Achieving Meaningful Use: Transitions in Care

Achieving Meaningful Use: Transitions in Care

Session 9

April 13, 2011

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Agenda

• Introduction– Overview of how Direct can be used to meet MU and State HIE

Program requirements to exchange transitions of care documents

• Panelists– Gary Christensen, CIO/COO, Rhode Island Quality Institute– Holly Miller, MD, MBA, FHIMSS, Chief Medical Officer, MedAllies

Inc.

• Q&A

• Poll

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Meaningful Use RequirementsMeaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3

Stage 1 Final Rule Stage 1 Final Rule Measure Proposed Stage 2 Proposed Stage 3

Provide summary of care record

50% (for both eligible providers (EPs) and auth. providers of eligible hospitals (EHs)

Perform at least one test of EHR’s capacity to electronically exchange information

EHR must enable a user to electronically transmit a patient summary record to other providers and organizations including: diagnostic test results, problem list, medication list, and medication allergy list.

Must use either HL7 CCD or ASTM CCR

Move current measure to core80% of summary care records provided electronically for transitions and referrals

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State HIE Program Responsibilities The Program Information Notice to State HIE grantees (dated July 6, 2010) outlined key

responsibilities that states and SDEs must address in 2011, specifically to address and enable three priority areas: e-prescribing, receipt of structured lab results, and sharing

patient care summaries across unaffiliated organizations.

Multi-stakeholder process

• Convene stakeholders with interest in patient care summaries(inc. providers, practices, etc.

• Conduct environmental scan to determine patient care summary metrics

• Perform gap analysis

Monitor/track MU capabilities

• Set baseline, monitor & track various patient care summary metrics:• % providers

sending patient care summaries electronically

Strategy to fill MU gaps

• Use phased approach

• Use policy or reg. levers to require electronic sharing patient care summaries

• Consider Direct to help rapidly enable the electronic exchange of patient care summaries

• Work with REC to start with gaps among small providers, hospitals, etc.

Consistency with national policies

/standards• Ensure consistency

with national standards, NWHIN specifications, federal policies and guidelines• Participate in S&I

Framework Transitions of Care initiative

• Implement a flexible approach

Alignment with Medicaid and public health

• Establish an integrated approach that represents Medicaid and public health programs

• Work with Medicaid and private payers to include interfaces as part of their contractual agreements with providers

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Why Direct for Transitions of Care?• MU-compliant. Direct use cases tied to MU priority

areas, including patient care summaries.• Standardized. Direct provides a standardized transport

mechanism for patient care summaries.• Simple. Simplicity helps adoption among low volume

practices and small, independent providers.• Scalable. Direct can be utilized beyond 2011 in meeting

future stages of meaningful use requirements and other business goals.

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Provider Sends Patient Care Summaries to Specialist and Back

Perspective: Primary care provider refers patient to specialist including summary of care record.Context: The provider has made the determination that it is clinically and legally appropriate to send the summary of care record to the specialist.Workflow Steps:1. Primary care provider refers patient to specialist including summary care record

a. Physician interacts with EHR to create information packet for delivery across Directb. Information packet crosses Direct Project to specialist physician’s EHR

2. Specialist sends summary care information back to referring provider through same workflow steps

HISP

PCP

Specialist

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Hospital Sends Discharge Information to Referring Provider

Perspective: Primary care provider refers patient to specialist including summary of care record.Context: Hospital has completed care and is preparing to discharge patientWorkflow Steps:1. At the time of hospital admission in the EHR, the PCP of record is verified with the patient 2. Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information

package to be transferred to the PCP of record within the Hospital EHR system3. Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g.

medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.)4. When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider5. Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions

and medications with patient

HISP

PCPHospital

Rhode Island Quality Institute Presentation

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Rhode Island Direct Pilot – Objectives

• Demonstrate the feasibility of levering Direct Project specifications as a vehicle for feeding clinical information from practice-based EHRs to the statewide HIE, currentcare

• Demonstrate Direct Project User Stories:– Case 1: Primary care provider refers patient to

specialist including summary care record – Case 2: Specialist sends summary care information

back to referring provider

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Rhode Island Direct Pilot – Summary

• RIQI worked with EHR vendors, targeted practices, and Beacon practices to: – Integrate Direct reference code (one line) into EHR platforms– Trigger the automatic creation of a Direct message (through

the reference code), the generation of a CCD and attachment to the message, and sending it to an HIE Direct mailbox

– Connect targeted, participation practices that use this interoperability model (through Direct) to the Statewide HIE as a Data Sharing Partner for currentcare

– Lever native Direct messaging as a means to improve PCP/Specialist coordination of care

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Hospital Sends Discharge Information to Referring Provider

Perspective: Primary care provider refers patient to specialist including summary of care record.Context: Hospital has completed care and is preparing to discharge patientWorkflow Steps:1. At the time of hospital admission in the EHR, the PCP of record is verified with the patient 2. Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information

package to be transferred to the PCP of record within the Hospital EHR system3. Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g.

medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.)4. When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider5. Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions

and medications with patient

HISP

PCPHospital

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Wouldn’t it be great if….

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Exchange of Health Information from EHR (EHR to HIE ): Easy as 1

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Beacon Intervention: Provider Notification

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Beacon Intervention: Quality Reporting

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Easy Exchange of Health Information from EHRs (Doc to Doc): Easy as 1,2,3

MedAllies Presentation

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MedAllies Direct Pilot Objectives• Overview: Enhance patient care and safety across

transition of care settings (hospital d/c and “closed-loop” consultation) by providing the real time transfer of pertinent clinical information across disparate EHRs in a fashion that is consistent with existing clinical workflows– Clinician adoption– Secure, fast, inexpensive and interoperable– Support small practices, large integrated delivery systems,

and everything in between– Support advanced primary care and accountable care models

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Hudson Valley – New York StateParticipants• HISP

– MedAllies

• Healthcare Organizations – Hospitals: Albany Medical Center, Health Quest Systems– Primary Care: Albany Medical Center, Community Care Physicians,

Health Quest Systems, Institute for Family Health, Scarsdale Medical Group,

– Specialists: Albany Medical Center, Asthma and Allergy Associates of Westchester

• EHR Vendors– Hospital: Siemens, Cerner– Primary Care: Allscripts, Epic, NextGen, eClinicalWorks– Specialists: Allscripts, Greenway

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Hudson Valley – New York StateHospital Discharge to PCP

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Hudson Valley – New York StateClosed Loop Referral (PCP to Specialist & Back)

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• Speed/difficulty of implementation– Two tracks: Technical and Clinical

• Coordinated to deploy a technically excellent solution that included extensive clinical participation and insight in the design

– Technical track focused on harmonizing the implementation of Direct messages and a common payload

– Clinical track focused on leveraging existing inpatient and ambulatory EHR workflows to incorporate Direct transactions

•  Ease/difficulty of ongoing utilization – Training

• Minimal – Project focused on integrating Direct messages into existing EHR

clinical workflows and preserving the practice-specific roles and responsibilities of the end users at each provider organization

• Ongoing utilization will require minimal additional training consistent with training for EHR upgrades

MedAllies Direct Summary

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• Speed/Latency– All of the Direct message exchanges in the MedAllies’ Direct pilot occur in

real time • Speed of transactions is latency between the MedAllies’ data center

and EHR locations - measured between 5 and 10 seconds– Data arrives to recipient prior to patient leaving last clinical area

• Workflow and Clinical Adoption– Use cases used most common transfer of care events where patient at risk– Clinical adoption key measure of project success

• Providers would only use the system if it were consistent with their established clinical workflows

– Need for messages to be pushed to the providers within their EHR systems

– “This is the Holy Grail of medicine.”» Dr. Ferdinand Venditti, the vice dean for clinical affairs at

Albany Medical Center and a practicing cardiologist

MedAllies Direct Summary

Provider Testimonials• Applicability of the Direct integration for the closed loop referral use case:

– “We struggle with the process of getting information to a consultant and getting it back. Being able to link and do it from inside our system is ideal. This is exactly what we would hope for in terms of being connected.”

• Kenneth Croen, MD, Scarsdale Medical Group, LLC  • Impact on current clinical workflow:

– (The Direct approach) “definitely mimics our workflow, but in a much more effective way, where we are much more likely to get the results from the consults and the information we are looking for.”

• Sarah Nosal, MD, Institute for Family Health•  Preferred mechanism for clinical messaging with respect to Meaningful Use: 

– “An HIE, where you have data posted, is a circumstance where an unknown patient presents and you want to see what information is out there on this patient. The ED is the ideal circumstance for that use case. A patient shows up, they are complaining of belly pain. You want to pull the universe of data out there that might help you decide what is going on. Versus a very pointed direct exchange between two clinicians, which is what we are talking about here.”

• Fred Venditti, MD, Albany Medical Center•  Privacy – security:  

– Direct approach “is one to one, physician to physician. There may be opportunities to share data that may be more restricted in an HIE.”

• Patricia Hale, MD, Albany Medical Center 

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Real Word Lessons – Enabling Transitions of Care with Direct

• Standards• Process• Anticipate• Communicate• Partnership • “Eyes on the Prize”

Additional Resources

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Using S&I Initiatives to Meet Meaningful Use

• S&I Transitions of Care Initiative– Will focus on supporting all transitions of care with a common

modular set of data that can be used both in a document context and to inform downstream clinical decisions (med rec, updating problem, allergy lists, decision support, etc.)

• The S&I Framework will develop:– Use Cases and Requirements– Vocabulary

• The communication/expression of specifications in CCR and CDA– Harmonization

• Document differences in C83 and CCR

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Additional Resources

• Transitions of Care work plan should be completed in July 2011

• State HIE Program Website– http://statehieresources.org/hie-priorities/

• S&I Framework, Transitions of Care Initiative– http://jira.siframework.org/wiki/display/SIF/Transition+of+Care+%2

8ToC%29+Initiative

• Direct Project Wiki– http://wiki.directproject.org/

• State HIE Program Website– http://statehieresources.org/hie-priorities/

Q&A

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Poll