In this report, we describe findings related to electronic health information exchange (eHIE) involving long-term and post-acute care (LTPAC) providers. These questions cover three general areas: preparing for eHIE between LTPAC providers and their exchange partners, implementing eHIE between LTPAC providers and their exchange partners, and assessing the impact of those activities.
We addressed these questions through several methods, including:
A review of grey and published literature from the past three years.
Discussions with 22 stakeholders representing 12 regions where eHIE initiatives involving LTPAC providers are completed or ongoing.
In-depth case studies of three eHIE initiatives in which LTPAC providers participate (one project in the Northcentral and Northeast regions of Pennsylvania and two projects in and around Minneapolis, Minnesota).
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. These include accountable care organizations (ACOs), hospital and post-acute care bundling, various integrated care delivery models, and Medicare's hospital readmission policy.1 eHIE between LTPAC providers and other providers is a promising and important strategy for achieving the goals of improving care coordination and quality, and reducing the cost of care.
Yet, despite the increased focus on the importance of LTPAC providers in the care continuum, results from this project indicate that integration into electronic data exchange is still in its infancy even among providers who were eligible to participate in the electronic health record (EHR) Incentive Programs. A recent Government Accountability Office report, for example, described 18 selected eHIE initiatives as being in their infancy.2 Moreover, integration of LTPAC providers into eHIE activities is generally not the robust, bidirectional exchange typically envisioned in earlier studies regarding the potential for improvements in care delivery and outcomes.3
LTPAC providers were sometimes involved in discussions and planning for eHIE in the region, However, LTPAC providers typically were not prioritized for early eHIE efforts by providers eligible for meeting meaningful use (MU), which required eHIE to meet Stage 1 and Stage 2 MU criteria for the Medicare/Medicaid EHR Incentive Programs. Additionally, since LTPAC providers were not eligible for Medicare and Medicaid EHR incentives, they often did not have certified EHR technology, necessary modules to support eHIE, or other technology solutions that would be needed to support exchange. Finally, some LTPAC providers and their trading partners were not yet convinced of the business case for exchange and/or wanted additional support (financial and technical) to implement EHRs, redesign workflows, and educate and train staff. While the fax and telephone have major limitations, moving to certified EHRs and eHIE is a significant challenge for LTPAC providers, their exchange partners, and any intermediary (e.g., Health Information Organization or vendor).
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. We conducted stakeholder discussions with stakeholders at the following organizations:
- Office of e-Health Initiatives (Tennessee);
- New York State Department of Health (New York);
- Keystone HIE (KeyHIE) (Pennsylvania);
- Massachusetts eHealth Institute (MeHI) (Massachusetts);
- Colorado Regional Health Information Organization (CORHIO) (Colorado);
- HealthInfoNet (Maine);
- Missouri Health Connection (Missouri);
- Michigan Health Information Network (MiHIN) (Michigan);
- Stratis Health (Minnesota);
- Ohio Health Information Partnership (OHIP) (Ohio); and
- Chesapeake Regional Information System for our Patients (CRISP) (Maryland).
The implementation of eHIE solutions between LTPAC providers and their exchange partners has been shaped by several factors including: the exclusion of LTPAC providers from MU Medicare/Medicaid EHR Incentive Program eligibility, an installed-base of technologies for the electronic reporting of administrative data (minimum data set, Outcome and Assessment Information Set), regional variation in the technical approaches to eHIE, the degree of hospital system competition and vertical integration within a region, financial resources for eHIE, and the strategies of national and regional LTPAC chains with facilities within a region.
In places where early progress has been made, the implementation experience has been slow and mixed. The challenges of creating an affordable, feasible and usable technological solutions is difficult--more difficult than many anticipated. As we describe further in this report, the technological solutions pursued have leveraged EHR technology that key exchange partners eligible for MU Medicare/Medicaid EHR Incentive Programs have developed, such as view-only portals, or eHIE efforts developed for other providers and now adding on LTPAC providers. Other implementation challenges have been changing technology, leadership turnover at key organizations, workflow redesign, provider concerns and misconceptions about federal and state privacy and security laws, and education and training. Other implementation challenges noted include competitive pressures and demands, lack of trust among some trading partners, and in some case legal concerns.
Lack of funding and the business case for LTPAC providers to participate in robust information exchange has led to use of opportunistic and often very local solutions. Even in markets where relatively robust exchange is occurring for acute care providers, including hospitals, laboratories, and outpatient care in clinics and physician offices, LTPAC providers most often are limited to view-only access to clinical documents and partial solutions that may be helpful short-term solutions (e.g., provider and hospital portals) but reduce incentives for adopting more robust, interoperable EHR systems.
However, a wave of new federal demonstrations and funding opportunities (e.g., ACOs, health information exchange (HIO) grants from the U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology and requirements and incentives is influencing eHIE initiatives and the states and providers that choose to participate in those initiatives, and could potentially encourage more widespread use of eHIE among LTPAC providers. For example, the presence of ACOs in many local markets across the United States is prompting some ACOs and key participants in 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 Improving Medicare Post-Acute Care Transformation Act also has the potential to accelerate LTPAC provider involvement in HIE through its provisions intended to encourage interoperable HIE with and by requirements for LTPAC providers reporting.
A potential wildcard in predicting LTPAC involvement in eHIE initiatives going forward is the technology used to engage in eHIE. Findings from the literature review, stakeholder discussions, and case studies suggest that 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. Instead, findings suggest that the likely near-term migratory path going forward will involve Direct Secure Messaging, view-only portals through hospitals and HIEs, and, due to considerable regional variation, smaller implementation efforts and assessment of their impacts (i.e., test of specific use cases). Other new innovative pathways, such as Transform, surrogate exchange environment, application program interface, and EHR, offer promising but more mid-term and long-term solutions.
Overall, progress is being made in involving LTPAC providers in efforts to engage in eHIE across the United States. New technology solutions offer better opportunities for more robust eHIE involving a wider swath of LTPAC providers. And new policy and market dynamics are convincing LTPAC providers, hospitals, medical groups, and other providers of the value to including LTPAC providers in eHIE efforts and are facilitating more robust eHIE more generally. Relatively little research is available on the impact of these eHIE exchange efforts because of the early stages of eHIE between LTPAC providers and their exchange partners, and there also are number of methodological challenges to these studies. However, the time is ripe for targeted research and evaluations to continue learning about what works and what does not work in eHIE initiatives involving LTPAC providers. The Urban Institute team describes promising approaches to conducting a targeted quantitative impact evaluation using ACOs or integrated delivery systems or networks. The results of such an evaluation as well as other evaluations already underway will help to identify and spread promising approaches to eHIE involving LTPAC providers across the country.