Enhancing the transition of care through data sharing and in-workflow solutions

Prawasini Singh & Sandeep Kumar
Published: November 27, 2023

The transition of care plays a pivotal role in a patient's recovery journey. It encompasses the movement between healthcare settings and interactions with various healthcare providers.              

These transitions, which include transfers between home-based care, hospitals, residential care facilities, and outpatient consultations, are critical moments that require the seamless exchange of patient data. Unfortunately, gaps in this data flow can lead to adverse outcomes, such as care delays, preventable readmissions, and even increased mortality rates. To illustrate, average hospital readmission rates in the U.S. can range between 11.2% to 22.3%. Such high readmission rates are bound to put a country's healthcare infrastructure under a lot of stress. However, with technological advances, these are increasingly better solutions aimed at providing positive outcomes for patients, payers, and healthcare service providers alike. Studies have found a 33% reduced readmission rate and a 29% decrease in ER usage with timely digital health initiatives. This paper will discuss Virtusa’s solution, powered by AWS Data-Driven Everything (D2E), to the problem of data continuity.

Fragmented care impacts heart failure treatment outcomes

Inadequate coordination and fragmented care in managing heart failure patients have led to numerous challenges and suboptimal treatment outcomes. Home health agencies play a vital role in supporting these patients, who often value their independence and cherish their quality time with loved ones. However, the presence of comorbid conditions, such as diabetes, alongside the complexities of heart failure, presents ongoing difficulties. Despite efforts by clinicians to develop tailored care plans, gaps in care are evident. Inefficient handovers between healthcare providers and inadequate sharing of patient information lead to treatment delays and fragmented care delivery. The outdated heart implants do not provide sufficient data for effective treatment, further compounding the issues. Inconsistent follow-up appointments, medication reconciliation problems, and limited access to support services further hinder the recovery process. These challenges increase the risk of complications and increase readmissions. Addressing the need for a coordinated and comprehensive approach to care is crucial to improve treatment outcomes and ensure smoother transitions of care for heart failure patients.



Figure 1: Data points in the transition of care for a patient with heart failure


Bridging the gap with the latest technologies

During the transition of care for patients like Sarah, it is crucial to address potential pitfalls and strive for better outcomes. In order to bridge gaps in the transition of care, healthcare systems must focus on the way accurate data continuity with good insight can be made available. This can happen by defining the care continuum as having three foundational elements:

  1. Robust, scalable, reliable, available, and secure platform to run the IT system
  2. Data standardization in Fast Healthcare Interoperability Resources (FHIR) format and agility for its continuous upgrade, to drive interoperability with other players in the ecosystem
  3. The AWS Data-Driven Everything (D2E) approach to visualize all the problems and opportunities: user experience, data exchange, data analytics and insights, data storage, data governance (legal and compliance)

Digital health platforms (DHPs) have emerged as a powerful solution. They leverage the capabilities of cloud computing, data analytics, and connectivity, and ultimately enable a secure and seamless exchange of patient information among different healthcare providers and settings.

AWS is a key enabler in this process, facilitating a comprehensive suite of solutions. Powered by Amazon Web Services like Amazon HealthLake, SageMaker, Transcribe, Platform, application programming interfaces (APIs), and others, the Virtusa Digital Health Platform (DHP) is able to facilitate the transformation in the transition of care process in a number of ways:

  • Data analytics and insights: Virtusa DHP provides foundational artificial intelligence/machine learning (AI/ML) components for piloting the advanced data analytics and predictive prognosis capabilities of the identified business case. Healthcare providers can analyze large volumes of patient data, extracting valuable insights that drive evidence-based decision-making and real-time analytics for different personas, including patients, service providers, and payers.
  • Personalized healthcare: By integrating electronic health records with patient-reported data, Virtusa DHP addresses the problem of fragmented patient data and provides a 360-degree view of a patient's health, enabling healthcare providers to gain insights and identify patterns. These platforms use data analytics and predictive modeling to generate personalized insights, risk assessments, and treatment recommendations, empowering healthcare professionals to deliver targeted interventions and efficient care pathways.
  • Patient engagement and empowerment: Digital health platforms powered by AWS can empower patients by providing them with secure access to their health records, care plans, and educational resources. Through patient portals and mobile applications, patients can actively participate in their care transitions, thus fostering engagement, adherence to treatment plans, and better self-management.

Figure 2: Data continuity with Virtusa Digital Health Platform (vDHP)


These solutions are not just desirable, but also critical to, a strong healthcare system. Virtusa DHP enables this by providing the following benefits:

  • Secure data storage and data transfer: With the help of Amazon HealthLake, S3 bucket, and encrypted data transfer services, Virtusa DHP provides robust, secured, and standard data services at rest, in data transfer, and in data archiving.
  • Interoperability and information exchange: Robust interoperability with Virtusa DHP allows disparate healthcare systems to communicate effectively. No longer ensconced in data silos, electronic health records, lab results, imaging studies, and other vital patient data can be securely shared between different healthcare organizations.

Not an easy transition

While a digitally enabled transition of care holds immense potential for improving patient outcomes and streamlining healthcare delivery, several roadblocks currently hinder its widespread adoption and realization.

Many long-established companies still operate on legacy IT systems that have integration constraints. This is not an easily addressable challenge, as these systems are critical to these businesses and not easily replaceable.

Advances in IT are not just leaving traditional companies behind; they are also posing a challenge for new-gen enterprises. The rapid pace of the ever-evolving IT landscape is only making the integration of systems more difficult.

Furthermore, the lack of a common data definition is leading to varied data compilation and distribution issues. This precipitates a lack of agreement between medical professionals and healthcare service providers regarding data sharing. Each organization ― and, in the worst-case scenario, each department in an organization ― may have different definitions of data and acceptable data quality. With privacy constraints, data sharing becomes even more complicated. In many cases, there is a lack of a structured mechanism for patient consent, which is required for data sharing related to treatments.

Reimagining the future with technology enablers

The transition of care is a critical phase in a patient's healthcare journey, requiring the seamless flow of information between different care settings and providers at the critical stage. In addition to this need, there is an additional need to have patients with chronic illnesses monitored for a longer duration in order to ensure their health.

In this regard, wearable devices, such as smartwatches and fitness trackers, are key enablers. They allow for continuous monitoring of vital signs and symptoms, providing real-time data. Virtusa DHP also enables connectivity and interoperability with these smart devices, facilitating remote monitoring and long-term care features for providers to use. The AWS-powered Virtusa DHP has the potential to be a game-changer in digital healthcare. These solutions are critical to providing patients with the care they need and deserve. 

Figure 3: Data interoperability with Virtusa DHP integration services


Virtusa’s DHP solution aims to address the above challenges and enable value realization by providing a ready-to-use platform for exploring use cases, developing PoCs, building business cases, and accelerating time to market through a “consult, ideate and execute” approach powered by AWS Data-Driven Everything (D2E).

Prawasini Singh

Prawasini Singh

Business Solution Provider
Medical Devices & Digital Health

Prawasini manages the product lifecycle strategy of medical devices, for a leading manufacturer in the U.S. market. She works closely with domain leaders and technology experts to deliver important turnkey projects, along with consulting on several proposals and GTM strategies.

Sandeep Kumar

Sandeep Kumar

Manager, Business Consulting
Medical Devices & Digital Health

Sandeep leads the product lifecycle and the release strategy of medical devices for a leading manufacturer in the U.S. market. He has also led clinical operations quality initiatives in the past. He works closely with domain leaders and technology experts to deliver important turnkey projects, along with consulting on several proposals and the GTM strategy.

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