and the Movement Towards Acute Care Data Transfer June 5 th, 2013 Larry Garber, M.D. Reliant Medical Group George Richardson CIO, VNA Care Network

Transcription

1 The Federal IMPACT Project and the Movement Towards Uniform Electronic Post- Acute Care Data Transfer New England Home Care Conference June 5 th, 2013 Larry Garber, M.D. Reliant Medical Group George Richardson CIO, VNA Care Network 1

2 Agenda Problems with care transitions IMPACT addressing LTPAC needs ONC s 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 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 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 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 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) 5 5

6 National care transitions experts overwhelmingly identified improving information flow and exchange as the most important t tool to improve care transitions (ONC, 2011) 6 6

7 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 t have EHRs But Long Term and Post-Acute Care was left out! 7 7

8 Yet Post-acute Care Costs are Rising faster than acute care costs 41% 107% Source: MedPAC,

9 Where do patients go after hospital? Everywhere! 9 9

10 Why LTPAC is so important Hospitalized patients are the sickest population and account for ~75% of Medicare costs ~40% of Medicare patients are discharged to traditional LTPAC settings (SNF, Home Health, Inpatient Rehab Facility, etc ) Hospitals must be responsible, and given the tools, to convey the information needed by the recipient of a patient during care transitions Sources:

11 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 11

12 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 i / d these data elements (LAND & SEE) Integrate and validate tools into Worcester County using Learning Collaborative methodology Measure outcomes 12 12

13 Developing National Standards to Support LTPAC Needs 13 13

14 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 14 14

15 14x14 Sender (left column) to Receiver (top) = 196 possibly transition types Transitions to (Receivers) In Patient ED Outpatient Behavioral LTAC IRF SNF/ECF HHA Hospice Amb Care EMS BH CBOs Patient/ Acute Care Services Health Community Transitions From (Senders) Hospitals Inpatient (PCP) Services Family 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 15 15

16 Receiver Data Needs Survey 46 Organizations completing evaluation 12 Different types of user roles 12 Different types of user roles 1135 Transition surveys completed Largest survey of Receivers needs 16 16

17 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 17 17

18 Five Transition Datasets 1. Report from Outpatient testing, treatment, e t, or procedure e 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 18 18

19 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 19 19

20 Five Transition Datasets Transitions to (Receivers) In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/ Transitions From (Senders) Services (PCP) Family In patient 5 ED Out patient services LTAC IRF SNF?ECF 5 HHA Hospice Ambulatory Care (PCP) CBOs 20 Patient/Family 20

21 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) National NY s emolst Multi-State/Multi-Vendor t 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 21

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

23 Care Plan Important in Transitions 23 23

24 Care Plan Permeates Datasets 24 24

25 How do they compare to CCD? Data Elements for Longitudinal Coordination of Care CCD Data Elements IMPACT Data Elements for basic Transition of Care needs Many missing data elements can be mapped to CDA templates with applied constraints 20% have no appropriate templates 25 25

26 Testing the IMPACT Dataset 26 26

27 Pilot Sites to Test the Datasets 9/2011 Selected Pilot Sites: 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 27 27

28 Nursing Facility Pilot Sites Beaumont Rehabilitation of Westborough Christopher h 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 28 28

29 IMPACT Learning Collaborative: Testing the Care Transitions Datasets 16 organization, 40 participants, 6 meetings over 2 months, and several hundred patient transfers 29 29

30 Learning Collaborative Surveys Surveys directly on envelopes carrying IMPACT packet, filled out by sender as well as receiver. Online survey at completion of pilot 30 30

31 Senders found the data 31 31

32 Receivers got most of their needs 32 32

33 Home Care needed even more! 33 33

34 Comment from IMPACT Survey 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 34 34

35 Turning Datasets into National Standards 35 35

36 New World of Standards Development National Coordinator for Health IT (ONC) Office of the Deputy National Coordinator for Programs & Policy Office of the Deputy National Coordinator for Operations Office of the Chief Privacy Officer Office of Economic Analysis & Modeling Office of the Chief Scientist Office of Policy & Planning HIT Policy Committee Defines Meaningful Use of EHRs Office of Science & Technology (formerly known as the Office of Standards and Interoperability (S&I)) 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 Office of Provider Adoption Support Office of State & Community Programs 36 IMPACT 36

37 S&I s Longitudinal Coordination of Care WG COMMUNITY-LED INITIATIVE Longitudinal Coordination of Care Workgroup Providing subject matter expertise and coordination of SWGs Developing systems view to identify interoperability gaps and prioritize iti activities, and align identified standards with the EHR MU Program G O A L S Longitudinal Care Plan SWG Identify standards for an interoperable, longitudinal care plan which aligns, supports and informs personcentric care delivery regardless of setting or service provider LTPAC Care Transition SWG Identify the key business and technical challenges that inhibit LTC data exchanges Define data elements for long-term and post-acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries 37 HL7 Liaison SWG Educate the LCC Community on related HL7 processes, framework and evolving standards relevant to LCC Gather and generate comments for HL7 Care Plan related evolving standards (Care Coordination Services & Care Plan Domain Analysis Model (DAM)) Patient Assessment Summary SWG* Established the standards for the exchange of Patient Assessment Summary (PAS) documents Provided consultation to the transformation tool being developed by Geisinger to transform the non- interoperable MDSv3 and OASIS-C into an interoperable clinical HL7 CDA document *Retired December

38 Coordinating standards efforts Work has been ongoing for the past few years to address the insufficient standards for transitions of care and care plans: ONC S&I Longitudinal Coordination of Care Workgroup CMS and ONC S&I: advancing standards for Electronic Submission of Medical Documentation (esmd) ASPE sponsoring and collaborating with S&I LCC WG to advance standards for interoperable assessments, assessment summary documents, and care plans DoD and VA are working to specify Home Health Plan of Care data HL7 Structured Document, Patient Care, Care Coordination Services, and Child Health Workgroups IHE Patient Care Coordination Technical Committee AHIMA LTPAC HIT Collaborative HIMSS: Continuity of Care Model 38 38

39 LCC Home Health Plan of Care Exchange: Conceptual Workflow Patient 2 Assemble & prioritize Input data of Home Health lh Plan of Care (HHPoC, AKA CMS 485) Create HHPoC Sign HHPoC 3 Convert, populate and display HHPoC 4 Store/Send Signed HHPoC 9 Receive, store & display original HHPoC and/or Communication document 1 Referral to HHA 6 Review Received HHPoC Either: Sign HHPoC Suggest changes to HHPoC 7 Receive, store 5 & display HHPoC Either: Attach Digital Signature to original HHPoC document, or Suggested changes to HHPoC 8 Store/Send Digitally signed HHPoC or a Communication document with comments Actor Key Care Team EHR System 39

40 IMPACT Transfer of Care CDA Document 40 40

41 Lantana has been contracted to work with LCC to make and ballot HL7 CDA IGs Shared Care Encounter Summary (Update to Consult Note): Office Visit i to PHR Consultant to PCP ED to PCP, SNF, etc Home Health Plan of Care (with esmd Digital Signature) Care Plan 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 41 41

42 EP, Hospital, and LTPAC EHR vendors want the standards Multiple vendors are participating in S&I LCC WG Multiple vendors are exploring incorporating the standards into their products Several intend to pilot the pre-balloted versions in their products in Massachusetts and New York by September Several national LTPAC providers are exploring incorporating these standards into their products 42 42

43 Timeline for Standards Development October 2012 MA HIway go-live in 10 large sites with CCD and LAND February 2013 Preliminary Implementation Guide completed July 2013 Pilot electronic Transfer of Care Datasets between 16 central Massachusetts organizations using MA HIway, LAND & SEE August 2013 Finish Implementation Guides using the S&I Framework and Lantana, incorporating pilot feedback November 2013 HL7 Balloted/Reconciled/Published Implementation Guides in Consolidated CDA 43 43

44 Getting Connected: LAND & SEE 44 44

45 LAND & SEE Sites with EHR or electronic assessment tool use these applications to enter data elements LAND ( Local Adaptor for Network Distribution) 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) 45 45

46 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 HIE s web mailbox Non-EHR users able to use SEE to view, edit, send CDA documents via HIE or Direct to next facility Can create a new document by copying an entire document and editing it, and/or importing sections from multiple documents Can use SEE for other workflows (e.g. completing INTERACT SBAR prior to sending patient to ER) Multiple staff can work on the new document at the same time, but not the same section at the same time SEE users can print copies of the document for family or ambulance transport 46 46

47 Copy data from another existing CDA document 47

48 Intuitive data entry for each section 48

49 Free Text Narrative can be added to any section 49

50 Type-aheads help users to find their data quickly from valuesets 50

51 Using SEE for LTPAC Workflows SNF patient getting sicker Subset of Transfer of Care dataset that is in SBAR (INTERACT) is completed 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 Copy can be printed for ambulance team 51 51

52 KeyHIE Transform Alternative Developed with AHIMA, ASPE, and S&I (LCC workgroup) HL7 Blltd Balloted. Nti Nationally available Wb Web service. LTPAC MDS or OASIS Clinical Summary HIE Copyright 2013 Keystone Beacon Community

53 Runs automatically Help desk support Self-service tools Easy for SNF/HHA to Use Copyright 2013 Keystone Beacon Community 53

54 LAND Sharing LAND & SEE Orion Health s Rhapsody Integration Engine Currently Modular EHR certified for MU1. MU2 (2014) pending We re trying to make some standard configurations available SEE Written in JAVA Baseline functionality software and source code that can connect to Orion s HISP mailbox via API available for free starting ~September 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 54 54

55 IMPACT Timeline for Next Steps Dates Activity 9/2012 5/2013 Integrate pilot sites into state HIE using LAND & SEE 6/2013 7/2013 Pilot site Go-lives with state HIE using LAND & SEE 8/2013 9/2013 Make SEE available under Open Source License 8/2013 1/2014 Evaluate hospital (re)admissions & total cost of care 55 55

56 Summary IMPACT is helping ONC s S&I Framework to develop national standards d to meet the needs of LTPAC organizations National HL7 standards for Transitions of Care and Home Health Plan of Care will be available at the end of 2013 LAND & SEE and KeyHIE Transform software will facilitate integrating LTPAC organizations into electronic health information exchanges and enable reusing data 56

57 Questions? 57