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POSTS BY TAG | care coordination






I greatly appreciated Dr. Daniela Lamas’ perspective in her New York Times article, You’ve Detailed Your Last Wishes, but Doctors May Not See Them. Much ink has already been spilled about the failures of the electronic health record to solve the biggest problems facing patients and health care providers today. This article described a particularly tragic failure: a small piece of absolutely critical information was present in the patient’s record, but it was buried in an ocean of text. Nobody saw it during the chaos of an Emergency Department (ED) admission.

Since then, Dr. Lamas has heard about many other “situations in which last minute ‘saves’ through extreme diligence or chance, such as the one I experienced, had led to a good outcome.” This problem is indeed widespread. A 2016 study in the Journal of Patient Safety estimated that medical errors caused between 210,000 to 440,000 deaths per year in the United States, and that total Preventable Adverse Events due to medical errors occur between 2 to 4 million times per year. It’s a staggering number, accounting for up to one sixth of all deaths in our country last year!

In her article, Dr. Lamas proposed some ideas for fixing this buried information issue. The ideas included:

1. “standards for sharing [...] across all electronic records”
2. “all health systems could require identification of a health care proxy for all patients”
3. “patients should be able to access their health records through a patient-facing interface, send in their own directives, or even update related notes”
4. “all related advance care planning documentation should be in one place in the medical record and accessible with one simple click of the mouse”

Interestingly, three of these wouldn’t help with a situation like this where the information was already present in the record, yet buried out of sight. And the fourth - putting advance care planning documentation in a single place - had already been done at Dr. Lamas’ hospital. The physicians just didn’t use that screen because “habits are hard to break, and without a clear set of incentives, training, and ongoing education, doctors (myself included) continue to record information about end-of-life conversations in progress notes, where they are not readily available”. When the EHR documentation burden is already so heinously high, it’s easy to see how caregivers wouldn’t rush to embrace yet another screen added into the mix. After all, it’s not reasonable to expect the Electronic Health Record to transcend or change its nature, which is, in Dr. Lamas’ words, “a clunky online version of a paper chart”.

She did reference another approach to solve this problem, “clever patient apps that work outside the electronic record”. For an app to help in such a situation, it must not live only with a single person. The patient may be unconscious or may not have their phone with them when they’re admitted. Their health care proxy may not be reachable right away, or perhaps the patient didn’t designate one. So to make absolutely sure that any health care provider who sees the patient can access this information, the app must live with everyone possible who is involved with the patient’s care. The patient, their family members, their health care proxy, each of their physicians, and perhaps most critically of all, their care navigator.

Many of the very sick patients such as the one in Dr. Lamas’ story already have a care navigator assigned to help them navigate through our fragmented health care system and to quarterback the communication among different care teams at different institutions. This person is like the patient’s health care guardian angel. In most cases, they know the patient better than any one physician.

As long as the care navigator finds out immediately when the patient hits the ED and which doctor is seeing them, they can spring into action and make sure the really important information gets to the right person in a timely way. With pMD® Care Navigation™, care navigators can find out instantaneously when the patient is admitted to the ED and have easy access to a concise summary of the truly critical information about the patient’s care plan and decisions.

If care navigators have critical information at their fingertips, are empowered to intervene with exceptional communication software, and find out automatically when patients have their moment of crisis, then we can let the Electronic Health Record go back to doing what it was always designed to do: being the digital filing cabinet. It’s time to move forward to the next generation of software for patients, families, physicians, and especially care navigators.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.



Health care practices are very active in a wide variety of reporting and often times report to various different organizations in order to track population health, positive outcomes, and quality of care. Some of these reporting mechanisms are hosted by government agencies, highly-regarded news sources, specialty councils, and national organizations. One such type of reporting is through a Clinical Data Registry. These type of registries are made up of similar medical practices and specialties to gain a better understanding of the care given to patients. This also allows groups to benchmark their organization against other participating groups. These registries collect information on the specified health care population and utilize the information to track trends in how disease is managed and how it is progressing within a population.

Why Participate in a Registry?

Participation in a registry allows organizations to gain additional benchmarking and provides access to best practices when looking to improve clinical outcomes and decrease cost. Through this registry data and research, clinicians and scientists will be able to establish patterns based on disease progression, current medical standards, and patient outcomes to determine and share best practices within a community of similar health care organizations. The hope is that this invaluable insight will progress beyond a zip code and expand into the big picture of national and global health care.

Here are just a few of the many registries to choose from:

US Wound Registry
National Palliative Care Registry
National Radiology Data Registry
Lung Cancer Screening Registry
National Cardiovascular Data Registry

Tracking and Reviewing Registry Data

Tracking data, compiling answers to survey questions, and reporting to an organization may sound a lot like incentive-based programs such as MIPS reporting. While participation of these programs are required by the government, reporting to clinical data registries is completely optional and benefit the group of health care organizations that participate by allowing them to see where they stack up against their peers. While these registries may vary in reporting mechanisms, the format of reporting is generally the same. Typically, there is an annual survey that would need to be completed, which always includes the requested data points. Health care organizations will review various metrics that are both clinical and care-based such as readmission rates, standards of care, diagnosis at the time of consult, patient engagement, etc. from the previous year and submit that data to the registry. This may require a need to do an in-depth review of clinical care, social work, and assessment of everyone who is part of the patient’s care team to get an accurate depiction of what is involved with caring for these populations.

How Can pMD Help?

Combing through a full year’s worth of data across multiple teams can be daunting, requires a considerable investment of time, and may leave you thinking, “There has got to be a better way!” Here at pMD, we are working with health care organizations who are at the forefront of population health and participate in these registries. We work closely with physician teams to capture more than just billing information but also additional clinical and pertinent information as well.  pMD has been well-established in working with physicians for tracking this type of information.

Now, with the use of our care coordination product, we are able to assist care coordinators and social workers with securely communicating with patients and their physicians and capture valuable information that would otherwise be lost in the sea of notes come time for reporting.

If you or your organization would like to hear more about what we are working on here at pMD, including our MIPS registry, charge capture, secure messaging, and care coordination software and services, or what we can do to help you achieve your goals, we invite you to reach out to us.
As a software engineer at pMD, I get to straddle the cutting edges of two very different industries: health care and technology. I’m familiar with how quickly the technology world moves -- developers jumping on a new front-end technology every other day, “sprinting” through “agile” hoops at the speed of light. But I’ve been surprised to learn how thoroughly the health care environment is also evolving. I’ve learned that over the next few years, physicians will be facing fundamental changes in the way they see and treat patients. It has been one of the most interesting parts of my job to not only learn about these changes, but to help providers transition to the health care environment as it transforms around them.

With value-based health care on the horizon, providers will need to bring the patient into the center of their care. For the more than 100 million Americans with chronic illnesses, for example, the occasional face-to-face encounter with a provider might not be enough. Obviously, for those types of patients, providers must think beyond the 30 minute annual checkup; with constant management of medication, treatment, and services. In today’s day and age, providers often have difficulty bridging communication gaps, leading to inconsistent data, increased expenses, and poorer outcomes for their chronically ill patients.

We are trying to solve that problem at pMD, and to help providers proactively coordinate their patients’ care. Every new feature we are working on supports providers as they take on this new paradigm shift. One of the simplest ways we help providers is by showing them how they can get reimbursed for adapting to this new, patient-centric health care model. For example, since 2015, Medicare has reimbursed providers who offer at least 20 minutes a month of non-face-to-face medical care to patients with two or more chronic diagnoses, through CPT code 99490. For our providers -- who have been using pMD's charge capture tool to record services outside of face-to-face encounters like medication reconciliation review and care coordination, and may soon start to use pMD for patient education -- this could prove to be a fruitful change that helps them transition to tomorrow’s health care system.

Last week eight of my colleagues and I were in Anchorage, Alaska working with physicians, nurse practitioners, social workers, care coordinators, patients, and more. Although we were meeting about an array of different items, including building and enhancing care communities, charge capture, secure messaging, and clinical data exchanges, they all share the same common goal of working in collaboration to fill the gaps in patient care.

Patients that are “frequent flyers” of hospitals often suffer from chronic conditions, bounce between many specialists, and are at higher risk of costly readmissions. Due to the fragmented nature of their care it can be difficult for caregivers to receive the right information about the patient at the right time. Big EHRs are drowning in data and are not always reliable to get the providers the bottomline, clinically relevant information they need in a timely fashion.

Doctors and staff throughout Anchorage are coming together in a grassroots effort to make change happen and improve the care that their patients are receiving, regardless of which provider in the community is delivering it. Connecting everyone together around the patient decreases medical costs, decreases duplicate tests, cuts down on medical mistakes, and it saves the patients and doctors valuable time, ultimately leading to better overall care.

This model of coordinated care in Alaska however, is not unique to Alaskans. What the caregivers in that part of the country have been able to do is create a connected care community where they are coordinating the care around the patients, especially as the patients move between providers and facilities. We’ve heard from customers in other areas of the country about this same mission of connecting the different caregivers together around the patient instead of the patient around each of the caregivers. An important part of the solution is having a secure channel to share information quickly and seamlessly, and at the foundation is the concept of one patient no matter how many doctors they see. pMD continues to be an integral communication platform for care teams, allowing them to send quick, secure, valuable information, and brings together a community so they can start talking with one another.
My best friend and I were catching up with each other when he says, "My mother was just diagnosed with cancer".

Then I felt it. That unmistakeable sinking feeling you get when you learn for the first time that a loved one has been diagnosed with a serious life threatening illness.

After learning this, we began talking through the experience from his mother’s perspective as a patient. It was interesting and informative but also incredibly frustrating. One recurring theme during our conversation was the fact that people naturally turn to friends and family for advice and support when health problems arise. This personal support network is then very likely to look online for additional information and potentially seek out people who share the same health concerns. I started to think about how pMD might be able to help.

One of the challenges we are solving at pMD is the coordination of patient care. We're learning that care coordination involves more than just the flow of information between patients and health care professionals. It also involves communication between patients and their advocates, and even patients and their peers.

Enabling the people involved in a patient’s care to turn to different sources for different types of information is incredibly powerful. And by including the patient's support network as part of their health care team, we can help patients receive practical advice for coping with day-to-day health situations or even receive emotional support from the people who are best equipped to provide it.

Health professionals remain an important, if not the most important, source of information for patients. But a patient’s peers are also a significant source of influence that can alter the course of a patient’s road to recovery.

Chronically ill patients in many parts of the U.S. face myriad complex challenges when it comes to coordinating their own health. About a month ago my colleague and I traveled to Anchorage, Alaska to meet with some of our more remote customers up north (we didn’t meet any moose this time). I had heard and read great things about the work that was happening with Alaska Innovative Medicine (AIM), which uses pMD’s care coordination and secure messaging tools to manage many of the chronically ill patients in the region. However, it’s one thing to read about the impactful and forward-thinking work that AIM is doing with the patient community in Anchorage, but quite another to experience it first-hand.

AIM partners with local primary care providers, specialists, case managers, social workers, home care nurses, dietitians, pharmacists, and others that are involved in a patient’s care. Their goal is to improve patient care and lower health care costs by preventing hospital readmissions, preventable ER visits, and reducing hospital stays. We had the opportunity to sit in on one of AIM’s meetings as they discussed the work they are doing with some of the other caregivers in the community.

The AIM team explained how they help patients manage their care when they are discharged from acute care facilities so they don’t have to manage their health on their own. They help patients with diagnosis education, interpreting hospital discharge instructions, medication education and reconciliation, connecting patients with additional caregivers, and integrating personal goals into health care plans. The AIM team acts as a safety net to fall back on if something isn’t working with a patient’s care.

Navigating the health care system is difficult to begin with, especially when a patient isn’t feeling well. And patients can feel very alone after they go home and try to manage their care themselves. A few patients who work with the AIM team were quoted as saying, “It helps when somebody cares” and “I now have someone to call when I need help. Thank you for not giving up on me.”

It was encouraging to see how AIM is reconnecting a fragmented health care system piece by piece. They are engaging and empowering patients, building up patient support systems to provide more successful health outcomes, and creating a more cohesive provider communication channel. pMD is excited to be partnered with AIM to improve the health care experience for Alaskans!

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.
As a pMD software developer, I try to get out in the field and work with our customers as often as possible. It’s important for me to see how pMD helps solve our users’ problems, and also to listen to ideas and feedback about new functionality we could add to make pMD even more powerful. Last week, I had the opportunity to travel to Anchorage, AK to meet with a number of practices in the community who use pMD.

Even though I’m from Seattle, I had never been to Alaska before, so I jumped at the chance to visit our 49th state. We landed in Anchorage to sunny and mild weather, which luckily stuck with us for the entire trip. I didn’t build in a ton of time during my stay to venture out into the Alaskan wilderness, but luckily the wildlife came to us! Upon arriving at what we thought was the location of our first meeting, we were greeted by two moose. We spent a few minutes on our phones researching how best to avoid W55.82XA, and then realized our intended destination was actually about two blocks away.


After narrowly avoiding an unwanted moose encounter, we had a series of extremely productive meetings. The medical community in Anchorage is very close-knit, and several of our customers are using pMD’s Care Coordination features to help all of the providers on a patient’s care team stay in sync with one another. We also learned about how some doctors in the area have started using pMD Secure Messaging along with charge capture in order to communicate with their colleagues in remote locations. Those locations often don’t have reliable cell service, which is needed for traditional SMS messages, but they do have WiFi, which allows pMD messages to be delivered.

As a developer, it was inspiring to see the product I work on help facilitate better patient outcomes and improved doctor communication. I always find visiting with customers to be a refreshing change of pace, but this trip in particular left me feeling more motivated than ever to build the next generation of features that pMD has in the pipeline.



Health care providers are under immense pressure coming from all directions in 2015. While the impact of the transition to ICD-10 is an immediate concern for many health care professionals today, there is another larger but less well-defined transformation looming in 2016 and beyond: the introduction of comprehensive care coordination models.

The transition from the existing Fee For Service (“FFS”) reimbursement model to new value based models is being driven by congress and the Affordable Care Act (“ACA”). The ACA is affording the nation opportunities to design and test new models of health care delivery to reduce spending and improve patient outcomes. Some of the new models being tested that you may be familiar with are Accountable Care Organizations (“ACOs”), Patient-Centered Medical Home (“PCMH”) and Medicaid health homes. All of these models aim to improve quality, safety, prevention, and coordination of care while benefiting the patient experience.

Providing coordinated care is not easy and is the responsibility of the care coordinator, who may be the patient’s primary care physician, a specialist, or someone specifically hired for this role. The care coordinator is the choreographer of an intricate dance between the patient and their network of service providers. Just as a good choreographer must understand the music and how it relates to each of the dancers, a good care coordinator needs to understand the patients’ needs and how they are best served by each provider or service.

In order to provide the best patient outcomes, a care coordinator will engage the patient, communicate a plan, assemble the team, and assist the patient in navigating their network of service providers. The care coordinator helps to ensure the best performances from their ‘dancers’ by making every improvement possible, giving each one the appropriate level of feedback, and facilitating communication in order to make sure that all of the details are taken care of.

One of the underlying principles of the ACA is that these new models of health care delivery cannot occur without payment reform. It’s easy to understand why. Models which reduce spending and improve patient outcomes are likely to result in reduced revenue for physicians as fewer unnecessary services are provided. Care coordination is also a cost to the provider which requires an investment in both personnel and infrastructure. If you add it all up, reduced income, increased expenses, and the fact that providers are not currently paid for providing care coordination results in a significant barrier to change.

So how does a choreographer recruit dancers to perform together? In order to attract providers, ACA is introducing payment reform by introducing financial incentives for providers to coordinate care. For example, within ACOs, providers get to keep a percentage of the savings generated by the ACO as long as they keep patients healthy. These incentives are being based on meaningful quality measures, such as Medicare’s PQRS measures which are not necessarily based on reducing expenditures but strengthening coordination of care.

The common theme of these value-based reimbursement models is to produce quality care that keeps patients healthy and at a reasonable cost. Accomplishing these goals requires a cultural shift toward patient-centric, collaborative care; a significant change in how patients and providers interact. This means enabling patients and providers to work together, and ensuring patients are receiving the care they need, in the right place, at the right time, by the right provider. Unfortunately, the necessary level of care coordination to create quality outcomes does not happen consistently through the existing FFS delivery model today. We need to improve.

pMD is looking ahead and actively developing new ways to facilitate care coordination. Through community based secure messaging technologies, enhanced PQRS capabilities, mobile charge capture, and our second-to-none integration expertise, we’re helping accelerate the transition to value-based care delivery (and making the dance more synchronized and fun!).

As a patient in the hospital, you might have a merry-go-round of doctors caring for you during your stay as you are seen by various specialists or when personnel shifts change. You also might naturally assume that each time you get a new doctor, they have extensively communicated with the last doctor about your medical information.

Unfortunately, this may not always be the case behind the scene. A large study conducted by the Agency for Healthcare Research and Quality (AHRQ) across 653 hospitals and with over 400,000 hospital staff recently revealed that handoff communication is the No. 2 area with most potential for improvement for most hospitals. Less than half (47 percent) of the hospitals in the study reported positive performance for patient handoff!

Handoff communication in hospitals happens when the responsibility for a patient is passed off from one heath care provider to another. Information about the patient’s care, condition, treatment, and services is also exchanged. Because the patient's critical health information is being communicated among the caregivers, handoff is important for quality care and patient safety.

Working at pMD, a mobile software company for health care providers, has allowed me to see first hand how valuable a good handoff system is for patient care. The degree to which health care providers perform patient handoff varies dramatically for different groups and specialties. Some groups communicate face-to-face for each patient after each visit, while others take part in almost zero handoff communication. It’s a scary reality from a patient’s perspective. Performing patient handoff can be loosely compared to going to the gym; you know how important it is and that you should exercise every day, but it’s easy to make excuses why you can’t.

After seeing the need for a better way for providers to communicate about patients, we integrated a simple, straightforward patient handoff functionality into our mobile charge capture software for more seamless communication among the providers. Health care providers are highly mobile and need a tool that allows them to access and exchange clinical information from anywhere at any time.

Studies such as this one conducted by AHRQ are helpful in bringing to light some of the trending problems facing health care today. Health care practices need to implement an effective and seamless handoff system to prevent important patient care information from getting missed. We need to make fewer excuses and focus on using a better patient handoff system. (And it wouldn’t hurt to hit the gym more often too!)

Source: Agency for Healthcare Research and Quality