June 23, 2009

Who is the ‘Coordinator’ within Care Coordination?

Filed under: Uncategorized — Tags: , , , , — HankMayers @ 5:27 pm

It seems that one of the touchstones for the HITECH components of the ARRA of 2009, is best summed up in this wording from the Medicare incentives:
“… such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of care, such as promoting care coordination (my emphasis).”

Indeed, the 6/16/09 ONC Meaningful Use material presented to the national HIT Policy Committee provided a separate criteria matrix for just care coordination (CC).
How the regional HIEs and the provider’s EMRs enable this technology is one of the hot HIT architectural questions of the hour right now. As tempting as it is to weigh in on this topic, I’d like to open some conversation on the related question of who will be the coordinator. After all, the answer will set some architectural directions for related HIT elements. Parenthetically, it has been clear that providers are expecting reimbursement premiums for the additional efforts required to fulfill the promises inherent in CC.
For those who were around when Human Services Integration (HSI) was coined in the 1970s, that experience taught that case management was an additional layer of service or staffing. This staffing need was partially due to the difficulty in obtaining information on available supplemental resources. More importantly, the absence of data standards, and the unpredictability of manual record exchanges, reduced case management objectives to simple advocacy. There was no long term funding interest in simple client advocacy. It did not change/improve the system.
The standardization, the immediate electronic exchange of information, and the focusing on the outcomes from care, are major game changers that hold great promise this time for truly integrating health care.
So, who will be the ‘coordinator’ in health care? I submit that, especially in health care, it will periodically change. For the child, the progression is likely to be first the pediatrician and then the family physician. For the adult, it would be the family physician or an internist, then the geriatric physician. For the adult that experiences a complicated case of cancer, the oncology group often assumes care leadership for a while due to the clinical complications of cancer. A person who experiences a life-threatening accident would shift to a special coordinator. So most persons would likely experience as many as 4 practitioners who would provide CC for them.
Notice that what I am suggesting here is that the ‘coordinator’ practitioner has control (to some extent) and/or awareness over any of the care being delivered by any other practitioner to the patient receiving the coordination. The HIEs and Care Coordination/Management features in the EMRs should be built to make sure that the coordinator is aware of care events in real time.
The 6/16/09 ONC Matrices include an important 2013 objective for reconciliations and exchange of information at times of transition from one setting to another. I caution everyone to not assume that these events are synonymous with transfer of coordinator designation. Some setting transitions would indeed involve a change in the coordinator, but most should not. If we fail to make this distinction, we will loose our ability to have a healthcare professional truly serve as a coordinator of care, just when we finally get the tools to enable him/her to succeed at the job.
What do others think?


  1. Chris: I am reading Part I after being imessrepd with Part II .I can’t tell which is better but both are great for me getting to know Healthcare systematically. I find that you have interleaved introduction, analysis, diagnosis and remedial measures of / for Healthcare domain. I cannot imagine that the professionals in this domain are as dumb and bumbling as you describe. Simple application of good old TQM Quality Improvement Methods and Tools would have averted a lot of problems you seem to have discovered. Perhaps you have separate reports on introduction, analysis, diagnosis and remedial measures of / for Healthcare domain. While the solutions you suggested may improve Healthcare Systems and Processes, there should be scope for others experts to participate and bring their expertise to bear on every phase from analysis to remedial measures. We should also know what alternatives are considered and set aside before finalizing conclusions of each phase. This may look like needless pondering and meandering but large complex applications like Healthcare need multiple inputs and consensus for commitment and sustained benefits.I have made a careful study of your article and added comments to point out how systematic Business Analysis and Requirements Engineering Methods and Tools would have caught the lapses at various stages of the healthcare project. I would like to share that with those who are involved in either Healthcare or BA&RE or both.I found that the first comment is very helpful. I will read and reply to other comments later.

    Comment by Siti — October 14, 2012 @ 7:35 am

  2. Hi Siti,

    You are quite correct that BA techniques, such as SixSigma, and are used with increasing frequency in healthcare management. Also, broad-based input (multiple participant such as doctors, nurses, technicians, risk mangers, etc) in problem analysis are equally important.

    Thanks for your feedback.


    Comment by HankMayers — October 14, 2012 @ 1:25 pm

  3. As a consultant in the hthleacare services for the past 20 years, I have seen a constant eroding of quality of patient care for the need of quantity of patients processed. This pushed on by the constant decreasing reimbursment for services. This new law is a definite path to rationing of hthleacare services. No EMR system will change this. The complex communicating and diagnostic systems will not be resolved by the Big Computer in the CLOUD. We continue to give up privacy and this law is a new step toward more of the same. I also hope that voting out all of the dems sill helps repeal this law. I saw this coming but my NO for Obama was not enough.

    Comment by Miszteer — November 19, 2014 @ 1:50 pm

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