On the Edge of the Future: Imperatives to Succeed in Healthcare’s Grand Transformation Part 2 Smarter care teams
6 December 6, 2016
Paul Grundy, MD, MPH, FACOEM, FACPM
Smarter Care Teams
Advancing this transformation, patient care is evolving from PCMH to an approach that we will call Smarter Care Teams. Borrowing key elements of the Medical Home model, the Smarter Care Team will consist of the key stakeholders that support patient care –primary care physicians and their clinical care teams, care managers, and hospital care teams, but with the patient at the center. The multi-disciplinary, multi-setting team will be supported by powerful analytics and cognitive computing that aid care team members in reducing the frequency and magnitude of adverse events. Patients will have access to the technology via mobile personal assistants that simplify the day-to-day monitoring required for chronic care prevention, connecting them securely and round-the-clock with their care teams. These technologies will send timely health reminders, and generally help them become active participants in their own care.
In the post-meaningful use era, it’s reasonable to ask whether all of this technology will actually improve patient care, rather than complicate it. To answer that question, consider the difference between the typical chronic care management process of today, and care team delivery that will become available in the age of cognitive computing and Smarter Care Teams. This transformation will be visible in four key areas on which successful healthcare organizations will focus:
- The evolution of the care team. Care teams today are typically led by the patient’s primary care provider. Specialty and ancillary care providers are coordinated, to one degree or another, rather than integrated into the team. By contrast, Smarter Care Teams will be patient-centered to encourage engagement by the team’s most powerful member: the patient. They will be fully integrated with specialty and ancillary providers to ensure that care is aligned and coordinated and risk is minimized for all providers. Finally, Smarter Care Teams will be connected across multiple channels 24/7.
- Data and analytics applied by the team. Most care management teams currently have access to siloed claims and electronic medical record (EMR) data. Smarter Care Teams, on the other hand, will have fingertip access to near-real-time data across the continuum of care from clinical, claims, financial, lifestyle and biometric sources, giving them a far richer set of data from which to glean insights leading to outcomes improvement. These data also will empower Smarter Care Teams to identify patients in their populations who are at increased risk for chronic disease, and to conduct outreach that can prevent progression to illness, helping to reduce financial exposure for all participants in ACOs or other shared risk arrangements across the continuum.
- The team’s activities. Typical care teams currently focus on engaging patients based on “spot checks” at key intervals (pre/during/post visit), and they prioritize care by segmenting the patient population according to risk. By contrast, Smarter Care Teams will engage patients at every point along their journey and across every care setting with care that is personalized for them and their condition, and provided in real time.
- The tools supporting the team’s workflow. To enable such personalized and real-time care, Smarter Care Teams will have access to the world’s evidence-based medicine guidelines as well as every piece of available information on a patient – not just discrete clinical data from the EMR but clinical, financial and lifestyle data collected from a myriad of sources. Moreover, workflow tools and the structure of the team itself will enable an integrated approach to care, informed by real-time access to cognitive information.
This vision is not part of some far-off future. We are actually standing on the precipice of this grand transformation today.
