1. Making an IMPACT on Care Transitions in Central Massachusetts January 16 th, 2013 Larry Garber, MD Medical Director for Informatics Reliant Medical Group

2. Conflicts of Interest None 2

3. Learning Objectives Attendees will be able to: 1.Express the current medical and economic impact of poor care transitions 2.Discuss the software system for enabling providers across the continuum of care to participate in the health information exchange 3.Explain the role of the IMPACT project in developing national standards for care transition datasets 3

4. Agenda Problems with care transitions IMPACT – working to improve care transitions ONCs S&I Framework - Developing national standards for transitions of care datasets LAND & SEE – software to facilitate integrating LTPAC into electronic health information exchanges (HIE) 4

5. 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

6. 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

7. 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 patients 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) 7

8. Ambulatory Care is Just as Bad 68% of specialists receive no information from the referring PCP prior to referral visits 25% of PCPs do not receive timely post-referral information from specialists (Gandhi, et al., 2000) 8

9. Is Massachusetts Different? Preventable readmissions waste $577 Million in Massachusetts annually MA ranks 35 th in the nation on measures of quality relating to coordination of care, such as preventable hospitalizations for chronic conditions and hospital readmissions (McCarthy, et al., 2009) 9

10. National care transitions experts overwhelmingly identified improving information flow and exchange as the most important tool to improve care transitions (ONC, 2011) 10

11. An Odd Twist of Fate 2008 – Economy crashed 2009 – ARRA passes, including the Health Information Technology for Economic and Clinical Health –$27 Billion for hospital and MD practice EHRs –Must use the EHR in a Meaningful way, including improved communication with others that have EHRs But Long Term and Post-Acute Care was left out! 11

12. Yet Post-acute Care Costs are Source: MedPAC, 2008 DeJong 2010 Rising faster than acute care costs

13. IMPACT Grant February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI): I mproving M assachusetts P ost- A cute C are T ransfers ( IMPACT) 13

14. IMPACT Objectives & Strategies Facilitate developing a national standard of data elements for transitions across the continuum of care Develop software tools to acquire/view/edit/send these data elements (LAND & SEE) Integrate and validate tools into Worcester County using Learning Collaborative methodology Measure outcomes 14

15. Developing National Standards to Support LTPAC Needs 15

16. 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 16

17. Stakeholders/Contributors State (Massachusetts) –MA Universal Transfer Form workgroup –Bostons 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) National –NYs 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 (ONCs 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)

18. Single dataset for all transitions? 175 element CCD 325 element IMPACT for basic LTPAC needs 480+ elements for Longitudinal Coordination of Care

19. 19 14x14 Sender (left column) to Receiver (top) = 196 possibly transition types

20. Receiver Data Element Survey 20 1135 Transition surveys completed Largest survey of Receivers needs 46 Organizations completing evaluation 12 Different types of user roles

21. 12 User Roles 21

22. 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 cant represent this variability in data needs Can be grouped into 5 types of transitions 22

23. 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 23 Five Transition Datasets

24. 24 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 Five Transition Datasets

25. 25 2 4 3 5 5 5 5 1 Five Transition Datasets

26. 26 Transfer of Care Care Plan Shared Care Encounter Summary Consultation Request Two Care Plan Datasets Home Health Plan of Care (CMS-485)

27. Testing the IMPACT Dataset 27

28. Pilot Sites to Test the Datasets 16 Worcester County Pilot Sites: –St Vincent Hospital and UMass Memorial Healthcare –Reliant Medical Group (formerly known as Fallon Clinic) and Family Health Center of Worcester (FQHC) –2 Home Health agencies (VNA Care Network & Overlook VNA) –1 Long Term Acute Care Hospital (Kindred Parkview) –1 Inpatient Rehab Facility (Fairlawn) –8 Skilled Nursing and Extended Care Facilities 28

29. Nursing Facility Pilot Sites Beaumont Rehabilitation of Westborough Christopher House of Worcester Holy Trinity Nursing & Rehab Jewish Healthcare Center LifeCare Center of Auburn (+EMR) Millbury Healthcare Center Notre Dame LTC Radius Healthcare Center Worcester 29

30. 30 IMPACT Learning Collaborative: Testing the Care Transitions Datasets 16 organization, 40 participants, 6 meetings over 2 months, and several hundred patient transfers…

31. Learning Collaborative Surveys Surveys directly on envelopes carrying IMPACT packet, filled out by sender as well as receiver. Online survey at completion of pilot 31

32. Senders found the data 32

33. Receivers got most of their needs 33

34. Home Care needed even more! 34

35. Office of the Chief Scientist National Coordinator for Health IT (ONC) Office of the Deputy National Coordinator for Operations Office of the Chief Privacy Officer Office of Economic Analysis & Modeling Office of the Deputy National Coordinator for Programs & Policy Office of Policy & Planning Office of Science & Technology (formerly known as the Office of Standards and Interoperability (S&I)) Office of Provider Adoption Support Office of State & Community Programs 35 S&I Framework convenes public and private experts, and proposes HIT/HIE standards HL7 ballots standards Secretary of HHS makes standards part of Meaningful Use and EHR Certification IMPACT HIT Policy Committee Defines Meaningful Use of EHRs HIT Policy Committee Defines Meaningful Use of EHRs New World of Standards Development

36. Getting Connected: LAND & SEE 36

37. LAND & SEE Sites with EHR or electronic assessment tool use these applications to enter data elements –LAND ( L ocal A daptor for N etwork D istribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR Non-EHR users complete all of the data fields and routing using a web browser to access their Surrogate EHR Environment (SEE) 37

38. Surrogate EHR Environment (SEE) Acts as destination for routed CCD+ documents Software hosted by trusted authority, accessed via web browser SEE is accessed via the HIEs web mailbox Non-EHR users able to use SEE to view, edit, send CDA documents via HIE or Direct to next facility Can select document type (e.g. Transfer of Care or INTERACT SBAR) to display section flags indicating their optionality Can reconcile 2 documents to create a third SEE users able to locally print copies of the documents or subsets of the documents 38

39. Using SEE for LTPAC Workflows SNF patient getting sicker –Subset of Transfer of Care dataset that is in SBAR (INTERACT) is flagged for completion by nurse online –Can re-use data received from hospital –Can re-use clinical assessment data (function, cognition, wound) from last MDS –Completed SBAR printed for chart Patient transfer to Emergency Department –Can re-use hospital, MDS, OASIS or SBAR data –Multiple users (nurse, social worker, clerk, etc…) can work on different sections online at same time –Completed ToC dataset sent electronically to ED –Subset can be printed for ambulance team 39

40. 40 Hospital Home Health PCP Non-standard EHR OASIS Non-standard EHR OASIS Nursing Facility Billing Program MDS Billing Program MDS LTPAC Communication Today – Paper!

41. 41 Hospital Home Health PCP SEE CCD+ OASIS Non-standard EHR OASIS Non-standard EHR OASIS LAND SEE CCD+ MDS Billing Program MDS Billing Program MDS LAND CCD+ LAND & SEE fill in gaps LTPAC Communication with LAND & SEE Nursing Facility

42. The Future with LTPAC EHR Standards 42 Hospital Home Health PCP CCD+ EHR MDS CCD+ EHR MDS CCD+ EHR OASIS CCD+ EHR OASIS CCD+ Nursing Facility

43. Timeline for Standards Development October 2012MA HIway go-live in 10 large sites with CCD and LAND April 2013Pilot electronic Transfer of Care Datasets between 16 central Massachusetts organizations using MA HIway, LAND & SEE September 2013 HL7 Balloting of new Care Transition and Care Plan standards for inclusion in Meaningful Use Stage 3 43

44. Disseminating the Seeds IMPACT Advisory Committee Massachusetts Care Transitions Forum Massachusetts QIO (MassPRO) Worcester Galaxy Pilot Sites Core IMPACT Team Another Galaxy Pilot Sites Core Project Team Another Galaxy Pilot Sites Core Project Team Another Galaxy Pilot Sites Core Project Team Another Galaxy Pilot Sites Core Project Team Another Galaxy Pilot Sites Core Project Team 44

45. TOMalley@Partners.org Lawrence.Garber@ReliantMedicalGroup.org Questions?

46. Bibliography Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine 138: 161-167. 2003. Gandhi, Tejal K., Sitting, Dean F., Franklin, Michael, Sussman, Andrew J., Fairchild, David G., and David W. Bates. Communication Breakdown in the Outpatient Referral Process. Society of General Internal Medicine (September 2000): 226- 231. doi:10.1046/j.1525- 1497.2000.91119.x. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/ Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007 Dec;40(6 Suppl):S40-5. Epub 2007 Sep 7. Lu, C. Y. and E. Roughead. Determinants of Patient-Reported Medication Errors: A Comparison Among Seven Countries. International Journal of Clinical Practice (April 6, 2011): 65: 733–740. doi: 10.1111/j.1742-1241.2011.02671.x. http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2011.02671.x/pdf. http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2011.02671.x/pdf Overhage JM, McDonald CJ, et al. A randomized, controlled trial of clinical information shared from another institution. Annals of Emergency Medicine 39[1], 14-23. 2002. Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003 Nov 11;169(10):1023-8. Van Walraven, C., Seth, R., Austin, P. & Laupacis, A., 2002. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med, Volume 17, pp. 186-92. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value of Healthcare Information Exchange and Interoperability. Hlth Aff (Millwood) 2005 Jan-Jun;Suppl Web Exclusives:W5-10-W5-18.