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Weekly Byte: Piecing Together Patient Care

The practice manager pulled up the patient that I named. This patient had long been part of her nephrology practice, and in many respects was like their thousands of other patients, but with one major difference: this patient had a care coordinator.

Her eyes widened as she looked at the patient in pMD and started reading the care coordination summary. "They know so much more about her than we do," she said quietly. Before her eyes was a concise summary of the patient's medical history, including an accurate medication list and the patient's overarching goals of care.

The care coordinator had painstakingly pieced together this summary using notes from hospital electronic health records, lengthy conversations with the patient and her family, conversations and secure text messages with health care providers who had seen this patient, and the electronic health records of multiple private practices.

By consolidating and summarizing all this fragmented information into a single note, and by using pMD not just for charge capture but also sharing information automatically across all the physicians in the community who might see this patient in the future, the care coordinator was ensuring that everyone who saw this patient would have the big picture. They would not be relying on the patient alone to provide complete and accurate information about her own medical history - something that the sickest patients are often unable to do.

As we left the nephrology group's office, I reflected on how many times I've seen physicians beaten down by technology that burdened them with excessive data entry and that generated massive, redundant electronic records for them to wade through looking for kernels of information. When they really need it, like a primary care doctor seeing a patient who was just discharged from the hospital, they can't get into the hospital's silo.

At that moment, I felt renewed excitement about working with the care coordinators who are the patient's ally in navigating our fragmented health care system. They can't be everywhere at once, but now their clinical summary can.
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