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St. Mark’s Family Medicine improves care coordination with healthIT

Paige Fieldsted, Sr. Communications Specialist, HealthInsight Utah

One Utah physician practice has embraced healthIT and is showing new technology can improve care and outcomes for their patients.

Dr. John Berneike and his staff at St. Mark's Family Medicine met with HealthInsight Utah staff to develop a workflow process to incorporate Emergency Notification System (ENS) messages from local hospitals into their care processes. ENS messages are sent to providers when they have a patient who is admitted, discharged or transferred from the hospital. Using this system, the team has goals of enhancing the transition of care process—from hospital discharge or emergency room (ER) follow-up, identifying patients in need of care coordination by monitoring utilization trends, and participating in care by communicating with ER physicians or hospital attending physicians.

St. Mark's Family Medicine is one of the first independent practices in Utah to develop a comprehensive care transitions process that is improving care for their patients. Dr. Berneike and his team have been seeing patients after hospital discharge—according to Centers for Medicare & Medicaid Services standards—for over a year. Using ENS messages, care coordination team members review hospital admission reports to locate hospitalized patients and make arrangements to see them prior to or immediately after discharge. Patients are given timely follow-up appointments to assess additional needs, new diagnoses and treatments, to reconcile medications and to provide general support and assistance.

Dr. Berneike hopes his practice will soon begin receiving discharge reports along with notifications which would provide the reason for hospitalization and enable his team to better prepare for follow-up appointments. With the ability to receive daily notifications of patient ER visits and hospital admissions and discharges through Utah's Clinical Health Information Exchange (cHIE)*, Dr. Berneike and his team are confident they will be able to intervene at much faster rates than before.

Within Dr. Berneike's team there is currently one staff member assigned to monitor and address discharges; another will review lists and monitor trends in patients seeking ER care and follow-up with those patients to determine care coordination needs; a third staff member will contact discharging facilities to get patient reports and other important data.

The St. Mark's Family Medicine team has already seen instances where patients needed faster interventions after hospital discharge because patients are often anxious, medicated, in pain or have other issues that keep them from fully understanding their hospital discharge instructions. The team is committed to improving care transitions for their patients. Having the opportunity and encouragement from Dr. Berneike's team to be more proactive with their health issues may improve patients' engagement in their health care and health.

Dr. Berneike is an Office of the National Coordinator for Health Information Technology (ONC) HealthIT fellow and is one of more than 1,700 providers in Nevada and Utah that the HealthInsight Regional Extension Center (REC) is currently supporting to enhance quality patient care through the effective use of technology.

*Utah's cHIE is managed and offered by Utah Health Information Network (UHIN), visit or for more information.