Case Managers, Others Can Monitor Utilization Patterns Through EHRs
By Melinda Young
Research into a novel cancer survivorship database to describe healthcare utilization patterns highlights how this information can be used to coordinate care after treatment — and how difficult it is to obtain.1
“My hope is we can inspire other people to use electronic health records and to improve overall care,” says Carlin Callaway, DNP, RN, lead study author and an assistant professor in the Survivorship Clinic at the University of Colorado Department of Medicine in Aurora. “We spend so much time putting information into an electronic health record [EHR] that now we need to figure out how to withdraw it and use the information. There are many lessons learned, and we should be sharing them with others.”
Barriers to optimal care coordination for people with cancer include gaps in information exchange, limited care coordination activities, and lack of clarity regarding provider roles — all of which create fragmentation in care.1
Treatment summary care plans can help bridge this gap. Care plans can help with communicating the need for preventive care following cancer treatment. Using health records to learn more about patients’ sociodemographics and health outcomes at a large cancer center provides an opportunity to analyze and better understand patient outcomes and health maintenance after primary cancer treatment.1
“Many people with whom I interact want to live as well as possible, as long as possible. What does that look like?” Callaway asks.
Sociodemographic data and post-treatment information could offer clues. Disease population data also might indicate how to improve handoffs and refine care coordination to include plans for ongoing care, general preventive screenings, managing comorbid conditions, promoting healthy behaviors, and offering psychosocial support.
The lessons Callaway and colleagues have learned from data on people with cancer in Colorado may help providers working with patients with cardiac disease in a different state, for instance.
EHR information is ubiquitous among health systems nationwide. But it is not necessarily used as well as possible. “What is it doing for us? What are all the boxes and options on our My Health Connection app, and how can we leverage those? What have they purchased that they’re not using to their full extent?” Callaway asks. “How do we engage people again in this post-COVID era?”
Before the COVID-19 pandemic, care coordination was incredibly complicated. “But care coordination after the pandemic is much more challenging,” Callaway says.
Mining data from health records suggests broad possibilities in treatment. “It is my hope we could learn more about people as a group who have completed treatment and figure out from the knowledge we’ve gained how to help others in the future,” she notes.
For example, people who have been diagnosed with cancer have higher rates of cancer as a whole. “How can we help them with follow-up care and overall wellness care and health maintenance care?” Callaway asks. “Many people with histories of cancer also have cardiovascular issues. Are we educating them on that?”
This is another teachable moment. “The holy grail is patient engagement and patients being able to leverage the electronic health record and leverage portal apps and set reminders for their own follow-up,” Callaway says. “If you have genetic-related cancer, and you need multiple visits with multiple teams, it would be so wonderful to have some way to tell your phone app, ‘Remind me in January to set up a visit in April with my nephrologist.’ I think we’re on the cusp of that.”
For patients of diverse socioeconomic and cultural backgrounds, providers need to connect with them in the best ways possible. “Those who don’t have access to technology may be the ones where clinics and care coordination follows a more traditional route,” she says.
But the overall goal is to help people live as well as possible for as long as possible by following through on preventive care where problems can be caught early.
“Can we prevent strokes? Can we prevent issues with other complex healthcare [of chronic disease] that makes care coordination that much more complicated?” Callaway asks. “Care coordination should be examined at every possible encounter.”
- Callaway C, Kuna EM, Overhoser L. Development of a novel cancer survivorship database to describe health care utilization patterns for Coloradans who have completed primary cancer treatment. J Cancer Surviv 2023;Dec 23. doi: 10.1007/s11764-023-01506-x. [Online ahead of print].
Research into a novel cancer survivorship database to describe healthcare utilization patterns highlights how this information can be used to coordinate care after treatment — and how difficult it is to obtain.
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