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Care coordination and interoperability between health data strengthens levels of care and reduces healthcare costs.


Christopher Jason


Driving care coordination is essential to providing a quality patient experience, helping to tie together patient care at the many healthcare facilities she may visit. But limited health data and EHR interoperability can get in the way, limiting providers’ ability to access patient information from disparate facilities.

Interoperability enables care coordination to deliver a patient’s health data from multiple providers and specialists. With patients attending different hospitals and specialists, the need for interoperability between multiple providers is key. Coordinated care reduces healthcare costs by eliminating repetitive tests and procedures.

Strong EHR use is found at the primary care level. However, it is still a work in progress at acute and post-acute hospitals.

Care coordination crucial to cohesive primary care

Strong EHR use is key for better care coordination between primary care and behavioral health specialists, said researchers in a 2017 study published in the Journal of the American Board of Family Medicine.


The study found that 67 percent of individuals with behavioral health (BH) disorders do not receive the care that they need, but when their care is integrated into the primary care setting, that issue typically improves.

“Most patients with BH conditions, including children, are seen in medical settings, most commonly primary care (PC), presenting the need and opportunity to replace separated systems of care that do not adequately meet the needs of patients with integrated, ‘whole-person’ care,” the researchers explained.

Integrating and coordinating specialty care — in this case behavioral healthcare — into primary care relies on EHR use and interoperability. Interoperable systems allow providers to access valuable clinical information from other providers who have previously treated the patient.

“Establish standard processes and infrastructure necessary for your integrated care approach: workflows, protocols for scheduling and staffing, documentation procedures, and an integrated EHR,” the researchers recommended.

And ultimately, this will streamline patient care. Interoperable systems between specialty and primary care providers ensures the specialty provider understands the patient’s current health conditions and can make informed medical decisions.


For example, when specialty providers can access the patient’s complete medical history, they can avoid re-testing and ensure that the patient receives the best care right away.

“This allows the caregiver to quickly find information about that patient and who’s responsible for them,” Mobile Heartbeat Vice President Jamie Brasseal told EHRIntelligence.com. “Providers can communicate with the appropriate colleagues — such as specialists or pharmacists or case mangers — very quickly, and without having to leave the patient’s bedside, or go search for that information at the nursing unit or in the EHR.”

Care coordination improving at acute care hospitals

Patients do not always receive acute or emergency healthcare in the same facility where they receive their primary care, which can create some data exchange challenges for acute care providers. With patient data stored in disparate systems, acute care providers can be left without critical information off of which they can base medical decisions.

In a recent survey from PointClickCare, 49 percent of acute care providers said they have very little ability to access or share patient data electronically, resulting in a struggle for providers.


“With better communication between the facilities, we would cut back on readmission and sending patients back to the ER and any sort of miscommunication,” said one participating hospital executive.

Reassuringly, many acute care hospitals are investing and focusing more on improving its data exchange efforts.

Seventy-three percent of acute care providers said they are putting a higher priority on implementing interoperable systems for transferring patients.

“Streamlining interoperability between systems creates huge opportunities for cost reduction, patient care improvement and reduced workloads for people on both ends of patient transfers,” researchers said.

“This type of health data exchange also helps improve the transparency of data between acute care and skilled nursing facilities, enabling a stronger relationship. And, it enables robust, population health capabilities that are scalable as the number of patients needing post-acute care grows.”

In a 2018 report from the ONC, 83 percent of hospitals that had the capabilities to send, receive, locate, and integrate patient health information from outside organizations into their EHR systems reported having the ability to access information electronically at the point of care.

“This is at least 20 percent higher than hospitals that engage in three domains and almost seven times higher than hospitals that don’t engage in any domain,” wrote Don Rucker, MD, national coordinator for health IT and Talisha Searcy, director of research and evaluation.

Educating the staff and providers on EHR use and information exchange will benefit the team in the long run and provide better care for patients in acute care

Promoting better EHR adoption in post-acute care

Interoperability challenges can follow patients and providers out of the hospital and into the rehabilitation process. Provider access to information about a patient’s acute hospital stay will be integral to quality post-acute care, but many providers see bumps along the road.

That same PointClickCare survey revealed that 84 percent of post-acute care organizations are still using at least some manual processes to exchange patient data with acute care hospitals. Organizations relying on fax, email, and paper-based solutions to exchange patient data could encounter mistakes, mismatched patient data, or omissions that could seriously hinder patient care.

But the Centers for Medicare & Medicaid Services (CMS) is working to address that gap.

After prompting nearly universal EHR adoption in acute care facilities, CMS is promoting widespread EHR adoption in post-acute care (PAC) settings.

In March 2019, the federal agency released a request for information (RFI) seeking input about the best ways to incentivize EHR adoption and use among providers in the post-acute setting

“PAC facilities are critical in the care of patients’ post-hospital discharge and can be a determining step in the health progress for those patients,” stated CMS in the RFI.

“Interoperable health IT can improve the ability of these facilities to coordinate and provide care; however, long-term care and PAC providers, such as nursing homes, home health agencies, long-term care providers, and others, were not eligible for the EHR Incentive Programs under the HITECH Act,” the federal agency explained.

CMS partly attributes the slow rate of EHR adoption in PAC settings to the lack of federal incentives available to PAC providers.

Nearly 65 percent of skilled nursing facilities used an EHR system in 2016, but rates of health data exchange remained low among this population of providers. Only 30 percent of skilled nursing facilities participated in health data exchange, and only seven percent had the ability to locate and integrate patient health data into patient EHRs.

The inconsistency between rates of EHR adoption in acute and ambulatory care settings and PAC facilities partly contributes to problems with transitions of care.

“For PAC facilities that do possess EHRs, vendor adoption of interoperable functionality has been slow and uneven,” stated CMS.

As the medical industry continues to become increasingly digital and complex, it will be essential for disparate organizations to have systems for exchanging data. Interoperable tools will help drive care coordination between primary care providers, specialists, and acute and post-acute care organizations. And in doing so, clinicians can work to drive whole-person health and efficient, quality care.