Awareness is growing that LTPAC providers play a critical role in care coordination and related payment and delivery system reforms intended to improve quality and reduce costs. Examples include ACOs and other new payment and care delivery models (e.g., PCMHs and health homes), Medicare's hospital readmission policy hospital, and post-acute care bundling. eHIE between LTPAC providers and their exchange partners is a promising and important strategy for achieving the ultimate aims of these reform namely improved health system performance.
This study found that progress is being made but increased focus on the importance of LTPAC providers in the care continuum has not yet translated into robust, bidirectional exchange involving LTPAC providers and key trading partners like hospitals and medical groups. Rather, participation of LTPAC providers in eHIE efforts is still in its infancy and generally does not involve the robust, bidirectional exchange initially envisioned in early stages of ARRA HITECH.
As our research shows, there are many challenges to further progress in the area of eHIE between LTPAC providers and their exchange partners. Some major barriers include: lack of funding to support adoption and use of certified HIT that supports interoperable HIE by LTPAC providers; lack of strong enough incentives for critical exchange partners (i.e., hospitals, medical groups, IDSNs) to engage in eHIE with LTPAC providers; competing demands for both LTPAC providers and their exchange partners; limited capacity on the part of many LTPAC providers to use HIT solutions and limited technical assistance to this sector to support and increase their ability to use technology solutions; competitive and proprietary concerns by providers and vendors; provider concerns and misconceptions related to federal and state privacy and security laws, and, a host of significant eHIE technological challenges, some of which disrupt workflow and discourage use. Consequently, as described through this report, eHIE efforts are often opportunistic and very local solutions.
Despite these challenges, our stakeholder interviews and review of the gray literature identified 12 regions around the country where LTPAC providers are involved in the planning or implementation of eHIE and have started to engage in eHIE with key exchange partners. Progress was made with previous funding, and as these existing federal funding opportunities end, new federal funding opportunities are beginning (e.g., ACOs, SIM grants, ONC HIE grants). These provide new opportunities and incentives that are influencing eHIE initiatives and the states and providers that choose to participate in them. For example, the presence of ACOs in many local markets across the United States is prompting some ACOs and key portions of them (e.g., hospitals) to reach out to LTPAC providers and conversely LTPAC providers in those communities to develop eHIE capacity as a way to ensure that referrals from local hospitals continue in the future. The IMPACT Act also has the potential to accelerate LTPAC provider involvement in HIE through its new requirements to standardize and make interoperable post-acute care assessment data.
Where LTPAC providers are participating in eHIE, they currently are often are limited to view-only access to clinical documents, DSM, and partial solutions (e.g., Transform, LAND/SEE). While providing an immediate solution, they have limits, and potentially reduce incentives for adopting more functional, interoperable HIT systems. A potential wildcard in predicting LTPAC provider involvement in eHIE initiatives going forward is the technology used to engage in eHIE. Policymakers, providers, and HIOs are continually trying to anticipate how the technology for enabling exchange with LTPAC providers will evolve and whether there will be a feasible, affordable technology solution in the shorter run and which technologies will be successful longer term. The availability of new technology solutions depends on the HIT/EHR and HIE vendor communities and whether they decide to move into the LTPAC space more aggressively. Findings from the literature review, stakeholder discussions, and case studies suggest that the technology continues to rapidly evolve and those interested in advancing LTPAC involvement in eHIE initiatives should not wait for a so-called "silver bullet" that will produce seamless exchange between LTPAC providers and their exchange partners.
Our findings suggest that the likely migratory path going forward will involve DSM, view-only portals through hospitals and HIE, and, due to considerable regional variation, smaller implementation efforts and assessment of their impacts (i.e., test of specific use cases). The current lack of certified HIT/EHR adoption in the LTPAC market segment constrains bidirectional exchange capability. Certified technology that support more robust forms of exchange are less likely to be adopted by enough LTPAC providers in the near term. Starting small and making incremental changes to EHR and eHIE capacity in the LTPAC setting would facilitate the availability of critical pieces of information needed to care for patients across providers (e.g., medication lists). Given these realities, DSM, view portals, and specific use cases can provide a cost-effective intermediary path forward for data exchange with LTPAC providers. Other new innovative technologies, such as Transform Tool are beginning to take hold and spread, and LAND/SEE is in early stages of implementation after years of planning and development. Even newer and more innovative applications like FHIR are promising but more long-term solutions.
These "pockets of progress" involving LTPAC providers in eHIE across the United States offer rich opportunities for research and learning. Maturation of HIT efforts in some regions, combined with new policy and market dynamics, are beginning to convince at least some LTPAC providers, hospitals, medical groups, and other providers of the value in eHIE efforts and are facilitating more interest in more innovative and robust eHIE approaches. Additionally, new technological solutions offer better opportunities for more robust eHIE involving a wider swath of LTPAC providers.
The time is ripe for targeted research about planning, implementation and impact, particularly what works and does not work and why in eHIE initiatives involving LTPAC providers. Our stakeholder interviews, literature review, and comparative case studies suggest that specific regions have a favorable environment, capable IDSNs, HIOs, and promising technological solutions from which we can learn much about implementation and impact. The Urban Institute team describes one promising approach to conducting a targeted quantitative impact evaluation using ACOs or IDSNs, approaches that could be used in the longer term, as well as potential strengths and limits to various research opportunities and approaches in this arena. The results of such an evaluation as well as other evaluations already underway will help to identify promising approaches to eHIE involving LTPAC providers across the country, provide sound evidence about their ongoing implementation experience, lessons learned, and short and longer term impacts.