GCN: Protecting At-Risk Veterans During a System Transition

The Department of Veteran’s Affairs faces a historic health care delivery challenge. As it transitions to a new electronic health record (EHR) system, the VA is also tasked with providing more holistic care to servicemen and women identified as high-risk. Disrupting patient engagement and care is not an option as this decade-long transition accelerates.

Those are the views of our own Paula Sanchez, MSN, RN and Clinical Systems Analyst at DSS, Inc. The publication Government Computer News recently published her article on the topic.

Paula writes that to meet this challenge, the VA is instituting care coordinators in its facilities. Nicknamed care “quarterbacks,” these coordinators are tasked with overseeing the entire picture of a patient’s care, which is especially important for veterans with chronic conditions such as diabetes. It’s common practice for Veterans Health Administration sites to use multiple clinical decision support (CDS) systems to support a variety of patient populations.

Unfortunately, this approach leads to disjointed patient information. Data is siloed in multiple systems and databases, which translates to crushing workloads for coordinators who are typically responsible from overseeing up to 1,200 patients. This disjointed care model is not just immensely tedious, it is error-prone and puts high-risk patients at even greater risk of readmission.

To demonstrate this risk, Paula shares the story of “Emma,” a veteran at-risk patient persona. Emma is a proud veteran who is hospitalized with elevated blood sugar levels and diagnosed with Type 2 diabetes. If everything goes according to her care plan, she will be treated and quickly discharged with everything she needs to manage her diabetes and get back to a healthy life. Sounds simple and straightforward.

But what if Emma lives alone? What if she doesn’t have reliable transportation? What if members of Emma’s care team only have a siloed view of their own interactions with her, unaware of other care she is or is not receiving? In this scenario, Emma could easily miss a follow-up appointment, accidently over medicate and end up rushed back to the hospital.

Paula then shares a different scenario with all the “dots” connected with integrated CDS technology, including the linkage of outpatient care with in-patient data. For the first time, this total picture can also include socio-economic data, such as transportation issues that could affect accessibility to care. After Emma receives her diagnosis of diabetes mellitus, her entire care team is given a clear view of her patient profile. Everything from her diagnosis, consults, labs and medications are readily available for fast collaboration and action.

Because Emma’s care team knows ahead of time that she lives alone and without reliable transportation, they take appropriate action before scheduling her follow-up appointment to ensure she has a ride. Emma arrives for her follow-up appointment as scheduled. She receives the additional support she needs to fully understand her diagnosis and how to medicate correctly moving forward. This kind of care honors our commitment to veterans and returns them to their healthy lives.

To understand more about how integrated, real-time CDS care dashboards can make these kind of improvements happen, read Paula’s full article here.