A clinician friend likes to joke: “general family practitioners know nothing about everything, and clinical specialists know everything about nothing.” All jokes aside, the complementary nature of the generalist/specialist teams is needed in healthcare today more than ever. Given the continued specialization of healthcare, there is tremendous pressure to make this model work when delivering patient care. Specialization has significant impacts when we consider the already inherent complexity of the healthcare system, and complex patients specifically.
The Continued Specialization of Healthcare
The continued specialization of healthcare is mutually reinforcing in today’s marketplace. Healthcare is structurally organized by specialty and independent practices; reimbursements are implemented by specialty; and quality, certifications, and compliance policies are governed by specialty. In addition, medical schools and health research continue to give rise to new areas of specialty and study. Even primary care (the generalist of health care) is now often split between hospitalists and outpatient clinics. There’s no stopping it. Today, if you’re going to interact with the healthcare system, chances are you and your family doctor will interface with multiple people across multiple care settings.
The Promise of Division of Labor Has Had Mixed Results
It’s well proven that the division of labor into specialties is generally more efficient. Think of an assembly line where each person focuses on doing one step in the assembly vs. everyone trying to do all steps. This premise has been true for healthcare in many cases, especially as it relates to new research, treatments, and advancements – all requiring deep specialization. However, it has not always worked well when delivering care to real-world patients who find themselves and their family physicians interfacing with multiple people and care settings.
A Massive Opportunity For a Unified Consumer Health Platform
Today, complex patients with more than one condition account for a disproportionate percentage of healthcare costs. These conditions can cut across several different specialists. Specialists often find themselves acting in isolation with incomplete information, adding care complexity for both providers and patients. This can lead to fragmented results, duplication, adverse drug reactions, incompatible treatments, iatrogenic illness, and poor health outcomes. The situation can easily get exasperated in smaller communities with specialist shortages and the need to go further afield to access the required specialist.
Additionally, behavior health care and community support for Social Determinants of Health (SDoH) can be even more disconnected from the patient’s overall care plan. This is significant considering patient lifestyle choices and psychological factors heavily influence most chronic conditions.
Enterprise-wide EMRs and EHRs covering inpatient and outpatient care settings have come a long way to help physicians be aware of diagnosis, prescriptions, and treatments from other specialists. This solution works well for the delivery of episodic care. However, it can fall short as it relates to ongoing care delivery, with changing conditions over time.
Under many circumstances, individual providers may not be immediately aware of all testing, treatments, prescriptions and actions being taken by other providers for the same patient. In effect, patients often receive multiple siloed care plans from the healthcare system.
Continuity Imperatives for Healthcare Systems
There have been several studies on continuity of care since care settings became more disparate. However, many resulting initiatives fall short, often focusing on adding new roles and/or processes, making only marginal improvements in outcomes. To be effective, solutions need to include policies, organizations, roles, processes, and technologies, that all come together to meet the following key imperatives:
- Information Continuity. This is the availability of all relevant, past, and present patient information to help make informed and more appropriate provider care decisions. This typically means that the solution can take advantage of information acquisition from disparate data sources, including other providers, behavior health specialists, community care managers, patient generated data, and patient device data. The data needs to be aggregated for viewing at the point of care in a timely fashion.
- Patient Care Plan Continuity. This includes the collaboration between providers to rationalize multiple treatment plans into a single compatible, coherent plan and to manage health conditions in a way that is responsive to a patient’s overall needs. This typically means that the solution is able to provide electronic forms, clinical documentation, provider collaboration tools, and digital communications to allow providers to collaborate on an interoperable patient care plan with the support of a care coordinator or general practitioner. The interoperable plan supports specialty treatments by individual specialists within a single compatible care plan for the patient.
- Care Delivery Continuity. This includes the engagement, prioritization, coordination, and execution of integrated clinical services that is responsive to the patient’s changing needs. The preferred solution can provide case management, assignments, notifications, alerts, patient measures, patient timelines, population views, clinical workflows, and reporting features with the support of a care coordinator or general practitioner.
- Patient Engagement Continuity. This includes the patient participation in their care plan and how they experience health services. The ideal solution supports patient access to their care plan and other related information anywhere from any device. The preferred patient portal solution includes: provider-circle-of-care network, family-circle-of-care network, self-registration, self-scheduling, telehealth, secure messaging, collaboration tools, health communities, health education, to-do’s, reminders, notifications, alerts, patient generated data, patient device data, remote patient monitoring.
Continuity imperatives above are dependent on each other. A Continuity of Care Plan is more effective if it’s based on all the relevant information available. At the same time, Continuity of Information is more complete if it includes patient generated information from Continuity of Patient Engagement.
Strategic considerations should include continuity imperatives above when considering a solution for delivering healthcare services to patients across multiple care settings in a typical health system.
Are you looking to reduce patient friction and improve continuity of care? The Healthfully Unified Consumer Health Platform can help your organization deliver benefits and patient engagement across the industry by enabling the end-to-end patient journey, from initial intake to ongoing delivery of services and beyond. Book a free demo with a solutions expert to get started.
Healthfully integrates with your organization’s existing enterprise solution to enhance your patient and provider experience for the following: intake and registration, scheduling and appointments, payments, telehealth and communication, patient health and wellness records, health and wellness management, advanced analytics and BI reporting, and more.