Health systems struggle with fragmented systems of care. Interoperability between hospital and primary care physicians’ data is often lacking, resulting in
To enable effective integrated care, patients, hospital physicians and referrers should have access to relevant data sets via secure digital front doors. Caregivers should be supported with remote assistance and telehealth and home monitoring should be used to improve patient outcomes.
1. Limited use of person data and social determinants in care plan
Enable patient self-management:
Give patients the information they need to improve their self-management. Healthcare providers should create or partner with existing health and wellness platforms to keep patients informed about and engaged with their own care.
2. Limited engagement outside of healthcare setting
Expand use of tele-health and home monitoring technologies. More frequent touch points between patients and their care teams can fine-tune treatment, especially of chronic conditions.
3. Cybersecurity risks in data exchange
Build a secure digital front door:
A secure digital front door can make it easy for patients to set up (and keep) those telehealth appointments. Follow-up from care teams becomes an ongoing process, rather than a note after an annual appointment.
4. Information loss during care transitions
Foster knowledge exchange:
It’s also important to increase communication and sharing among members of the patient’s care team, including their primary care physician, specialists, and hospital staff as appropriate. Lab results, imaging, EHR data, home monitoring data, and more should be readily available, in a secure way, to all appropriate care team members.
5. Variable access to the right clinician at the right time
Remote assistance from clinical specialists and e-learning programs can help caregivers become skilled contributors to the patient’s care and improve patient access to healthcare.
A central, smart platform with real time, secure information flow can enable care continuity.