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IMPACT - Connecting Long Term and Post-Acute Care Organizations to the Healthcare System of the Future February 2013 Drs. Larry Garber and Terry OMalley.

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Presentation on theme: "IMPACT - Connecting Long Term and Post-Acute Care Organizations to the Healthcare System of the Future February 2013 Drs. Larry Garber and Terry OMalley."— Presentation transcript:

1 IMPACT - Connecting Long Term and Post-Acute Care Organizations to the Healthcare System of the Future February 2013 Drs. Larry Garber and Terry OMalley

2 Agenda Problems with care transitions What is Long Term and Post-Acute Care (LTPAC)? IMPACT – addressing LTPAC needs 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) 2

3 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) 3

4 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) 4

5 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) 5

6 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) 6

7 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) 7

8 National care transitions experts overwhelmingly identified improving information flow and exchange as the most important tool to improve care transitions (ONC, 2011) 8

9 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! 9

10 Yet Post-acute Care Costs are Source: MedPAC, 2011 Rising faster than acute care costs

11 What is LTPAC? 11

12 Physician Office 12 Living at Home CBS Outpt. Rehab Home Health Adult Day Care PACE Assist Living Nursing Home SNF LTACH IRF Acute Care Hospital Emergency Department Urgent Care Psych Hospital Hospice Facility Home Hospice Outpt. Behav. Health Acuity of Illness Intensity of Care Adapted from Derr and Wolf, 2012 Low High The Spectrum of Care Outpatient Testing/Pharmacy/DME

13 13 Living at Home Home Health PACE Assist Living Nursing Home SNF LTACH IRF Hospice Facility Home Hospice Acuity of Illness Intensity of Care Adapted from Derr and Wolf, 2012 Low High Traditional Long-Term and Post-Acute Care (LTPAC)

14 Physician Office 14 Living at Home CBS Outpt. Rehab Home Health Adult Day Care PACE Assist Living Nursing Home SNF LTACH IRF Urgent Care Hospice Facility Home Hospice Outpt. Behav. Health Acuity of Illness Intensity of Care Adapted from Derr and Wolf, 2012 Low High IMPACTs View of LTPAC Outpatient Testing/Pharmacy/DME

15 Physician Office 15 Living at Home CBS Outpt. Rehab Home Health Adult Day Care PACE Assist Living Nursing Home SNF LTACH IRF Acute Care Hospital Emergency Department Urgent Care Psych Hospital Hospice Facility Home Hospice Outpt. Behav. Health Acuity of Illness Intensity of Care Adapted from Derr and Wolf, 2012 Low High The Spectrum of Care Outpatient Testing/Pharmacy/DME

16 How is LTPAC Different Than Acute Care or Typical Office-Base Care? 16

17 Type of LTPAC Patient Closer to end of life Greater number of health concerns, meds, healthcare providers, and care settings Reduced cognitive capabilities Increased risk of adverse events Reduced mobility; increased risk of falls Increased transportation issues/costs Less financial and social support More legal issues 17

18 Type of LTPAC Organization Limited financial and human resources Fewer incentives for EHRs or HIE participation –Less likely to have risk-sharing contracts –Not part of HITECH/Meaningful Use Limited technological infrastructure: –LAN/WIFI –IT Security/Policies/Backup/Redundancy –EHR, if present, likely to be ASP model Being asked to care for increasingly more complex patients

19 MUs Impact on LTPAC Meaningful Use defines the datasets that Hospitals send when patients are discharged ~40% of Medicare patients are discharged to traditional LTPAC settings (SNF, Home Health, Inpatient Rehab Facility, etc…) These patients are the sickest population and account for ~80% of Medicare costs Sources: 19

20 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) 20

21 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 21

22 Developing National Standards to Support LTPAC Needs 22

23 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 23

24 MA DPH Universal Transfer Form Started with DPHs 3-pg Discharge Form Sought input from LTPAC receivers Reviewed existing forms and datasets: –MDS –OASIS –IRF-PAI –INTERACT Sought expert opinions Resulted in 7-page UTF 24

25 Massachusetts Paper UTF Pilot 25

26 26 14x14 Sender (left column) to Receiver (top) = 196 possibly transition types

27 27 Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information Black circles = highest priority Green circles = high priority 27

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

29 11 Types of Organizations 29

30 12 User Roles 30

31 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 31

32 32 Black circles = highest priority Green circles = high priority A single paper form cant represent this variability in data needs 32

33 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 33 Five Transition Datasets

34 34 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

35 Five Transition Datasets

36 Additional Contributor Input 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) –Transfer Forms from Ohio, Rhode Island, New York, and New Jersey

37 37 Transfer of Care Care Plan Shared Care Encounter Summary Consultation Request Two Care Plan Datasets Home Health Plan of Care (CMS-485)

38 A. B. C. D. E. 38 Situation-specific Data Elements Variable Base on Situations: A.Setting B.Diagnoses C.Medications D.Treatments E.Procedures

39 39 Care Plan Permeates Datasets

40 How do they compare to CCD? 175 element CCD 325 element IMPACT for basic LTPAC needs 480+ elements for Longitudinal Coordination of Care

41 Testing the IMPACT Dataset 41

42 Pilot Sites to Test the Datasets 9/2011 – Applications sent to 34 organizations Selection Criteria: –High volume of patient transfers with other pilot sites –Experience with Transitions of Care tools/initiatives 16 Winning 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 42

43 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 43

44 44 IMPACT Learning Collaborative: Testing the Care Transitions Datasets 16 organization, 40 participants, 6 meetings over 2 months, and several hundred patient transfers…

45 Learning Collaborative Surveys Surveys directly on envelopes carrying IMPACT packet, filled out by sender as well as receiver. Online survey at completion of pilot 45

46 Analyzing data elements helped 46

47 Senders found the data 47

48 Receivers got most of their needs 48

49 Home Care needed even more! 49

50 Comment from Pilot Site Survey 50 While we knew what ED's and hospitals required, we didn't realize Home Health Agencies needed much more than what we typically sent. - Skilled Nursing Facility

51 Advancing Interoperable HIE Identify need for electronic HIE Identify gaps in HIE standards Fill gaps in standards: Work with ONC S&I, HL7, other Standards Development Organizations (SDOs) Ballot Needed Standards 51 Regular/On-going communication with CMS, ONC, HIT Policy and Standards Committee regarding need for and status of standards

52 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 52 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

53 Longitudinal Coordination of Care Workgroup Patient Assessment Summary Sub- Workgroup LTPAC Care Transition Sub- Workgroup Longitudinal Care Plan Sub- Workgroup Providing subject matter expertise and coordination of SWGs Developing systems view to identify interoperability gaps and prioritize activities Establishing the standards for the exchange of Patient Assessment Summary (PAS) documents Providing consultation to transformation tool being developed by Geisinger to transform the non- interoperable MDSv3 and OASIS-C into an interoperable clinical document (CCD+) Identifying the key business and technical challenges that inhibit long-term care data exchanges Defining data elements for LTPAC information exchange using a single standard for LTPAC transfer summaries Near-Term: Developing an implementation guide to standardize the exchange of the Home Health Plan of Care (former CMS 485 form) Long-Term: Identify and develop key functional requirements and data sets that would support a longitudinal care plan S&Is Longitudinal Coordination of Care WG 53

54 Original S&I ToC Use Case Scenario 1 - Provider to provider: User Story 1 - Hospital/ED to PCP Discharge Instructions Discharge Summary User Story 2 - Closed Loop Referral Consult Request Consult Summary Scenario 2 - Provider to patient: User Story 1 - Discharge Instructions and Discharge Summary to patients PHR User Story 2 - Closed Loop Referral where copies of Consult Request and Consult Summary are sent to patients PHR 54

55 55 Relationship to S&I ToC Scenarios Type 3 Dataset: Scenario 1 & 2/User Story 2 Consult Summary Type 5 Dataset: Scenario 1 & 2/User Story 1 Type 4 Dataset: Scenario 1 & 2/User Story 2 Consult Request

56 56 LTPAC Poster Child Scenarios Type 3 Dataset: Scenario 1 & 2/User Story 2 Consult Summary ED to SNF Type 4 Dataset: Scenario 1 & 2/User Story 2 Consult Request SNF to ED Type 5 Dataset: Scenario 1 & 2/User Story 1 Hospital to Home Health Agency HHA PCP (HH POC Subset) Anticoagulation CHF

57 S&I Care Plan Use Case Scenario 1 - Complete handoff of care from the sending care team to a receiving care team (Hospital to SNF) Scenario 2 - Between care team members during shared care : User Story 1 – Between PCP and Home Health Agency for HH Plan of Care (CMS-485) User Story 2 – Between PCP and outside Physical Therapist Scenario 3 – Between providers and patient 57

58 Timeline for Standards Development October 2012MA HIway go-live in 10 large sites with CCD and LAND February 2013 Preliminary Implementation Guide completed May 2013Pilot electronic Transfer of Care Datasets between 16 central Massachusetts organizations using MA HIway, LAND & SEE July 2013Finish Implementation Guides using the S&I Framework and Lantana, incorporating pilot feedback November 2013 HL7 Balloted/Reconciled/Published Implementation Guides in Consolidated CDA 58

59 Getting Connected: LAND & SEE 59

60 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) 60

61 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 61

62 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 62

63 63 Hospital Home Health PCP Non-standard EHR OASIS Non-standard EHR OASIS Nursing Facility Billing Program MDS Billing Program MDS LTPAC Communication Today – Paper!

64 64 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

65 The Future with LTPAC EHR Standards 65 Hospital Home Health PCP CCD+ EHR MDS CCD+ EHR MDS CCD+ EHR OASIS CCD+ EHR OASIS CCD+ Nursing Facility

66 Advantages of LAND & SEE Most role-based authentication uses EHR, using work that local organizations have already done Most users (docs & nurses) only work out of 1 system Data re-used whenever possible No blended central clinical data repository Case/discharge managers or nurses can control when and where to route documents because theyre the ones that know when and where! Non-EHR users get same HIE transport functionality as EHR users Relatively low-cost to deploy and support Easily scalable and replicable 66

67 Standard Configurations of LAND Necessary to support some advanced characteristics of IMPACT: MDS XML documents from Nursing Facilities OASIS XML documents from Home Health agencies Expanded data set beyond what is in a standard CCD 67

68 Outbound LAND configurations Merge a standard CCD and a second XML document that contains additional data elements into a Transfer of Care CDA document Transform data element transmitted via an HL7 2.x Results interface from an EHR into a Transfer of Care CDA document Transform an MDS XML file into a CCD* Transform an OASIS XML file into a CCD* * Exploring the use of Pennsylvanias KeyHIE Transform ( AKA The Gobbler) as cheaper alternative 68

69 Inbound LAND configurations Transform a Transfer of Care CDA document into a free-text document Transform a Transfer of Care CDA document into a free-text document and transmit it to an EHR via an HL7 2.x Transcription interface Transform a Transfer of Care CDA document into discrete data elements and transmit them to an EHR via an HL7 2.x Results interface Transform a Transfer of Care CDA document into a standard CCD and a second XML document that contains additional data elements 69

70 Next Steps for Pilot Sites Update gap analysis using expanded dataset Catalog which data elements are captured (and by whom using what vocabulary) electronically, on paper, or not at all with current standard process Of those captured electronically (including CCD, MDS & OASIS), identify process (technology & workflow) to make these available to LAND (for Phase 2). Identify workflow to review new documents in SEE Notification by or text message, and to whom? View online vs. print? Who does it and where? Can any of the data elements received be electronically filed discretely for re-use using LAND? Identify workflow to update and send SEE document with current info when discharging to Home Health or ED transfer How can standard and non-standard data elements be collected and added online using SEE to the documents being sent? How will copies be printed for patient and ambulance? Additional computers, printers, or chairs required?

71 IMPACT Timeline for Next Steps 71 DatesActivity 9/2012 – 3/2013Integrate pilot sites into state HIE using LAND & SEE 4/2013 – 5/2013Pilot site Go-lives with state HIE using LAND & SEE 2/2013 – 9/2013Ballot updated datasets in S&I Framework and HL7 6/2013 – 7/2013Make SEE available under Open Source License 4/2013 – 9/2013Evaluate hospital (re)admissions & total cost of care

72 Sharing LAND & SEE LAND –Orion Healths Rhapsody Integration Engine –Well make some standard configurations available SEE –Written in JAVA –Baseline functionality software and source code that can connect to Orions HISP mailbox via API available for free starting ~July 2013 (Apache Version 2.0 vs. MIT open source license) –Innovators can develop and charge for enhancements, for example: Integration with other vendors HISP mailboxes Automated CDA document reconciliation 72

73 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 73

74 Questions?

75 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: 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): doi: /j x. Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform 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: /j x. Overhage JM, McDonald CJ, et al. A randomized, controlled trial of clinical information shared from another institution. Annals of Emergency Medicine 39[1], Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ Nov 11;169(10): Van Walraven, C., Seth, R., Austin, P. & Laupacis, A., Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med, Volume 17, pp 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.


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