How technology can transform fragmented patient care

Breaking down care silos: How true integration solves the healthcare coordination challenge for small practices

As a small practice physician, you’ll recognize this scenario: Your patient visits urgent care over the weekend for chest pain, picks up a new prescription at a retail clinic, and has a telehealth follow-up with a cardiologist on Monday. When they come to see you Tuesday morning for their routine appointment, you have no record or insight into these critical interactions.

This scenario is becoming increasingly common as healthcare grows more complex. Six in 10 Americans have at least one chronic medical condition, and 4 in 10 are managing multiple conditions — patients who  require care from numerous specialists across different settings.¹ Each interaction generates vital clinical information, yet most of it never makes it back to you, their primary care home.

Such fragmentation creates operational challenges, but more importantly, it puts your patients at risk and your practice under pressure. Communication failures are among the most frequent causes of harmful medical errors, with an estimated 67% of communication errors relating to handoffs — the critical moments when patient care responsibility transitions from one provider to another.² When critical patient information doesn’t follow patients between providers, the risk of missed diagnoses, medication errors, and duplicated care increases significantly.

Meanwhile, you and your practice absorb the administrative burden of tracking down missing information, following up on incomplete referrals, and managing patient frustration when their care feels disjointed. For small practices with limited staff, these operational costs — from time spent making calls to delays in treatment decisions — can be overwhelming.

You’re facing an uphill battle, as you try to deliver comprehensive care with little insight into what’s happening to your patients outside your walls. You need a solution that not only connects the fragmented elements of patient care but also organizes them meaningfully and delivers the insights necessary to make informed decisions that ensure the highest quality care for your patients.

When your patient visits an emergency room over the weekend, their discharge summary, medication changes, and test results automatically flow into your athenaOne EHR through these interoperability networks. No phone calls, no faxes, no delays.

Care coordination solutions: Three pillars of connected care for small practices

athenahealth’s approach to solving healthcare’s fragmentation problem rests on three pillars that work together to create truly connected care. Instead of adding another layer of complexity, these solutions integrate into existing workflows to make interoperability invisible to providers while dramatically improving patient outcomes.

Pillar 1: Interoperability that works: Three networks power seamless data exchange

athenahealth participates in the industry’s most comprehensive interoperability networks — CommonWell, Carequality, and TEFCA (Trusted Exchange Framework and Common Agreement) — to ensure your practice can access patient data regardless of where care was provided. In fact, 90% of athenaOne® customers connect to CommonWell, facilitating essential data sharing with other EHRs.³ CommonWell serves as athenahealth’s primary pathway for connecting to a nationwide network of health information exchanges, while TEFCA represents the future of standardized, government-coordinated interoperability that athenahealth has been actively implementing since 2024.

Here’s how this works: When your patient visits an emergency room over the weekend, their discharge summary, medication changes, and test results automatically flow into your athenaOne EHR through these interoperability networks. No phone calls, no faxes, no delays. Most technology solutions can establish connections to these networks, but few take the critical next step of organizing and contextualizing the information they receive. Practices end up buried under avalanches of raw patient data, struggling to extract meaningful insights on their own.

Pillar 2: Intelligent data management: ChartSync and automated reconciliation

ChartSync represents athenahealth’s AI-powered approach to managing external clinical data, preventing small practices from being overwhelmed with raw information. Instead, its intelligent algorithms use machine learning to identify, deduplicate, and present only the most clinically relevant information from external care sites.

For example, when a patient at Mountain Laurel Medical Center, a federally qualified health center serving Maryland and West Virginia, arrives for a follow-up visit after receiving care at multiple external facilities, ChartSync’s machine learning algorithms automatically scan incoming records from regional hospitals and specialist clinics. Rather than presenting providers with duplicate lab results, redundant medication lists, or outdated imaging reports, the system intelligently identifies the most recent cardiac workup, current diabetes management notes, and relevant specialist recommendations — deduplicating redundant information and surfacing only what's clinically actionable for that specific visit.

This real-world implementation has delivered dramatic results. According to Jessie Storey, Director of IT, “Features like ChartSync have streamlined access to critical patient data, allowing providers to maintain comprehensive records with ease.” He noted that while the first patient visit may be challenging, "the second time that patient comes in the door, the degree of insight and background the clinical teams have into that patient makes the value of interoperability really click.

In their first 18 months on athenaOne, Mountain Laurel Medical Center enjoyed significant performance boosts:

• Collections increased 20%
• Claims billed increased 27.3%
• Time to bill decreased 19.02% (from 4.2 to 3.4 days)
• Charges by first billed date increased 23.3%

Pillar 3: Actionable clinical intelligence: Surfacing care gaps in real-time

Think of clinical decision support as a smart assistant that continuously monitors patient information and taps you on the shoulder when something important needs attention — a potential medication conflict, an overdue cancer screening, or a care gap that could impact your patient’s health. AI-driven algorithms continuously analyze care gaps, medication conflicts, and follow-up needs based on comprehensive patient data from multiple sources, learning from patterns across thousands of patient interactions to call out the most clinically significant insights.

For example, consider what happens during a routine appointment when your athenaOne’s AI-powered clinical intelligence automatically alerts you that your patient had an emergency room visit three days ago for chest pain. The alert comes complete with the ER physician’s findings, medication adjustments, and recommended follow-up care. This real-time intelligence ensures you never miss critical information that could impact your treatment decisions.

The athenaOne advantage: Integrated care coordination solutions for small practices

The fragmented patient data problem that plagues healthcare has a solution: true integration. Here’s why athenahealth makes coordinated care a reality for small practices: everything talks to each other. Your clinical alerts don’t just pop up and disappear — they connect to your care management workflows. Your patient data doesn’t get trapped in silos — it flows seamlessly between tools.

This integration transforms how small practices deliver care. Critical patient information follows patients wherever they go. Care gaps get identified automatically instead of falling through the cracks. Providers make informed decisions with complete patient histories at their fingertips. Care teams can focus on patient care coordination instead of chasing down missing information.

Don’t let fragmented patient data compromise your care quality or practice efficiency. Experience athenaOne’s seamless interoperability today.