It is widely agreed that managing care for many patients outside of the acute setting can improve patient outcomes, their experience, reduce costs and ensure appropriate staffing. However, the question remains as to how to actually make the shift towards these models of care.
Care across the health and care system must be digitised with connected, integrated and safe technologies. Only then can disparate data sources be connected to offer opportunities for identifying the most appropriate level of care and setting for patients, keeping them out of acute care if unnecessary and facilitating informed decision making. Connected care enables us to identify that frail elderly person who is known to be at risk of falls and ensures proactive community attention to support them in the home.
In the past, the term interoperability has often been used to describe connecting departmental data systems across the hospital to facilitate the patient journey within the four walls of that acute organisation. Having departments and services ‘talk’ to each other streamlines the process and the experience for patients, as well as reducing duplication, errors and waste. This kind of data connectivity really is just the beginning in terms of potential for building a comprehensive picture of an individual’s health and care. Interoperability in current terms refers to big data collaboration across the wider health and care system – from primary care, acute, mental health and community, to social services and long-term care – to support a holistic patient journey across venues of health and care, regardless of data provenance. Pulling together multiple data sources into a single longitudinal record enables a care provider to proactively intervene ensuring that a diabetic has had their podiatry assessment or that a young asthmatic has their inhaler with them on high pollen days.
Integrated care is a key element of modern healthcare. Patient-centric systems improve the health of populations and communities, and reduce the cost of care delivery and increase productivity. Furthermore, interoperability not only improves patients’ safety but also standards of care.
Transformation has become a commonly used term in healthcare that is applied to a vast range of areas. We believe that true transformation relates to a whole-system change across the entire health and care economy that delivers value-based care, reduces morbidity and keeps people out of unnecessary hospitalisation. Technology is only a small part of the solution - transformation at such scale depends on strong partnerships, common goals, supportive policy, and appropriate data governance and protection models. To deliver real integrated health and care, it should be a fundamental patient right that their data can flow to the appropriate place where it is needed for health or care regardless of provider, vendor or venue.
By defining conditions that would determine when hospitalisation is deemed appropriate and necessary, we can similarly deduce when it is not.
There will always be clinical reasons for sicker patients requiring acute-level care and associated services and facilities. However, technology can identify patterns and commonalities from big data collaboration, not only supporting informed decision making, but also identifying the most appropriate level of care for a patient based on a combination of factors. Not only does this afford the opportunity to minimise memory-based care decisions, but also ensures consistency enabling the care provider to make proactive decisions.
Beyond technology just being interoperable, the ability to use it to prevent and reduce morbidity is now real, rather than it just reducing mortality in the acute. Applying advanced intelligence across large volumes of connected data allows us to interpret and analyse multiple data sources, and provide clinical recommendations at both population and person levels through providing actionable insights directly into health and care professionals’ workflow and information systems. We can now predict citizens’ risk and take necessary actions to help keep them out of hospital.
Improving health and care demands a community-wide effort in which everyone is informed, connected and accountable.
Technology is also enabling citizens to take direct participation in their own care, opening new channels of communication with care providers. Through the use of portals, self-monitoring devices, telehealth and other patient engagement tools, access to care can be improved as well as promoting opportunities to maintain good health and wellbeing in the home. Individuals should be empowered as part of their own care team to provide self-reported data to be analysed in conjunction with multiple other data sources to facilitate informed decision making.
As well as supporting techUK’s interoperability charter, Cerner are proud to be at the forefront of data sharing and connectivity worldwide. We co-founded the CommonWell Health Alliance and the INTEROpen group, as well as championing FHIR® adoption in the UK. We firmly believe in advancing policy that supports shared information and technology to break down silos and put the patient at the centre.
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