Q: How are the economics of new care delivery models affecting day-to-day clinical processes?

A: It’s apparent that isolated transactional approaches to care delivery will no longer be feasible. It’s an economic model that care delivery organizations cannot sustain, given an aging population and increasing prevalence of chronic disease. We have to align care providers to do the right thing at the right time. And that means an end to siloes and a new level of transparency to everything that’s happening to their patients – especially when care involves a variety of settings, providers and systems.

Each contributor to a patient’s care may be using a different electronic medical record. Our systems must be able to bring together each piece of that mosaic, regardless of what particular IT systems are used. So that every provider involved has a comprehensive picture of everything that is happening – to individuals, and in the population at large.

Q: If you face reductions in reimbursements, how do you get the greatest value from the resources you have?

A: We have a finite amount of resources available for maintaining the well-being of a given population. You will need to channel resources deliberately and carefully, where they are needed most to support the health of the population as a whole. That means knowing where the risk is.

Traditionally, care managers spent too much time gathering data from paper records, multiple EMRs and claims. This was not only inefficient, but yielded a view that was only historical, not prospective. As a result, clinicians were only able to focus on the top 5 to 10 percent of patients in the community we serve. We can leverage utilization metrics to direct resources to where they are needed most.

With the right tools, we can look at those patients’ clinical data, health risk assessments and claims data. That gives us specific direction about where to assign navigators, or care coordinators. We can be  proactive and reach out to our population to take preventive measures needed to keep patients well and out of the hospital. Did the patient receive her medication? Did she follow up on that appointment?

If your care coordinators are focused on the entire population, there are simply not enough hours in the day to be able to provide this kind of proactive, integrated support. The tools we have now enable us to monitor the population in real time, based on all available information, and provide timely interventions that have an impact on care and wellness. Clinicians can focus on being clinicians instead of chasing information across the community.

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About Siemens: Siemens provides healthcare IT solutions and services that enable care delivery organizations to thrive as they address access, costs, quality, and safety of patient healthcare.