Nationwide Care Transitions: Empowering the Provider, Empowering the Patient

Travel photography

More than 2.5 million passengers fly domestically in the U.S. every day. How many of those people do you think remember to bring their health records with them in case of emergency? While I don’t know of any source tracking that statistic, my personal experience would lend me to believe it is very few.

This time of year, it feels like even more people are traveling. While it's summer, people can still come down with a cold, or something worse that requires them to seek medical attention.

What happens when those two collide – when you are sick or injured while traveling far from home?

Most likely you feel out of sorts, perhaps even somewhat helpless. You don’t have access to a familiar medical provider, so you find yourself at a local urgent care center or emergency room trying to recall when you had your last tetanus or flu shot, or perhaps you are not even able to share or recall your medical history due to your current condition. In those circumstances, the attending provider also may feel helpless, or at least handicapped, to ensure they are providing you the best care for your situation.

Let’s follow the story of Cynthia, a 66-year-old woman from Naples, Florida. As her story unfolds, you’ll learn how a nationwide network and services can be leveraged to improve care coordination and delivery when Cynthia faces an unexpected injury while visiting her daughter in Colorado.

Only a couple months before her injury, having experienced shortness of breath during her morning walk, she was diagnosed and treated for a pulmonary embolism, and then subsequently discharged on an anticoagulant. This adds not only depth to her medical history, but also a complexity that is more easily addressed with ready access to Cynthia’s recent health records.

Over the course of several months as Cynthia transitions through multiple settings of care in two different states, a national record locator, patient identification and linking, and data query and retrieval services work cooperatively through a network across various end users, venues of care and health IT systems, including personal health records, electronic health records (EHR) and biometric solutions.

Modern, FHIR-Based Access

As Cynthia’s story plays out following her initial visit to her local primary care provider, the hospital she is referred to both queries and retrieves important documents detailing Cynthia’s history from across a network using FHIR (Fast Health Interoperability Resources), including records from her visit to her primary care provider (PCP) earlier that same day. Ready access to this information permits Cynthia’s acute care provider to act swiftly and decisively with immediate testing to confirm the probable pulmonary embolism diagnosis that her PCP noted in the records from her visit.

Patient Linking

Once enrolled in this network during a visit to her primary care provider, any participating provider can link Cynthia’s disparate records, creating a more complete health record available to the providers who need it – even at locations where she has not previously received care. Through unique innovations in patient linking, Cynthia’s provider can review her records even before the patient is seen, giving them invaluable insights regarding her medical care to date before the patient walks in through the door.

Record Locator Service

Throughout her journey across state lines and different venues of care, providers use a record locator service (RLS) to search for records linked to Cynthia’s identity within the network, no matter where the care is delivered. This service is critical to keeping a person like Cynthia at the center of her care. With RLS, Cynthia’s providers have a “virtual table of contents” at their disposal that specifies the available locations for her patient records.

Direct Patient Access to Consolidated Health Records

As she works toward a full recovery with a follow-up to a clinical specialist, Cynthia accesses her own health records right at home via her personal health record, which leverages the network to pull in her health records from all her providers connected to the network, regardless of their EHR. This allows Cynthia to proactively prepare for her appointment by reviewing and noting any necessary updates to her records. Having this information ahead of time not only allows Cynthia to make her provider aware of any changes, it empowers her to help take control of her own health.

From beginning to end, Cynthia’s story provides unique insights into what goes on behind-the-scenes of smooth care transitions fostered by collaboration, and the noticeable value it offers to both the provider’s workflow and the patient’s care.

I know we all hope to never experience an injury or sudden illness, particularly away from home, but life is unpredictable. With electronic access to their health records – for both patients and their providers, hopefully that feeling of helplessness will be lessened and Cynthia, or whoever the next person may be, can focus on getting back to her active life.

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The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

Originally published March 1, 2018, updated June 27, 2018