Table of contents/Highlights:
How Seamless Interoperability Improves Outcomes: A Patient Story
Betsy Johnson* is an active 68-year-old retiree who recently moved from Maryland to Massachusetts to be closer to her son Charles. Although she suffers from several chronic conditions, including diabetes, Betsy leads an active lifestyle that includes daily walks. Betsy is also a tech-savvy healthcare consumer who takes an active role in monitoring her health. She uses an app to track her blood pressure, she keeps up with her medication through reminders, and she tracks her steps and heart recovery time with an iWatch.
When Betsy had a stroke and fell while alone in her apartment, her iWatch automatically called 911 after she remained unresponsive for over a minute.
What makes Betsy’s case different is that as she made her way through the healthcare system following her stroke, her providers all had access to her most current clinical data. This allowed them to provide her with the best care. This solution was enabled by a patient-centric clinical record that accompanied Betsy as she travelled from one facility to the next.
Betsy was lucky. Poor coordination among care providers and a lack of access to current and accurate patient data can have deadly consequences. Fifty percent of the time crucial information, such as medications, equipment needs, or the presenting problems are not available when the patient arrives at a facility.
In this story, the payer who provides Betsy’s Medicare Advantage Plan offered an innovative program to help reduce overall healthcare-related costs and improve her outcomes. Initially this was part of a pilot provided to Medicare patients, who are more likely to have multiple chronic issues and encounter a transition of care event.
Powered by Smile Digital Health, a FHIR-based data and integration platform, and PatientShare, which enables secure data sharing, this system includes a longitudinal health record that follows a patient throughout their healthcare journey, and includes security, privacy and transparency features.
Prior to her fall, Betsy set up an account and made sure her son Charles was named as her healthcare proxy. The system includes patient-mediated exchange features powered by user-managed access and consent. This enabled Betsy to create consents about who could access her data. These computable consents enable the system, which includes patient-mediated exchange features, to immediately grant access to authorized users so that Betsy’s entire care team has access when needed.
The end result for Betsy was a seamless care experience, while her providers were empowered to make informed decisions about her care and treatment.
Step 1: The Local Hospital
After Betsy’s iWatch called 911, an ambulance arrived and Betsy was admitted to the local hospital. After assessing Betsy’s mental and physical status, doctors diagnosed her as having suffered from an ischemic stroke. Betsy’s designated healthcare proxy and emergency contact, Charles, was immediately notified. The hospital had access to Betsy’s clinical data to inform care, including her medication and problem list. Betsy remained in the hospital for seven days.
Seamless interoperability at work
Betsy’s current medical information from the health information exchange was pulled into the transitions of care data hub, via a Fast Healthcare Interoperability Resource (FHIR®) application programming interface (API). The hospital was able to access Betsy’s complete record from the data hub. Not only was the local hospital informed of Betsy’s medical history her healthcare providers could add more information into the data hub throughout her journey, including her assessments, discharge information and any new or altered medications, all using the FHIR API.
Step 2: The skilled nursing facility (SNF)
After a week at the hospital, Betsy was discharged to the local SNF. An up-to-date, accurate patient record was available to Betsy’s SNF providers by the time she arrived, enabling them to make decisions about her care informed by her recovery to date.
Upon admission, providers reviewed her record and ascertained her mental and physical state, creating new assessment records at the hub to reflect required CMS assessments. At the SNF, Betsy received daily physical therapy and emotional support to help her cope with concerns about the long-term impact of her stroke. Betsy gradually improved and after 20 days at the SNF (day 27 after the stroke and fall), she was discharged and permitted to continue care at home with home nursing services and physical therapy. A nurse performed a discharge assessment before Betsy left the SNF.
Seamless interoperability at work
Care providers at the SNF were able to see Betsy’s complete medical status, plus updated medication list, discharge information, and assessments from the local hospital. The detailed assessments informed clinicians’ of Betsy’s progress prior to arriving at the SNF. The assessments performed at the SNF were written back to the transitions of care data hub, along with other pertinent information, such as any changes in medications and the treatment plan from Betsy’s time at the SNF. All assessments performed at the SNF were transferred in order to properly inform her care going forward. Betsy’s primary care provider (PCP), other care team members, and family members were able to review her progress through the updated record.
Step 3: Home-based care
Once Betsy was back at home, a home health nurse visited her on a daily basis, and Betsy received physical therapy every other day. The nurse tracked Betsy’s vitals and progress at each visit. The nurse also completed assessments of Betsy’s recovery at predetermined intervals. Her notes updated Betsy’s record in the data hub so her PCP and family could see how her recovery is progressing.
The continuation of informed care at the home is critical to success after experiencing a chronic episode. Too often this can be a point of failure when medical records are not available. One study found that over 50% of patients discharged from an SNF experienced mortality or an acute episode within 90 days of leaving the SNF, in part because information was lacking to inform the transition. Luckily for Betsy, her home health nurse had the necessary information at her fingertips to provide informed care and help Betsy transition towards recovery.
As Betsy gradually became more active, she resumed walking in her neighborhood, tracking her steps on her iWatch. This data helped her physical therapist assess her progress.
Seamless interoperability at work
Betsy’s entire care team was able to track her progress through the updated record. Her family was also able to track her progress, allowing them to provide appropriate support. As Betsy continued to recuperate at home, her nurse and physical therapist tracked improvements in her condition. Her nurse and physical therapist tracked improvements in her mobility and updated the data hub.
The current state:
Insufficient data leading to gaps during transitions of care
While Betsy’s story is a success, it does not reflect the current standard of care. Without a comprehensive solution that centralizes all patient data and is accessible to patients, their family members, and healthcare providers, there are significant gaps in the system. Many patients who undergo a medical event involving several transitions of care have a very different experience from Betsy’s. These patients–and their providers and caregivers–grapple with a system where data is often fragmented or missing entirely, and where there’s an increased burden on patients and their families to provide medical information at points of urgent need.
Poor coordination among care providers and a lack of access to current and accurate patient data can have deadly consequences. According to the Coalition to Improve Diagnosis–comprised of more than 60 leading healthcare and patient advocacy organizations–incomplete communication during care transitions was identified as one of the main obstacles impeding diagnostic accuracy. An estimated 40,000 to 80,000 people die each year from diagnostic errors in US hospitals alone.
Without a patient-centric longitudinal record, medication discrepancies may also occur during transitions of care, leading to adverse events. According to one recent study, patients transitioning from a hospital to an SNF are susceptible to medication-related errors resulting from fragmented communication between facilities. The study revealed that at least one medication discrepancy was discovered in 77.6% of SNF and 76% of long-term care pharmacy medication lists. Of the 69 SNF staff interviewed for the study, 20.3% reported patient care delays due to omitted documents during the hospital to SNF transition.
Lastly, without a patient-centric longitudinal record, there’s an increased reliance on patients and their families to supply accurate information. Not only is patient recall unreliable, some patients may be unconscious and family members may not know a patient’s full medical history or list of medications.
Disjointed information, a lack of care coordination, and poor communication among providers can result in patients not receiving proper care, which in turn can lead to an adverse event and hospital readmission. Hospital readmissions are costly: In 2018, there were 3.8 million 30-day adult hospital readmissions in the United States (for all causes), with an average readmission cost of $15,200. These readmissions can contribute to readmission penalties; in 2020, a full 47% of hospitals had Medicare payments reduced due to such penalties. In the current environment, keeping records in sync across multiple care facilities adds administrative costs.
Seamless interoperability addresses these issues by supporting a patient-centric system that works better for patients and the providers who care for them. The FHIR standard enables interoperability and supports creating a complete patient longitudinal health record that achieves the goal of more effective and efficient care.
The future state:
A holistic approach to care enabled by seamless interoperability
Innovative solutions that address the challenges outlined above are built around the concept of a patient record following the patient to each location in the healthcare system. In Betsy’s case, her record travelled with her during each transition of care, accumulating data along the way. Current, up-to-date clinical data was available at each facility, properly informing Betsy’s care. This was enabled by PatientShare powered by the Smile data and integration platform.
Betsy’s case illustrates the importance of seamless interoperability supported by a FHIR-based read/write repository that enables data exchange in both directions. In Betsy’s case, this ensured a smooth transition between different facilities during her healthcare journey and empowered her providers to make more informed decisions, while reducing the administrative burden. Providers at each facility were always aware of her previous care along with any changes in Betsy’s condition, treatments, or medication list.
A 2019 Gartner Research report** states that “a new, more expansive view of interoperability is in order. It predicts how interoperability will facilitate the entire care delivery life cycle and go beyond sharing information.” The Gartner Research report further states that “effective care transitions involve successfully completing complex care arrangement scenarios that are now done via phone and fax and other means. These complex arrangements are driven by real-time patient-related events that could be more effectively and efficiently orchestrated through an appropriate set of FHIR APIs.” Software solutions that employ FHIR APIs, like PatientShare, are key in enabling the transition from moving data around to orchestrating workflows.
PatientShare provides the option of adding another level of interoperability called Patient-mediated Exchange. This approach uses the HEART standard, which is a set of profiles that enhance the underlying standards of FHIR, OAuth, OpenID Connect and UMA (User Managed Access). Together, this approach puts the patient, or their proxy, in control of their data exchange while providing extra levels of security, privacy and transparency.
It works like this: The patient creates an electronic consent defining what she wishes to share at a granular level, with whom, and for how long. A “granular level,” refers to the patient deciding which parts of her data she wishes to share. PatientShare further provides a summary of her consents and an easy system to manage them. Built-in transparency enables the patient to see who has accessed her data and when.
On the receiving side, if a user has been granted permission, they would sign in, prove they are who they say they are, and would then have immediate access to any data shared with them. They would have access only to data that was explicitly shared by the patient.
PatientShare integrates with external identity providers, recommending that installations require a high level of authentication. Users are identity-proofed only once in advance using high-level multi-factor authentication, to ensure users are who they say they are.
Standards-based solutions that employ FHIR APIs, like PatientShare, facilitate collaboration across disconnected healthcare systems. These solutions go beyond enabling secure sharing of clinical data: the software also helps patients engage in their own care and can support adding patient-generated data to the picture.
We are now at an inflection point where the goal of secure seamless interoperability can become a reality, thanks to these advancements, which are brought to life in game-changing health technologies like PatientShare, powered by the Smile FHIR data platform. These solutions are not only bridging gaps in the healthcare system, they’re helping transform the health technology landscape. The result is better outcomes, greater transparency, more effective care collaboration, a reduced burden on providers, an improved patient and family caregiver experience, and lower costs for healthcare systems.
*Betsy Johnson is a fictional person, but her story is illustrative of real patients’ experiences.
The original persona for Betsy originated with Patient Centric Solution’s (PCS) early work with the PACIO work group where they focused on exchanging CMS assessments across care facilities. PCS then expanded the story to showcase a patient record that follows the patient and includes having Betsy create consents to enable secure access to her health data.
** Healthcare Provider CIOs: Shift Interoperability Strategy From Moving Data to Orchestrating Workflow, Barry Runyon, Gartner, February 25, 2019