Care Evolution

From HIMSS 2023 Interoperability showcase

Mrs. Jones is a 69-year-old Medicare beneficiary who used to be on Medicaid and more recently fee-for-service Medicare and now has just joined a Medicare advantage plan. Her health plan offers her an innovative app available via mobile phone or web that lets her aggregate her data from CMS fee-for-service, her old Medicaid provider, and her local tertiary care hospital and independent primary care practice. Her health plan uses these records to identify that she is caught up on her colonoscopy and diabetes care, while her congestive heart failure was identified as something to monitor more closely. Her health plan also offers Mrs. Jones a wearable device to help manage and track her congestive heart failure at home while the plan’s care team provides personalized care that is informed by her telehealth encounters with their national telehealth provider. Mrs. Jones accepts an invite to participate in a diabetes research study conducted by a partnering academic health center and uses the app to permit sharing her aggregated health records with the research team. With real world data and participant reported outcomes from people like Mrs. Jones, the research institution’s big data / machine learning team uses their aggregated, longitudinal, real-world evidence dataset to uncover new insights about what is most effective in improving patient engagement with their oral hypoglycemic regimen. Overall, this demo shows the benefit of inferring a lifetime person record by assembling claims, EHR, social determinants of health, wearable, and at-home care data for health care organizations committed to innovative patient-centered care.

Value
A lifetime medical record using patient-mediated access to provider, claims, and wearable data increases individual control and convenience, enhances personalized care, and improves trial participation and results with real-world evidence.