Achieving Meaningful Use:
Transitions in Care
Session 9
April 13, 2011
Agenda
• Introduction
– Overview of how Direct can be used to meet MU and State
HIE Program requirements to exchange transitions of care
documents
• Panelists
– Gary Christensen, CIO/COO, Rhode Island Quality
Institute
– Holly Miller, MD, MBA, FHIMSS, Chief Medical Officer,
MedAllies Inc.
• Q&A
• Poll
2
Meaningful Use Requirements
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule
Stage 1 Final Rule
Measure
Proposed Stage 2
Proposed Stage 3
50% (for both eligible
providers (EPs) and auth.
providers of eligible
hospitals (EHs)
Perform at least one test of
EHR’s capacity to
electronically exchange
information
Provide summary of care
record
EHR must enable a user to
electronically transmit a
patient summary record to
other providers and
organizations including:
diagnostic test results,
problem list, medication list,
and medication allergy list.
Move current measure to core
80% of summary care records
provided electronically for
transitions and referrals
Must use either HL7 CCD or
ASTM CCR
3
State HIE Program Responsibilities
The Program Information Notice to State HIE grantees (dated July 6, 2010) outlined key
responsibilities that states and SDEs must address in 2011, specifically to address and
enable three priority areas: e-prescribing, receipt of structured lab results, and sharing
patient care summaries across unaffiliated organizations.
Multi-stakeholder
process
Monitor/track MU
capabilities
Strategy to fill MU
gaps
• Convene
stakeholders with
interest in patient
care
summaries(inc.
providers,
practices, etc.
• Conduct
environmental scan
to determine
patient care
summary metrics
• Perform gap
analysis
• Set baseline,
monitor & track
various patient care
summary metrics:
• % providers
sending patient
care summaries
electronically
• Use phased
approach
• Use policy or reg.
levers to require
electronic sharing
patient care
summaries
• Consider Direct to
help rapidly enable
the electronic
exchange of patient
care summaries
• Work with REC to
start with gaps
among small
providers,
hospitals, etc.
Consistency with
national policies
/standards
Alignment with
Medicaid and
public health
• Ensure consistency
with national
standards, NWHIN
specifications,
federal policies and
guidelines
• Participate in S&I
Framework
Transitions of
Care initiative
• Implement a
flexible approach
• Establish an
integrated
approach that
represents
Medicaid and
public health
programs
• Work with Medicaid
and private payers
to include
interfaces as part
of their contractual
agreements with
providers
4
Why Direct for Transitions of
Care?
• MU-compliant. Direct use cases tied to MU priority
areas, including patient care summaries.
• Standardized. Direct provides a standardized transport
mechanism for patient care summaries.
• Simple. Simplicity helps adoption among low volume
practices and small, independent providers.
• Scalable. Direct can be utilized beyond 2011 in meeting
future stages of meaningful use requirements and other
business goals.
5
Provider Sends Patient Care
Summaries to Specialist and Back
Specialist
HISP
PCP
Perspective: Primary care provider refers patient to specialist including summary of care record.
Context: The provider has made the determination that it is clinically and legally appropriate to send the
summary of care record to the specialist.
Workflow Steps:
1. Primary care provider refers patient to specialist including summary care record
a. Physician interacts with EHR to create information packet for delivery across Direct
b. Information packet crosses Direct Project to specialist physician’s EHR
2. Specialist sends summary care information back to referring provider through same workflow steps
6
Hospital Sends Discharge
Information to Referring Provider
Hospital
PCP
HISP
Perspective: Primary care provider refers patient to specialist including summary of care record.
Context: Hospital has completed care and is preparing to discharge patient
Workflow Steps:
1. At the time of hospital admission in the EHR, the PCP of record is verified with the patient
2. Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information
package to be transferred to the PCP of record within the Hospital EHR system
3.
Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g.
medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.)
4. When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider
5. Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions
and medications with patient
7
Rhode Island Quality Institute
Presentation
Rhode Island Direct Pilot –
Objectives
• Demonstrate the feasibility of levering Direct
Project specifications as a vehicle for feeding
clinical information from practice-based EHRs to
the statewide HIE, currentcare
• Demonstrate Direct Project User Stories:
– Case 1: Primary care provider refers patient to
specialist including summary care record
– Case 2: Specialist sends summary care information
back to referring provider
9
Rhode Island Direct Pilot – Summary
• RIQI worked with EHR vendors, targeted practices,
and Beacon practices to:
– Integrate Direct reference code (one line) into EHR
platforms
– Trigger the automatic creation of a Direct message
(through the reference code), the generation of a CCD and
attachment to the message, and sending it to an HIE
Direct mailbox
– Connect targeted, participation practices that use this
interoperability model (through Direct) to the Statewide
HIE as a Data Sharing Partner for currentcare
– Lever native Direct messaging as a means to improve
PCP/Specialist coordination of care
10
Hospital Sends Discharge
Information to Referring Provider
Hospital
PCP
HISP
Perspective: Primary care provider refers patient to specialist including summary of care record.
Context: Hospital has completed care and is preparing to discharge patient
Workflow Steps:
1. At the time of hospital admission in the EHR, the PCP of record is verified with the patient
2. Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information
package to be transferred to the PCP of record within the Hospital EHR system
3.
Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g.
medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.)
4. When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider
5. Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions
and medications with patient
11
Wouldn’t it be great if….
12
Exchange of Health Information from
EHR (EHR to HIE ): Easy as 1
13
Beacon Intervention: Provider
Notification
14
Beacon Intervention: Quality
Reporting
15
Easy Exchange of Health Information
from EHRs (Doc to Doc): Easy as 1,2,3
16
MedAllies Presentation
MedAllies Direct Pilot Objectives
• Overview: Enhance patient care and safety across
transition of care settings (hospital d/c and “closedloop” consultation) by providing the real time transfer
of pertinent clinical information across disparate
EHRs in a fashion that is consistent with existing
clinical workflows
– Clinician adoption
– Secure, fast, inexpensive and interoperable
– Support small practices, large integrated delivery systems,
and everything in between
– Support advanced primary care and accountable care
models
18
Hudson Valley – New York State
Participants
• HISP
– MedAllies
• Healthcare Organizations
– Hospitals: Albany Medical Center, Health Quest Systems
– Primary Care: Albany Medical Center, Community Care Physicians,
Health Quest Systems, Institute for Family Health, Scarsdale
Medical Group,
– Specialists: Albany Medical Center, Asthma and Allergy Associates
of Westchester
• EHR Vendors
– Hospital: Siemens, Cerner
– Primary Care: Allscripts, Epic, NextGen, eClinicalWorks
– Specialists: Allscripts, Greenway
19
Hudson Valley – New York State
Hospital Discharge to PCP
20
Hudson Valley – New York State
Closed Loop Referral (PCP to Specialist & Back)
21
MedAllies Direct Summary
•
•
Speed/difficulty of implementation
– Two tracks: Technical and Clinical
• Coordinated to deploy a technically excellent solution that included
extensive clinical participation and insight in the design
– Technical track focused on harmonizing the implementation of
Direct messages and a common payload
– Clinical track focused on leveraging existing inpatient and
ambulatory EHR workflows to incorporate Direct transactions
Ease/difficulty of ongoing utilization
– Training
• Minimal
– Project focused on integrating Direct messages into existing EHR
clinical workflows and preserving the practice-specific roles and
responsibilities of the end users at each provider organization
• Ongoing utilization will require minimal additional training consistent
with training for EHR upgrades
22
MedAllies Direct Summary
•
•
Speed/Latency
– All of the Direct message exchanges in the MedAllies’ Direct pilot
occur in real time
• Speed of transactions is latency between the MedAllies’ data
center and EHR locations - measured between 5 and 10
seconds
– Data arrives to recipient prior to patient leaving last clinical area
Workflow and Clinical Adoption
– Use cases used most common transfer of care events where patient
at risk
– Clinical adoption key measure of project success
• Providers would only use the system if it were consistent with
their established clinical workflows
– Need for messages to be pushed to the providers within
their EHR systems
– “This is the Holy Grail of medicine.”
» Dr. Ferdinand Venditti, the vice dean for clinical affairs
at Albany Medical Center and a practicing cardiologist
23
Provider Testimonials
•
•
•
•
Applicability of the Direct integration for the closed loop referral use case:
– “We struggle with the process of getting information to a consultant and getting it back. Being
able to link and do it from inside our system is ideal. This is exactly what we would hope for
in terms of being connected.”
• Kenneth Croen, MD, Scarsdale Medical Group, LLC
Impact on current clinical workflow:
– (The Direct approach) “definitely mimics our workflow, but in a much more effective way,
where we are much more likely to get the results from the consults and the information we
are looking for.”
• Sarah Nosal, MD, Institute for Family Health
Preferred mechanism for clinical messaging with respect to Meaningful Use:
– “An HIE, where you have data posted, is a circumstance where an unknown patient presents
and you want to see what information is out there on this patient. The ED is the ideal
circumstance for that use case. A patient shows up, they are complaining of belly pain. You
want to pull the universe of data out there that might help you decide what is going on.
Versus a very pointed direct exchange between two clinicians, which is what we are talking
about here.”
• Fred Venditti, MD, Albany Medical Center
Privacy – security:
– Direct approach “is one to one, physician to physician. There may be opportunities to share
data that may be more restricted in an HIE.”
• Patricia Hale, MD, Albany Medical Center
Real Word Lessons – Enabling
Transitions of Care with Direct
•
•
•
•
•
•
Standards
Process
Anticipate
Communicate
Partnership
“Eyes on the Prize”
25
Additional Resources
Using S&I Initiatives to Meet
Meaningful Use
• S&I Transitions of Care Initiative
– Will focus on supporting all transitions of care with a
common modular set of data that can be used both in a
document context and to inform downstream clinical
decisions (med rec, updating problem, allergy lists,
decision support, etc.)
• The S&I Framework will develop:
– Use Cases and Requirements
– Vocabulary
• The communication/expression of specifications in CCR and
CDA
– Harmonization
• Document differences in C83 and CCR
27
Additional Resources
• Transitions of Care work plan should be completed in
July 2011
• State HIE Program Website
– http://statehieresources.org/hie-priorities/
• S&I Framework, Transitions of Care Initiative
– http://jira.siframework.org/wiki/display/SIF/Transition+of+Care+%
28ToC%29+Initiative
• Direct Project Wiki
– http://wiki.directproject.org/
• State HIE Program Website
– http://statehieresources.org/hie-priorities/
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Q&A
Poll
30