Dianne Gray, Chief Innovation & Patient Advocacy Officer

Yesterday I received news that a 65-year-old breast cancer patient I worked with had died, leaving behind her 39-year-old daughter, a fiancé, her daughter’s father and her 85-year-old mother. Her healthcare journey provides one more example of the way too many lives end in a fragmented healthcare system where too few patients and their families get the information and care they need, when they need it.

This patient’s Western healthcare experience was not unusual. Her healthcare providers discussed her diagnosis with her and prescribed traditional treatments for Stage IV breast cancer. She found the treatments unbearable and decided to go the route of holistic therapies for two years, without ever checking in with her clinical team.  

While more bearable, her holistic treatment plan involved care duplication, a lack of care coordination, and more than a few hospitalizations and ER visits. The patient’s family went the entire journey without the support of a social worker, chaplain, or palliative care team interface, which meant that they stitched together psychological, spiritual and support care as best they could without help.  

When the cancer spread to the woman’s brain, a family member reached out to me through someone I had helped as an end-of-life doula. I discussed palliative care with the woman, who first wanted to talk to her prior oncologist about resuming her previously prescribed protocol. She was determined to “think positively” and was death averse, so she didn’t want to discuss advance care planning. 

However, the treatment she was considering was not practical for several reasons, including the fact she had moved too far from her original physician’s office. She found a new oncology practice that provided no palliative care referral or consult. That practice had trouble obtaining previous medical records and found it difficult to develop a complete and correct history because by this point, the patient couldn’t remember medications, clinical history or other affiliated provider information, which  slowed important decision making.

Talking to the family after the woman’s death, one  family member said, “We felt like we were stranded on an isolated island in the middle of the ocean…and not in a good way.”   

“The doctors didn’t talk to each other, and we ended up having to be the ones repeating basic information a hundred times. Couldn’t someone have given us better information about what to expect, even if it was to acknowledge that my mother was going to die ?” exclaimed the daughter.

As patients live longer with illnesses that involve multiple diagnoses and treatments, better care coordination is not only essential for ensuring more effective and efficient care. It is also critical for providing more compassionate care. This case overview highlights the importance of having complete and current data that can be shared between every member of the care team.

Data at the Point of Care (DPC) is a CMS pilot program that is enabling data sharing to help prevent or lessen the issues too many patients face as they try to navigate the American healthcare system.

DPC aims to fill medical history gaps by providing clinicians with three years or more of Medicare Fee-for-Service claims data. This secure, structured, and standardized data gives every clinician on the care team the information they need to improve the quality of beneficiary care and coordinate with the entire care team. Additionally, it removes the burden of responsibility from the patients and their loved ones to remember every detail of their medical histories.

DPC means that more time is available for the provider to deliver quality care and share information regarding new diagnoses, medications, vaccines, completed procedures and other information with other clinics, including urgent care, hospitals and other ER visits.

Acclivity Health is one of the first companies to become involved with the DPC pilot so that we can make this data available to the clinicians and hospice organizations and ease the burden on patients and their families. Together, we are helping to create connected care communities that provide more efficient and compassionate care.

The CMS claims data, when used at the point of care, offers multiple benefits to providers and patients, including:

  • Better care coordination
  • Reduced duplication of care 
  • Ability to predict potential risks, allowing for proactive planning
  • Reduced utilization of acute care services
  • Reduction of healthcare silos through improved communication  
  • Greater confidence in medical decision making
  • The ability to establish palliative and hospice eligibility
  • The ability to prognosticate longevity

If you’d like to learn more about how Acclivity Health is making Data at the Point of Care accessible and is helping to improve advanced care management, please email us at info@acclivityhealt.wpengine.com or call 904-562-1368.