A Platform for Automation and Success with Care Management

Goals of the project

North Shore-LIJ is a health system serving the needs of over seven million people through 17 hospitals, 400 ambulatory practices, and three skilled nursing facilities as well as home and hospice care. Our healthcare system, including its CareConnect insurance company, is at the forefront of payment reform and population health management.

With our rapid and ongoing growth, the operational complexity of being so large and diverse, and the changes driven by accountable care reforms such as bundled payment, we’ve had to overcome several challenges. Among the first is improving care coordination and outcomes for our highest risk patients. Our vision was to aggregate and normalize all information about each patient from across our entire provider network, regardless of which electronic health record (EHR) is used, and then make it actionable in realtime. Examples include automating alerts that can help prevent unnecessary admissions when a known patient presents in the emergency room, or notifying providers when there’s a significant change in a patient’s clinical data.

To support these innovations, North Shore-LIJ made the strategic decision to invest in HealthShare, the health informatics platform from InterSystems. We used HealthShare as the foundation for building a care coordination application with rule-based systems for identifying high-risk patients, assessing needs, sharing care plans across providers and locations, supporting efficient workflows, and providing quality metrics for continuous improvement.