Health Information Exchange
and
Care Coordination for Persons Receiving
LTPAC Services
ASPE and CMS Briefing
Jennie Harvell
Larry Garber, MD
Terry O’Malley, MD
Bill Russell, MD
Walter Rosenberg, MSW
March 28, 2013
1
Challenges and Problems

Transitions in Care and instances of shared care are
common.

Health information is siloed, often not shared (or
shared in time) across providers/caregivers, and not
shared between health information systems.

The lack of timely health information exchange
results in:
◦
◦
◦
◦
◦
Poor continuity and coordination care
Errors resulting in safety and quality problems
Redundancies in tests/other services
Avoidable ER admissions and hospital readmissions
Unnecessary costs
2
Health Information Exchange
A national priority:
 Essential for the success of many health
system reform activities
 HHS published an RFI on the policy and
programmatic levers to accelerate HIE,
including for persons who receive LTPAC
services
https://www.federalregister.gov/articles/2013/03
/07/2013-05266/advancing-interoperability-andhealth-information-exchange
3
Agenda

The need for exchanging information at times of
transitions in care and shared care

Low cost and near term solutions for engaging
LTPAC providers in HIE activities

Exchanging information across acute, post-acute,
and long-term service and support providers

Advancing standards for the interoperable
exchange of information to support transitions of
care, shared care, and care planning

Questions and Answers
4
Communication & Adverse Events
• Poor care coordination increases the chance
that a patient will suffer from a medication
error or other health care mistake by 140%
(Lu, et al., 2011)
• Communication failures between providers
contribute to nearly 70% of medical errors
and adverse events in health care
(Gandhi, et al., 2000)
• 150,000 preventable ADEs ($8 Billion
nationwide wasted) each year occur at the
time of admission due to inadequate
knowledge of outpatient medication history
(Stiell, et al., 2003)
5
Problems With ED Visits
• Physicians in the Emergency Department
(ED) lack important or critical patient
information 32% of the time
• 15% of ED admissions could be avoided
if the ED had outpatient information
(Stiell, et al., 2003)
6
Problems After Hospital Discharge
• 1.5 Million preventable adverse events annually nationwide
from discharge treatment plans not followed (Forster, et al.,
2003)
• When multiple physicians are treating a patient following a
hospital discharge, 78% of the time information about the
patient’s care is missing (van Walraven, et al., 2008)
• 20% of Medicare patients are readmitted within 30 days.
Preventable readmissions waste $26B nationwide annually
(McCarthy, et al., 2009)
• Timely information often does not follow from hospital
discharge to community-based providers.
7
National care transitions experts
overwhelmingly identified
“improving information flow and
exchange” as the most important
tool to improve care transitions
(ONC, 2011)
8
Problems with Current Standards
• Health IT standards are lacking for needed
HIE:
– Lack standardized Care Plan terminology and
definitions
– Consolidated CDA (C-CDA) document types
(e.g. CCD) fail to meet the needs and
responsibilities of physicians, patients, hospitals
and LTPAC providers as senders and receivers
of information during transitions of care
9
Datasets for Care Transitions
• Traditionally – What the sender thinks
is important to the receiver
• Future – Also take into account what
the receiver says they need
10
IMPACT Grant
February 2011 – HHS/ONC awarded
$1.7M HIE Challenge Grant to state of
Massachusetts (MTC/MeHI):
Improving Massachusetts Post-Acute
Care Transfers (IMPACT)
11
14x14 Sender (left column) to Receiver (top)
= 196 possibly transition types
Transitions From (Senders)
Transitions to (Receivers)
In Patient
ED
Outpatient Behavioral
Acute Care
Services
Health
Hospitals
Inpatient
LTAC
IRF
HHA
Hospice
Amb Care
EMS
BH
CBOs
Patient/
Community
(PCP)
Inpatient Acute Care Hospital
Emergency Department
Outpatient services
Behavioral Health Inpatient
Long Term Acute Care Hospital
Inpatient Rehab Facility
Skilled Nursing/Extended Care
Home Health Agency
Hospice
Ambulatory Care (PCP, PCMH)
Emergency Medical Services
Behavioral Health Community
Community Based Organizations
Patient/Family
12
SNF/ECF
12
Services
Family
“Receiver” Data Needs Survey
•
•
•
•
•
Largest survey of Receivers’ needs
46 Organizations completing evaluation
11 Types of healthcare organizations
12 Different types of user roles
1135 Transition surveys completed
13
Findings from Survey
• Identified for each transition which data
elements are required, optional, or not
needed
• Each of the data elements is valuable to
at least one type of Receiver
• Many data elements are not valuable in
certain care transition
• A single paper form can’t represent this
variability in data needs
• Can be grouped into 5 types of transitions
14
Five Transition Datasets
1. Report from Outpatient testing,
treatment, or procedure
2. Referral to Outpatient testing, treatment,
or procedure (including for transport)
3. Shared Care Encounter Summary
(Office Visit, Consultation Summary,
Return from the ED to the referring facility)
4. Consultation Request Clinical Summary
(Referral to a consultant or the ED)
5. Permanent or long-term Transfer of Care
to a different facility or care team or Home
Health Agency
15
Five Transition Datasets
Shared Care Encounter Summary:
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc…
Consultation Request:
• PCP to Consultant
• PCP, SNF, etc… to ED
Transfer of Care:
• Hospital to SNF, PCP, HHA, etc…
• SNF, PCP, etc… to HHA
• PCP to new PCP
16
Five Transition Datasets
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
5
3
In patient
ED
1
Out patient services
5
LTAC
IRF
5
SNF?ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
17
5 4 2
CBOs
Patient/
Family
Additional Contributor Input
•State (Massachusetts)
–
–
–
–
–
–
MA Universal Transfer Form workgroup
Boston’s Hebrew Senior Life eTransfer Form
IMPACT learning collaborative participants
MA Coalition for the Prevention of Medical Errors
MA Wound Care Committee
Home Care Alliance of MA (HCA)
–
–
–
–
–
–
–
–
–
–
–
–
–
–
NY’s eMOLST
Multi-State/Multi-Vendor EHR/HIE Interoperability Workgroup
Substance Abuse, Mental Health Services Agency (SAMHSA)
Administration for Community Living (ACL)
Aging Disability Resource Centers (ADRC)
National Council for Community Behavioral Healthcare
National Association for Homecare and Hospice (NAHC)
Transfer of Care & CCD/CDA Consolidation Initiatives (ONC’s S&I Framework)
Longitudinal Coordination of Care Work Group (ONC S&I Framework)
ONC Beacon Communities and LTPAC Workgroups
Assistant Secretary for Planning and Evaluation (ASPE)/Geisinger MDS HIE
Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE)
INTERACT (Interventions to Reduce Acute Care Transfers)
Transfer Forms from Ohio, Rhode Island,
New York, and New Jersey
18
•National
Longitudinal Care Coordination
Shared Care Encounter Summary:
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc…
Home Health Plan of Care
Care Plan
• Anticoagulation
• CHF
Consultation Request:
• PCP to Consultant
• PCP, SNF, etc… to ED
19
Transfer of Care:
• Hospital to SNF, PCP, HHA, etc…
• SNF, PCP, etc… to HHA
• PCP to new PCP
How do they compare to CCD?
Data Elements for Longitudinal
Coordination of Care
IMPACT Data Elements
for basic Transition of
Care needs
CCD Data Elements
• Many “missing” data elements can
be mapped to CDA templates with
applied constraints
• 30% have no appropriate templates
20
ADVANCING HEALTH INFORMATION
EXCHANGE TO IMPROVE CARE
DELIVERY AND COORDINATION:
EXCHANGING ASSESSMENTS AND
CLINICAL SUMMARIES
Bill Russell, MD
Seasons Hospice and Palliative Care
ONC Consultant, Theme 2 Challenge Grants
21
PAINTING THE PICTURE OF CLINICAL
DOCUMENTATION IN LTPAC:
22
Moving to Electronic Records
• Most providers try to maintain paper records while converting
to EHR’s
• Hybrid Charts (Partial paper documents plus electronic data in
multiple systems) create datasets that are even more
fragmented.
• There are now multiple additional sources of electronic data
• Institutional Pharmacy, Laboratory, Physician EHR data,
Referral source EHR and Health Information Exchange
– Providers are responsible for a core of health information
as described in Conditions of Participation, but:
• Accessing this data is associated with cost to facilities
• IT resources to collect and integrate this information
are constrained or unavailable.
23
EHR Technology for LTPAC
• LTPAC care delivery depends on a complementary set of
clinical data
– Nursing, Rehab and Supportive Care Assessments
– Care planning and coordination
• At present, HIT functionality in LTPAC focuses on
compliance and financial performance
– Clinical assessments are implemented around required tasks
(e.g. Fall or Skin Integrity risk assessments) but the “story of the
patient” is often difficult to extract from the LTPAC EHR.
• Health IT standards are available for:
– Federally required assessments.
• However, assessments are not generally exchanged using these health
IT standards
– Functional and Cognitive status.
• Otherwise, there are few standards for document
structure, assessments and terminologies that support
clinical services in LTPAC.
24
Moving Forward
• Strategic Planning is needed to advance
electronic health information exchange and
re-use to support care coordination on behalf
of persons who receive LTPAC services.
Strategic planning could guide development
and use of HIT/EHRs that will support:
– caregiving, HIE, and care coordination in this
sector, and
– successful implementation of the MU program
• At present, interoperable health information
exchange with LTPAC providers is at best
“opportunistic ”
25
GETTING IT RIGHT IN LTPAC:
26
“Meeting Them Where They Are”
• Singular pocket of complete IT adoption
– Federally Required Assessments
Strategy: Make electronic data created for MDS and
OASIS submissions available for interoperable
exchange in ToC and Shared Care
• While the exchange of assessment data has limits:
– It provides some clinically useful information at times of
ToC and shared cared; and
– It is a starting point for engaging LTPAC providers in HIE.
27
Keystone Beacon Community
Transitions of Care Use Cases:
Acute discharge to nursing homes
(NH)
Acute discharge to home health
agency (HHA)
NH discharge to HHA
NH transfer to emergency
department (ED)
Use Case barriers:
• NH/HHA with no EHR
• NH/HHA with EHR,
but no HIE interfaces
• HIE interfaces, but no
standard CCD
(both NH and HHA)
HHA patient with ED visit
28
LTPAC to HIE
Transform™
Advanced through the Standards and Interoperability (S&I) Initiative.
HL7 Balloted. Nationally available Web service.
LTPAC
MDS or OASIS
Clinical Summary
HIE
Copyright 2013 Keystone Beacon Community
Used with Permission
29
Approach – Easy to Set up
Set up:
1. Enter site
information
2. Point to
assessment
folder
3. Enter e-mail
4. Identify recipient
of LTPAC
Summary
Visit http://transform.keyhie.org
30
Approach – Easy to Operate
Operation:
1. Runs automatically
2. Self-service tools
3. Help Desk support
Visit http://transform.keyhie.org
31
Sample LTPAC Summary from MDS
32
Annual Pricing
Entity (Metric)
Small
Medium
Large
Nursing Home (# Residents/beds)
0-49
50-199
200-399
Home Health Agency (# Medicare patients)
0-99
100-299
300-499
Principles:
Annual fees:
1. No set up or
transactions fees
2. One low annual fee
3. Sustainable operations
4. X-Large group pricing
• Small facility $499 ($40/mo.)
• Medium facility $699 ($60/mo.)
• Large facility $899 ($75/mo.)
• XL/Group pricing available
Visit http://transform.keyhie.org
33
“Meeting Them Where They Are”
• Widespread adoption of clinical process change to improve care of
patients with Change in Condition:
– INTERACT Program
• Widespread adoption of ADL tracking systems because of their
affect on payment
Strategy: Leverage LTPAC ADL tracking software, MD EHR adoption, HIE
and DIRECT (secure) Messaging to support the creation and
exchange of a Change in Condition Document. This allows:
Notification of off site physicians when a NF resident has a change in
condition to increase Medical Provider participation in assessments
and decision making. Inspired by INTERACT, this workflow is currently
specific to NF. Future use cases could include caregivers of
homebound patients.
Improved shift to shift and discipline to discipline communication around
at risk persons.
Documentation becomes available to ED’s or consultants if a patient
requires emergency services or additional assessments to improve
care
34
OK Challenge Grant
• Extensive Implementation Plan and “Boots on the Ground” with
NFs
• Overcome barriers by working with vendors and providers to adapt
ADL tracking software to alert and document Change in Condition
• Collaborated with AHRQ to overcome implementation barriers
• Developed a Health IT standardized (CCD format) for SBAR*
(nursing note generated with Change in Condition)
• Connected to HIE and exchanging from the NH to physicians and
hospitals the electronic Change in Condition/SBAR document.
*SBAR: Situation, Background, Assessment, Recommendation, a technique used for
communication in health care organizations, including NHs.
35
36
Preliminary Metrics (October-December 2012)
Short Description
Ratio of Completed SBARs
and Health Alerts to hospital
transfers
2207 (SBARs and Health Alerts grand
total)
81 (Transfers)
3.6%
Ratio of Completed SBARs
hospital transfers
260 (Completed SBARs)
81 (Transfers)
31%
Ratio of Completed Health
Alerts to hospital transfers
1947 (Health Alerts total)
81 (Transfers)
4.1%
9 (Satisfied residents)
13 (Surveyed Residents)
69.2%
% of Patients Surveyed with a
Positive Care Transitions
Experience
Incomplete measurements pending
% of transfers from NRHS to NF
with completed transfer form
NA
NA
Pending
% of transfers from NF to ED with
completed transfer form
NA
NA
Pending
% of transfers from NF to Inpatient
Admit with completed transfer
form
NA
NA
Pending
37
Summary
• Medically complex patients are increasingly
cared for in LTPAC settings
• Information flows between hospitals,
physicians, and LTPAC providers are
fragmented.
• Technology solutions are limited by
– Inconsistent adoption
– Poorly aligned standards
38
Summary
• Need a strategic plan to advance widespread
interoperable health information exchange and re-use
on behalf of persons who receive LTPAC services.
• Strategies to close the gap include:
– Increase use of certified EHR Technology in LTPAC
– Develop standards to create and exchange content
relevant to LTPAC
– Receiver specified document content
– Lightweight and low cost technologies to connect critical
information sets and introduce Health Information
Exchange to the LTPAC sector
– Automation of best practices shown to reduce hospital
readmissions
39
40
Care Coordination
and
Health Information Exchange
Bridge Model Perspective
41
Social work in transitions
• Bridge model history
– Rush University Medical
Center
– Aging Care Connections
• Themes emerged
– Hospital-community
disconnect
– Aging network
underutilization
– Systemic barriers
– Information transfer
problems
42
Illinois Transitional Care Consortium
•
•
•
•
•
•
Aging Care Connections
Health & Medicine Policy Research Group
Rush University Medical Center
Shawnee Alliance for Seniors
Solutions for Care
University of Illinois, School of Public Health
43
The Model
• “How are you now?”
• Three phases
– Pre-discharge
• Interdisciplinary team
• Community services
• EMR research
– Post-discharge
•
•
•
•
Interwoven assessment and intervention
Intensive care coordination
Motivational interviewing
Coordinating post-discharge providers
– 30-day follow-up
44
Aging Resource Centers
•
•
•
•
•
Represents a true hospital-community partnership
CMIS system
Community resource information
Care planning
EMR access for community social workers
45
Illinois Hospital Association
partnership across the State
8 sites
Chicago & Suburbs, IL
6 Sites*
North
Dakota
State Unit
on Aging
Danville, IL
Community-based
organization (CBO),
Aging Network
Brooklyn,
NY*
CBO
Philadelphia,
PA*
Area Agency
on Aging
East Lansing, MI*
 Area Agency on Aging
San Fernando, CA*
Health care organization
*Community-based Care Transition Program replication sites.
Brunswick, GA
Area Agency on Aging
Carbondale and Herrin, IL
2 sites, CBO, Aging Network
46
De facto teams
Coordinating
existing
systems to
better serve
older adults
and their
caregivers
Hospital
Primary
Care
Physician
Aging
Network
Nontraditional
Resources
Client
Home
Health
Community
Based
Agencies
Pharmacy
Skilled
Nursing
Facility
Caregivers
47
Information interface
• Area Agencies on Aging
• Community-based Care Transitions Programs
• Home health agencies
– Telehealth
•
•
•
•
Patient EMRs
Primary Care Physicians
Pharmacy
SNF
48
PERFECT
•
•
•
•
•
•
Plan of Care
Equipment/Supplies
Reconciliation
Follow-up with physician
Expectations met?
Coordination of care
– Non PCP coordination (community services,
DMEs, etc.)
• Therapy
49
Advancing Interoperable
HIE – development and
adoption of HIT standards
50
Advancing Interoperable HIE
Identify need
for electronic
HIE
Ballot Needed
Standards
Regular/On-going
communication with CMS,
ONC, HIT Policy and
Standards Committee
regarding need for and status
of standards
Fill gaps in standards:
Work with ONC S&I,
HL7, other Standards
Development
Organizations (SDOs)
51
Identify gaps in
HIE standards
S&I’s Longitudinal Coordination of Care WG
• Initiated in October 2011 as a community-led
initiative with multiple public and private sector
partners
• Advances interoperable health information
exchange (HIE) on behalf of LTPAC
stakeholders and promotes LCC on behalf of
medically-complex and/or functionally impaired
persons
• Goal: identify standards that support LCC that
are aligned with and could be included in the
EHR Meaningful Use Programs
– Identified content standards that were included in
the EHR Meaningful Stage 2 Programs for
Functional and Cognitive Status.
– Influence Meaningful Use Stage 3 standards for
HIE for transitions in care and care plans.
52
S&I’s Longitudinal Coordination of Care WG
Longitudinal
Coordination of
Care Workgroup
LTPAC Care
Transition SubWorkgroup
Patient Assessment
Summary SubWorkgroup*
•
Identifying the key
business and technical
challenges that inhibit
long-term care data
exchanges
•
Establishing the
standards for the
exchange of Patient
Assessment Summary
(PAS) documents
•
Defining data elements
for LTPAC information
exchange using a single
standard for LTPAC
transfer summaries
•
Providing consultation to
transformation tool being
developed by Geisinger
to transform the noninteroperable MDSv3
and OASIS-C into an
interoperable clinical
document (CCD+)
*Retired December 2012
53
• Providing subject matter expertise and
coordination of SWGs
• Developing systems view to identify
interoperability gaps and prioritize activities
Longitudinal Care
Plan SubWorkgroup
•
Identifying and
developing key
functional requirements
and data sets that
support exchange of
care plan, including
home health plan of
care.
Coordinating standards efforts
Focused on standards needed for Transitions of Care (ToC)
and Care Plans. Collaborators include:
–
–
–
–
–
–
ONC S&I ToC, esMD and LCC WGs
HL7 Structure Documents and Patient Care Workgroups
IHE Patient Care Coordination Technical Committee
AHIMA
ASPE
MA IMPACT Program
Deliverables include:
• HL7 Balloted standards: C-CDA refinements for exchange of: Functional
Status, Cognitive Status, and Pressure Ulcer Content, and LTPAC
Assessment Summary Documents. Balloted standards for Questionnaire
Assessments.
• IMPACT TOC Data Set
• Care Plan Glossary
• Recommendations to HITPC RFC Stage 3 MU
54
IMPACT Transfer of Care CDA Document
55
LCC WG Care Plan Glossary and Use Case
56
Lantana will work with LCC to make and
ballot HL7 CDA IGs
Shared Care Encounter Summary:
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc…
Consultation Request:
• PCP to Consultant
• PCP, SNF, etc… to ED
Home Health Plan of Care
(with esMD Digital Signature)
Care Plan
Transfer of Care:
• Hospital to SNF, PCP, HHA, etc…
• SNF, PCP, etc… to HHA
• PCP to new PCP
Mar 13
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sep 13
Oct 13
Dec 13
LCC WG Timeline: Mar 2013 – Dec 2013
LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS
LCC & HL7 Care Plan Coordination
LCC Care Plan Use Case 2.0 Development & Consensus
ToC IGs Development (Transfer Summary, Referral Note, Consult Note)
HL7 Ballot & Reconciliation
Care Plan/ Home Health Plan of Care IG Development
HL7 Ballot Package Development
Pilot Identification & Engagement
IMPACT ToC Pilot Monitoring
IMPACT Care Plan Pilot Monitoring
Milestones
NY Pilots Monitoring
Lantana Contract
Awarded
Care Plan IGs Complete
ToC IGs Complete
IMPACT Go-Live
FACA LCC WG Briefings
HL7 Intent to Ballot Due
HL7 Project Scope
Statement Due
58
HL7 Fall Ballot Open
NY Care Coordination Go-Live
HL7 Final Ballot Due
HL7 Ballot
Publication
Contacts
Lawrence.Garber@reliantmedicalgroup.org
 Tomalley@Partners.org
 drbruss@gmail.com
 walter_rosenberg@rush.edu
 Jennie.Harvell@hhs.gov

59