How Unified Patient Records Support Whole-Person Care

February 14, 2022 - Last year, Franciscan Health, a 14-hospital system with facilities in Indiana, Illinois, and Michigan partnered with Innovaccer to create unified patient records to support whole-person care.

Whole-person care is a strategy that allows providers to treat patients by looking at their full spectrum of needs, including medical, behavioral, and socioeconomic. According to specialists, whole-person care is essential to improving overall patient health as it enables providers to know their patients, identify issues and create targeted treatments to fit their unique needs.

By examining their electronic health records and databases, Franciscan Health identified the need to create a unified patient record to track network performance, using insights to make care decisions.

Unified patient records and their benefits

Sriram Bharadwaj, vice president of digital innovation and applications at Franciscan Health, explained the health system has “data islands” with information associated with a specific patient. Additionally, providers outside the organization will have data related to the same patient.

“For us to really take care of the patient, we need those data islands to be bridged together, to pull the information to provide that information back to the physician at the point of care. Physicians can then understand how that data was utilized in the past by another commission or how the data will help them make a better diagnosis when they see the patient,” Bharadwaj told HealthITAnalytics.

“For us to deliver that information across from several non-aggregated data islands, we pulled together and created a unified patient record to understand what's happening with the patient across those spectrums of activity. That is what we talk about when we say a unified patient record.”

Franciscan’s approach involves health system employees working together to solve problems and propose solutions to serve the community better. With the unified patient record, they aim to:

• Enhance quality and coordination of care efficiency throughout all primary care practice sites by increasing care and coding gap closures.
• Optimize collaboration of the care management team, physicians, and hospitals as a point-of-care application within a clinical decision support program accessible throughout the health system.
• Provide insights on cost, utilization, quality, and opportunities within the health system and along the care continuum.
• Improve patient outcomes from the previous performance year.

“The benefit of using this technology is it is more information at the point of care to deliver better care protocol[s] and drive care efficiency with a better process for the patient to also get better faster, quicker,” Bharadwaj said.

Creating a unified patient record has been critical to supporting care coordination at Franciscan Health.

Bharadwaj explained the hospital system made what they refer to as “pods,” which provide physicians with a look at the patient from several different angles.

“If you take an average high comorbidity patient, you might have a pulmonologist, a cardiologist, an intensivist, and a PCP associated with the pod. All of them need to see the data that's happening with the patient. If it's the specialist that's seeing the patient afterward or the PCP that's seeing them today, or if the other specialists saw them last week, they all have to have the patient information in their hands,” Bharadwaj explained.

Potential challenges and goals moving forward

Although the use of a unified patient record can significantly advance whole-person care and outcomes, it is not without its challenges.

“The challenges that can arise is that you could be flooded with data because the patient might have data in several locations that you might pull together, and then it becomes difficult for the person in front of you to handle all of that information. That's one of the biggest challenges,” Bharadwaj stated.

While pulling together large amounts of data from several locations can be challenging in terms of organization, Bharadwaj explained that issues could also arise due to user error.

“The second biggest challenge is the person who is sitting in front of the camera, or the computer could forget the ability to use that data as well or could just choose to not use the data at all,” Bharadwaj said.

“We have to educate them on the value of what they're seeing in front of them. We have to give it to them in a way that makes sense in snippets rather than in bulk. We must give them something actionable in a very transparent but not jarring manner to get them to utilize their information effectively.”

But by providing the necessary education and improving the accessibility of patient data, health systems can enable medical professionals to develop better treatment plans based on the patient’s unique needs.

Bharadwaj explained that when more data and information is provided to physicians, they can better understand how to treat the patient and produce positive outcomes. This data expands past what a physician’s specialization might be.

“If I can get genomic data of that patient, the data of their families, their information about what they did in the past, that will be helpful to get a better picture. Lastly, we must look at social determinants of health. The SDOH [data] examines the situations that the patient has had in the past in terms of location, types of care, and more. This data provides physicians, clinicians, nurses, and caregivers with the complete information about the patient,” Bharadwaj said.

As Franciscan Health continues its partnership with Innovaccer and grows its unified patient records, the organization plans to advance its whole-person care practices to improve outcomes.

“We have only started scratching the surface by pulling in some EMR information, claims information today. We have several other data sources that we are going to be incorporating as we move forward. That is where we are today in 2022,” Bharadwaj continued.

“As we grow with this model and as we encompass all of this other data that I talked about, we will make it rich enough for what you would typically see as predictive analytics associated with a particular patient, delivering a personalized care plan and care record for the patient.”