to monitor network leakage and promote appropriate steerage—driving patients to seek care within the network of low-cost, high-quality providers.

The Advisory Board meeting provided a good perspective on the state of the industry leading in to HIMSS15. Caradigm will be hosting several panel discussions in our booth (#7307) that will feature industry experts as well as the sharing of third-party survey research related to population health, ACO best practices, DSRIP and Data Privacy and Security. You can check out the full schedule of Caradigm events at HIMSS here.

Advisory Board National Meeting Day 1: Balancing Population Health and Fee-for-Service

Post by David Lee

Product Marketing Manager, Caradigm

I had the pleasure of attending the Advisory Board’s national meeting recently in Seattle where the central theme was how healthcare must adapt to the channel disruption it is facing with value-based reimbursements. The shift to value-based reimbursements has changed the fundamental mechanics of healthcare, which in turn has changed the rules for success. It’s really channel disruption on the scale of what Amazon did to retail and what Netflix did to video rentals.

One of the biggest takeaways from the meeting was that healthcare organizations can benefit from rethinking their value propositions as they operate in both a value-based and fee-for-service (FFS) environment.  It doesn’t have to be an either or proposition. In fact, providers that can identify the sweet spot between them can achieve the greatest success in terms of being innovators of quality, serving the most people in their region and in achieving financial growth.

Here’s how the two models can co-exist. For providers to succeed, they have to win at two distinct points-of-sale:

1) They must be the network chosen in risk-based agreements with payers and employers 

2) They must be chosen by patients who need healthcare services

To succeed in the first point of sale, providers need to extend their reach through new partnerships or clinical integration, and establish strong population health management capabilities – data control, healthcare analytics, care coordination and patient engagement. They can then leverage these capabilities to become a low cost, high quality and high access provider that gets selected for more public and commercial contracts. The addition of new contracts plus the ability to generate shared savings from those contracts is an attractive proposition for providers.   

To succeed in the second point of sale, providers have to innovate by appealing to patients as consumers of healthcare services. Providers can increase utilization of preventive and other necessary services by considering patient needs and solving the dissatisfaction with how they obtain healthcare services today. There’s many different ways a provider can approach this such as by offering telehealth services, or creating specific packages tailored towards certain conditions such as diabetes management that includes blood tests, exams and nutritional services.  It can be as simple as communicating better with patients and reminding them to come in for regular exams. Providers that appeal to patients as customers can build loyalty, which is critical because it’s often easy for patients to change where they get their health services.

The Advisory Board national meeting was a great check in on the pulse of the industry leading in to HIMSS where I look forward to continuing the discussion. Caradigm will be hosting several panel discussions in our booth (#7307) that will feature industry experts as well as the sharing of third party survey research related to population health, ACO best practices, DSRIP and data privacy and security. You can check out the full schedule of Caradigm events at HIMSS here.

The Future of Healthcare – Patient Engagement is Due for a Paradigm Shift

Post by Beth Sutherland, RN, BSN

Clinical Product Manager, Caradigm

Just as healthcare is making the shift from volume to value, the concept of Patient Engagement needs to be reimagined in several important ways:

View patients as healthcare consumers with varying levels of engagement in their own care…
Some patients will actively choose how, where and when to access healthcare based on cost, quality data and other patient’s reviews. They expect personalization and patient-centricity from their healthcare providers, and make decisions based on being directly responsible for healthcare costs.

Other patients may feel overwhelmed by managing their health and will require a more guided and supportive approach to understanding, monitoring and potentially confidently managing their conditions at some point.

Acknowledge the impact of factors such as behavioral economics in decision-making…

The reality is people often don’t make rational decisions – in fact, many irrational factors influence thinking such as:

  • Status Quo bias: “This is what I’ve always done…”
  • Complexity Aversion bias: “Too many factors to consider…”
  • Present Time bias: “Going to the gym now is too hard…”
  • Peanuts effect: “It was only 1 donut a day (for 10 years)…”

Important health-related behavior changes need to be framed for patients in recognition of these biases – the long-term impacts of old habits can be re-framed relative to current goals, incentives can be created to establish more immediate payoffs for difficult changes and seemingly overwhelming tasks can be broken into a series of smaller, achievable wins that build confidence and belief that “Yes, I can do this.”

Health goals and behavior changes must be made relevant to each patient by relating them to individual, personal priorities:
For behavior change to occur, care has to fit meaningfully into patient’s lives. Patients are motivated more by personal goals rather than potentially overwhelming healthcare metrics. Patients care more about spending time with their grandkids or being able to walk their dog rather than controlling blood glucose levels or lowering blood pressure. By understanding these priorities and reaching patients with relevant, personalized messages at the right time outside of the care setting, the likelihood of successfully triggering positive health-related behaviors increases dramatically.

For success in population health management to be achieved, Patient Engagement must evolve from being a non-essential, ‘nice to have’ function to a critical driver of success. By clearly demonstrating the value and ROI that patient engagement can bring to the management of populations, the role that patients play will finally be recognized – for the impact it can have in their own success and that of care teams. When patients are truly activated to participate in their own care and own the management of their health, the industry will be transformed.

How Some Accountable Care Organizations (ACOs) are Taking the Lead

Post by Christine Boyle

Senior Vice President of Marketing, Caradigm

The number of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) has continued to grow steadily as there are now approximately 405 participants after the latest wave of 89 newly accepted applicants.[i] Participating as a MSSP ACO gives healthcare organizations a low-risk means to start transforming to value-based care while they change processes and acquire new health IT infrastructure. Although the program is still fairly new, having only been around since 2012, about 25 percent of ACOs have started to separate themselves from the pack by being able to generate shared savings.[ii]

Being able to generate shared savings is crucial for ACOs because the underlying premise of value-based care is that coordinated, preventive and evidence-based care will both improve the health and  lower the per capita cost of a defined population. Furthermore, the sharing in cost savings helps offset reductions in fee-for service revenue, pay for new health IT infrastructure, and builds organizational momentum for the expansion of risk-based contracting. However, generating shared savings has been an elusive goal for the majority of MSSP ACOs to date.    

Dr. Randall Williams, MD wrote an interesting article on this topic recently on Pharos Innovations discussing why most ACOs have fallen short of generating cost savings. His hypothesis is that “…most ACOs are still working on basic organizational issues like:

  • Integrating their doctors
  • Getting CMS claims data into a format that can be analyzed
  • Documenting and reporting quality performance metrics

While that work is necessary, it is not at all sufficient. It won’t generate the cost savings required to get to the shared savings bonus opportunity.” [1]

Dr. Williams believes that the ACOs that have been successful in generating shared savings have focused heavily on reducing avoidable admissions and readmissions.  He makes an excellent point that ACOs need to transition from a tactical focus on operationalizing their ACOs to a strategic one that will drive greater results. 

Transforming to value-based care is a complex process because it impacts the entire organization. For ACOs to achieve greater results they have to move away from siloed efforts and approach value-based care as a series of interconnected activities. It is not just solely about data, not solely about analytics and not solely about clinician workflows. It’s about all of those activities operating in an integrated manner and augmenting each other. This is known as an enterprise population health approach that integrates data, analytics, and workflows across the entire organization to support new care models. An enterprise approach leads to synergies and efficiencies across the organization that are the difference makers when trying to drive results as quickly as possible for a targeted population.

2015 is a critical year for ACOs to hone in on the strategies and health IT infrastructure that will help them move into the leaders group of ACOs generating shared savings. We have just published a new whitepaper entitled “ACO Best Practices for Shared Savings” that explores this topic more by profiling the strategies used by a few successful ACOs and recommending what ACOs could be doing differently this year.

Download the whitepaper here.

[i] Evans, M. (2014, December 22) 89 ACOs will join Medicare Shared Savings Program in January. Modern Healthcare. Retrieved from

[ii] Kocot, S., Mostashari, F., White, R. (2014, February 7) Year One Results from Medicare Shared Savings Program: What it Means Going Forward. Retrieved from:

[iiI] Williams, Randall, MD. Want to win with value based purchasing? Start with the fundamental challenge. February 2015.

The Future of Healthcare: Innovating Coordinated Care

Post by Scott McLeod

Director of Product Marketing, Caradigm

One of the most impactful developments in healthcare today is the movement towards coordinated care. It’s essential as more healthcare organizations engage in population health management and participate in a broader health network with a variety of partner providers. Many providers have recognized that the care of a high-risk patient is a team-based activity that requires the coordination of a variety of clinicians and care givers serving different roles. It also involves a series of processes – intake, screening, assessment, developing a plan of care, reviewing a plan of care, making contact with care givers, reviewing medications, etc. To deliver the best patient outcomes possible, providers need to ensure that these processes are being completed efficiently and consistently across the team.  

The idea of coordinated care is not new, but being able to deliver it effectively is starting to become a reality as new health IT emerges to help enable it. A care team is made up of a diverse group of clinicians and family members that can include primary care physicians, specialists, a lead case manager, an in-patient case manager, a field coordinator that works on non-clinical tasks, a pharmacist, community organizations, and family and friends that may be providing support such as transportation or helping pick up medications. That’s a lot of people and a lot of information that is needed to properly care for just a single patient. Multiply that by potentially thousands of patients in a care management program, and it becomes clear why coordination and efficiency can be challenging.

Here’s how health IT can innovate care coordination. First, it brings together all the data and information needed to care for a patient from all systems across the health network. All care givers have a 360 degree view of the patient that includes the plan of care, medications, lab results, vitals, documents, immunizations etc. When an update is made, all care givers have that update in real-time. With a full 360 degree view of patients, the care team can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient-centered care by incorporating patient personalized goals.

Second, it transforms the efficiency of clinician workflows, which leads to increased productivity and consistency of care. Physicians can see care gaps and close them while still in the presence of a patient. Care plans, task lists and interventions can be automatically generated from the patient’s clinical information and assessment responses. Complete medication histories can be brought into single patient views that display order and fill history for easier review. Patients that may need immediate attention can also be tracked across the continuum through event-based alerts (e.g. admissions, discharges or Bluetooth device alerts). Lastly, all of the needed tasks are being assigned to the right team members assuring “top of license” activity.  

From the patients’ perspective, they’re on a better path to become healthier as they receive care focused on wellness and preventive measures. They’ll also receive a better patient experience as they don’t have to repeat answers and all care givers are up-to-date on their information. Care coordination is one of the foundational strategies healthcare organizations must employ to achieve the Institute for Healthcare (IHI) Triple Aim of 1) Improving the patient experience 2) Improving the health of populations and 3) Lowering the per capita cost of care. With a little help from innovative new health IT, coordinated care can become a reality.