The Patient Protection and Affordable Care Act (ACA) resulted in many changes in the U.S. healthcare delivery system and presented challenges for healthcare providers. Healthcare is now morphing into a more comprehensive approach to the continuum of care. Care coordination has been identified as an important solution to address these obstacles within the current healthcare structure and to meet the demands and needs of complex patients within the system.

The expansion to consider populations entails a more targeted, efficient and data-driven approach. Population based care coordination provides multi-level care based on the populations and patient-centered principles. The importance and inclusion of populations in the care coordination process provides an opportunity to increase care efforts and improve outcomes.


The Coordination of Care

The healthcare system is often characterized by fragmented care, communication failures and unnecessary or redundant tests and services. Ensuring a healthcare system that is building better care plans, preventing care gaps, and stopping multiple emergency room visits is the ultimate goal.

Care coordination involves organizing patient care activities and sharing information among all of the participants concerned with a patients’ care to achieve safer and more effective care. Collaboration with internal stakeholders, understanding the data, and the use of data analytics is key in order to capitalize on keeping populations healthy. Care coordination can improve the patient experience, improve health outcomes, and lower costs. It is also a way to help patients gain more self-control over their care. It can include; tracking referrals, managing medication use, and aligning treatment plans for patients with several health issues.


HIE Interoperability and Measured Outcomes

The implementation of interoperability systems removes the road blocks created by having siloed and disparate databases. With the “plumbing” now in place, there is opportunity for innovation and direct access to more and complete data sets. Private and public sectors are now working together and putting their patients forward which will improve and refine healthcare communications and outcomes.

Healthcare payers and providers will need access to validated measures of patient‐centered outcomes across a spectrum of health conditions. Healthcare systems will need a credible way to measure and address potential gaps among subpopulations and identify groups in most need of improvement. Interoperability is creating a master clinical data repository that enables providers and clients to access the ‘single source of truth’ information they need, when they need it. In turn, this integration of data will also support the larger goal of improving population health.

Want to streamline cross-communication between providers, counties, EHRs, payers and other systems? Learn more about the eINSIGHT HIE solution.

Understanding Your Population

In order to adapt to the changing models within the healthcare system, organizations must understand the populations they serve and the current and future drivers of risk within those populations.

Access to population health data for automated analysis can proactively identify high utilizers along with their unique configuration of needs thereby guiding targeted treatment and promoting collaborative and systematic coordination of care. Organizations can become highly effective through real-time evaluation of services they provide and demonstrating improvements in the health outcomes of their population.

The real cost in a healthcare system are those who don’t get better. Those that don’t get better have many compounding factors which collectively produce high utilizers. The first step is to identify these clients so that information and resources from various disciplines can be utilized to provide targeted or person-centered care.

For the first time, HIE allows for the collection of data on populations at a local, and regional level, combined with other factors, such as the social determinants of health. This makes it possible to implement machine learning (ML) and Artificial Intelligence (AI). Service providers and their health plan payers can analyze the information to automate the identification of high utilizers.

A single care approach is no longer possible with these complex set of factors. Understanding the comprehensive needs of high utilizers and implementing a wraparound team of service is fundamental to improving and sustaining outcomes. Whole person care includes things such as housing, employment, addiction, behavioral health, primary care, and other social services in order to meet the unique holistic needs of each client.


Social Determinants of Health Data

Using technology, Fast Healthcare Interoperability Resources (FIHR) and application programming interface (API) to include the social data is critical to know which social determinants will move the needle. Understanding the full story of a person and their community to address their health is paramount, as there will not be value-based care unless there is an understanding of their social determinants.

Evaluating and building the care coordination approach includes making sure to have the right number and level of staff for your population needs. Assessing the current and predicted risk and access to demographic data may reveal the need for a new or differing skill set from the current care structures. Looking beyond the four walls includes tapping into the community to create the relationships and foundation for true population health.


Investing in Care While Lowering Costs

The cost of individuals with uncoordinated care is on average 75 percent higher than matched patients whose care was coordinated1. The improved outcomes are beyond just their health providing optimal patient experiences and cost efficiencies.

When reducing the redundancy in visits, facilitating access to specialty care and community-based services, and allowing team members to share information about a patient there are better outcomes and consistency with best practices. For example, by focusing on attaching the right resource to the right need can help keep a high-risk patient from multiple emergency department visits.

Strategic coordination can also engage communities to interact on a regular basis with primary care clinicians and the medical community, driving necessary screenings and education, and potentially avoiding the onset of costly diseases. It can drive efforts for both the highest utilizers of care and those emerging-risk patients to reduce disease progression or development with early engagement aimed at prevention and education.

Engaging in value-based care is changing the cumbersome reporting and payment mechanisms. The data is being rolled up in one central registry in real time. The gold standard is to provide non-duplicative, continuous, comprehensive and timely care. This new landscape moves away from costly case management and siloed systems in the direction of better health outcomes over a broad spectrum of life including health behaviors, social and economic factors and physical environments while lowering costs.


eINSIGHT Bridges the Gaps

eINSIGHT recognizes how important a targeted, efficient and data-driven approach to care is and the efforts that need to be made in order to improve outcomes. Real-time access to more and complete data sets and providing the measures to address potential gaps among subpopulations is paramount for better outcomes. eINSIGHT’s Health Information Exchange is an HL7-FIHR standards based master Clinical Data Repository and the ‘single source of truth’ information needed that ensures the integration of data that supports improvements in population health.


(1) McKenzie, B. December 1, 2018. Conifer Health Solutions. Improving Patient Outcomes Through Care Coordination and Population Health Management. Retrieved from:

Want to streamline cross-communication between providers, counties, EHRs, payers and other systems? Learn more about the eINSIGHT HIE solution.