1. Health Information Exchange “The Shift Towards Outcomes-based Care Coordination”

2. “Next Generation of Connected Health”
Patient Coordination of Care Across the Care Delivery Spectrum
Patient Care Coordination

3. “Next Generation of Connected Health”
Care will be coordinated and/or integrated - across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services).
Care will be facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Share the right care information at the right time with those involved in a patient’s care leading to better care coordination and increased adherence to evidence-based medicine.
Focus on transforming physician-patient collaboration to improve outcomes and lower costs.

4. “Next Generation of Connected Health”
Integrate health information from a variety of sources and filter it against evidence-based guidelines to provide patient-centric, actionable information to improve care coordination of patients.
Care Managers
Patient
Patient Planner
Data in:
Patient Data Warehouse
Reporting
Claims, eRx, Labs, Risk Identification and Stratification, Eligibility, Health Risk Assessment Surveys
Clinical Intervention Notes, Lab Values, Follow-up, DM Program Enrollment, Physician Office Messaging, Patient Risk Status, Patient
Patient Input and Access
Patient Planner Registry and Practice Planner – Data Management and Decision Support
Reporting and Payment System: Select Measures and Patient Cohorts – Generate Results 4

5. Summary: “Next Generation of Connected Health”
Transforming Physician-Patient Collaboration to Improve Outcomes and Lower Costs
Informed Patients
They have the information and physician support necessary to effectively make decisions and better manage their health.
Prepared Physicians
At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care.
Local Accountability for Cost, Quality and Capacity
Standardized Performance Measurement
Shared Savings