Why patients are falling through the cracks

Have you been there? A medical emergency lands you in the ER only to be discharged with a stack of papers, prescriptions to fill, and instructions for your doctor. Will those papers make it to your next appointment? Will you be able to answer, “What diagnosis did the ER give? How many weeks are you supposed to take this RX?” It depends on what kind of fog you were in when you left.

There must be a better way.

Healthcare’s most dangerous moments often do not happen in the emergency room, but when the patient moves from one system to another—from hospital to home or from specialist to primary care. In transitions, communication breaks down easily, plans fall apart, and information that should (and needs to) follow a patient doesn’t.

The result: There are no triggers for critical follow-up appointments, physicians lack notifications that a patient has new medications, and rehabilitation centers lack insight into care plans. At best, a patient’s records are faxed days later; more likely, they remain siloed and are of no use for coordinating care. 

While health record digitization has come a long way, significant gaps remain that cost patients and employers millions of dollars annually, and, in some cases, even lives. Every failure drives up insurance premiums, strains a fragile workforce, and adds costs to an industry that’s almost a fifth of the American economy. Providers need easier access to patient data, and they also need to receive automatic alerts for potential issues and critical next steps for each of their patients.

THE VICTORY THAT ISN’T … YET

Since 2008, the healthcare industry has poured hundreds of billions of dollars into building a digital infrastructure to move patient data between systems. Almost 500 million health records have been shared through federal interoperability frameworks. Health information exchanges (HIEs) are processing millions of transactions daily and electronic health records (EHRs) are communicating across state jurisdictions. All of this is supported by federal information-blocking laws that require data to flow freely and, by most measures, healthcare connectivity is considered a success.

But connectivity and fast, informed, meaningful actions are not the same. Right now, patient data flows through systems, but the real problem is that it then gathers dust without agency or follow-through. This is where patients get hurt and costs escalate. 

Uncoordinated care costs the United States roughly $340 billion annually in wasted resources and causes morbidity and mortality. At least 1.5 million people are harmed by medication errors annually, resulting in thousands of deaths. In my family, my grandfather was prescribed four separate Prednisone prescriptions by several physicians who never communicated. The duplicated medications burned out his adrenals and nearly cost him his life.

The current healthcare infrastructure does nothing to prevent scenarios like this because it was designed to store and move information, not assign actions to its deluge of data.

The healthcare infrastructure was not built equally. Hospitals and large health systems designed their structure for impressing executives while overlooking frontline worker challenges. Skilled nursing facilities, home health agencies, behavioral health providers, and community organizations, to name a few, are left on the sidelines. Most of them still rely on fax and phone to attempt to coordinate care, and workers are burning out.

PASSIVE DATA MUST BECOME ACTIVE DATA

AI in clinical work is creating a seismic shift, but smarter algorithms and fancy dashboards won’t fix uncoordinated care. Real-time, automated alerts, open communication, and transparency across a patient’s care journey will.

When healthcare systems share information, they can reduce hospital readmissions by 25% according to our client experiences. When providers share real-time notifications of critical patient events and care plan changes, it allows for fast follow-up, medication change routing, and real-time records. This helps avoid dangerous transition events and significantly improves operational efficiencies among medical staff.

Technology exists to meet frontline workers where they are, but healthcare must stop treating data access as a finish line. To bring about change, policymakers need to start rewarding systems that turn actioned data into better patient outcomes, especially in rural, community-based, post-acute settings. Before we layer intelligence on top of ineffective, unequal infrastructure, we must fix the basics.

Healthcare can’t afford to let patient data sit idle; the repercussions are too severe.

Effie Carlson is the CEO of Watershed Health.

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