Critical to the success of any community-wide high utilization program is the ability to share pertinent information amongst community members.  This is particularly challenging within the healthcare industry, where health systems utilize a wide number of information platforms and information is rarely shared across platforms.  And added to this we must consider the sensitive nature of the psychosocial issues experienced by high utilization patients, often encompassing issues such as behavioral health and substance use, which carry their own set of regulatory compliance guidelines around information sharing.  Most community care systems – hospitals, jails, law enforcement agencies, out-patient medical providers, mental health institutions, substance treatment programs, court systems, and housing authorities (to name just a few) – have transitioned to electronic record-keeping, but in most cases information sharing is very limited within systems of care (say, between hospital, or between law enforcement agencies), and extremely rare across systems.

Being able to share pertinent information amongst all members of a care community is critical; if we can’t share information, we might all be working towards a common goal, but we are essentially speaking different languages, with a very limited understanding of what each other is doing.  This invariably leads to poor organization, duplication (often multiplication) of efforts, and ultimately wasted community time and resources.  Multiple agencies may be doing great work, but often in a vacuum, with the patient lost amongst an array of poorly coordinated efforts.

To help facilitate greater success, CBC Solutions recommends Collective Medical to make this critical information sharing possible. The Collective Platform seamlessly connects each member of a patient’s care team together for effective collaboration on even the most complex patients. Their platform empowers physicians, nurses, and other care providers to improve the quality and efficiency of patient care through actionable real-time patient notifications. Their nationwide network of engaged care team members offers transparency for providers through patient histories and collaborative care plans—identifying vulnerable patients in real-time and helping care teams address their needs at the point-of-care.

Fortunately, within the last decade, significant progress has occurred in implementing systems of “common language” across communities.  Many health systems now have electronic record systems that can be shared amongst all members of that system, and regional government programs have provided much-improved data sharing in certain target communities. But arguably the greatest progress has occurred via the adoption of platforms that allow for HIPPA secure data sharing across institutions, care systems, and in some cases across the county and state lines.   It is very common for an emergency physician to have access to care plans, recent visit histories, and information on prescriptions that may have been filled even earlier that day when certain platforms are in use within or across states.  In the state of Washington (where I reside and practice) we experienced a 15% decrease in frequent utilizer emergency department visits just by the implementation of a state-mandated common data-sharing platform in 2011.

We feel the criteria for a valuable community-wide IT platform include:

  • Ability to interact with all community electronic medical records
  • Ability to engage with state Prescription Monitoring Programs databases
  • Serve as a portal for prompt sharing of customized patient care plans
  • Allows for data sharing across state lines
  • Can be shared with multiple community partners in HIPPA compliant fashion
  • Immediate access by appropriate end-user providers – Emergency department personnel, admission hospital personnel (hospitalists, social workers and hospital-based care coordinators), and out-patient providers (primary care providers and patient care specialists)

A high functioning common community IT platform is a critical component in the success of any community-based high utilization program. CBC Solutions is proud to partner with Collective Medical to facilitate a successful outcome for communities.

You can review other Community High Utilization Program Best Practices, and find additional information HERE.