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Posts tagged with "care coordination"

Care Coordination, The Holy Grail of Good Medicine

Appropriate patient care revolves around a team of individuals that includes the patient, a variety of clinicians and other providers, caretakers and patient advocates. The members of this team must collaborate to ensure that the best possible decisions are made on the patient’s behalf. As clinicians, scientists and innovators develop new technologies to redesign health care to make the patient experience more efficient, effective, and better, coordination of care with the patient at the center must always take priority.  Some of the hallmarks of care coordination include:

• Is there proper communication and full information sharing going on?
• Is one provider serving as the gatekeeper, insuring that everyone who should be involved is kept informed?
• Is care well- coordinated, particularly when there are multiple providers and in pre- and post-operative situations that involve teams of clinicians:  primary care, specialists, nurse practitioners, Fellows, etc.

My recent experience at MGH represents care coordination at its best. In 2014 I had a total hip replacement.  At the end of June 2017, upon return from a trip to Japan that involved extensive climbing and walking, my hip suddenly became extremely painful. What could this be?  By the time I returned to the US I was running a fever. I contacted my primary care physician and my hip surgeon. Blood tests revealed that all of my inflammatory disease markers were significantly elevated.  Additional tests including MRIs of the hips and back and blood work that tested for metal in my system indicated that the painful hip was filled with fluid. That was drawn out by a team of radiologists.

Care coordination for all of this fell to my hip surgeon who set up an email chain that included my primary care doctor, my rheumatologist, my back surgeon, the radiology team and ultimately a specialist who performs hip revision surgery. Additionally, I was kept in the loop by the surgeon who texted me at least three times a day to check on my fever, pain level, how I was feeling and to keep me appraised of test results as they came in.

All of the tests on the fluid that was withdrawn from the hip came back negative for infection. I was presenting with a very unusual case of an individual whose hip protheses that was put in place in 2014 was deteriorating. Metal was flaking off into the muscle tissue which in turn caused the large pool of fluid to collect. This was a very rare occurrence   The hip surgeon who had done thousands of total hip replacements using the same prothesis told me that six of his patients over a period of several decades had developed this problem.

On September 8, I had surgery and am recuperating with all of the restrictions regarding mobility that hip surgery requires.  Although the underlying cause of this problem remains a puzzle to everyone on the team, I continue to be totally impressed with the quality of care that I received.

I attribute such good coordination to the fact that I get all of my healthcare in one location where my many clinicians can email each other and view the notes in a common health record, enabling them to work together for smooth coordinated care. In my situation, which was by no means clear cut, everyone was focused on what the best course would be for me, the patient, and I was kept informed and consulted at all times.

The availability of the MGH patient portal also made it easy for me to track all of my labs, tests and provider letters.  I was able to send off quick communications to my clinicians when I had questions, I was able to schedule and view appointments and find links to helpful information.

All patients want health care experiences like this. The factors that made it possible were as follows:

1. Easy to use tools that enabled quick and effective communication with my providers, including mobile apps that enabled me to enter updates and access the latest information.

2. The appropriate resources and instructions that enabled me to manage much of my own care.

3. Transparency in all aspects of my care.

In summary, coordination of care is made much more difficult when all of a patient’s providers are not under one umbrella organization.  However, it remains an essential hallmark of good medicine that needs to be given much more attention than it currently receives.  Care coordination will not happen without the active participation of the patient, and it is critical that clinicians and providers everywhere embrace that practice.  It is also essential that going forward, patients, clinicians and medical institutions work together to achieve as much transparency in care practices as possible, so that everyone is on the same page and there are no surprises.

Collaborative Teams that Include Patients Make Care Coordination Possible



Care coordination requires that the right information reaches the right people within an optimal time frame, so that a  patient’s full information is always at the point of care, and all of the follow-up clinical work, as well as the claims processing behind it, is in place.


This system works pretty well in a contained  health care setting such as Kaiser Permanente, the VA or Group Health in Seattle,  that has an established digital health record, a viable patient portal and a committed patient population that works with their providers to insure their care coordination.


For the rest of the health institutions and group practices in this country that are not in a contained health care setting, care coordination is difficult at best. There is no question that electronic health records, patient portals and health information exchange  that provide  access to patient information are critical for care coordination.


Although these are in place in many practices; absent in many others, it is not enough.There has to be a culture of cooperation between physicians and patients that is often missing.


Today, communication of  orders for care, health histories, lab results, treatment information, medications, allergies and other vital data are often missing when the patient arrives to receive care.


How can that change?


(1) By having the tools for collaborative exchange of information in place. With cloud computing there are no longer bandwidth restrictions for enabling these technologies, although the costs have to come down. Even with the tools in place, there has to be the desire on the part of the all of the stakeholders in the provider community – primary care physicians, specialists, hospital administrators, pharmacists, labs, payers, and patients – to  work together to address this problem and take appropriate actions to make it happen.


(2) By involving  patients, encouraging them to establish personal health records, and enabling them to assume some of the responsibility for bringing their  information needed at the point of care with them so that it is available when they seek care. There are three distinct configurations available to individuals who want to establish personal health records:


(a) Stand alone data repositories that enable patients to create their own personal health record, and store and maintain it on a secure web site (e.g. WebMD and Revolution Health).


(b) Tethered systems that are an extension of an individual’s provider health record which the individual can access through a portal. (e.g.PHRs created at a payer’s web site)


(3) Interconnected PHR, an external repository of an individual’s health  data created by the individual(e.g. Microsoft Health Vault or Dossia).


We cannot assume that patients are going to remain passive recipients of health care, leaving it to their providers to worry about coordination of care. Patients can, and  must become part of the team that is managing their health.  They must take positive actions to assume control over their health information so care coordination  will become a reality and patients will receive better quality, safer health care.


Join me as I discuss patients portals and their role in patient engagement and collaboration.