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Population Health knowledge hub

Learn how successful population health management can benefit your patients and your medical organization.

Coordinated health care: seamless care transitions

Coordinated health care is the Holy Grail of the health care industry. Not only has it been generally recognized as an essential element of high quality care, it has also been mandated by the federal government via Affordable Care Act and CMS requirements and by insurance companies through risk-based contracts. The goal is to create the seamless, secure exchange of vital information and images from a patient record to health care organizations, providers and facilities — whether in your coordinated care network or not.

But coordinated health care is not easy to achieve in an industry where hundreds of technologies – few of them designed to work together – are being used by general practices, specialty offices, hospitals, rehab centers, pharmacies, testing centers, health exchanges, and other health care organizations. The result is that the extended health care team's view of a patient can become fragmented into disconnected bits of information.*

Having the right population health management tools in place can help foster coordinated health care by integrating and organizing complete patient health information and facilitating its instant, secure availability among all authorized providers in your coordinated care network. Population health management tools that are part of a cloud-based health information technology system connect providers through a single, shared instance of software, which enables disparate systems to interact.

Cloud-based tools provide access to complete, secure patient data from any device – anywhere, anytime – via a web browser. Vendors of cloud-based software and services can also harmonize data from multiple sources. And, finally, it is much more economical to create individual interfaces for healthcare organizations participating in population management via the cloud, because it is only necessary to create an electronic connection for each organization once. Participants can even remain on a legacy EHR and still integrate with other organizations to effectively coordinate care.

Two other elements of successfully coordinated health care are the ability to schedule patient appointments and administer billing across the care continuum, no matter how many health organizations are involved in managing a population. The former ensures that patients will get the care they need in the setting most appropriate and the latter that both patients and providers understand the total cost of care.

* Improved care coordination. Available at:

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