This document summarizes a case study of using digital health records and care coordination to help a patient with complex medical and social needs. The case manager collected the patient's health data from various sources and providers, assembled it into an online health record using the Mayo Clinic PHR. This coordinated record helped facilitate improved care as the patient transitioned to a new healthcare system. The document advocates for greater interoperability, public education, and a patient-centered approach to digital health adoption and meaningful use.

1. From Confusion to Fusion
A case managers and patient advocates use case
demonstrating existing web-portal technology to establish
a bases for treatment planning
Jeffrey Harris
Untangled Healthcare
June 2011
Untangled Healthcare
Assisting communities to monitor and
improve healthcare
www.untangledhealthcare.com

2. • Digital shared continuous history
• Magical transfer of data across vast
distances including pictures, treatments,
diagnosis, test results
• Computers converting data to information
shared with the service providers who
include patient and family as active
component of treatment team
• Shared accountability for well-being
• Patient recall (interview)
• Paper records
• Manual processes with forms
• X-ray film and Fluoroscopy
• Microscopes and Cell Counts
• Postal Service
• Telephones
• Fax Machines
• Human Computers
E-Healthcare
Making sense of it all
Jeffrey Harris
Untangled Healthcare
From Confusion To Fusion (we hope?)
Who are you
people?
What are you
doing?
I can’t remember
all of my doctors
and why my
parents passed
away?
We are
better
informed
I am more
healthy.,
knowledgeable,
motivated and
accountable
Past Present Future

3. “The Future is here :But not evenly distributed.”
Dean Sperry Hartford Ct.
A case manager perspective on “the state of the State”
My Background (Two Lenses: Case Manager and Patient)
Paraprofessionals lens:
Professional
1980-1988 Acute Care Respiratory Therapist to Division Director;
1989-1997 Program Director | Cross-Venue Physical Medicine and Rehabilitation
(chronic heart failure, moderate to end stage COPD)
1998-2001 clinical knowledge expert to start-up software company developing web-
native n-tiered community case management system;
2002-2006 Director of clinical informatics NC Community Care (Medicaid PCCM
program)
2007-2011 Consultant: Population management, Clinical integration
Personal
Diabetic dx 1968’
Spinal Stenosis dx 1999
Insulin pump user since 1984 (Joslyn Center Patient Education Program)
Self advocate since the onset of prospective reimbursement and managed care

4. Question: Given patient status how would the clinical world
find all of this information during assessment?
Patient interview
SS Dept. attempt to locate data
Repeated testing to R/O dx
Hospital Critical Path
Discharge to community
New Medical History Variant
Disconnected from future episodes
Classic Scenario
Poor transition management
No portable record

5. In two years she:
1. Was a victim of domestic
violence
2. Transitioned from military to
public health systems
3. Was treated by 12 physicians
and surgeons and behavioral
health specialists
4. Was placed on twenty two
different medications some of
which were within the same
class and directly
contraindicated
5. Lost her ability to think clearly
6. Lost her family
7. Lost everything…save her best
friends of over twenty years
8. So here we are.
Helping a friend
• Our friend with her treatment records
and medicine when she arrived at our
home

6. Use Case: Care Coordination, Management and Advocacy
Long standing friend in need of help; fell through Florida’s Safety Net
Patient Classification:
Demographic: 50 y/o Caucasian female
Bio- Complex comorbidity (degenerative spinal disease,
acute trauma with questionable TBI, constellation of
auto immune diseases
Psycho- History of episodic substance abuse ETOH and
prescription narcotics, depression, PTSD
Social- Indigent, Income= $1300/MO; homeless; divorce in
process, domestic violence victim, Medicare dually
eligible SSDI, Post graduate degree in behavioral
health
Functional- Mental: Cognitive defects memory and executive
function
Physical: Chronic pain limitations to locomotion and
IADL
Summary: Can’t work, can’t drive, can’t think = NO HOPE

7. Helping a friend
• Provide food and shelter
• Collect Data
• Assemble on-line health record
• Draft clinical and social summary
• Research best institutions for identified problems
• Make appointments
• Provide Transportation

8. Data collection
• Objective:
• Gather as much as possible and
filter for sentinel information
– Diagnosis
– Procedures
– Providers
– Medications
– Hospitalization Episodes
• Store Data in secure online
repository with proven
connectors to EMRs, PHRs
and Vendor Hubs e.g. Quest,
CVS
• Methods:
Claims extract
Good for preventive svcs, providers
Hospitalizations and visits.
Dx missing on claim records not helpful
Required many hours of patient interview to
reconcile ‘truth’
Microsoft HealthVault
Note for Microsoft:
Blue Button download to MS Health Vault
faulty (TXT ONLY), file incompatibility need xml
or CCR. If third party to provide connector
don’t advertise Health Vault Connectivity
Walgreens RxHub connect did not work
CVS did work. If these are user issues then tell
us what to do please.

9. Assemble on-line health record
Attempt to connect health-
vault to Blue Button Health
Record
Test Failed
Blue Button record effort
aborted
Attempt to connect health-
vault to Mayo Clinic PHR Test Successful
Established Mayo Clinic PHR
and completed data entry for
patient
Mayo PHR
Summary
Record
CVS used
as
Pharmacy of
choice

10. Transported Patient to UNC HealthCare with
Summary Documents and Films
Final Outcome
Combined Mayo
PHR with Manual
Clinical Summary
Patient
Mayo
PHR
Medicare
UNCCVS
Health
Vault
Patient Team Today
Primary Care MD
Psychiatrist
Physiatrist
Behavioral Health Program
Portable Health Record
Medications
Start = >20
Today = 8
Functional Status
Independent all IADL
Self transportation
Self perceived health status improved

11. What we need (IMHO)
• First and foremost: A straw-man model of what
industry is building and utility to consumer. A five
minute elevator speech that a person at the local
ice cream stand will understand
• Public Education Program (Uniform and Nation Wide)
• Vendor collaboration on interoperability
• Monitoring of meaningful use from the patients
perspective
• Thanks for listening!!!!

12. Untangled Healthcare LLC
Untangled Healthcare
Assisting communities to monitor and improve healthcare
919 627-5038 Cell
919-779-7368 Office
email: JeffHarris@untangledhealthcare.com
Linkedin: Jeffharris75 on Linkedin
Blog: http://www.untangledhealth.com/
Website: http://www.untangledhealth.com/
Twitter: http://twitter.com/UntangledHealth