Care Coordination is Broken and You Can Fix It

Posted by Christian Kratsas on 11/12/15 1:07 PM


Care coordination is complex. Interoperability is far from reach. Patient information is difficult to track, especially when primary care physicians and specialists utilize different EHR systems. You need to stay competitive and make faster, smarter decisions. You want to fix these challenges, but you can’t because you don’t have the resources.

EHRs and practice management systems have referral order capability but are transactional and not built for true closed loop referral management. There is a difference between tracking and managing your patient referrals. So how are you going to manage health populations and improve patient care?

A study by Health Affairs shows that only 14% of physicians shared information with providers outside of their organization. 

It’s hard to imagine efficient care coordination when the referring physician has no confirmation that their patient scheduled an appointment with the specialist and received the care that was suggested. The situation happens too often. And if you want to keep up in the value-based care race, it’s time for a change.

Breaking through care coordination limits

Transactional care coordination is limited. It lacks clear optics into the next stages of your patient’s care. Plus, your care coordinators are tied up with excessive, tedious work matching and closing out referral orders. Even with Direct Secure Messaging (DSM), this is a limited point-to-point solution. With the kind of referral volume experienced by most practices, closed loop referral management is impossible. Administrative time on the phone and faxing and tracking paperwork is not the job you want them to do.


Your EHRs do a good job at capturing data and presenting a clear view of your patient’s history within your own organization. But, they’re lacking the ability to manage care coordination outside the walls of your practice.  Interoperability between EHRs is simply transactional.

"Referrals need to be managed more expeditiously and effectively across different organizations."

On the other hand, High-Performance care coordination is efficient. It can be achieved in a new world of care where physicians are building a network of preferred referral partners. Care coordinators are increasing productivity with closed loop, cloud-based software. In return, physicians are receiving a 360 degree view of their patient’s history. Not only can Meaningful Use criteria be achieved, but all participants involved in the care continuum receive insight into their own statistics and performance in these exchanges.

With the availability of real-time, actionable analytics, the best organizations can continuously improve within their referral network.

Achieving valuable connectivity

Most hospital-employed physicians are sharing clinical data on the same EHR system.

However, according to the Office of the National Coordinator for Health Information Technology (ONC), less than 25% of hospitals are able to share information outside of their organization.

There’s lifesaving data within hundreds of hospital EHRs that never make it to the patient’s PCP. The lack of connectivity is crushing patient-centered care.

Conversely, independents are using different systems to exchange health information.

Physicians Practice's 2014 Technology Survey found that only 18% of independent practices are involved in a state-run proprietary Health Information Exchange (HIE).

The questionable immediate return leaves practices skeptical. Mix that with the additional resources and budget it takes to upkeep an HIE interface and your board would likely say “no” to this option.

That doesn’t mean Independents aren’t willing to share data with other practices and hospitals. However, even large independent PCP practices have limited infrastructure to build out a complete and connected network.


You can’t afford to operate in a silo. Fee For Service (FFS) is losing in the quantity vs. quality race. It takes shared data and actionable metrics to facilitate high-performance care within a connected network. In a connected network, providers are able to track patients through the full continuum of care and communicate seamlessly with one another. It’s the foundation for successful at-risk contracting -- and the future of coordinated care.

Build your own network of high-value, low-cost partners. Break the care coordination limits and share performance metrics and patient information seamlessly across a universal platform. Instill a culture of high-performance care coordination and fix your broken care coordination model.

Interested in learning more about high-performance data for care coordination? Give us some basic information and we’ll help you fix your broken care coordination model.




Do you have your own network strategy? Share your thoughts in the comments below!


Topics: Coordinated Care, Healthcare Analytics, Referral Network