Patient information is often siloed in various healthcare facilities and clinicians have no ready means to access patient health information outside their facility. 

This often leaves a patient having to repeat laboratory tests, or at risk of medication errors. Patients need a digital care plan that outlines their treatment plan, adjusts to meet their changing needs, and follows them as they go through each step of their treatment. One Canadian province is well on its way to achieving exactly that through a Care Coordination Tool (CCT), which puts patients at the centre of their care.

The tool not only enables a living, digital care plan that can be can be viewed and updated by members of a patient’s care team, but it also allows authorized family members to have access to pertinent details of the plan and be apprised of their family member’s progress. Care plans are made more transparent to both patients and their families, which leads to a better understanding of the specific procedures, medications and desired outcomes. CCT also allows for patients to have greater control over their health, as they can review their care plan and ask for adjustments as appropriate.

On the clinician side, CCT allows authorized healthcare providers to create and update care plans and give secure visibility to other providers within the patient’s circle of care. It also offers users the ability to receive notifications which are sent whenever the care plan has been altered. CCT is already seeing promising results, with increased communication translating to better patient care and bridging of important care gaps.

Putting care back on track 

Stories of patients in need of a solution like CCT abound within our healthcare system. One story described a patient who was dealing with two chronic diseases but was stuck bouncing between care providers, with few positive results. Even though this patient attended regular appointments the care providers often were unable to communicate with each other – leaving the high-needs patients feeling helpless and care providers unsure of next steps.

By setting up patients with a coordinated care plan and a care team that reflects the needs of these patients, we can help clinicians collaborate with ease. The CCT enables meaningful access to patient data for multiple care providers, and can provide the most accurate patient data, both past and present. The care team is also given greater insight into the patient’s treatment plan and their progress. As a tool for care providers, the CCT can be viewed, updated, and facilitate ongoing communication between members of a care team and those they care for.

Following the path

But the CCT’s strength doesn’t just include bridging communication gaps between care providers, it also gives the patient a voice. An example is one of a 90-yearold palliative patient that has multiple specialists within his care team. One of the aspects of his care that mattered most to him was making sure that his family understood his end-of-life wishes, primarily the desire to stay in his home rather than be constrained to a hospital bed. But as with many cases, family members may not be ready or willing to discuss these decisions and difficult choices. Through the CCT, end-of-life wishes can be captured on the care plan where they are recorded and can be shared with family members in order to help make important decisions. Patients appreciate the ability to relay their wishes as it pertains to their care journey and benefit from increased dialogue within their circle of care, including family members.

In the end, the palliative patient was able to have a peaceful death at home which was conveyed by way of his care plan. Patients shouldn’t be expected to navigate our healthcare system alone. With help from the Care Coordination Tool and other digital solutions, we can tear down communication barriers and provide patients with quality care that takes their voices into consideration. The CCT gives care providers a means of wrapping care around the patient, and allows them to build plans that evolve with patients as they travel through their path of care. With Digital Health Week (November 14-20) approaching, it’s important to recognize the work that has already been done to improve healthcare delivery. Use the hashtag #thinkgdigitalhealth on social media to find out the difference Canadians are making.

This article originally appeared in an article on the Healthcare Information Management & Communications Canada website.

About the author: Matthew Maennling is accountable for services delivery for Orion Health in Canada.