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Better coordinated care

Better coordinated care

Attacking the costs and harms of fragmented and duplicative services by coordinating care and supporting providers to collaborate more effectively.


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Better coordinated care

A growing proportion of patients are in contact with a multiplicity of different professionals and agencies with no clearly defined person leading care. Without effective coordination there is a significant risk of duplication or neglect, and the experience of care will be poor. Across many industries digital technologies have been used to successfully streamline and better coordinate complex services — the same is increasingly true in healthcare. Shared health and social care records can be linked to give a 360-degree view of patients and their situation. This shared perspective can support multidisciplinary teams working together and improve their clinical decision making. This may be particularly important in cases where lifestyle and environmental factors play a significant role in a patient’s overall health status. If all healthcare professionals have access to all patient information in real time there is significant potential to expedite necessary care and to reduce waste in the system, such as the duplication of tests.

A lot of patients are on multiple care pathways and yet they are not really receiving a personalized care pathway that’s being delivered by a consistent care team. It’s pockets of care. — Neil Williams Medicom Innovation Partner

Western Diabetes Institute and ClickMedix, US

The Western Diabetes Institute is an “integrated practice unit” in California which co-locates multiple services needed by patients with diabetes. Partnering with ClickMedix, they are using a range of cross-specialty services including patient engagement tools and self-assessments, tele-consultation with a network of specialists, and real-time outcome monitoring. By sharing reports and care plans between the patient and multiple providers they have significantly improved glycaemic control levels, as well making treatment planning quicker and more cost-effective. ClickMedix suggest that physicians are able to consult with 4–10 times more patients with their system, while at the same time there has been a 50–90 percent reduction in hospital visits for patients with multiple chronic diseases.

In the UK, Nervecentre allows inpatient teams to seek specialist advice from other specialties by sending an instant message to the relevant specialist, who then receives the referral details along with all the patient information, their up-to-date observations and results and location in the hospital. Referred patients are automatically added to the list of the receiving team (allowing easy integration into their ward rounds) and the referring team is able to see the status and outcome of the referral. One radical way of ensuring all relevant professionals have immediate access to integrated clinical data is by putting the entire record in the hands of the patient. This approach has been adopted by Patients Know Best (see below), which functions as a ‘patient portal’ allowing patients to own, store and control access to their clinical notes.

We are currently seeing a lot of technology to standardize and improve care at the hospital level. The next stage is to see that same thinking applied to the system level, where chronic diseases are necessitating a totally new way of working in the community. — Alberto De Negri KPMG in Italy   

Patients Know Best (PKB)

Originally designed for patients with complex, rare or multiple conditions, PKB allows patients and their caregivers to create an account to which all their clinical information from multiple providers (e.g. laboratory results, GP notes, outpatient clinic letters) can be uploaded. Available in 14 languages, the system allows any healthcare professional authorized by the patient to log in and see the complete record. In addition, PKB has a library of self-help material including videos and links which can further aid in self-management, as well as providing instant messaging services for patients to interact directly with their clinical team and the option for online consultations via videoconferencing. As CEO Dr Mohammad Al-Ubaydli says, “the best way to achieve integration is to give power to the patient. After all, they’re the only ones involved in every appointment and interaction”.  

Specific lessons

Don’t crowd out informal exchanges between clinicians: Automated systems that share clinical results or opinions digitally can discourage the informal human exchange of views and advice across healthcare teams, which often enrich and improve clinical decision making in complex cases. Health professionals need to create physical or virtual opportunities for provider-to-provider collaboration. 

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