Community Record of Care for Accountable Communities of Health

April 29, 2016

Community Care Management – A dynamic, interactive challenge


Written by Duncan West


What processes and tools do providers and the broader community need to support care management and population health? Mental and visual models often help understand the broad picture and get us out of the details of filling out some form or spreadsheet.

In the last several days a post and a web seminar have provided two very insightful models and discussions of what is required for care management. First Opinion piece “What Minecraft can teach the health care system,” was posted by Dr. Isaac Kohane of Harvard Medical School. He described enviously watching a team of local and remote middle school students work together solving problems, tracking progress, coaching each other, and coordinating actions toward a common goal in the virtual world they were building together.

His reason for envy?

"I’ve spent my career working in some of the world’s most advanced hospitals, and now chair Harvard Medical School’s Department of Biomedical Informatics. I can tell you with assurance that the use of team technology in the American health care system lags decades behind the seamless coordination that Minecraft players take for granted.

How often, in your experience as a patient, family member, doctor, or nurse, do all the members of the care team actually know what the current plan is, and who else is on the team? How easily can all team members monitor activities, figure out if the care is on the right track, and instantly conference to organize a course correction if needed?"

Dr. Kohane goes on to cite several reasons for the current state of care management, unique systems, the conflation of billing and medical care records, and lack of patient involvement. It is his Minecraft example which is attention grabbing with: teams built on the fly, communicating via several channels and adapting as the game avatars and the virtual world change, grow, or die.

A more formal examination of care management followed on Tuesday, April 26 in a one hour HIS seminar “Provider-Led Care Management: Trends and Opportunities in a Growing Market” presented by Matthew Guldin, an analyst, with Chilmark Research.

Matthew Gulden of Chilmark Research presented a web seminar about trends in care management. He contrasted an EMR model of a stack of documents to a care management model of a hollow sphere of connected nodes.

Not as invocative as the Minecraft model, but clearly different than a siloed electronic medical record. Care management must be dynamic, adaptive and is fundamentally social both among providers and with patients.

MIN-NS and other regional HIEs are at the center of support for this emerging and evolving Engagement model of care management. Matt Guldin of Chilmark summarized the natural path to Community Care Management from its roots in Inpatient Care Management.

We support all three models of care in our area. MIN-NS provides tools for identifying organizations involved in the care of patients being discharged from inpatient care. In-Network care is supported with alerts to providers when patients of a provider are seen in the Emergency Room. Community Care is supported currently with our work with local Area Agency on Aging and studies on the needs for specific modalities of care. Looking forward, Community Care Management is the model underneath MIN-NS’ proposals to HCA for coordination of care for inmates, and the addition of social service and volunteer agencies into Health Information Exchanges

The presentation “Provider-Led Care Management: Trends and Opportunities in a Growing Market. can be seen and heard here on YouTube. The slides alone are available here. The report on which the presentation is based is available for purchase here on the Chilmark site.