Vendor Launches Ambulatory Health IT Tool for Care Coordination

Health vendor CarePort has launched a health IT solution that aims to improve care coordination for ambulatory providers.

As hospitals increasingly rely on ambulatory providers to support whole patient care, ensuring access to patient records across the care continuum is key to improving care quality.

Through an electronic referral process, CarePort Ambulatory allows physician groups and other ambulatory providers to connect patients to home-health services and community-based organizations that provide resources and services such as durable medical equipment, physical therapy, transportation, and food insecurity programs.

“As care is increasingly delivered outside the four walls of a hospital, physician groups and other ambulatory providers require the capabilities to support whole patient care,” Lissy Hu, MD, CarePort CEO and founder, said in a public statement.

“Our newest offering enables ambulatory providers to efficiently coordinate with home- or community-based organizations, and track and monitor care across settings – helping achieve the best possible outcomes for patients,” Hu continued.

Providers can integrate the care coordination solution directly into the EHR, allowing them to launch the referral tool within their workflow.

Providers can use the tool to search a national database of services to find the best fit for the patient. Then, providers can maintain two-way communication throughout the referral process to ensure patients’ needs are met within their home or in the community.

“The CarePort platform takes away all of the manual detective work in transitional care management,” said Bill Johnjulio, MD, chair of AHN Primary Care Institute and medical director of Physician Partners of Western Pennsylvania. “The platform provides us with the contextual information we need, in real-time, to better monitor patient transitions across the continuum of care.”

With data from more than 1,000 hospitals and external data sources like health information exchanges (HIEs), the database provides physicians with real-time information to monitor patient discharges, transfers, and readmissions across the continuum.

This insight into patient status will allow physician groups to stay in tune with an individual’s health journey and re-engage with a patient, if necessary, according to representatives.

Saint Peter’s Healthcare System in New Jersey recently integrated CarePort to adhere to the new Medicaid/Medicare conditions of participation rule.

The rule requires hospitals to direct message the individual’s care team regarding patient events such as emergency room visits or admittance and discharge from the hospital. CMS enforcement of the rule begins on July 1.

“The idea is that the message is generated automatically by the EHR when one of these conditions are met,” Jordan Tannenbaum, vice president, CIO, and CMIO at Saint Peter's Healthcare System, told EHRIntelligence in an interview earlier this month. “The result of this is better follow-up, less readmissions, and overall better care because it's supposed to follow up after a hospital encounter.”

“The API has the benefit of having a lot of information about those direct addresses for all the different post-acute care positions and providers,” Tannenbaum continued. “They have a record of who has seen this patient outside that we don't know.”