Health Information Exchange in Post-Acute and Long-Term Care Case Study Findings: Final Report. D. Selected Sites

09/18/2007

Preliminary information was gathered by the research team through web searches and interviews with informants at each site. The expectation was that the team would gather enough information to determine if each site met the majority of the selection criteria and if they would be amenable to a site visit. This information was then shared with the ASPE Project Officer and together the project team and the ASPE Project Officer prioritized the list of candidates. The final list of sites was selected in January 2006. The approach was to first select the host site, and then determine if the main referral recipients from this site included three or more (affiliated or unaffiliated) PAC or LTC settings. The exception to this approach was Erickson Retirement Communities. Erickson is a CCRC and provides the spectrum of health care to the elderly, with the exception of hospital and hospice care. Therefore, for this site visit, we asked Erickson to provide us with names of hospitals and any community PAC or LTC settings that may serve Erickson residents.

The following four host sites were selected for site visits based on the preliminary background information obtained. More in-depth information was obtained later in the project as the site visit details were confirmed, as well as during the site visit. Specifics can be found for each site visit in Appendices B through E, and are in the order in which the site visits were conducted.

Erickson Retirement Communities
(Site Visit Dates: July 12-14, 2006)

Erickson Retirement Communities, Catonsville, Maryland, owns and operates 13 CCRCs in the United States. Four of their communities are considered "mature campuses" aimed at providing "total care" for retired individuals. One of the mature sites, the Catonsville campus includes a medical center that acts much like a physician's office for Erickson residents, a Medicare-certified HHA, inpatient and outpatient rehabilitation services, a SNF, and an ALF (personal communication with Daniel Wilt, Vice President Information Technology, March 23, 2006). Erickson employs certain medical specialists (e.g., podiatry, dentistry) and allows other independent clinicians to treat patients on campus. However, it does not own or operate most specialty clinics and does not own or operate any acute care centers. Three additional CCRCs are under construction and Erickson plans to establish additional communities throughout the country. Because Erickson's information technology approach is highly centralized--all campuses' EHRs are run out of the central office in Maryland and accessed using high speed network connections--they believe that their per site information technology costs will be reduced as they implement EHRs in new locations.

Erickson uses one EHR (GE Centricity) at the medical center on campus, and another (HealthMEDX) for the SNF (Renaissance Gardens) and the HHA. One forward-thinking, patient-centric advancement made by the information technology team at Erickson is the development of an electronic chart summary, which is generated from their EMR and can be accessed via the web or at any of their facilities' workstations. The chart summary includes, but is not limited to, relevant current and historical clinical information such as advanced directives, medication lists, laboratory results, problem lists, and contact information for patients and caregivers. Care coordination is facilitated as physicians electronically access this information on or off campus and communicate pertinent data in a timely manner to the ED physician when a patient requires acute care. In November 2005, Erickson launched a website6 providing residents access to their medial records for no additional cost. This and other online health information services are discussed in greater detail in Section III.G below.

At the time of the site visit, Erickson was not involved in a HIE organization in their area/region, although it is their desire to do so. They have initiated preliminary discussions with providers in their region on this topic.

Unaffiliated HDSs and PAC/LTC sites: St. Agnes Hospital and Hospice, Johns Hopkins Home Health Agency.

Erickson PAC/LTC sites: Renaissance Gardens (SNF and LTC NH), Erickson's on-campus HHA.

Montefiore Medical Center
(Site Visit Dates: August 2-4, 2006)

Montefiore Medical Center (Montefiore) is an integrated HDS in Bronx, New York, providing a full range of services, including specialty care to Bronx residents as well as patients outside of this borough. Montefiore serves a medically underserved population, a large number of whom are young, minority, and poor (Greg Burke, Vice President of Planning, Montefiore Medical Center, presentation slides from November 2004). The Montefiore HDS includes an acute care hospital (Montefiore Medical Center), a large HHA, and contracts with a number of SNFs in the area. Montefiore uses IDX's LastWord in both the inpatient setting as well as for ambulatory care at 28 sites. LastWord contains data from every Montefiore encounter for 1.8 million patients; currently this includes laboratory test results, medications, and images, but does not include notes and consults. Some scanned information also is represented. E-prescribing has been in place for close to a year. Montefiore also is one of several acute care hospitals involved in the creation of the non-profit entity called the Bronx Regional Health Information Organization (BxRHIO). At the time of this report, the other collaborators in the BxRHIO include several hospitals, over 40 community-based primary care centers, one NH, two HHAs, payors, physician offices, and laboratories. A month prior to our August 2006 site visit, Montefiore was awarded $4.1 million from the New York Department of Health for seed money (called HEAL-NY) to commence a data exchange RHIO in the Bronx. The focus of the Bronx RHIO is to facilitate sharing of clinical data among providers with disparate systems and levels of sophistication in using EHR systems (personal communication with Greg Burke, Vice President of Planning, Montefiore Medical Center).

Unaffiliated PAC/LTC sites: Schervier Nursing Care Center (SNF), the VNS of New York (HHA), the Jewish Home and Hospital (SNF).

Affiliated PAC/LTC site: Montefiore Home Health Agency.

Intermountain Health Care
(Site Visit Dates: August 9-11, 2006)

IHC is a non-profit health care system that provides care to residents of Utah and Idaho. This institution is one of the pioneers in HIT, with a long history of excellence in the area of quality improvement. Homer Warner, MD; Stanley Huff, MD; and others at IHC were among the first users and developers of EHR systems. LDS Hospital, one of IHC's hospitals in Salt Lake City was visited. Intermountain provides over 60% of the acute care market in Salt Lake City and has more than 27,000 employees enterprise-wide. LDS Hospital alone has 4,700 employees. Intermountain employs 550 physicians and has another 3,000 affiliated physicians with limited (read-only) access privileges to the electronic health information system (HELP system). Intermountain also has 92 clinics. According to one source, 17,000 people can access (with varying levels of permission) the Clinical Data Repository that is part of the HELP2 system.7 LDS Hospital is a member of the Utah Health Information Network (UHIN), a community health information network that began in 1993. UHIN is a coalition of health care providers, payors, and state government with, initially, the common goal of reducing costs by standardizing the transmission of administrative data, particularly payment data. The network community sets the data standards, using recognized national standards (e.g., HL7 messaging and NCPDP standards), to which providers and payors voluntarily agree to adhere. The UHIN standards are then incorporated into the Utah state rule regarding payment of health care via the Insurance Commissioners Office (UHIN, 2007).

UHIN operates as a centralized secure network through which the majority of health care administrative transactions pass statewide. Nearly all Utah payers and providers are participating in this project. UHIN developed a tool (UHINT), which they provide free of charge to providers for use in submitting electronic claims. The tool is provided so that even the smallest sized provider can submit claims and electronically receive remittance advices.8 State officials indicate that the exchange of standardized electronic transactions has drastically reduced the amount of paper processing required for payors and has streamlined the payment of claims and remits, which has resulted in providers receiving payment more quickly. Under an Agency for Healthcare Research and Quality (AHRQ) grant, UHIN is pilot testing the electronic exchange of a limited set of administrative and clinical data (medication history, discharge summaries, history and physicals, and laboratory results with a small number of providers). This pilot involves the exchange of information form payer to hospital only, no PAC or LTC providers are in the pilot. The results of this pilot study are not yet available, but the UHIN developers note informally that health care providers involved in the UHIN are beginning to request and require these clinical and administrative data. For example, UHIN developers are noticing an increase in feature requests from users (e.g., setting a statewide standard for credentialing physicians, account reconciliation). Because of the adoption of emerging technologies such as messaging and web-based connectivity (in place of earlier less nimble, less scalable, and more expensive technologies), UHIN's ability to fulfill those requests is keeping pace (personal conversation with Jan Root, Standards Manager, UHIN.

Unaffiliated PAC/LTC sites: Christus St. Joseph Villa (SNF), Community Nursing Service (CNS) (HHA), Hillside Rehabilitation (SNF), and CareSource (HHA and Hospice).

Affiliated PAC/LTC sites: IHC does not own any PAC or LTC facilities.

Indiana Health Information Exchange
(Site Visit Dates: September 13-15, 2006)

The IHIE is a non-profit venture connecting a number of HDSs in Indiana. The IHIE, led by Dr. J. Marc Overhage, comprises over 48 hospitals and has approximately 3,000 physicians who access the network. With AHRQ funding and a variety of other sponsors including BioCrossroads,9 regional and local hospitals, and the Regenstrief Institute, the IHIE recently implemented a community-wide clinical messaging project to support e-HIE between physicians and hospitals. Each participating partner has access to a limited amount of patients' clinical results using a single IHIE-controlled electronic mailbox called Docs4Docs (discussed in detail in Section III.G.6 of this report).

The IHIE was a health care market member in one of the four consortia10 awarded a HHS contract in 2006 requiring the development of four prototypes for a NHIN architecture. All three health care market members within the Computer Science Corporation (CSC) consortia (IHIE, MA-SHARE [Massachusetts], and Mendocino HRE [California]) helped to develop, test, and demonstrate a prototype, based on common, open standards. Of particular interest for this project, required components for all four prototypes: (1) were designed to facilitate HIE using the Internet, not creating a new network; (2) allowed for communication to occur between many different types of EHR systems; and (3) allowed for different types of software and hardware that could be included in the system. As stipulated by HHS, the prototype architectures were submitted to HHS in January 2007 and on February 14, 2007, CSC announced their success with exchanging health information through their NHIN prototype. Health data were securely transferred between MA-SHARE, the IHIE, and the Mendocino Health Records Exchange, as well as local public health departments within those regions (CSC, 2007).

Unaffiliated PAC/LTC sites: Beverly Enterprises at Brookview (HHA), VNS of Central Indiana, Briarwood Rehabilitation, Kindred Long-Term Acute Care Hospital.

Affiliated sites: Lockefield Village Rehabilitation and Healthcare Center (SNF), Wishard Health Services (Hospital).

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