Virtually Healthcare - IHE Patient Care Coordination (PCC)
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Patient Care Coordination

Patient Care Coordination Manager (Community)

Patient Care Coordination Manager (Community)


Patient Care Coordination (Scheduling, Referrals and Reports)

Patient care coordination involves the deliberate organization of patient care activities and information sharing among all participants to ensure safe, effective, and patient-centered care, ultimately aiming to meet individual needs and preferences.

Key Aspects of Patient Care Coordination:

  • Deliberate Organization: It's not just about providing care, but about how care is provided, ensuring a smooth and efficient process.
  • Information Sharing: Effective communication between all involved parties (patients, families, healthcare providers, and other relevant individuals) is crucial.
  • Patient-Centered Approach: Care coordination focuses on understanding the patient's needs, preferences, and goals, and tailoring care accordingly.
  • Goal: To achieve safer, more effective, and higher-quality care by coordinating efforts and resources.
  • Who's Involved: Care coordination involves a variety of individuals, including patients, families, healthcare providers (doctors, nurses, therapists, etc.), case managers, and other relevant professionals.

Benefits:

  • Improved Outcomes: Better health results and a higher quality of life for patients.
  • Reduced Costs: More efficient care and fewer unnecessary tests or treatments.
  • Enhanced Patient Experience: Patients feel more supported and empowered in their care journey.
  • Increased Patient Satisfaction: Patients are more likely to be satisfied with their care when it is well-coordinated.

Examples of Care Coordination Activities:

  • Developing and implementing care plans: Working with patients and their families to create a plan that addresses their specific needs and goals.
  • Facilitating communication: Ensuring that all relevant information is shared between healthcare providers and patients.
  • Coordinating appointments and referrals: Helping patients navigate the healthcare system and access the necessary services.
  • Providing education and support: Helping patients and their families understand their condition and how to manage it.
  • Addressing social determinants of health: Recognizing that factors beyond medical care, such as housing, transportation, and food security, can impact health outcomes.

Health Information Exchange

Health Information Exchange (HIE) refers to the electronic sharing of patient data and information across different healthcare organizations, enabling providers to access and view a comprehensive view of a patient's medical history, improving care coordination and patient outcomes.

  • What it is: HIE facilitates the electronic transfer of clinical and administrative information between various healthcare organizations, such as hospitals, clinics, and pharmacies.
  • Purpose: The primary goal of HIE is to improve patient care by providing healthcare providers with timely and accurate information, leading to better diagnoses, treatment plans, and overall patient outcomes.
  • How it works: HIE systems typically involve secure networks and standardized data formats that allow healthcare organizations to share patient data electronically.

Benefits:

  • Improved Care Coordination: By providing a comprehensive view of a patient's medical history, HIE enables healthcare providers to make more informed decisions and coordinate care more effectively.
  • Reduced Errors: Access to complete patient information can help prevent medical errors, such as medication errors or duplicate testing.
  • Enhanced Efficiency: HIE can streamline workflows and reduce administrative burden for healthcare providers.
  • Better Patient Outcomes: Improved care coordination and access to timely information can lead to better patient outcomes.

Examples:

  • Directed Exchange: Allows authorized healthcare providers to request and receive specific patient information from other organizations.
  • Query-Based Exchange: Enables healthcare providers to search for and retrieve patient information from participating organizations.
  • Consumer-Mediated Exchange: Allows patients to access and share their own health information with authorized individuals or organizations.

Challenges:

  • Data Quality: Ensuring the accuracy and completeness of shared data is crucial.
  • Interoperability: Different systems and technologies need to be able to communicate and share data effectively.
  • Privacy and Security: Protecting patient data and ensuring compliance with privacy regulations is essential.
  • Cost and Implementation: Setting up and maintaining HIE infrastructure can be costly.

Outline Design

Patient Care Coordination

Enterprise Service BusIntegration Engine (TIE)Repository Service andMessage RoutingDocument TransformationUnstructured Correspondenceemail + pdfDocument Processing ServiceReferralBARSReferralHL7 v2 REF_I12ReferralI12Discharge ReportHL7 v2 ORU_R01Online ConsultationsConsultation WritebackData Capture ServiceDischarge ReportR01«database»Health Document Sharing (XDS)support for NRL«database»Clinical Data Repository«database»Clinical Data RepositoryPrimary Care«database»Clinical Data RepositoryExternal Primary Care«database»Clinical Data RepositorySecondary CareFHIR Message T02FHIR QuestionnaireResponseFHIR MessageBespoke FHIR MessagesFHIR Message I12FHIR Message R01FHIR Collection/MessageFHIR Message R01FHIR RESTfulFHIR Message/IM1 TransactionHL7 v2 MessageFHIR MessageGP ConnectSend DocumentFHIR Message T02/T01IHE XDS/DSUBm

Patient Care Coordination


Health Information Exchange

Health Information Exchange(Clinical Portal)«database»Health Document Sharing (XDS)«database»Clinical Data Repository«database»Clinical Data RepositoryPrimary Care«database»Clinical Data RepositorySecondary CareAlternatively IM1 Bulk can be usedto store records in a central CDRHL7 IPA (FHIR)HL7 IPA (FHIR)IHE MHD (FHIR)converted from XDS SOAPHL7 IPA (FHIR)converted from IM1 Transactionor GP Connect

Health Information Exchange