Health Information Exchange in Post-Acute and Long-Term Care Case Study Findings: Final Report. B. Exchange of Clinical Information


1. Introduction

HIE is an integral component of health care workflow and is important in the provision of quality care to patients. When the exchange of health information is performed well, care provision can achieve positive health outcomes. When information exchange is not performed well (e.g., it is untimely, inaccurate, or absent) potentially costly inefficiencies may occur or it may result in adverse events.

HIE across care settings is very complicated, regardless if the mechanism is electronic or manual. Such exchange involves multiple health settings with different information needs and with different levels of HIT adoption and technological sophistication. Ideally, information exchange should be two-way, with an opportunity for the receiving provider to ask clarifying questions or request supplemental information. However, often communication is a one-way transaction. Although information technology will not, nor should it replace face-to-face interactions, HIT can facilitate and augment information exchange. The goal of interoperable HIT has become a national priority in recent years. HIENs/RHIOs have been identified as important mechanisms in this regard and have experienced prolific growth. One of the requisite tasks for HIEN developers is to formalize who are the network partners and determine what information needs to be exchanged. Often, it seems that there has not been an explicit understanding and agreement about the range of partners that need to be involved in these networks, nor has there been a formal consensus building process for determining the content of information to be exchanged and when. A positive consequence of the push for HIT adoption has been the recognized need to formalize HIE relationships among information "trading partners." Therefore all entities that need information should be included as partners.

Understanding how HIT can be used to facilitate HIE requires a concomitant understanding of the influence of HIT on the daily workflow of health care professionals. In some cases, the workflow issues have been identified to be more challenging than technological issues. Discussions between HIE partners are beginning that further explore this interface and are focusing on questions such as: How can HIE be engineered such that it supports rather than detracts from health care professionals' patient care responsibilities? What information should be exchanged and when in the process of a daily routine should this occur? How can HIT facilitate this exchange?

With this recognition of the mutually dependent relationship between HIE and workflow, the following discussion provides a framework upon which the observations and key issues identified in subsequent sections can be interpreted.

2. What Are the Workflow/Communication Issues?

The four site visits reinforced the central roles that workflow and communication play in HIE and the importance of considering and planning for the desired workflow/communication issues to realize some of the efficiency gains that may be achieved though HIT implementation.

a. Workflow. Information technology is a cross-cutting issue, an observation that permeated the site visit discussions at many levels. In general, relatively highly-paid professionals in hospitals and PAC, and LTC settings are expending a significant proportion of their time on clerical tasks rather than attending to patients' clinical needs. Implementation of EHR solutions did not necessarily provide solutions to this inefficiency. It was common for sites to report that nurses and physicians read from a computer screen or print out a patient's health data from one electronic health application only to manually re-enter the information into another electronic health application (such as an EHR).

Physicians, nurses, and other representatives (admission coordinators, information technology professionals, etc.) from the study sites generally had not considered how the recipient of electronic information could re-use the information to streamline and make workflow processes more efficient. In most cases, the clinicians were not consciously aware of the amount of time and effort that was being expended on multiple tasks involving the re-entering of data that was otherwise electronically available. In many instances, representatives seemed to simply insert electronic documents into existing workflow processes and as a result perpetuating (unnecessarily) duplicative administrative tasks.

The lack of standardized HIT/HIE applications also contributed to inefficient practices. Because of the lack of interoperable EHRs, for example, respondents described manually re-entering laboratory results received electronically into their own EHR system, because the laboratory and receiving health care setting's EHR systems did not have the capabilities of exchanging this type of data electronically.

However, further probing revealed that the manual re-entry of data sometimes was considered to be of value. For example, the literature reports that manual re-entry of a medication list from one system or medium to another may add value in terms of quality and safety, while risking the introduction of new errors (e.g., transcribing the wrong dosage, misspelling the medication that is similar to another medication that treats something completely different or is contraindicated) (Brody, 2007). During site visit discussions, clinicians acknowledged that this manual re-entry activity was not simply a clerical process but rather something that provided an opportunity to cognitively assess whether the medications were in fact appropriate, whether any additional diagnostic testing was required, and whether the patient might be at risk for an adverse drug reaction. Occasionally, the notion of trust also would arise--clinicians seemed to place greater trust in information that had gone through the manual re-entry process. Thus it remains to be determined how these vital tasks will be accomplished once more advanced (e.g., interoperable) electronic solutions are forthcoming. The authors speculate that there always will be a need for "the human element" in reconciling information such as the medication list--information technology solutions will merely augment and assist them in these care processes.

In a typical workflow process, keeping track of when a particular task (e.g., obtaining physician's signature, orders) was completed so that the next person could do her/his job was reported as something on many people's "wish list" for what they would like their EHR to do for them. Current practice requires a great deal of time spent manually tracking tasks that could easily be automated in the EHR.

b. Importance of interpersonal relationships. The importance of interpersonal relationships among health care professionals cannot be overstated. The site visit team observed how established interpersonal relationships impacted HIE. Typically, patient information sharing occurred among hospital discharge planners and/or social workers, and NH and home health care agency intake coordinators. Interestingly, the importance of interpersonal communication was no less in care settings that had the capacity to share information electronically versus those that primarily shared information on paper. For example, despite the fact that several hospitals and NHs in New York and Utah have invested in a proprietary software program, Extended Care Information Network (ECIN), to facilitate more efficient referrals (described in further detail below), it is not uncommon for disposition discussions to precede the distribution of the ECIN information. Thus, although this technology was put in place to facilitate hospital referrals to SNFs/HHAs, informal, less technological approaches (e.g., face-to-face discussions, telephone, faxes) often were the primary mechanisms of data exchange, with HIT being a supplement to this data sharing activity. The perceived value of relationships that exists between these professionals was of more importance when compared to the technology. Our site visit team observed that intake coordinators in referred facilities often received the patient's information telephonically from their hospital colleagues in advance and had already accepted the patient by the time the patient's information is distributed in electronic transfer/discharge summaries, such as ECIN.

c. Other issues that impact communication between referring and receiving providers. Communication and information exchange between some of the observed health care settings was not hindered by a lack of technological solutions. For example, in Maryland, Erickson (a CCRC that provides all health care to their residents with the exception of acute care and hospice) and the local hospital (St. Agnes) have a very close working relationship and freely communicate. Erickson physicians are able to treat their patients should they be admitted to St. Agnes, and they have read-only access to the St. Agnes EHR, but still need to print out anything they would like to have in their Erickson health record. St. Agnes also allows an Erickson-employed nurse to work in the hospital to facilitate discharges back to one of the Erickson facilities (e.g., their SNF, Renaissance Gardens).

Clearly communication between these two entities is occurring, as is HIE, of which most at this point is still manual. Technology was not considered a hindrance; in fact, the leaders at St. Agnes commented that technology is a minor issue in solving the problem of e-HIE. Rather, issues such as who is responsible for protecting the privacy of data at the time of e-HIE and who is liable for the accuracy of the data were identified as the barriers to effective information exchange across health care settings, particularly unaffiliated settings. Further, it remains to be determined who should pay to populate the specific data fields that often are idiosyncratic to each referring/receiving provider. Transmitting data requested by the receiving provider likely will create additional costs (including personnel, programming, troubleshooting/maintenance, upgrades, etc.). The multiplicity of formats may be too burdensome and costly for some providers. For example, the development of an interface between St. Agnes and Erickson to facilitate data sharing was reported by Daniel Wilt (Senior Vice President of Erickson Information Technology Department) to initially cost approximately $50,000, which then would require maintenance and upgrades over time. This interface only benefits this one relationship between these two entities. Creating unique interfaces to support all referring and receiving sources may be unnecessarily costly and inefficient.

In fact, concern about the relatively high cost of an almost unlimited number of needed idiosyncratic interfaces gave rise to the emphasis in recent years concerning the need for HIT standards to support interoperable HIE. For example, it is anticipated that the use of: (i) the HL7 CCD implementation guide and the content standards referenced in that guide; and (ii) standards to support e-prescribing will allow the exchange and re-use of this information without the need for these costly interfaces. However, as described below, during out site visits we observed very limited use of HIT standards to support the electronic exchange of patient information.

d. Timeliness of the communication/information exchange. The element of time permeated through nearly every discussion that occurred during the four site visits. In particular, when hospital staff believe that a patient is ready for discharge and will require short-term placement in a NH or a referral for home health care, receiving providers must be in a position to quickly decide whether or not to accept the patient, often based on incomplete or even inaccurate information. NH staff at Jewish Home and Hospital Agency (JHHA) and Schervier (New York) both commented that information received from local hospitals often is incomplete, and varies depending on the person completing the discharge form at the hospital. As a result, the receiving facilities/agencies may make poorly informed, inaccurate decisions and may not be in a position to meet the patient's needs upon admission.

3. Health Information Exchange Across Care Settings: Hospitals, Post-Acute, and Long-Term Care

Older adults with acute and chronic health conditions often receive care in multiple, disparate settings by a number of care providers (e.g., primary care physician, one or more specialists) who may or may not share (complete) information. The transfer of timely and accurate information across settings and providers is critical to the execution of effective care transitions. Practitioners need an understanding of the patient's goals, baseline functional status, active medical and behavioral health problems, medication regimen, family or support resources, durable medical equipment needs, advanced directives, and ability for self-care (Coleman, 2002; Coleman, 2003; HMO Workgroup on Care Management, 2004). Without this information, service duplications may occur, important aspects of the care plan may be overlooked, and conflicting information may be conveyed to the patient and family caregivers. Incomplete information transfer can result in critical errors, such as the patient returning home without life-sustaining equipment (e.g., supplemental oxygen or equipment used to suction respiratory secretions). The absence of information about an older patient's baseline level of cognitive function may result in an acute decline in cognitive status being mistaken for chronic dementia. Furthermore, a lack of understanding of a patient's functional health status, including both physical and cognitive, may result in transfer to a care venue that does not meet her or his needs. Thus, improved HIE (manual or electronic) is a critical step toward reducing medical errors, improving quality, and increasing efficiencies for patients who receive care across settings.

This section focuses on HIE across affiliated and non-affiliated acute care hospitals, PAC, and LTC providers. Specifically, it examines information exchange between hospitals, physician offices, NHs, home health care agencies, and, in one setting, a CCRC. To frame this discussion, it is important to note that while there are similarities between how care is delivered in each of these settings, there also are key differences that potentially influence both the content and process of information exchange. Hospitals, PAC, and LTC settings treat patients with different needs, have different staffing ratios, different clinical information needs, different orientations and approaches to assessment and management, and face different regulatory and reimbursement requirements. These disparate requirements translate into different data needs. Further, providers' HIE often is guided by the need for compliance with existing policies and regulations, including required reporting for patient assessment instruments (PAIs) such as the MDS and OASIS, the Pre-Admission Screening and Annual Resident Review (PASARR),12 the New York State Patient Referral Instrument (PRI),13 and Medicare Conditions of Participation (CoPs).14

This section begins by describing the clinical domains that the literature identifies as needing to be exchanged and then compares these domains with what was observed on the four site visits, including what is not being exchanged. Next, promising new developments that could support improved HIE will be featured. Key aspects of clinical workflow issues then will be described, followed by comparing and contrasting how health information is exchanged among affiliated and unaffiliated providers. This section will conclude with observed facilitators and barriers to HIE, including e-HIE.

a. What is the content of information exchanged. Based on a review of published literature, summaries of large national conferences, and documents produced by professional societies; at present there is no consensus on the content and type of information exchange needed between hospitals, PAC, and LTC settings. Four distinct national efforts that have begun to address this question include:

  1. The CCD (HL7 and ASTM, 2006).

  2. The Uniform Patient Assessment for Post-Acute Care tool (CMS, 2006). The UCDHSC developed a concept paper for CMS that provided recommendations for developing a uniform assessment tool that would cut across all PAC settings. The Deficit Reduction Act of 2005 requires the demonstration of a comprehensive assessment at the time of hospital discharge to determine appropriate placement and the use of a use a standardized PAI across all PAC sites to measure functional status and other factors during the treatment and at discharge from each provider. CMS awarded a contract to RTI International to specify the elements of this tool (which has been named the Continuity Assessment Record and Evaluation (CARE) instrument) and perform a demonstration project.

  3. The HMO Care Management Workgroup (HMO Workgroup on Care Management, 2004).

  4. The Veterans Affairs Geriatrics and Extended Care (GEC) Referral Discharge Planning Tool (Department of Veterans Affairs, 2006).

Each of these efforts evolved separately. A comparison of the individual domains and classifications needed for information exchange from each of these efforts is shown in Table 3. While there are many similarities among the four efforts with respect to the selection and inclusion of key clinical domains, there are also a considerable number of differences observed as well. A detailed description of the first four efforts can be found on the ASPE website15 (Coleman, et al., 2007). One of the important differences between the CCD and the other activities listed above, is the HL7 CCD identifies not only the pertinent health care domains for which patient specific information may need to be exchanged at the end of an episode of care, but the CCD also specifies the HIE content and messaging standards that enable standardized electronic exchange of a CCD-compliant transfer/discharge document.

While there often was overlap in the clinical domains included in these HIE specification, there was considerable variation in the type of data within each of the domains. For example, each of the efforts identified a problem list and advance directives. However, the GEC (VA) tool does not list allergies and medications because the tool is designed to complement core information available in the VA EHR. The GEC (VA) tool and the Uniform Patient Assessment tool both are more strongly oriented toward PAC and LTC and as a result, have more items that reflect the types of care more typically addressed in these settings such as continence and skin integrity. Some care settings, such as EDs, desire a much smaller subset of core data items as they do not have the opportunity to review much data during the brief clinical encounter.

Within Medicare's regulatory framework, the CoPs include requirements concerning information exchange at the time of transfer for hospitals, NHs, and HHAs (CMS, 2001; Coleman et al., 2007; Hughes, 2003). Where explicitly identified in the CoPs, the required clinical domains at the time of transfer are comparable to those clinical domains specified in the four national efforts described in Table 3.

Responses from those interviewed revealed a high level of consistency in the content of information needed to support HIE at the time of transfer. For example, Wishard Hospital (Indiana) considers the discharge summary, insurance information, medication list, allergies, problem list, and advance directives among the core information needed at the time of transfer from an SNF or HHA to the hospital or vice versa. LDS Hospital in Utah assembled a similar list and added physical therapy (PT) notes. Erickson Retirement Community (Maryland CCRC) regards medications, allergies/intolerances, medical problem list, advance directives, clinical notes, radiology reports, laboratory results, and clinical notes as the highest priority clinical domains. When the JHHA, a New York NH, transfers a patient to hospital, an information packet is prepared that includes a medical summary of recent events completed by the physician, a handwritten medication list, immunization list, EKGs (if available), and recent laboratory tests. Staff at Schervier (New York NH) also send this same set of information with patients who are transferred to the ED or hospital and, in addition, complete an internally-developed standard transfer form that describes the reason for transfer.

TABLE 3: Overlap of Clinical Domains and Clinical Information to be Exchanged Between Acute Care Hospitals, Post-Acute, and Long-Term Care Settings
Key Clinical Information to be Exchanged CCD (HL7, CDA) Uniform Pt Assessment (CMS) HMO Care Mgmt Workgroup GEC (VA)
Purpose (i.e., transfer) X      
Payers X      
Advance directives X X X X
Support (persons/family)/Caregivers Information X X X  
Functional status X X X  
Cognitive X X   X
Physical X X    
ADLs/IADLS, baseline, current   X X X
Problems, Prognosis X X X X
Family History X      
Social History X      
Allergies, Adverse Reactions, Alerts X X X  
Medications X X X  
Medical equipment X X X X
Suppliers       X
Immunizations X X    
Vital signs X      
Results X      
Procedures X      
Encounters X      
Plan of Care X X    
Health Care Providers, PCP X X X X
Goals of care X X   X
Discharge instructions, disposition   X X  
Pain   X    
Skin integrity   X   X
Sensory deficits X X    
Dietary needs   X   X
Continence   X   X
Falls risk   X    
Current services receiving in home   X   X
Capacity to perform self care, educational needs X X X  
Ethnic/cultural considerations/language X X X X
Self-rated health status   X    
Source of referral       X
Where does patient live, with whom     X X
Homebound status       X
Additional information (environmental hazards)       X
Weight bearing       X
Referring to which program     X X
Estimated duration of care       X
Skilled care services needed       X
Behaviors and symptoms       X

In contrast to the states of Indiana, Utah, and Maryland, New York State regulations mandate the information that must be made available to the receiving care team prior to a patient's transfer. The sending institution (typically the hospital) must complete the PRI for all patients being referred for Part A covered SNF care, and New York nursing staff must be certified to complete the PRI. The PRI scores the patient on intensity of care with categories including physical and cognitive function, medications for the last seven days, recent laboratory results, x-rays, PT and occupational therapy (OT) notes, and wound care. In addition to supporting HIE, this tool facilitates an appropriate match between the patient care needs and the care setting.

b. What information is not being communicated/exchanged. Across all four of the site visits, the most common clinical content not routinely exchanged between the hospital and the PAC/LTC settings was the patients' current mental status and recently exhibited behavioral symptoms. NH staff at Lockefield Village (Indiana extended care facility associated with Wishard Hospital) commented that they rarely receive information about a patient's mental and behavioral status prior to transfer from the hospital. When information is provided, it often is incomplete or inaccurate. These frustrations were echoed by the JHHA and Schervier (New York SNFs/LTC facilities). Staff at both facilities recognized that current financial incentives to discharge patients from hospitals as quickly as is reasonably possible, are not always aligned with full disclosure by the referring hospital of a patient's status. Not only could this information delay a potential transfer or discharge from a hospital, disclosing such information may trigger PASARR screening and require further evaluation by mental health professionals. Consequently, hospitals may not share this information with potential receiving NHs.

While not included on any of the lists described above in Table 3 of clinical domains for which information exchange is needed, the second most cited type of clinical content that is not reliably transferred across settings is PT notes. Despite a relatively high level of integration, Erickson Retirement Communities staff (Maryland CCRC) noted that there is no existing mechanism to ensure that the clinical information charted by the physical therapist in Renaissance Gardens (their SNF) is transmitted to the physical therapist in home health care (which is on the same campus) to which the patient has been referred or discharged. Renaissance Gardens and the Erickson HHA both use the same EHR (HealthMEDX). Similarly, both JHHA and Schervier (New York NHs) identified PT notes as rarely included but nonetheless needed in the transfer information received from the referring hospital.

Patients' wound status was the third most commonly observed clinical data not reliably exchanged, but reported as needed. Briarwood (Indiana NH) staff commented that not having this information left them unprepared to meet a patient's needs, either because they did not have the on-site expertise to evaluate and treat the patient or because care required specialized equipment, dressings, or therapies that was not available in their facility upon admission. Had they known the extent of the patient's need prior to admission, they may not have accepted the patient knowing they did not have the on-site expertise.

Advance directives also were not consistently shared. Providers attributed part of the problem to the fact that these documents often "stand alone" from other health-related information and therefore are more likely to become separated from other transfer documents. Often, family caregivers were asked to provide a duplicate copy of the patient's advance directive, as providers noted that requesting the information from the transferring institution was often unproductive. Although regulatory requirements mandate that admitting facilities request an advance directive on all patients, the same requirements do not mandate what happens to the actual advance directive document and whether it becomes an integral part of the patient's record. Clinicians at the hospital and PAC/LTC sites visited often noted that advance directives are sometimes misplaced, misfiled, or mishandled by the receiving health setting. The importance of these documents for ensuring patient centered care cannot be overstated. Patients complete these documents to convey to health care professionals what type and duration of treatments that they believe to be either acceptable or unacceptable. The inaccessibility of these documents may result in undesired treatments being administered, desired treatments being withheld, or inexcusable violations of a patient's religious or cultural practices (Morrison, Olson, Mertz, & Meier, 1995).

With regard to medications, staff at JHHA and Schervier (New York NHs) were appreciative that they generally received the medication list and sometimes the Medication Administration Record (MAR) from the referring hospital. However, they expressed a desire to extend the time period that the hospital provides medication reporting to a full 14 days. This would facilitate more accurate completion of documentation required by the MDS (version 2.0 for NH resident assessment and care screening) and used in the calculation of Resource Utilization Groups-Version III (RUG-III) needed for payment. RUG-III categories and appropriate payment rates are based upon the level of nursing requirements, and residents with greater or specialized nursing requirements, therapies, and other conditions are reimbursed at a higher level. Receipt of timely and accurate information from transferring institutions is imperative for accurate assessment (CMS, 2007b).

Members of the site visit team uniformly heard that hospital and PAC settings would stop chronic care medications upon admission and inadvertently not restart them upon discharge. Often, if it were not for the patient or other family member's initiative, these chronic care medications would be forgotten with resulting potential for adverse effects.

Finally, information that describes the roles and contact information for family members was rarely shared across settings. Interestingly, this information was rarely identified during the site visits as key clinical content to be shared at the time of transfer, yet patients receiving home care rely on loved ones and other caregivers to a great extent.

In summary, considerable overlap was observed with regard to the type of health domains for which information was exchanged between the clinical categories addressed by the four national efforts described in Table 3 and the type of health information that was exchanged by providers in the sites that were visited. However, considerable variation in the specific type of data within each of the domains that was exchanged and sometimes reported as needed also was observed. Reasons for this variation include: (1) that the specific types of health information to be exchanged often reflect the idiosyncratic agreements between the sending and receiving providers; (2) providers within health delivery organizations/systems have not reached an agreement on the type of health information that is needed to be exchanged; and (3) regulations require the exchange of certain types of data; and in some cases, regulatory activity dictated the type of health information that must be exchanged. In addition, during the site visits two clinical categories were observed that had been mentioned in the previously described national efforts as not being the type of information routinely shared across care settings. The first was information that describes the roles and contact information for family caregivers, as they play an essential role in implementing the care plan. Secondly, the patient's physical, cognitive, and behavioral status were not routinely identified as a high priority clinical category by hospital, PAC, or LTC providers, despite the importance of this information in matching the patient's care needs to an appropriate PAC setting.

c. How and what information is exchanged with affiliated and unaffiliated health settings. Although it was anticipated that HIE between affiliated settings would be more complete, efficient, and likely be accomplished electronically, the site visits did not confirm these assumptions. In fact, HIE between affiliated settings was found not to be significantly different from HIE between unaffiliated settings. Generally, HIE was found not to be timely or complete regardless of affiliation between health care providers, and regardless of availability of electronic health information in the referring provider's health information system. What follows summarizes the findings for HIE between affiliated settings and unaffiliated settings, particularly at times of discharge and transfer to a new health entity.

In general, the site visits uncovered relatively few examples where HIE had been formally addressed by affiliated health settings. The receiving providers were rarely asked to articulate their needed clinical information or clinical content and their preferred mode of communication. Rather, the sending provider largely determined these parameters, and this is true regardless of the direction of the transfer. The exception to this is Erickson Retirement Communities; because their employees (e.g., physicians) functioned as both a "sender" and a "receiver" of health information (their physicians treated patients sent to St. Agnes hospital for acute care as well as at all phases of care on the Erickson campus), they were able to design and communicate the needed information.

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