In a data-driven world, can analytics make health care more effective for the most vulnerable patients? It’s a central question for all of us as care providers. At Partners HealthCare, it starts with Partners eCare, our electronic medical record platform—the infrastructure for data-driven innovation within our care network. One of those innovations, a new set of event notification tools including PatientPing, PreManage ED, Massachusetts eHealth Collaborative (MAeHC), and Mass HiWay, promises to solve a vexing health care system problem: how to track patients as they move among the labyrinth of providers that comprise the system.

To understand how these tools work, imagine an elderly patient presents at the ED of Hospital A with acute pneumonia. A few months later, after a fall at a family member’s home in another town, she heads to the ED of Hospital B, which treats her for a fractured hip. At discharge, she’s referred to a rehabilitation facility unaffiliated with Hospital A or B. Even more complex, her primary care provider is affiliated with Hospital C, which has received no record of any of these care episodes.

The tools bridge gaps by creating national communities of engaged providers who receive real-time notifications—whenever and, importantly, wherever, their patients receive care. This enhanced communication across patients’ care teams enables safer, more seamless care transitions, and easier intervention in high-risk cases—a core objective of Partners’ role as an Accountable Care Organization (ACO).

“Knowing when our patients go from Massachusetts General Hospital (MGH) to one of our Collaborative Skilled Nursing Facilities (SNFs) is pretty easy,” says Donna Rusinak, Senior Project Manager for Post-Acute Care at MGH. “But now transitional care managers can see if our patients have been sent to a SNF from outside our system. It really allows us to track those patients, reach out to them, and not unintentionally ignore them.”

Event notification tools go both ways—for example, if a Beth Israel Deaconess Medical Center patient is admitted to a Partners hospital, they can be referred out to a Beth Israel-affiliated post-acute facility upon discharge. Knowing where a patient regularly receives their care allows for a more thoughtful, coordinated transition back into their own health care system while opening a bed for one of our patients.

Read more on event notification and its role in strengthening the care continuum.

Topics: Integrated Care, Innovation

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