SHIN-NY Support for NYS PCMH New York State created the Statewide Health Information Network for New York (SHIN-NY) to allow the electronic exchange of clinical information and connect healthcare professionals statewide. New York ehealth Collaborative (NYeC) is a non-profit organization working in partnership with the New York State Department of Health to improve care delivery by collaboratively leading, connecting, and integrating health information exchange (HIE) across the state. The Statewide Health Information Network for New York (SHIN-NY) The SHIN-NY connects eight regional networks, or Qualified Entities (QEs), that allow participating healthcare professionals, with patient consent, to quickly access electronic health information and securely exchange data statewide. The regional networks enroll participants within their community, including those from hospitals, clinics, FQHCs, home care agencies, payers, and ambulatory practices, among others, so they can access and exchange electronic health information with any other participant in their region. The SHIN-NY is integral to the success of state and federal initiatives propelling healthcare toward a fully integrated, patient-centered system. Today, the SHIN-NY connects virtually all of hospitals in New York State, over 80,000 medical providers, and represents millions of people who live in or receive care in New York. New York State Patient-Centered Medical Home (NYS PCMH) The Patient-Centered Medical Home (PCMH) practice model has been adopted and recognized by practices nationwide and has been shown to strengthen the clinician-patient relationship while improving the quality of care at a practice. This collaborative care model has been shown to result in improved practice staff and patient satisfaction, system efficiency, and may reduce overall practice costs. The New York State Patient-Centered Medical Home (NYS PCMH) model is designed to provide direct technical assistance for primary care practices to achieve NYS PCMH recognition and thrive under value-based payment arrangements. Practices can leverage SHIN-NY services to meet certain New York State Patient Centered Medical Home NYS PCMH standards and achieve their transformation goals. NYS PCMH success will require access to patient data, coordinated communication between care team providers, timely notification of critical patient events, and the ability to exchange patient information to support care coordination. 1 SHIN-NY Support for NYS PCMH November 2018
Core Services Offered through the SHIN-NY All QEs offer free basic services to participating members. Some of these core services include: Patient Record Lookup Patient Record Lookup (PRL) functions like a highly secure search engine, allowing participants to retrieve individual patient records from across the state after receiving consent from the patient. Participants can easily look up patient records, no matter where patients have received care in the State. Alerts Alerts allow participants to receive real-time updates about their patients. For example, if a patient enters or is discharged from a hospital, a subscribing provider can receive an Admittance, Discharge, Transfer alert. Similarly, a hospital can instantly be alerted if discharged patients subsequently visit another emergency room. In short, this automatic subscription service keeps providers informed of the status of their patients, further enhancing care coordination efforts and creating an integral resource in reducing readmissions statewide. Secure Messaging Secure Messaging gives participants the ability to seamlessly exchange authenticated and encrypted clinical data. It s similar to highly secure email between providers. Results Delivery Results Delivery provides diagnostic results and reports to ordering clinicians and others designated to receive results either directly into the providers EHR or through an online clinical viewer. Core Services in Action: Examples of SHIN-NY Core Services Directly Enabling or Indirectly Supporting PCMH Note: These case examples assume that the patient has provided written affirmative consent to access data to the practice/providers in question. PCMH Concept Competency D Knowing and Managing Your Patients (KM) The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers. KM14 Medication Reconciliation Reviews and reconciles medications for more than 80 percent of patients received from care transitions In an effort to effectively monitor Patient X, a 70-year-old male with COPD, diabetes, hypertension, and depression who has been in and out of the hospital several times in recent months, the practice needs to ensure that he is taking the correct medications as they have been prescribed. By subscribing to the notifications and alerts feature that is offered as a SHIN-NY core service, the practice will be alerted when Patient X is admitted to and discharged from the hospital. The practice s workflow can be tailored to trigger the provider to consult the clinical records through Patient Record Lookup. Viewing the patient record through the SHIN-NY allows the provider to find out whether Patient X was prescribed any new medications in the hospital or told to discontinue any others. Additionally, the practice can communicate securely with other providers treating Patient X via Secure Messaging regarding the medication decisions they have made for him. The utilization of these services provides a multi-tiered strategy for the practice to stay on top of Patient X s medication regimen. 2 SHIN-NY Support for NYS PCMH November 2018
PCMH Concept Competency F Knowing and Managing Your Patients (KM) The practice identifies and establishes connections to community resources to collaborate and direct patients to needed support. KM28 Case Conferences Has regular case conferences involving parties outside the practice team (e.g., community supports, specialists, etc.) Patient O is a 27-year-old-woman who has a history of mental illness and uncontrolled diabetes. In recent years, she has struggled to maintain stable housing. Patient O s primary care practice uses regular case conferences to stay connected with community support that help her stay healthy, adhere to her medications as prescribed, and keep her housing. Patient Record Lookup assists this practice by providing complete and timely information on Patient O, which is critical for effective case conferences. Primary care providers can then share relevant information with the community-based entities and behavioral health providers who are part of Patient O s care team. All of these providers can exchange secure direct messages about Patient, receive her lab results, if the ordering providers copies them on the request. Community-based and behavioral health organizations connected to the SHIN-NY can subscribe to the same notifications and alerts that the practice receives when Patient O is admitted, discharged, or transferred. This type of coordination and communication via the SHIN-NY indirectly supports the requirement for PCMH practices to have regular case conferences including these external providers. PCMH Concept Competency C Care Coordination and Care Transitions (CC) The practice connects with other health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care. CC15 Sharing Clinical Information Shares clinical information with admitting hospitals and emergency departments Patient K is an 18-year-old male who has developed an infection at the site of what was initially a mosquito bite. He now has a high fever and is acting confused. Patient K presents to the emergency department after hours and on the weekend. The practice will receive a notification/alert when Patient K is admitted to the ED and subsequently admitted to an inpatient bed. The physician can utilize Secure Messaging to share any relevant clinical information with the hospital, such as Patient K s medications, allergies, other current conditions, and medical history. The hospital will also be able to utilize Patient Record Lookup to access Patient K s clinical information that has been uploaded bythe practice. The access to this information could be critical in the successful treatment of Patient K s potential infection. 3 SHIN-NY Support for NYS PCMH November 2018
Value-Added Services In addition to the core services, many of the QEs offer value-added services that may be of interest to providers. Fees and availability of these services vary across the state; providers are encouraged to discuss which value-added services are available within your QE. Some examples of value-added services may include, but are not limited to: Advanced Alerts/Clinical Event Notifications Advanced alerts, or clinical event notifications, allow providers to stay informed about their patients medical events above and beyond the alerts available under the Core Services category (inpatient and ED admit/discharge/transfer). QEs offering these services will deliver real-time alerts that will be routed to subscribed providers. Examples of Advanced Alerts may include: Skilled Nursing Facility (SNF) admit/discharge, incarcerations/release from jail, patient expiration New patient lab values (ex. HbA1C results) Analytics-based updates (ex. Predicting risk for future event or diagnosis). Patient Portals Patient portal services allow patients to view their own records and, in many cases, enable providers to securely communicate and share information with their patients. This could include sending secure messages or reminders to patients related to their need for preventive care services, immunizations, and chronic or acute care services, among others. Portals also offer a way for providers to contact patients who have not been seen recently, send appointment reminders, or request that patients send data they collect at home (ex. blood pressure readings, blood sugar levels, etc.). Analytics/Population Health Insights These tools can aggregate which then can be analyzed and compared to identify trends. Providers may be able to develop reports and make clinical decisions for cohorts of patients based on this information. Image Exchange Image Exchange allows QE users to access, view, and transfer diagnostic quality medical images from connected hospitals and clinics with their region. Through a QE s Clinical Viewer, QE users may access radiology, cardiology, and EKG reports and images from imaging provider locations within a community. Clinical Data Forwarding (leveraging the One-to-One Exchange Framework) Clinical Data Forwarding allows for the disclosure of Personal Health Information (PHI) via the SHIN-NY by one of the patient s providers (a QE participant) to one or more other QE participants who are either treating the patient or performing quality improvement and/or care management activities for such patient, without needing to obtain affirmative written consent. Examples of this type of exchange include electronic notification of admission and discharge at participating hospitals, feed of clinical lab results, referrals to a specialist, a discharge summary sent to the location where the patient is transferred, or clinical information sent from a QE participant to the patient s health plan for quality improvement or care management/ coordination activities. 4 SHIN-NY Support for NYS PCMH November 2018
Who is Connected to the SHIN-NY? Each QE enrolls a diverse set of participants within their community. QEs maintain complete and up-to-date lists of participants on their websites, per New York State requirements. SHIN-NY Connections Initiative (SCI) The New York State Department of Health (NYS DOH), with support from the Centers for Medicare & Medicaid Services (CMS), has established the SHIN-NY Connections Initiative (SCI) to increase health information exchange (HIE) adoption and to help offset the cost for primary care practices connecting to a QE. Practices enrolled in the NYS PCMH program are eligible for SCI. The completion of an eligible EHR interface to a QE will satisfy the requirements of NYS PCMH standard CC 21. Learn more about SCI here. Healthcare organizations may connect with the QE that best aligns with their business, operational, and service delivery needs. Contact Information Please contact one of the state s QEs to learn more about how to connect to the SHIN-NY. Bronx RHIO (Greater NYC) Charles Scaglione Executive Director cscaglio@bronxrhio.org HealtheConnections (Central New York Region) Rob Hack President and CEO rhack@healtheconnections.org HEALTHeLINK (NYC & Long Island) Healthix (Western New York Region) Dan Porreca Executive Director Tom Check President and CEO dporreca@wnyhealthelink.com tcheck@healthix.org HealthLinkNY (Southern Tier, Catskill & Hudson Valley Region) Staci Romeo Executive Director sromeo@healthlinkny.com Hixny (Capital Region) Bryan Cudmore Vice President Account Management bcudmore@hixny.org New York Care Information Gateway (NYC Area & Long Island) Nick VanDuyne Executive Director nick.vanduyne@nycig.org Rochester RHIO (Rochester & Finger Lakes Region) Jill Eisenstein President and CEO jeisenstein@grrhio.org 5 SHIN-NY Support for NYS PCMH November 2018