Taking Lessons on Care Coordination from Professional Sports

Transcription

1 Taking Lessons on Care Coordination from Professional Sports PANELISTS Dr. Russell Leftwich - Chief Medical Informatics Officer, Tennessee Office of ehealth Initiatives MODERATOR Kate Berry Chief Executive Officer, NeHC October 4, 2013

2 Join the NeHC membership program Benefits of being a NeHC member include: Recognition as a contributor to national discussions on the future of health IT Networking with public and private sector health IT thought leaders Leadership opportunities in strategic workgroups Learning through free NeHC University classes and materials Access to members-only resources and information Visibility through discounted sponsorship of NeHC programs Insights from semi-annual member briefings and strategic discussions Learn more at 2

3 2311, LLC Digital Collaboration Solutions AARP Elsevier ADVault (MyDirectives) George Washington University AEGIS.net, Inc. GetWellNetwork, Inc. Alere Wellogic, LLC Governor's Office of Electronic American Academy of Nursing Health American College of Physicians Hawaii Health Information Audacious Inquiry Exchange Axesson Health Information Associates Azuba HealthCrowd Beaumont Health System HEALTHeLINK Best Practice Partners HealthLINC, Inc. Booz Allen Hamilton HealthShare Bay Area CAQH HealthTechture, LLC CareCompanion Healthwise University of Alabama at Iatric Systems Birmingham Ignis Systems Corporation Cherokee County Health Indiana Health Information Services Council (SMRTNet) Exchange (IHIE) Coastal Connect Inland Northwest Health Continua Health Alliance Services (INHS) DataWeb, Inc. INRange Systems, Inc. dbmotion iphysicianhub DC Smart AV/IT Consulting and Joseph H. Kanter Family Training Foundation Defran Systems, Inc. (Netsmart) Kaiser Permanente Delaware Health Information Kansas Health Information Network Network, Inc. Denver Health Kidney Cancer Association NeHC Members Kinergy Health, LLC Koss on Care, LLC Krames StayWell, LLC Kroll Advisory Solutions MedAllies, Inc. Michigan Health Connect Mosaica Partners My-Villages, Inc. National Quality Forum (NQF) NCHICA Neighbor's Keeper NEOS Next IT Corporation Ochsner Health System OneCare OneHealthPort Optum Orion Health Patient Engagement Systems PatientPoint Pharmacy e-health Information Technology Collaborative Point-of-Care Partners, LLC Polyglot Systems, Inc. Privacy Analytics, Inc. Quality Insights of Delaware REC RIQI RISC Management & Consulting Rochester RHIO Sajix, Inc. Sharp Healthcare Standard Register Surescripts Texas Health and Human Services Commission, Office of e-health The Connected Health Economy The National Council for Community Behavioral Healthcare TLD Systems, Inc. (CME Online) Tower Strategies U.S. Department of Veterans Affairs UCF College of Medicine Innovation Team University of Michigan Health Informatics Program Vital Health Software WellSpring Consulting West Virginia Health Information Network (WVHIN) Whatcom Health Info Ntwk, LLC (HInet) Yeaman and Associates Zweena Health

4 NeHC University Thanks Our Sponsors! Dedicated webinars with speaking opportunity annually. Inclusion in NeHC University promotion via media and stakeholder channels. NeHC University recognition including logo and link on the NeHC University website. Listing in NeHC s Directory of Technology Solutions Providers. For more information, contact kprendergast@nationalehealth.org 4

5 Upcoming NeHC University Programs October 15: No HIE? No ACO! Health Information Exchange in the Era of Accountable Care 12:00PM to 1:00PM EST Dr. Karen Bell, CCHIT Mark Jacobs, DHIN James Younkin, Geisinger Salim Kizaraly, Stella Technology, INC Mark Stevens, Best Practice Partners October 18: National HIE Governance Forum Meeting Mark 12:30-2:00PM Your Calendar EST October 22: Improving Health Literacy to Improve Patient Engagement 1:00PM to 2:00PM EST Leslie Kelly Hall, Healthwise Karen Baker, Healthwise 5

6 Presentation slides are available at A recording of the webinar will be posted within 48 hours of the conclusion of the webinar Want more? You can also continue today s discussion by joining the NeHC University group in NeHC s online community: 6 6

7 Please enter your questions in the Q&A window at the bottom right of your screen You can also send us an at tweet a question using hashtag #NeHC, or comment on our Facebook page at

8 Care Coordination: It should work like a professional sports team on Sunday Russell B Leftwich, MD Chief Medical Informatics Officer Tennessee, Office of ehealth Initiatives

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10 A paradigm shift: Every patient has their own team

11 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

12 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

13 7 providers in 4 different organizations

14 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

15 Provider matching: déjà vu Electronic addresses External references: Provider directories

16 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

17 Your job is to cover 3 rd base! First string, back-up, or special teams? Family and community caregivers Active or waiting to be called-up

18 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

19 What about that game plan?

20 Health Conditions/ Concerns Active Problems Disease Progression Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc ) Risks Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual ) Patient Status Functional Cognitive Physical Environmental Assessments Treatment Side effects Patient Status helps define the patient s current conditions, concerns, and risks for conditions Risks/concerns come from many sources

21 Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc ) Patient situation (access to care, support, resources, setting, transportation, etc ) Disease Progression Health Conditions/ Concerns Active Problems Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc ) Risks Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual ) Prioritize Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Patient Status Functional Cognitive Physical Environmental Assessments Treatment Side effects Goals are created collaboratively with a patient taking into account their statuses and Care Plan Decision Modifiers

22 Care Plan Disease Progression Health Conditions/ Concerns Active Problems Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc ) Risks Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual ) Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc ) Patient situation (access to care, support, resources, setting, transportation, etc ) Patient allergies/intolerances, and history of response to prior interventions/actions Prioritize Decision Support Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Patient Status Functional Cognitive Physical Environmental Orders, etc.. Decision Support Assessments Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc ) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Side effects The Care Plan is comprised of Health Concerns, their Goals, Interventions, Assessments and the Care Team members that actualize it

23 Care Plan Disease Progression Health Conditions/ Concerns Active Problems Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc ) Risks Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual ) Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc ) Patient situation (access to care, support, resources, setting, transportation, etc ) Patient allergies/intolerances, and history of response to prior interventions/actions Prioritize Decision Support Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Patient Status Functional Cognitive Physical Environmental Orders, etc.. Decision Support Assessments Outcomes Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc ) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Side effects Interventions and actions achieve outcomes to progress towards goals.

24 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

25 Care Team Members each have their own responsibilities Care Plan Health Conditions/ Concerns Active Problems Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc ) Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc ) Patient situation (access to care, support, resources, setting, transportation, etc ) Patient allergies/intolerances, and history of response to prior interventions/actions Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Patient Status Functional Cognitive Physical Environmental Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc ) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention

26 What does it take to win? Team roster Contact info Everyone knows what role they are playing There is a game plan Everyone knows the game plan Coach shares the scouting report on opponent

27 The scouting report: The clinical summary, Continuity of Care Document (CCD)

28 Remember the Game of Telephone? 28

29 Why Direct was created and where did it come from?

30 Office of the National Coordinator Direct Project Convened in early 2010 Open government initiative Create low cost, secure means of exchange Point to Point message transmission DoD Secure messaging & transport protocols Existing Internet Protocols Part of Nationwide Health Information Network

31 The result: NwHIN Direct Direct offers a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the internet point-to-point

32 Meaningful Use EHR Certification Hospitals and providers must use certified EHR EHRs certified under ONC 2014 Certification must create and receive Direct Messages Must also create and consume HL7 CDA documents Continuity of Care Document (CCD) Summary of care required by MU2 on transitions Musts: demographics, meds, problems, allergies May have procedures, history, exam, lab, etc

33 Care Planning and the Path Forward ONC Standards & Interoperabilty Framework Transitions of Care Initiative Longitudinal Coordination of Care Health Level 7 (HL7) Patient Care WG Care Plan Domain Model 2013 Consolidated CDA Update Transfer summaries and care plan Home health plan of care

34 Should we form the National Healthcare League? Patient-centered care teams, each with their own roster, their own care plan, and the patient s goals.

35 Please enter your questions in the Questions window on the right side of your screen. Dr. Russell Leftwich Chief Medical Informatics Officer Tennessee Office of ehealth Initiatives You can also send us an at tweet a question using hashtag #NeHC, or comment on our Facebook page at 35

36 Thank you for your participation! National ehealth Collaborative th St. NW, Suite 300 Washington, DC (877)