Picture this: Every member of a patient's care collective – family, friends, home health providers, specialists, therapists, even pharmacists – can see what's happening when appropriate and receive alerts about that patient when necessary.

"Everyone involved has their own view of what is happening and each view is different … and important," said Sean Slovenski, CEO of Intel-GE Care Innovations. "They all play a part."

That scenario is part of what would make an informed, digitally-connected care team so powerful. Traditionally, however, care teams have for the most part existed within a hospital or clinic.

But there is evidence that's changing.

Mobile, telehealth tools

Thanks to digital health tools and the trend toward delivering care outside the hospital or clinic, some providers are already exactly what a care team is and how it operates. 

Medical devices, mobile tools, sensors, telehealth services and remote monitoring products, in fact, are helping connect otherwise disparate people who comprise a care team via real-time smartphone communications, portals and, in some cases, mobile access to the electronic health record.

To Paul Kusserow, CEO of the home healthcare company Amedisys, these connections are a boon to both patients and providers. 

[Related: 5 ways to fuel patient engagement.]

On the clinician side, that means extending monitoring and treatment into patients' homes.

"Technology has allowed us to access patients in more remote locations and allowed us to capture data on our patients that can be used to provide for the best health outcomes," Kusserow said.

The flip side? Patients benefit by being safer and more connected in their homes.

"Biometric monitoring and passive sensors, for example, allow patients to feel more at ease knowing they are connected to care providers and socially to their loved ones and family," Kusserow added.

Remaining challenges

The primary driver in harnessing care coordination and other IT tools has been to address gaps in care – such as when a patient moves from one location to another, or responsibilities are handed off from one member of the care team to another, or a message or data needs to be sent.

Technology has helped ease those transitions, Slovenski and Kusserow agreed, but it hasn't solved all the issues, and sometimes it has created new ones.
Imagine an app that doesn't work properly, or can't access the data a home health aide needs to properly treat a patient. How about a home health monitoring device that isn't accurate or reliable, or one that is hacked or rendered useless by malware?

"The main concern will be accuracy and the ability to simply work," Kusserow pointed out. "It is of paramount importance that these technologies provide highly accurate data and actionable analytics to decision makers. At the end of the day, the failure to do so directly impacts the well-being of the patient. If it all works, the relationship between the patient and care provider should be strengthened; it allows more people to become caregivers and patients to be more comfortable."

To that end, last month Intel-GE Care Innovations partnered with the Stanford Center on Longevity to host "The CI Hackfest: Redefining the Care Team." The event sought to highlight various technologies available to care providers, be they clinicians, family members or home healthcare workers.   

Slovenski said the focus of the event wasn't necessarily on the technology itself, but on how it's being used to understand the human dynamic in all of this.

"You're in an environment where you want to lock eyeballs with people," Slovenski said. "But that environment is changing."

That's where the care team comes into play, he explained, and why it's important to create a network that motivates each member to participate. How can caregivers use technology to give the clinician a better sense of the patient's life in between the tests, visits and readings? And how can they motivate the patient to follow a care plan when he or she is out of the hospital and away from the doctor's office and health aide?

Another issue: payment models. Healthcare hasn't gotten around to figuring out how to pay doctors for their time away from the patient, so doctors are more inclined to resort to visits and procedures that they can be paid for.

"Reimbursement for these technologies should mirror the way we are being reimbursed, with a focus on quality," Kusserow said. "If these technologies drive great clinical quality and improve outcomes of patients, then there is a case for reimbursement."

Only as complicated as need be

Even though the latest and greatest apps, devices, remote monitoring, mHealth and telehealth tools are enabling a new, more collaborative and informed care team, those products have natural limitations.

"Technology can only go so far," Slovenski said. "If you get to the root, it's a motivational issue. Find out what works and what doesn't – it's definitely not a one-size-fits-all approach – and fashion a care plan around that."

That's why it's important to expand and redefine the care team – and include all of the players in the plan.

It may be as complex as a smartphone-based alert system that routes to the right caregiver at the right time in case of emergency, or as simple as a reminder slipped into a home health monitoring kit to gently nudge both patient and nurse to step on the scale each day.

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