New Opportunity for Network Value: Using Health IT to Improve Transitions of Care 600 East Superior Street, Suite 404 I Duluth, MN I Ph or I Joe Wivoda CIO June 19, 2014

The National Rural Health Resource Center is a nonprofit organization dedicated to sustaining and improving health care in rural communities. As the nation’s leading technical assistance and knowledge center in rural health, The Center focuses on five core areas: Performance Improvement Health Information Technology Recruitment & Retention Community Health Assessments Networking

What was inside the envelope? Face sheet Three medication monographs What was NOT inside the envelope? Current medication list (8 medications) Any orders Discharge summary Lab results Radiology reports Care plan or goals

Transitions of care where appropriate information is sent to the receiver had (caretransitions.org): Significantly less likely to be readmitted Saved money ($300,000 for 350 patient panel over 12 months) Meaningful Use Stage 1: Try something! Meaningful Use Stage 2: Do something! Source:

Core Requirement 12 Objective: “The eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.” Objective is so important, it has three measures!

“The eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals.” Note: The word “electronic” is not used here…

“The eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network.” Note: “Another setting of care or provider of care” includes lots of things…

“The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN.” Note: “Another setting of care or provider of care” includes lots of things…

“The eligible hospital or CAH must satisfy one of the two following criteria: Conducts one or more successful electronic exchanges of a summary of care document, which is counted in "measure 2" (for eligible hospitals and CAHs the measure at §495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR (b)(2); or Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.” Note: Can’t just exchange within your network if they are all using the same EHR…

“Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. At a minimum this includes all discharges from the inpatient department and after admissions to the emergency department when follow-up care is ordered by an authorized provider of the hospital.” Note: Internal transitions will usually not count…

“Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another. At a minimum this includes all transitions of care and referrals that are ordered by the EP.”

Where does a Critical Access Hospital discharge patients? Home Primary care Specialty care Home care Long Term Care Hospice Tertiary hospital 50% will need a Summary of Care record 10% need an electronic Summary of Care record

Where does a clinic (Eligible Provider) refer patients? Specialty provider Physical Therapy Behavioral Health Diabetes Educator Others? 50% will need a Summary of Care record 10% need an electronic Summary of Care record

The summary of care record has now been clearly defined: Patient Name Referring provider’s name and contact information Procedures Encounter diagnosis Immunizations Lab results Vitals (height, weight, BP, BMI) Smoking Status Functional Status Demographic Information Care plan w/ goals Care team Discharge Instructions Reason for referral Current problem list Current medication list Current allergy list

Many are not participating in Meaningful Use LTC Homecare/Hospice Most are not connected to an HIE Meaningful Use let us off the hook! Expense of query-based exchange Silo thinking still dominates, health reform still not "real"

Query-Based Exchange: “Joe is in the ER, and we don’t have any of his records. What hospitals and clinics has Joe utilized and can we get those charts?” Direct Exchange: “Joe is in our facility and we need a copy of his chart, please don’t send it via fax!”

Think of Direct as secure , except: Trusted senders and recipients Health care’s “private” secure system! Can carry multiple packages, including C-CDA, scanned images, etc Often integrated into EHRs Relies on a Health Information Service Provider (HISP)

Integrated into your EHR – Physician work list – Messages As a portal – Useful for LTC, Home Care, others Patients can have Direct addresses –

Referral patterns are key – Help your members understand the importance of their referral network – More than “We life flight patients to…” Understand Direct – First step for exchange – Important for Meaningful Use Transitions of Care – What opportunities with HISPs are there? What is your local HIE doing?

What are the options for Direct Is there a required HISP that the EHR vendor has partnered with? How is Direct integrated into the EHR? How are summaries of care, or any CCD, created and sent from the EHR? How will this affect workflow? What departments will be affected? Begin talking with referral partners. Use an 80/20 rule.

Even if a provider is not eligible for meaningful use they should still be involved. What are the options with the EHR? What are the options for Direct? Talk with referral sources and understand what they are doing with Direct

 Understand the Transition of Care measures  Look up the CMS Tip Sheet  Understand Direct  Understand your member’s needs  What EHR vendors?  What HISPs do they need to use?  What are their referral patterns?  Understand your members referral partners too!

Joe Wivoda National Rural Health Resource Center 600 East Superior Street, Suite 404 Duluth, MN (218)