How to use telehealth and EHR solutions to bridge primary, specialist and hospital care delivery

Lisa is one of the 422 million people worldwide living with diabetes. This morning she woke up with a headache. As expected, she worries that the headache could be related to her condition. Perhaps, it’s a sign of hyperglycemia (high blood glucose)? She’s uncertain how to proceed. 

Should she check her blood glucose levels? Afterwards, should she call her GP, or her endocrinologist? Is it merely a simple headache from stress or dehydration? Something she ate? The beginning of a migraine? 

Is she mis-managing her condition? 

For Lisa, the long-term implications of how she manages her patient journey really matter. For instance, if untreated, hyperglycemia could result in ketoacidosis, otherwise known as a diabetic coma. In addition, a poorly-managed diabetes condition increases her risk for serious health consequences such as kidney damage, blindness, and the number-one cause of death, cardiovascular disease. 

How patients became healthcare “project managers”

In recent decades, we have witnessed a trend in medicine: specialization. Care providers specialize in a particular area, niching themselves to expertly solve complex and specific health issues. On one hand, this makes a lot of sense. If you’re having problems breathing due to asthma, likely you prefer to see an allergist who puts all their professional energy into treating this specific condition. 

On the other hand, this trend is not without drawbacks. In a revealing opinion article, oncologist, author and Fulbright scholar Ranjana Srivastava points out that this “invaluable technical craft” of specialization also has disadvantages. This “super-specialization” has contributed substantially to creating healthcare silos, which create administrative inefficiencies (e.g., losing patient data when switching providers or duplication of services) and also impact the quality of care.

“With GPs being forced to refer people living with diseases to specialists without having the time to integrate and analyse all the results, functional silo syndrome is almost guaranteed to be endemic.” (Laurence Sperling / World Economic Forum)

Between fragmented care silos and PCPs stretched too thin, there’s nobody to connect the dots, to coordinate care between primary care units, specialists and hospitals, or to disseminate information between data systems. 

That leaves the management of a patient’s journey to…the patient. The one stakeholder in this care-ecosystem who (likely) lacks medical expertise and training and who may be experiencing illness-related stress and trauma, the patient, is now responsible for this crucial task. It’s clear, we need a better solution to bridge the gaps between provider silos without putting the burden on patients.

Solutions to bridge the gaps and holistically connect care delivery

The ESRD program at Boston’s Brigham and Women’s Hospital serves as an interesting case study in addressing care delivery fragmentation. This program coordinates the care journeys for patients with end-stage renal disease (the gradual failure of the kidneys), a condition that between 10 to 40 percent of diabetic patients will face—don’t forget about our patient, Lisa. 

For this program, a specific nurse is in charge of hospital discharge assessments for patients, documenting all relevant information and then communicating this information to PCPs, dialysis units, and other specialists. If a patient is admitted to the emergency department (ED), this nurse provides patient information to the ED team. Additionally, the program nurse helps facilitate placement on transplant waitlists.

The results of this program speak for themselves. Between 2016 and 2019, high-risk patients experienced five fewer ED visits/hospital admissions on average per year and the program saved twice the amount that it cost to run it: “We calculated $428,000 in savings from 74 avoided ED visits and 34 avoided admissions, and over $1 million in savings attributable to facilitated transplantations.” 

What was the critical component from this successful case study? There was a centralized single source (the nurse) communicating important patient information to all providers involved.

The importance of seamless access to information and data 

A major component to bridge care delivery gaps is centralized information sharing, and this is where technology comes in. In a call for integrated care to bridge silos, Laurence Sperling, professor, doctor and chair of a World Heart Federation group, states:

“One of the most urgent actions to be taken is to improve access to patient data and medical information across all care teams. Technology is critical for this […] The tools exist, so these must be put in place.”

Dr. Sperling then specifically identifies virtual healthcare, explaining how it can offer systems that ensure “that not just raw data but analysis and insight is shared across medical teams.” We agree. Digital healthcare options are key to facilitating and scaling information sharing, and we have two specific solutions in mind.

Telehealth and EHR (electronic health record) solutions

Let’s jump back to Lisa’s situation to illustrate how these two solutions work together. 

Through 24Health’s telehealth solution, Platform24, rather than going it alone, Lisa has the help she needs, when and where she needs it. Using Platform24, she can:

• access patient resources to learn more about headaches in diabetics
• review her blood sugar levels through continuous, real-time remote monitoring 
• message her care team from home through the app, which based on her specific condition and current symptoms is automatically triaged to the appropriate medical provider
• “visit” via video or in-person with a PCP or specialist (based on triaging), who can offer advice, a treatment plan, or a prescription 

Any information she self-reports, the data from remote monitoring, her medical history, and the notes, analysis and prescribed plan by her medical providers are stored in a centralized EHR system. This EHR system is accessible through the single entry-point platform to everyone involved in her care delivery: Lisa, her family if she chooses, her PCP, specialists, clinics, and hospitals. 

When seamlessly integrated, these two solutions can significantly improve information sharing between fragmented departments and specialists. No longer burdened by the stress or time costs of “project manager,” Lisa can now relax and concentrate on improving her health habits. Knowing that all the information is up-to-date and easily accessible in a centralized record, her professional care providers can get the whole patient picture, communicate easily with colleagues in the same interface, and truly provide holistic care. 

We have the tools to substantially enhance care delivery by connecting healthcare silos. Let’s finally put them together. 

—

Connect with us about the topic of EHRs and the Digital “Front Door,” and read more about the benefits of EHR/Telehealth collaborations.

Written in collaboration with Amy Harris