Health Information Exchange in Post-Acute and Long-Term Care Case Study Findings: Final Report. C. Health Information Exchange Areas of Commonality

09/18/2007

The four site visits afforded the opportunity to better understand approaches, and compare and contrast how HIE is (or is not) accomplished electronically or manually between both affiliated and unaffiliated health settings. The following discussion will focus on four areas of commonality addressed at each of the visited sites:

  1. Information exchange at times of discharge/transfer.
  2. Communication with physicians.
  3. Medication ordering/e-prescribing.
  4. Laboratory/radiology orders and results.

The illustrative Table 2 will be re-used in the following discussion to display the range of electronic functioning observed during the site visits for each of the focus areas noted above.

1. Information Exchange at Times of Transfer/Discharge

The single document designed to encapsulate a patient's hospital course, the hospital discharge summary, was frequently cited by the receiving care teams as not being available in a timely manner. Several sites confided that the receiving providers (i.e., acute care hospitals, specialists, and EDs) only want specific information, and receipt of "extraneous" information frustrates the sending providers' efforts to care for the patient. For example, PAC/LTC providers sending patients to the ED may include recent laboratory results, a current medication list provided by the NH or HHA, advanced directives, progress notes, and the like. Likewise, those interviewed from hospitals and EDs indicated that they often experienced "information overload," that is, the PAC/LTC settings provided too much detail at ED admission (i.e., information that the attending ED staff do not believe they need to care for the patient).

As Table 4 shows, despite the potential advantages that provider affiliation might suggest for e-HIE at times of transfer, little evidence for interoperability or auto-population of data fields (e.g., in transfer/discharge documents) was found. The site visits confirmed that when exchanging health information either between affiliated or unaffiliated providers, sending paper documents with the patient and/or facsimile transmissions remain the predominant communication approaches to support any type of HIE to and from physician offices, hospitals, PAC/LTC settings, pharmacies, and laboratories. The information sent was primarily in the form of handwritten summaries of electronically available information, supplemented by photocopies of pertinent information such as the MAR, recent laboratory results and diagnostic imaging results, or recent assessments. Medication information was more likely to be sent with the patient while laboratory data and hospital discharge summaries were more likely to be faxed at a later date. In some cases, paper and facsimile information transfer was supplemented by telephone communication. The examples below are illustrative and do not cover every observation found during the site visits.

Indiana -- When patients are transferred from Lockefield Village or Briarwood Health and Rehabilitation (two SNFs) following a Part A covered stay to home health care, communication with the receiving HHA is via phone or fax, or both (Level 1). However, the five participating hospitals involved in the IHIE Docs4Docs portal can remotely access information. Because this is a new technology, they first are starting with hospital discharge transcriptions and laboratory/radiology ordering and reports (not a complete discharge summary, but components of it). At the time of the site visit, medication ordering and monitoring (an integral part of a discharge summary for use at times of transition) were not accessible through the Docs4Docs portal, but the technology would allow for this capability--it is more the issue of when, which is why the authors rated the exchange of hospital discharge summaries as a Level 2/3 feature in Table 4.

The Wishard Hospital EHR can electronically produce a clinical summary for patients as they enter the ED that includes reason for visit, problem list, medications prescribed by affiliated doctors, recent dictations of affiliated physicians, recent laboratory results, recent radiology results, and immunizations. Advance directives are not part of the summary. For those patients who are not admitted to the hospital, there is an opportunity to update the ED summary and send this information with the patient back to the nursing facility at which the patient is placed. However, this is not done routinely (Level 2).

TABLE 4: HIE Capabilities by Level With a Focus on Exchange of Information at Times of Discharge/Transfer
  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 HIE 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 requirements1 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
Discharge/ Transfer2 Indiana
Maryland
New York
Utah
  1. E.g., OASIS and MDS reporting to CMS.
  2. Range of electronic functioning observed site visits noted here.

Maryland -- Erickson Retirement Communities, a CCRC in Catonsville, Maryland, provides all PAC and LTC to their residents that live on campus, with the exception of hospice. Their campus also does not have an acute care hospital or specialists on staff, but their physicians treat their patients if they are transferred to St. Agnes (an unaffiliated hospital that receives the majority of Erickson residents who are hospitalized). Erickson sends an electronically-generated (i.e., auto-populated) transfer summary with all patients who are referred to the unaffiliated ED or acute care hospital, and also to any affiliated specialists. This summary is printed from the Erickson GE Centricity EHR and a paper copy accompanies the patient (Level 2). St. Agnes hospital's ED physicians provided input and feedback during the development of this transfer summary. Such input was considered an important factor to the utility of the transfer document.

New York -- Although the majority of HIE related to discharge/transfer was manual, exceptions also were noted. During the visit, the site visit team learned of the state-mandated PRI. Specifically, the State of New York requires hospitals to use the PRI when patients are transferred from a hospital to a NH or SNF. New York permits either electronic or manual exchange of the PRI form. The PRI and supplemental information are distributed electronically from Montefiore Medical Center (Bronx hospital) to local area NHs using ECIN, a software program that only requires the use of a web-enabled PC. Each provider needs to purchase and install the software and pay a monthly/annual fee for its use.16 ECIN is an Internet-based automated PRI that claims HL7 compliance. Use of the HL7v2.X standard supports the standardized messaging of the PRI form but the content of the PRI form is not standardized. This level of sophistication would be included in Level 3 of Table 4 above.

Awareness of ECIN capabilities (i.e., a software program that produces and electronically transmits hospital discharge information such as that found on the New York PRI form) seemed widespread among the four cities visited; however, no one at any site, including sites visited in New York, mentioned current or planned expansion of ECIN's use of HL7 messaging standards to support the exchange of additional clinical content such as demographic and clinical information. Instead, those who did use ECIN merely viewed the information on a web-display rather than importing this information and using it for other purposes. Information is sent by the referring institution to a list of NHs from a pick-list menu on line. As explained by NH staff in New York, when a referral arrives at the NH, an e-mail or pager alerts the staff. At this point, the receiving NH has the opportunity to e-mail back or call to ask questions and/or indicate its interest in accepting the patient. NHs without ECIN may receive the PRI via fax (Level 2).

According to Montefiore, ECIN helped reduce hospital length of stay (LOS) for NH-bound patients from ten to eight days. For Montefiore, some of the fields (mostly demographic and insurance) of the PRI can be auto-populated, while others (e.g., laboratory results, medications, and PT notes) are copied-and-pasted electronically from the Montefiore EHR (CIS). Representatives from Montefiore reported that prior to automation, the tool-based PRI completion process required 30-40 minutes to complete whereas after automation, it is completed in 10-15 minutes.

However, e-HIE is not necessarily maximally enabled even when a patient is transferred to an affiliated provider and both the sending and receiving providers have EHRs. For example, if a patient is admitted to Montefiore Medical Center (hospital) while actively receiving home health care, the Montefiore Home Health Agency (MHHA) coordinator based in the hospital will print a transfer summary from the MHHA EHR (which is a Misys product) and place a hard copy in the hospital record. This is particularly valuable as the ED and hospital staff do not have access to Misys and at present, there is no electronic interface between the Montefiore Medical Center EHR (CIS) and the MHHA EHR. MHHA staff have read-only access to the Montefiore Medical Center's EHR (CIS). This is a Level 2 capability. When a patient is discharged from Montefiore home health services, a discharge template in Misys is generated that is populated in part by Misys and in part completed by the nurse who manually types in remaining fields. This summary is sent to the attending outpatient physician in paper form that can then be scanned into the Montefiore Medical Center's EHR (also a Level 2 function).

In these examples, implementations of multiple non-standardized EHR products (the MHHA's use of Mysis, and the Montefiore Medical Center's use of CIS) while most likely decreasing staff time to complete discharge/transfer documents, have created a barrier to electronic exchange.

Utah -- All health settings visited in Utah (including LDS Hospital, two NHs and two HHAs) are at Level 1 or 2 as it relates to discharge/transfer. When patients are discharged from Brookview (NH) to an HHA, information is printed from their EHR or photocopied from the chart and mailed or faxed to the receiving provider setting. At CNS, another HHA in Utah, intake care coordinators manually re-enter information received from the hospital into its EHR (HomeSys) because information received from the hospital is not standardized and does not interoperate with the CNS EHR. Intake coordinators at Hillside Rehabilitation, a NH, scan (digitize) paper-based hospital information as they receive it and upload the digital representations into its EHR (Blue Step).

At LDS Hospital, the discharging physician routinely dictates the complete discharge summary after the patient is discharged. The lag between when the patient is discharged and the dictation is complete varies depending on the physician and ranges from one day to three weeks. The dictated hospital discharge summary is transmitted by fax or mail to the receiving NH/HHA. For example, when admitting a new patient, CareSource, a HHA in Utah, requests a history and physical, demographic sheet, medication list, and current progress notes. On average, they receive this information 75% of the time (in a paper format and it may require up to three follow-up phone calls to obtain (Level 1). This observation confirms an earlier observation about the incentives for e-HIE; whatever the incentives, they do not operate uniformly across patients and across providers. For example, the incentives for a SNF administrator to move toward e-HIE with a hospital may be that she/he would get timely and accurate information at the time of discharge. For the hospital, the incentive to adopt HIE strategies with a local SNF may be to have the capacity to discharge their patients more quickly and therefore save money and free up a bed for a new patient.

With respect to transfers in the reverse direction (e.g., NH to hospital), the site visits revealed a modest improvement when it came to the completeness and timeliness of HIE. For example, when patients are urgently transferred to the hospital, the staff member in charge of medical records at Brookview NH helps to create a handwritten form that includes a current medication list, recent laboratory results, insurance status, skin status, code status, physician name and contact, and facility contact information. Many of these clinical domains are gathered from the NH's EHR but are handwritten onto the form (this would fall between Levels 1 and 2). The template for this form was not the result of a discussion between Brookview and the receiving hospital.

2. Communication with Physicians and other Clinicians

It is worth repeating that electronic access to an EHR is sometimes limited to certain physicians and other clinicians (e.g., nurse practitioners, physician assistants, nurses, therapists, social workers). As such, Table 5 shows that some sites have fairly sophisticated modes of communication, including electronic means, while others rely solely on phone and/or fax.

Indiana -- As previously mentioned, IHIE has launched the Docs4Docs physician portal. Participating physicians (no other clinicians such as nurses, therapists, or social workers had access at the time of the site visit) and five Indianapolis hospitals can obtain a limited set of information (laboratory and radiology results and discharge descriptions on patients treated by any of the participating hospitals and/or physician practices). Each physician has a unique identifier within the portal, and is able to look at these results for any of their patients being treated at any of the participating health settings. However, currently there are no NHs or HHAs that are part of the IHIE. So access to any health data obtained while patients are being treated in these settings is limited to the ordering physician. Thus, although the range of use puts Indiana at a Level 3 in Table 5 for this function, the electronic capability documented is limited to certain physicians and hospitals.

At Wishard hospital, a computer terminal has been set up in Lockefield Village (an extended care facility that offers both Part A SNF coverage and LTC, and is physically located on the Wishard campus). To some extent, Wishard hospital and Lockefield access the same EHR (at least for Medicare Part A SNF patients), but the amount of data stored in the EHR is limited for Lockefield Village residents. Specifically, some of the daily physician and nurse charting for the Medicare Part A SNF patients at Lockefield Village is entered into the Wishard EHR, but physical therapists only enter their discharge summary into the Wishard EHR (Level 2). Other documentation gathered and entered by the physical therapists for patients in Lockefield Village (e.g., therapy notes) are stored in a paper record maintained by Lockefield. For their LTC residents (i.e., non-Medicare Part A), no physician and nurse charting is entered or stored in the Wishard EHR. Rather, all medical record information on behalf of all non-Part A covered nursing facility residents at Lockefield Village is paper (Level 1).

TABLE 5: HIE Capabilities by Level Regarding Communication with Physicians and Other Clinicians
  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 HIE 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 requirements1 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
Communication with Physician/ Clinician2 Indiana
Maryland
New York
Utah
  1. E.g., OASIS and MDS reporting to CMS.
  2. Range of electronic functioning observed site visits noted here.

Maryland -- As described before, Erickson provides care for residents who are independent and may require occasional check ups, PAC SNF care, long-term NH care, and home health services. Their outpatient clinic uses GE Centricity and their SNF/NH (Renaissance Gardens) and home health services use HealthMEDX. The physicians have access to both EHR systems while on campus. Nursing and other clinical staff working at the SNF/NH or HHA only have read/write access to HealthMEDX and, based on role of the staff person, may or may not have read-only access to the outpatient clinic's EHR (GE Centricity). Specifically, Erickson NH and home care nurses and administrators have read-only access to outpatient physician notes, medication list, and recent laboratory tests from the outpatient clinic's EHR (GE Centricity), which is the same permissions offered to the St. Agnes ED physicians and nurses (Level 2). When an Erickson resident is seen by an Erickson physician in St. Agnes, they have read-only access to the St. Agnes EHR and can print information and bring it back to Erickson where it becomes part of the medical record. (It is manually entered into the EHR of the location that the resident is placed in once they return to the Erickson campus. Erickson physicians also can remotely access the St. Agnes hospital EHR, again with read-only privileges (Level 2).

New York -- Through a recently awarded New York State HEAL NY grant, the VNS of New York is developing a portal for physicians to access health information of VNS patients with a common data presentation. The goal is to improve communication between home care and physicians to reduce re-hospitalizations, complications, and duplication of tests. Portal information will go directly into the physician's EHR as the VNS of New York medical record. At the time of the visit, the VNS of New York was piloting the web portal with seven regional physician practices that all use GE Centricity/Logician EHR (Level 2/3).

The VNS of New York also is participating in a pilot project with Weil Cornell Medical School to develop an electronic CMS 485 (e-485) form, which is the plan of care for home care services. Although the actual use of the e-485 form is no longer required by CMS, CMS does require that the HHA collect and document all of the information found on the form, so many HHAs continue to use the form out of convenience. The project expectation is that using the form will improve communication between the referring hospital, the VNS, and patients' primary care physicians; patient care; and reimbursement processes (Level 3). The hospital physician would begin the process of writing electronic orders on the e-485 at the time of hospital discharge. The outpatient physician would then be asked to sign the original e-485 and any subsequent additions electronically. The original and subsequent e-485 are transmitted to the VNS. This software comes with a timer that can count the number of minutes the start of care clinician spent on home health plan of care oversight to facilitate documentation for billing. Pilot testing conducted in four physician practices has revealed that use of the e-485 led to enhanced data completion. For example, the physical function section went from 28% complete to 94% complete and the mental status section went from 6% complete to 100% complete.

Utah -- In Utah, the NHs and HHAs visited corresponded with outpatient physicians via phone and fax (Level 1). There is no electronic transfer of information with unaffiliated physicians.

3. Medication Ordering/Electronic Prescribing

There is an expanding evidence base that documents serious medication quality and safety problems are occurring during care transfers (Coleman & Berenson, 2004; Forster, Murff, Peterson, Gandhi, & Bates, 2003; Moore, McGinn, & Halm, 2007). Older persons who receive care across multiple settings often are prescribed medications from different physicians who may or may not have knowledge of the complete medication list. The Joint Commission and the Institute for Health Care Improvement have recognized the scope of this problem and have provided national leadership to providers to support their efforts in counteracting medication problems through reconciliation at each point of transfer.17 Just as the systematic ordering, tracking, reconciling, and administration of medication are crucial to ensuring that quality and safety, so is the exchange of this information across providers and across settings. Thus, the four site visits explicitly addressed HIE with respect to medications and is shown in Table 6.

TABLE 6: HIE Capabilities by Level Regarding Medication Ordering/E-prescribing
  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 HIE 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 requirements1 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
Medication Ordering/ E-prescribing2 Indiana
Maryland
New York
Utah
  1. E.g., OASIS and MDS reporting to CMS.
  2. Range of electronic functioning observed site visits noted here.

Observations on medication ordering and/or electronic prescribing, particularly at the NHs and HHAs visited, indicate that with few exceptions, care settings are at Level 1 or 2. In general, NHs worked primarily with their own LTC pharmacy. Physicians did not send electronic medication orders but rather faxed medications orders to the NH. Staff at these NHs then faxed the order to the LTC pharmacy and manually entered the order into their EHR (if they had an EHR). For those NHs with a more robust EHR (e.g., Erickson Retirement Communities in Maryland), the re-entry of medication information into an e-MAR application was possible.

With respect to home health care patients, physicians prescribed medications directly to the patient who was responsible to have them filled. HHAs do not have an equivalent electronic MAR, but rather are accountable for documenting what the patient reports she/he is taking. This reconciliation in the home is done at the start of care, usually by a start of care nurse or therapist. Of the HHAs visited, most reconciled this medication list on paper and kept it in a paper chart. The list also may have been entered into the EHR either at the point of care (e.g., the VNS of New York has laptops that clinicians use in the home and collect/enter health data during the home visit) or at the end of the day by either the clinician who collected the information or by a clerk at the agency.

Other observations obtained during the site visit related to e-prescribing and medication ordering are discussed by state below, including sites' future plans. (Note, as future plans have not yet been implemented, they are not reflected as an electronic capability in Table 6.)

Indiana -- The site visitors were informed by the host site (IHIE) that the state was close to finalizing a statewide mandate for e-prescribing, but at the time of the visits, this was not required and not widely used. John Pipas, the CEO of the VNS of Central Indiana (HHA), confirmed that the VNS's communication with pharmacies was by fax but that this would change once mandated statewide e prescribing was initiated (date to be determined). In a follow-up communication in July 2007 with Michael Weiner, MD (host at the University of Indiana/Regenstrief), Dr. Weiner mentioned that Wishard Health Services (the hospital visited as part of the Indiana site visit) did move to uniform e-prescribing in early 2007 even though the state has not yet mandated it.

Brookview (NH) uses a single pharmacy that is part of a national chain, Pharmerica. All communications with this pharmacy are via fax.

Maryland -- Erickson Retirement Communities uses Omnicare/Neighborhood Pharmacy (which has a branch located on its campus). Approximately 80% of independent residents and close to 100% of residents receiving PAC and LTC use this pharmacy. All data from Omnicare are sent to Erickson via fax or phone and are manually re-entered into either CareMEDX for Renaissance Gardens (the NH/SNF) or home health patients, or GE Centricity (for the on-campus outpatient clinic). Erickson is developing a pilot e-prescribing program between the physicians who treat residents of the RG facility and Omnicare/Neighborhood Pharmacy, but at the time of the site visit, this pilot study had not been launched.

New York -- The hospital and NHs visited all have a single in-house pharmacy that is used.

Utah -- The skilled NHs visited in Utah also use fax and phone to communicate with their single unaffiliated pharmacy (Level 1).

4. Laboratory/Radiology Ordering and Results

HIE on behalf of patients receiving PAC/LTC services who also require radiology or clinical laboratory services generally were observed to be manual (Level 1), see Table 7. As above, innovative or future plans are highlighted in the discussion below.

TABLE 7: HIE Capabilities by Level Regarding Laboratory/Radiology Orders and Results
  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 HIE 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 requirements1 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
Lab/Radiology Ordering and Reporting2 Indiana
Maryland
New York
Utah
  1. E.g., OASIS and MDS reporting to CMS.
  2. Range of electronic functioning observed site visits noted here.

Indiana -- The Docs4Docs portal, as previously described has the capacity for participating physicians and hospitals to electronically access laboratory results. It is limited, however, because patients seen at local area PAC or LTC settings that have laboratory or radiology orders/results will not be included. Furthermore, the IHIE's future plans include having laboratory and ambulatory imaging sites included in the network.

Brookview (NH) contracts with a single laboratory and all laboratory orders and results are provided via fax and are filed in a paper record. These results also are entered into their EHR, VistaKeane.

Maryland -- Erickson uses Quest Laboratories and Mobile X Radiology. Data from these two providers are sent to Erickson via fax or phone and in most cases, laboratory and radiology data are manually re-entered into either CareMEDX for Renaissance Gardens (the NH/SNF) or home health patients, or GE Centricity (for the on-campus outpatient clinic) (Level 2). Quest Laboratories are used by the outpatient clinic, home care, SNF and the LTC facility (referred to as the Residents Gardens or RG). As noted earlier in this report, Erickson is developing a pilot e-prescribing program between the physicians who treat residents of the RG facility and Omnicare/Neighborhood Pharmacy.

New York -- Montefiore Medical Center (hospital) has a single clinical laboratory. The JHHA (SNF/NH) and the MHHA also use the hospital's laboratory. JHHA staff have read-only access to laboratory results and must maintain paper copies of the Montefiore laboratory results as part of the JHHA record systems. All MHHA laboratory results go to the Montefiore Medical Center's clinical laboratory. One result of this centralization is that ordering staff physicians or their agents (e.g., physician assistant or nurse practitioner) have electronic access to results in a timely manner if they initiate that access by querying the EHR for the results. In other words, they are not sent a reminder that results are available, but nonetheless, they have access to the results.

Schervier (New York NH) uses a single laboratory, Lawrence Laboratory. Clinicians (e.g., therapists, nurses, social workers) at the Schervier NH may initiate view-only computer access to the laboratory results from Lawrence Laboratory. They are then printed out and stored in the paper record at Schervier.

Utah -- All sites visited in Utah are at Level 1 or 2; that is, all laboratory and radiology information exchange among the sites visited is by phone, fax, or paper accompanying the patient.

LDS Hospital has a robust EHR that has the capability to electronically share information, but when asked why this was not done with any local NHs or HHAs, informants remarked that their information technology department was faced with more pressing priorities that needed their attention.

Interestingly, although St. Joseph's Villa (Utah NH) uses IHC's laboratory, the IHC laboratory sends laboratory results via fax or phone (in the case of urgent results). Nursing staff at St. Joseph's Villa then send results to the attending physician via the physician's hand-held Blackberry®, and a paper copy of results are maintained as part of the patient record.

Hillside Rehabilitation Center, another NH in Utah, uses Schrieber Laboratory. Physician orders for and results from laboratory services are faxed (urgent results are phoned); and do not populate the EHR (BlueStep). However, Hillside has made a financial investment in a single pharmacy and can electronically send (order) medication information that auto-populates the pharmacist's queue.

CNS, an HHA in Utah, uses multiple laboratories with the specific selection largely governed by insurance or geography. Physician orders for laboratory and radiology services are not received electronically by CNS. These results are sent via fax, with critical values conveyed via phone. CNS maintains paper copies of laboratory and radiology orders and results and also manually enters orders and results into their EHR. The other HHA visited in Utah, CareSource, communicated only with outside parties (e.g., laboratories, pharmacies, physicians, hospitals) via fax or phone.

View full report

Preview
Download

"HIEcase.pdf" (pdf, 1.68Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEcase-A.pdf" (pdf, 236.81Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEcase-B.pdf" (pdf, 115.31Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEcase-C.pdf" (pdf, 169.18Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEcase-D.pdf" (pdf, 134.56Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEcase-E.pdf" (pdf, 150.97Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®