CCD Integration for chronic care management to improve patient care

Overview

A healthcare company in Boston offers services for patients with chronic conditions. They focus on helping rising risk patients who are difficult to reach. Their goal is to improve patients' quality of life and keep them out of the high-risk population. By using technology and innovative care models, they've helped many patients achieve better health outcomes and reduced healthcare costs for payers and providers.

Business Need

The Chronic Care Management (CCM) department in a hospital needed to generate Continuity of Care Documents (CCDs) with additional patient information at custom events to ensure seamless care for chronic patients. However, the standard CCD generated by the Electronic Health Record (EHR) system was missing critical data elements, such as Insurance Priority, Order, Encounter Date of Visit, Visitor Name, Reason for Visit, Physician Last Name and First Name, Patient Status, Date of Death, etc. The hospital required CCDs to be generated in batch for a given day when there were updates to patient demographics, problem list, medications, physicians and insurance plan information, visits/encounters. CCM would develop care plans for the patients based on the information received and transmit charges (DFT) back to the Cloud-based EMR application.

Challenges

The hospital faced several challenges in achieving its business objective:

1. The standard CCD generated by the EHR system did not include critical patient information.
2. The Cloud based EMR has standard triggers for CCD documents, which did not align with the hospital's requirements.
3. The CCM application required a master library integration to recognize providers and locations, and DFT inbound for charges.

Solution

KPi-Tech developed an Interface ecosystem to address these challenges and achieve the hospital's business objective. We utilized tools such as Talend, JavaScript readers to build custom CCDs, Kafka for message queueing, and AWS API Gateway for secure APIs. Our solution included the following steps:

1. We created a custom CCD document that included the missing data elements and sent it to the CCM application. This ensured that the care navigators had all the critical patient information required to create care plans.
2. We used a Talend Job to send the master library to the CCM application, which consisted of provider information. This enabled the CCM application to recognize providers and locations accurately.

Technology Stack

1. Mirth Interface Engine
2. Java Script
3. Talend
4. Kafka

Results

Our technology-driven workflows enabled the care navigators to drive greater clinical insights into interventions on behalf of their physician partners. The customized CCDs with critical patient information helped the care navigators positively, directly, and deeply impact the lives of patients and those who care for them. These clinical insights helped patients achieve life-changing results every day. The hospital achieved its business objective of seamless care for chronic patients, thanks to our Interface ecosystem. The solution was highly scalable and ensured uptime, thus meeting the hospital's requirements for scalability and uptime.