Health Information Exchange in Post-Acute and Long-Term Care Case Study Findings: Final Report. A. Background

09/18/2007

As noted in Section I, in addition to reporting on the current status of the use of HIT, one of the specific objectives of the visits was to identify the information needed at times of transition, determine how these data were (or were not) exchanged across care settings, and to identify barriers/facilitators to the exchange of data. Project objectives also included investigation of the method by which data are exchanged (electronically and not electronically) and the extent that data are exchanged between physician offices, laboratories, and pharmacies and PAC and LTC facilities.

The sites were not randomly selected, but rather were chosen based on criteria noted in Section II. The findings, therefore, are not necessarily representative for all settings, nor are the sites' HIT solutions replicable without taking into account the nuances of each site (e.g., size of the city, other competitors in the area, involvement of one or more "champions").

All four sites are located in medium to large metropolitan areas. Each site visit had a host or "hub" site and then three or more "spoke" sites. Three of the four host sites had an acute care hospital as the hub site, while the fourth (Erickson in Maryland) had a CCRC as the hub site. Three of the four had HIE organizations in various stages of development (Utah, Indiana, and New York). The fourth site (Maryland) had a well established albeit non-automated data exchange relationship with the local hospital. Thus, all four sites had processes in place that support information sharing across settings, including non-affiliated providers.

As suggested, health information can be exchanged across a variety of providers in a variety of ways. In an early attempt to delineate the different levels employed by different entities in sharing electronic health information, Walker and colleagues developed a four-level taxonomy describing the different stages of health care information exchange and interoperability (Walker et al., 2005). These levels are paraphrased below:

  • Level 1: Non-electronic data--no use of information technology to share information (examples: mail, telephone).

  • Level 2: Machine transportable data--transmission of non-standardized information using basic technology (e.g., fax or personal computer [PC]-based exchange of scanned documents, pictures, or portable document format [PDF] files). The information being exchanged cannot be electronically manipulated.

  • Level 3: Machine-organizable data--structured messages are used to transmit non-standardized data. This requires that the receiving computer "translate" data from the sending computer. This often results in imperfect translations and loss of meaning. Walker provides the following examples of this level of health information and interoperability: e-mail of free text, or PC-based exchange of files in incompatible/proprietary file formats, HL7 messages.

  • Level 4: Machine-interpretable data--exchange of structured messages that contain standardized and coded data.

Similarly, we observed the use of HIE applications and tools across many of these levels, including HIE that was completely paper-based, with the use of phone and fax to convey information to entities outside of the setting, to limited observations of standards-based, computer-readable, e-HIE that occurred using EHRs. Further, we found a wide range of HIE applications being used even within individual health care organizations. For example, during the site visits it was observed that organizations had both paper and e-HIE applications As a result, it was not possible to consistently apply the HIE and interoperability levels described by Walker et al. to describe the levels of HIE and interoperability within a single organization.

The following tables are heuristic guides to frame the site visit team's observations of HIE capabilities found as a result of the four site visits. Table 1 identifies four levels of HIE--where the first level reflects use of less sophisticated, earlier HIE applications (e.g., fax, telephone, mail) and the use of paper-based records, and the fourth level reflects completely interoperable HIE using standards-based EHRs.

TABLE 1: Levels of Health Information Exchange
Graph: Levels of Health Information Exchange

Table 2 is illustrative with features described for each level to suggest a progression from less to more sophistication in terms of HIE. This table was constructed based on literature review as well as our observations concerning HIE and use of EHRs across the sites selected for this study. Although none of the settings observed have reached Level 4 (i.e., completely interoperable EHR systems, using standards-based applications to share information with affiliated and non-affiliated providers), it is included as the purported "future goal" for many of these settings. As will be described in more detail throughout this report, in general, we observed that:

  • Most HDSs (e.g., hospitals and physician offices) included in our site visits were at Levels 1, 2, and/or 3 for purposes of HIE, and were generally at Level 1 for purposes of HIE with PAC/LTC providers; and

  • Most PAC/LTC providers also were at Levels 1, 2, and/or 3. However, there were few instances in which PAC/LTC providers were observed to electronically exchange health information with hospitals, physicians, and other providers/clinicians, and there were a few instances in which the PAC/LTC providers were completely paper-based (Level 1).

  • Not unexpectedly, there may be variation within each Level as well so that, for example, a setting may be rather sophisticated in Level 3 for a function such as e-prescribing or laboratory result reporting, but in that same setting they may not have other electronic information sharing. So while they would be categorized as Level 3 using these criteria, they would be at the "low end" of it. Therefore, labeling an entire health setting at a particular level is not yet feasible, and this is why there are four areas of focus that are broken down by level later in the document. This report highlights our observations concerning the levels of HIE for the providers included in the site visits related to four clinical areas:

    • transfer/discharge;
    • communication with physicians/other clinicians;
    • medication ordering/e-prescribing;
    • laboratory/radiology ordering and results reporting.
TABLE 2: Illustrative Examples of HIE Capabilities by Level
  Level 1
Paper-based Record/ No EHR
Level 2
Combined Paper Record/EHR
Level 3
EHR Used/Limited Electronic Data Exchange, Some HIT Standards Used
Level 4
Completely Interoperable EHR System, Use of HIT Standards
HIE Methods
  • Fax
  • Phone/Voice
  • Photocopy to pass on by hand
  • Face-to-face
  • Fax
  • Phone/Voice/Face-to-face
  • Print/Photocopy to pass on
  • Limited non-standardized electronic HIE (e.g., e-mail to & from physicians)
  • Fax, Phone/Voice/ E-mail, Photocopy
  • Some electronic data exchange standards (i.e., messaging standards) in use
  • Increasing use of electronic HIE (e.g., components of EHR may be electronically exchanged)
  • Electronic fax downloaded into EHR
  • Standards-based data exchange (i.e., use of messaging standards)
  • Standardized content exchanged
  • Standardized e-HIE across key components (e.g., lab results, medication ordering) of care continuum
Features/Attributes of Patient Health Information and Electronic HIE1 No Electronic HIE (i.e., not electronic data) No EHR Some e-HIE Limited use of EHR Data exchange limited to certain systems Access to data limited to user role/ discipline EHR is primary record Standards-based EHR system (i.e., EHR content is standardized)
May have software for AR/AP, scheduling No Anytime/ Anywhere Access May allow for images to be imported Clinical information collected on paper & entered into EHR Continued but limited use of paper record Some use of standards (messaging &/or content) Interoperable with internal & external systems Record can be electronically exchanged/ is transportable
  Meets minimum regulatory requirements2 Limited Anytime/ Anywhere Access Decision support features & alerts used Anytime/ Anywhere Access Computer Empowered Interoperable System Anytime/ Anywhere Access
Facilitators of HIE   Limited involved in HIE Network (e.g., admin/claims data) Some clinical content exchanged within HIE Network Greater amount clinical information exchanged/shared within HIE Network
  1. These are illustrative examples only and are not necessarily reflective of what was observed during site visits. No site visit has attained Level 4.
  2. For example, OASIS and MDS reporting to CMS.

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