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Health IT Success Stories

Dr. Fisch Improves Care Coordination for a High-Risk Population

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Dr. Tobe Fisch is a primary care internist and Director of Practice Innovation at Princeton Health Affiliated Physicians/Princeton Medicine (Princeton Medicine), the outpatient practices of Princeton HealthCare System in Princeton, New Jersey. As the Director of Practice Innovation, Dr. Fisch is responsible for optimizing electronic health records (EHRs) at Princeton Medicine and leading the practices’ Stage 2 meaningful use efforts. When Dr. Fisch and Princeton Medicine began participating in the Comprehensive Primary Care initiative, they knew they could use Health IT to improve care coordination and health care quality for their patients.

Patients with Complex Care Needs

Princeton Medicine serves a large number of frail patients with multiple chronic conditions. These patients often have multiple care needs and regularly see several different providers. This presents a significant challenge for Dr. Fisch and her colleagues, who must identify and manage the complex needs of these frail patients in coordination with other providers. “Our aim is to help our frail patients manage their care, stay as healthy as possible, and avoid unnecessary emergency room admissions and hospital stays,” explained Dr. Fisch.

Health Information Exchange

Motivated by the CPCI to improve care coordination at Princeton Health, the first step for Dr. Fisch and her colleagues was identifying their high-risk patients. Using their EHR system to generate lists of high-risk patients – such as patients with multiple chronic conditions, recent emergency room visits or hospitalizations, or polypharmacy – Dr. Fisch and her colleagues were able to quickly identify their high-risk population.

After identifying the high-risk population, Dr. Fisch and her colleagues knew they could use health information exchange (HIE) to improve care coordination for their patients. In early 2013, Princeton Medicine’s EHR system was interfaced with Princeton HealthCare System’s newly established HIE, Princeton HealthConnect. The connection to the HIE enables Dr. Fisch and her colleagues to have instant access to patient health information generated throughout the health system to better coordinate and manage patient care. “Blood tests, radiology results, pathology results, dictations, and discharge summaries are all automatically brought into our EHR system as soon as they are available,” explained Dr. Fisch.

HIE has opened the door for Princeton Health’s structured, multi-step care coordination process, which is intended to improve care coordination for the group’s high-risk patients.

  • When a patient is admitted to the hospital, the HIE sends a notification to a clinical portal monitored by Princeton Medicine’s care coordination nurses.
  • One of the nurses then notifies the patient’s primary care provider or specialist at Princeton Medicine and the hospitalist who admitted the patient so the care team can determine why the patient was admitted and formulate a care plan.
  • When the patient is discharged, the HIE notifies the care coordination nurse again.
  • The nurse then works with the patient to manage the patient’s care plan and reconcile the patient’s medications, schedules a follow-up appointment with the patient’s primary care provider, and reports the discharge to the primary care provider.

Through this systematic care coordination process, Dr. Fisch and her colleagues are able to better manage and coordinate care for their high-risk patients. “With Health IT, we can rapidly communicate and formulate a care plan when one of our patients is admitted to the hospital,” explained Dr. Fisch. “When each doctor knows exactly what is going on with his or her patients, we can deliver the best care possible.”

Improved Care Coordination

Health IT and HIE have enabled Dr. Fisch and her colleagues at Princeton Medicine to improve health care quality for their high-risk, frail patients. Dr. Fisch and Princeton Medicine increased immediate post-discharge follow-up with patients from 0% to 100%. The practices also decreased time to primary care physician office follow-up so that most of Princeton Medicine’s patients are seen within 7 to 14 days of hospital discharge. Most importantly, because Dr. Fisch and her colleagues are using Health IT to keep track of problems before they turn into admissions, Princeton Medicine estimates it has seen about a 30% decrease in hospitalizations among their high-risk patients.

In the coming months, Dr. Fisch and Princeton Medicine plan to use the HIE to begin communicating directly with their patients and to share clinical information with other providers in the health system. Princeton Medicine has already introduced a patient portal, which enables patients to electronically view their test results and will soon include clinical summaries as well.

Furthermore, Princeton HealthCare System is working to expand Princeton HealthConnect to as many of its affiliated providers as possible. “We are encouraging other medical practices to join the HIE so we can use it to communicate about our patients across the medical neighborhood,” explained Dr. Fisch. “In the long run, I am looking forward to exchanging data with providers throughout New Jersey when our local HIE is connected to a statewide exchange that is in development.”