The document discusses the rise of connected care in the U.S. healthcare system. Regulatory changes and new technologies are driving a shift towards a more connected and collaborative system focused on quality of care. Connected care aims to provide the right care at the right time and place through greater data sharing and care coordination between providers. Key technologies like electronic health records, mobile devices, analytics and cloud computing will enable connected care by facilitating access to patient information across settings. However, connected care also faces challenges in standardization, physician buy-in, and integrating fragmented systems.

1. Connected Care: Heightened Imperatives
Regulatory changes, combined with powerful advances in cloud
computing and advanced analytics, create a favorable environment
for U.S. healthcare providers, payers and patients to stay connected,
and enable anywhere/anytime care via mobile devices and social-media
tools and techniques.
• Cognizant Reports
cognizant reports | July 2013

2. cognizant reports 2
Executive Summary
The U.S. healthcare industry’s business landscape
is set for drastic changes. Regulatory forces and
the availability of new technologies are driving
a fragmented landscape towards a connected,
collaborative and coherent future focused on
quality of care and outcomes. The upcoming era
of connected care encourages groups of health-
care organizations to collaborate and share
patient data, knowledge and insights from day-to-
day operations – seamlessly. These groups, known
as Accountable Care Organizations (ACOs), repre-
sent a move away from quantity to quality of care
delivered over a defined period of time across the
healthcare continuum. Simply stated, the goal of
connected care is to provide the right care at the
right place at the right time.
Providers will have to work closely with payers
in order to make a connected care system work.
The payment model encouraged by the U.S.
Patient Protection Affordable Care Act (PPACA)
will impact payers and providers alike – requiring
them to work out optimal payment models. Key
drivers for connected care – such as the value-
based purchase (VBP) system that incentivize
better outcomes, and meaningful use,1
which
encourages the adoption of electronic health
records (EHRs) – are prompting healthcare pro-
viders to implement operational and process
changes to improve accountability and derive
maximum benefits. Among the key requirements
for providing continuous, connected care is the
ability to proactively identify and monitor at-risk
populations. To achieve this, patient information
must be accessible across care-giving teams and
settings.
Moreover, connected care requires patients to
carry devices that track their health and send
realtime data to hospitals. For this to work, the
group of care providers need a technology plat-
form that is interoperable, and can collate data
from all care settings to support shared decision
making by care team members and patients. Sev-
eral healthcare systems in the U.S. are already
taking the first steps toward connected care, and
the results look promising.
Technology will play a crucial role in achieving the
overall objective of connected care. Care provid-
ers will need to securely connect their underly-
ing medical systems with health IT systems to
improve their chances of making the most of the
system being put in place.
We believe the following are key imperatives for
care providers in the connected care era:
• Integrate medical systems with longitudinal
health records from all providers in all care
settings.
• Actively engage patients in their health via
timely education about their conditions and
treatment options using traditional and online
multimedia channels.
• Transform the work culture from an individual-
driven to a team-driven model of care.
• Deploy mobile applications for tasks such as
making appointments; utilize wearable devices
for collecting and sharing data.
• Use big data analytics to understand behavior
and improve patient compliance, as well as to
ensure treatment effectiveness and efficacy.
• Create a presence on social media to engage
with patients.
Drivers and Enablers of Connected Care
The Patient Protection Affordable Care Act is a
landmark legislation. Driven by objectives such
as accountable care, the legislation is a force
that mandates collaboration among care provid-
ers. However, there are other important reasons
that make connected care a necessity for the U.S.
The country’s healthcare system has long been
plagued by high costs and fragmentation – often
resulting in poor medical outcomes and a lack of
standardization in medical practices and decision
making within and across heathcare systems.
Much of this pivots around IT and process integra-
tion, or the lack of it, across teams and depart-
ments. A typical Medicare beneficiary usually
consults two physicians and five specialists a
year, whereas chronically ill patients consult as
many as thirteen physicians a year.2
The absence
of interoperability among disparate healthcare
systems restricts the sharing of patient medical
records. Also, the lack of coordination among
physicians often results in higher utilization of
services and poor care outcomes. The responsi-
bility for coordinating these visits and managing
the patient often falls on family members, who
may not be able to handle it effectively.
A rapidly aging population places a greater cost
burden on healthcare providers. In the past decade,
the over-65 U.S. population has increased 15%.3
Data shows that healthcare costs rise dramatically
for Americans over 65 years as compared with

3. cognizant reports 3
The meaningful use standards for electronic
health records, which will be adopted in three
stages (see Figure 2, next page), are having a
positive effect. According to the Office of the
National Coordinator for Health IT, hospitals’
adoption of EHR technology to meet meaningful
use objectives has resulted in marked improve-
ments, with non-federal acute care hospitals
recording 32% to 167% increases in their capabil-
ity to meet these objectives.7
Beyond this, advances in telecommunication
technologies such as smartphones and mobile
medical devices – referred to as mHealth – enable
remote monitoring of patients, and will also
propel the execution of connected care. The use
of mobile devices for health purposes has shown
encouraging growth. A survey by Pew Internet
found that 31% of cell phone owners and 52% of
smartphone users have used their devices for col-
lecting health-related information.8
For care pro-
viders, social media accessed via smartphones,
tablets or more conventional computers is a
potential tool for encouraging patient engage-
ment. This could be through social networks
owned by the providers, such as Mayo Clinic’s
Connect9
social network, or through other popu-
lar sites, such as Facebook.
Cloud computing, combined with big data
analytics, will be the backbone of a connected
care platform. Effective cloud deployments
will enable care providers to store data from
various sources – including wireless remote
monitoring devices and applications connected
to the care system – as well as update and
share medical records across venues and health
populations. Insights gleaned from advanced
The Growing Burden of Chronic Disease
Figure 1
Source: The Impact of Chronic Disease on U.S. Health and Prosperity: A Collection of Statistics and Commentary,
Partnership to Fight Chronic Disease, 2009.
29%
31%
39%
41%
53%
54%
62%
Stroke
Pulmonary conditions
Hypertension
Heart disease
Diabetes
Mental disorders
Cancers
Projected rise in cases of seven of the most common chronic diseases, 2003-2023
their counterparts in countries such as Spain and
Sweden.4
The high incidence of chronic illnesses and their
projected growth is another source of concern
for care providers. Cases of cancer, diabetes and
five other major chronic conditions are expected
to increase by more than 50% by 20235
(see
Figure 1). Containing these chronic diseases could
help save billions of dollars in direct healthcare
expenditures.
Hospitals are also bracing for a shortage of trained
medical staff, especially nurses. The projected short-
age is expected to be between 800,000 and one
million by 2020.6
This will put additional pressure on
hospitals already overcrowded with patients.
The solution to these
problems lies in a para-
digm shift in the way care
is delivered. Care pro-
viders are realizing that
connected care, with its
focus on continuous care,
disease prevention and
remote monitoring, offers
the best way forward.
Fortunately, the underly-
ing technologies that will
support connected care
are evolving rapidly. These
include remote monitoring devices, mobile appli-
cations, big data analytics and cloud comput-
ing. The growing adoption of electronic medical
records and the increase in health-related infor-
mation exchanges also bode well for the future
of connected care.
Care providers
are realizing that
connected care–
with its focus on
continuous care,
disease prevention
and remote
monitoring–offers
the best way
forward.

4. cognizant reports 4
munity care providers spread across settings,
a connected care system will need to ensure
that data related to patient outcomes is shared
seamlessly and securely among all team mem-
bers. Widespread adoption of EHRs by physicians
and hospitals will also be crucial. The benefits of
meaningful use – namely complete and accurate
information, better access to information and
patient empowerment – can only be realized if the
adoption levels for EHRs increase significantly.
For example, although the cumulative use of elec-
tronic health records has recorded a substantial
increase over the past two years (see Figure 3,
next page), the total number of health profes-
sionals who attested to meaningful use under the
Medicare program as of May 2012 was 62,226,
which represents only 12.2% of the total eligible
physicians in the U.S.10
In order to avoid penal-
ties that come into effect in 2015, this number, as
well as the resulting increase in meaningful use,
will need to increase rapidly. The goals of each
of the successive stages of meaningful use (see
Figure 2) are progressively harder to achieve.
Therefore, greater adoption of EHRs for clinical
decision making is crucial for the overall effec-
tiveness of the meaningful use program.
analytics will drive better decision making for
individual patients, as well as patient populations.
Importantly, cloud storage can bridge the data
gap among physicians at different locations,
which will ultimately create a virtuous loop of
secure data flow that can drive more informed
decision making and result in better outcomes for
patients.
Connected Care for Providers
Connected care focuses on providing appropriate
care intervention at the right time, in the right
setting, and with the right providers.
To derive the most from value-based purchas-
ing, or VBP, care providers must shift their focus
from sick care to well care (i.e., early intervention
to avoid hospital admissions and readmissions).
Since incentives are structured to discourage cost-
ly, inappropriate care, hospitals will need to work
on prevention, which includes educating patients
on self-care, constant monitoring, and keeping
track of population health statistics to understand
patterns and devise appropriate strategies.
Given that care providers will share account-
ability for outcomes, and with multi-disciplinary
care teams involving physicians, faculty and com-
The Evolution of Meaningful Use
To achieve meaningful use, eligible providers and hospitals must adopt certified EHR technology and use it to achieve
specific objectives. Getting there involves the following three stages:
Stage 1
2011-2012
Data capture and sharing
Stage 2
2014
Advance clinical processes
Stage 3
2016
Improve outcomes
Stage 1: Meaningful use
criteria focus on:
Stage 2: Meaningful use
criteria focus on:
Stage 3: Meaningful use
criteria focus on:
Electronically capturing health
information in a standardized
format.
More rigorous health information
exchange (HIE).
Improving quality, safety and
efficiency, leading to improved
health outcomes.
Using that information to track
key clinical conditions.
Increased requirements for
e-prescribing and incorporating
lab results.
Decision support for national
high-priority conditions.
Communicating that information
for care coordination processes.
Electronic transmission of patient
care summaries across multiple
settings.
Patient access to self-management
tools.
Initiating the reporting of clinical
quality measures and public health
information.
More patient-controlled data. Access to comprehensive patient
data through patient-centered HIE.
Using information to engage
patients and their families in
their care.
Improving population health.
Source: HealthIT.gov
Figure 2

5. cognizant reports 5
dollars spent, but also in the quality of care deliv-
ered. Several care systems have developed their
own versions of ACOs, and are taking first steps
toward a connected care future. These ACOs, such
as the Arizona Connected Care, Accountable Care
Alliance and NewHealth Collaborative, are trying
out payment models, taking into consideration
the upside (cost savings)
and downside risks (penal-
ties for missing payment
targets). They are also con-
tracting private and public
payers under various risk
arrangements.
Although these are early
days, the benefits of coor-
dinated care are already evident. A survey of
seven ACOs by the Commonwealth Fund11
found
cost benefits derived by reducing hospitalization,
lowering the costs of care and lessening emer-
gency room use.
With greater technological integration between
health IT and mHealth, plus advanced analytics
and data storage technologies such as cloud com-
puting, the benefits of a coordinated care system
will be wide-ranging. mHealth alone, for example,
will create cost savings for U.S. care providers
by allowing doctors to reach patients beyond
hospital premises – reducing the burden on hos-
pital staff, and empowering patients regarding
self-care. According to Juniper Research, the
global cost savings from mHealth will be between
Meaningful Use of Electronic Health Records
Figure 3
Cumulative attestations of meaningful use of electronic health records by primary care physicians and specialists
increased substantially during the period from April 2011 through May 2012.
Source: Early Results of the Meaningful Use Program for Electronic Health Records, The New England Journal
of Medicine, February 2013.
CumulativeNo.of
Attestations
0
10,000
20,000
30,000
40,000
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Month
Specialist
Primary care physician
Under the bundled payment model introduced by
the PPACA, a single payment will be made to the
participating group of institutions for a defined
episode of care. For such a payment model to
work, information about the service provided
(including associated costs) by each institution/
physician at different stages of care will have
to be made available. Under a value-based care
model, accountable care organizations (ACOs)
will be encouraged to devise strategies and agree
upon performance benchmarks with all the play-
ers, especially payers (see sidebar next page). The
new model encourages hospitals to improve their
remote monitoring efforts so that they can more
optimally time patient admissions. Hospitals will
also need to work out ways to integrate disparate
sources of data – ranging from clinical and finan-
cial data to standard costing – in order to derive
insights that can drive improvements in processes
and care. This requires a robust, secure, clinically
integrated and interoperable IT infrastructure.
Even as care providers put in place the tech-
nologies to enable connected care, they need to
understand that the center of the connected care
universe will be the patient. Decisions made at
each stage of the patient’s journey will need to
consider their needs and preferences.
System-wide Benefits of Connected Care
With its ability to improve coordination within
the currently fragmented care system, connected
care is perhaps an inevitable next step. The costs
of uncoordinated care are too high – not just in
Sharing data freely
is at the heart of
a connected care
implementation –
and this is where the
challenges begin.

6. cognizant reports 6
reside primarily in silos – making it hard to com-
municate across disparate systems. At the same
time, HIE interoperability is a key requirement of
future payment systems.
It is therefore critical that
healthcare players agree
on standards, and work to
make their IT systems and
processes compliant with
these standards.
Standardization is also criti-
cal for measuring and mon-
itoring the quality of care
provided under the value-
based purchasing system.
While ACOs continue to
develop metrics to measure
performance, they experi-
ence a considerable time
lag in accessing reports
on cost savings and qual-
ity improvement.14
This makes it crucial for care
providers to ensure the quality and reliability of
the data collected, as this will have a direct bear-
ing on the quality of metrics created based on
the data.
Apart from these broad technological challenges,
caregivers will face significant challenges at
the organizational level. The most prominent
will be generating physician and staff buy-in to
coordinate with other care providers. Physicians,
who are used to making care decisions based on
personal evaluation and judgment, may find it
HIE interoperability
is a key requirement
of future payment
systems. It is
therefore critical
that healthcare
players agree on
standards, and
work to make
their IT systems
and processes
compliant with
these standards.
US$1.96 billion and US$5.83 billion by 2014,12
with
U.S. and Canada among the top beneficiaries.
Widespread connected care will also see the cre-
ation of a feedback loop among various stake-
holders in the care cycle, including physicians,
patients and payers. Such a virtuous cycle can be
leveraged for better decision making at a broader
level. Advanced analysis of cross-sectional data
can support effective management of chronic
diseases, public health monitoring and quality of
life. The types of emerging analytics approaches
include predictive, prescriptive and comparative
analytics.13
Sharing of data on outcomes among
care professionals and researchers creates the
opportunity to reduce medical errors.
Challenges Facing Connected Care
A connected care environment requires disparate
and mutually exclusive sets of players to work
together. These include care providers, payers,
network operators, mobile and medical device
manufacturers, and health information exchanges
(HIEs). Given the current state of fragmentation
in the U.S. healthcare system, creating such an
environment requires overcoming wide-ranging
cultural and technological obstacles.
Sharing data freely is at the heart of a connected
care implementation – and this is where the chal-
lenges begin. Sharing electronic health records
across care settings is now considered a neces-
sity by most industry players. However, due to a
lack of open standards, this is difficult to imple-
ment. Currently, healthcare data and processes
Quick Take
Payer Interoperability
Payers will have a key role to play in a connected care setup as well as the process of healthcare reform.
At the heart of this partnership will be the sharing of data between payers and providers (i.e., payer
interoperability).
Lately, payers have taken active interest in HIEs as seen in Aetna's acquisition of HIE provider Medcity.
This means that going forward payers will be able to access data related to clinical outcomes, risk and
population management. This in turn will enhance their ability to utilize providers' services and track the
appropriate metrics for reimbursements such as reduced readmission rates.
For a connected care system to work, payers and providers should be able to agree upon clinical and cost
goals and share resources. It is, therefore, important that ACOs approach payers early on and develop
reasonable performance benchmarks. This will also enable ACOs to get the best out of the VBP system
and also meet meaningful use goals.

7. cognizant reports 7
difficult to consider input derived from analysis
of large chunks of data or the opinions of their
counterparts in other hospitals/clinics. A survey
of 13,500 physicians by Merritt Hawkins on
behalf of the Physicians Foundation found that
62% of physicians believed the ACO model of
care is unlikely to increase the quality of care or
decrease cost.15
Given these perceptions, top management will
play a key role in clinical and cultural change man-
agement. Clinical change management revolves
around realigning existing processes to coordi-
nate with a larger group of physicians across care
settings. Fine-tuning these processes will involve
creating clear channels of communication and
sharing clinical data among settings.
Challenges will also arise on the data-sharing
front as various stakeholders, including device
manufacturers, network operators, insurance
companies and patients, will want a say in who
owns the data. Solving this issue upfront will be
critical for a coordinated care deployment to be
successful.
Transforming Care
A patient-centered connected care model
will require hospitals to bring about drastic
changes in their operating models. From increas-
ing the adoption of EHRs, to improving the shar-
ing of related data, to encouraging physicians
and patients to base their care decisions on the
insights derived from that data requires top
leadership to drive organization-wide cultural
changes, especially toward fact-based decision
making. As caregivers move to provide more care
remotely, they will need to improve their levels
of engagement with the patient community by
deploying technologies that enable this to hap-
pen. We believe the following points should be the
top priorities for care providers as they prepare
for a connected care future:
• All about patient data: When it comes to
sharing data, hospitals need to design their
medical records so that users are not over-
whelmed by the sheer volume of information.
Patient records shared with physicians should
have role-based permissions to ensure the
right information is presented to them
and that the patient data is appropriately
protected. Moreover, the terminology used in
these records should be standardized across
the board to ensure there are no discrepancies.
Hospitals should also implement tools that will
allow collection of patient data and transmit the
data necessary to calculate population health
metrics.
• Embracing analytics and big data: New-age
data analytics offer powerful tools for making
sense of the deluge of data that hospitals deal
with today. In a connected care environment,
these tools will help hospitals aggregate clini-
cal, administrative, socio-economic and patient-
generated data — improv-
ing their understanding
of processes and care
outcomes. Hospitals can
combine this knowledge
with principles of behav-
ioral economics to gain
insights into patient com-
pliance, risk stratification
and the design of appro-
priate interventions.
• Automation and inte-
gration: Care providers
in an ACO set up will
need to integrate their
existing health informatics with medical pro-
cesses. Automation of care processes needs
to be accompanied by the integration of these
processes, which are currently uncoordinated
and exist in silos of data. This will be crucial
for deploying a connected care strategy that
produces insights generated on a daily basis.
These insights can be used to improve out-
comes at all the connected care settings.
• Patient education: Health systems need to
adopt a fresh approach to patient education.
This will include providing various tools that
will help proactive patients and/or their family
members gather the health information they
need. These tools include Web sites and mobile
apps that provide treatment options and
educational materials. This will ensure
engagement at the very beginning of the care
cycle. As the patient moves through the care
continuum, tools such as mobile apps for
scheduling physician appointments should be
made available.
Patient records
shared with
physicians should
have role-based
permissions to
ensure the right
information is
presented to them
and that the patient
data is appropriately
protected.

8. cognizant reports 8
• Feedback loops: Virtuous loops of informa-
tion flowing among hospital-based physicians,
nurses, ambulance services and patients can
significantly empower care providers by allow-
ing them to provide just-in-time interventions.
A feedback loop for a chronic condition such
as heart disease could consist of daily weight
information that triggers just-in-time interven-
tion over the phone, reducing hospitalization
and improving patient self-care – ultimately
resulting in cost reductions for the health
system.
• Going mobile: Mobile phones and mobile health
devices are crucial for remote monitoring and
self-care. Therefore, it is critical for a health
system to have a mobile strategy in place
that addresses these requirements. mHealth,
though it is in the nascent stages, holds tre-
mendous promise for improving patient care
and reducing costs. Care systems should pro-
actively integrate this into their strategy.16
• Getting social: In a connected care future, social
media will act as a key component in engaging
patients and the community in general. Rich
content is the key to a strong social media pres-
ence. There are plenty of examples of hospitals
using social media to
not only connect with
patients, but also under-
stand what kind of infor-
mation the patient com-
munity seeks. On Mayo
Clinic’s Connect social
network, for example,
patients connect and
share their experiences,
physicians and research-
ers share stories about
their research, and spe-
cialists discuss patient
care, innovations and
new treatments.
Competing in the post-
reform era will require pro-
viders to effectively reduce
the total cost of care while
improving quality and
patient/member satisfaction. Technologies such
as mobile, big data analytics and cloud computing
will play a key role in patient-centered, connected
care and will help providers reduce costs and
improve patient engagement, as well as elevate
quality and outcomes.
A feedback loop
for a chronic
condition such
as heart disease
could consist
of daily weight
information that
triggers just-in-time
intervention over
the phone, reducing
hospitalization and
improving patient
self-care – ultimately
resulting in cost
reductions for the
health system.
Footnotes
1
Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS)
Incentive Programs that governs the use of electronic health records and allows eligible providers and
hospitals to earn incentive payments by meeting specific criteria.
2
“The Fragmentation of U.S. Health Care – Causes and Solutions.” Oxford Press.
3
“65-and-Older Population Soars.” USNews.com, January, 2012.
4
2012 - The Year In Healthcare Charts, Forbes.com, December 30, 2012.
5
“The Impact of Chronic Disease on U.S. Health and Prosperity: A Collection of Statistics and Commen-
tary.” Partnership to Fight Chronic Disease, 2009.
6
“America’s Nursing Shortage by the Numbers.” soliant.com, September, 2009.
7
“Hospital Adoption of Electronic Health Record Technology to Meet Meaningful Use Objectives:
2008-2012.” The Office of the National Coordinator for Health IT, March, 2013.
8
“Mobile health has found its market: smartphone owners.” Pewinternet.org, November, 2012.
9
http://connect.mayoclinic.org/.

9. About Cognizant
Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process
outsourcing services, dedicated to helping the world’s leading companies build stronger businesses. Headquartered
in Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep
industry and business process expertise, and a global, collaborative workforce that embodies the future of work.
With over 50 delivery centers worldwide and approximately 162,700 employees as of March 31, 2013, Cognizant is a
member of the NASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500, and is ranked among the
top performing and fastest growing companies in the world.
Visit us online at www.cognizant.com for more information.
World Headquarters
500 Frank W. Burr Blvd.
Teaneck, NJ 07666 USA
Phone: +1 201 801 0233
Fax: +1 201 801 0243
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Email: inquiry@cognizant.com
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­­© Copyright 2013, Cognizant. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without the express written permission from Cognizant. The information contained herein is
subject to change without notice. All other trademarks mentioned herein are the property of their respective owners.
10
“Early Results of the Meaningful Use Program for Electronic Health Records.” The New England
Journal of Medicine, February, 2013.
11
“Early Adopters of the Accountable Care Model - A Field Report On Improvements In Health Care
Delivery.” The Commonwealth Fund. March, 2013.
12
Juniper Research: “Mobile health monitoring services to save healthcare providers between $1.9 and
$5.8 billion globally by 2014.” May, 2010.
13
“Four types of data analytics that providers are using to improve population health.” Mecitynews.com,
March, 2013.
14
“Early Adopters of The Accountable Care Model - A Field Report on Improvements In Health Care
Delivery.” The Commonwealth Fund, March, 2013.
15
“A Survey of America’s Physicians: Practice Patterns and Perspectives.” The Physicians Foundation.
September, 2012.
16
“20 Hospitals with Inspiring Social Media Strategies.” medicalbillingandcoding.org, January, 2012.
Credits
Author and Analyst
Akhil Tandulwadikar, Senior Research Associate, Cognizant Research Centerr
Subject Matter Experts
Sashi Padarthy, Practice Leader, Cognizant Business Consulting’s Healthcare Provider Practice
Design
Harleen Bhatia, Design Team Lead
Meenakshi Sundaram Thambusamy, Designer