Health Information Exchange in Post-Acute and Long-Term Care Case Study Findings: Final Report. E. What Are the Facilitators and Barriers to Health Information Exchange?

09/18/2007

1. Facilitators

a. Timely Communication. Timely information transfer can financially benefit both the hospital and the PAC/LTC provider. For all Medicare-certified SNFs, the reimbursement for Part A Medicare patients (i.e., the daily payment rate) is based, in part, on the patient's medical problems and co-morbid conditions. To determine whether a facility can meet a patient's care needs under the prevailing rate, timely communication of a patient's PAC needs from the hospital can facilitate a more efficient and clinically appropriate transfer. Ensuring that the receiving provider has comprehensive information on a patient's current needs and plan of care can facilitate appropriate classification under the Medicare payment system. Under the diagnosis-related group payment mechanism, hospitals have an incentive to discharge patients as quickly as possible. To the extent that timely communication translates into a reduced LOS, hospitals stand to benefit financially.

It is worth noting that the four site visits were conducted in geographic regions that have a relatively small penetration of Medicare Advantage (managed Medicare) providers. Thus, the site visit team did not have the opportunity to explore the influence of a health plan on HIE. In other regions of the country, a health plan can require that contracted NHs and HHAs contribute to or update the patient's problem list, allergies, medications, advance directives, and recent diagnostic tests while patients are under their care (Coleman, 2002; Coleman, 2003; HMO Workgroup on Care Management, 2004).

b. Interpersonal Relationships as a Facilitator to HIE. As previously mentioned, good, cross-organization interpersonal relationships are important to ensuring that health information is exchanged and the value of interpersonal relationships in facilitating HIE persists even when HIT solutions are being implemented by the health care providers involved in the information exchange. Clinicians who practice in multiple settings can facilitate timely and accurate HIE across care settings. For example, at Erickson Retirement Communities (Maryland), the primary care physicians follow their patients when they are hospitalized at St. Agnes hospital. This creates opportunities for the physicians to gather more complete information while managing the patient across either care setting. The physicians are responsible for medication reconciliation across sites of care. In addition, Erickson employs a care coordinator who also follows Erickson patients while being treated in St. Agnes hospital, arranges their discharge back to Erickson, and where appropriate, initiates services such as Part A Medicare skilled nursing care. The coordinator collects pertinent information prior to hospital discharge, including the treatment course and discharge information, and faxes it/hand-delivers it to the appropriate clinician at Erickson. Evidence of the importance of this coordinator was a response to many site team questions regarding information exchange--"Our coordinator handles that."

Similarly, a physician practice employed by Montefiore Medical Center (New York hospital) continues to follow discharged patients who require skilled care in selected NHs. Having physician groups employed by the provider creates the opportunity to develop more standardized protocols to patient care, including clinical pathways and expectations for information exchange. MHHA has staff liaisons in Montefiore Medical Center who facilitate home health care referrals. Along with the VNS of New York, MHHA has coordinators who visit two or three of the larger NHs to attend weekly patient reviews and help facilitate referrals from Part A skilled nursing to home care. At Wishard Hospital (Indiana), the VNS of Central Indiana has a staff liaison who is granted limited access to the hospital EHR. The liaison begins the process of entering hospital data into a laptop that provides access to the home health EHR (Misys), and then this information is shared electronically with the home health nurse assigned to the case.

c. Patient Identifiers. Use of HIT to appropriately exchange accurate patient information is facilitated by the ability to identify the patient who is the subject of the exchange, sources of needed information, and the providers and other persons who are the intended recipients of the information. Montefiore Medical Center (New York hospital) recently mandated the use of a single patient identifier to track patients in their electronic health information system. An important advantage of this approach, particularly in an area such as the Bronx that tends to serve the patient from cradle to grave, is that historical data stored in the Montefiore system are more easily accessible. A single patient identifier also helps ensure that the care team is treating the correct patient, particularly when the patients' first and last names are the same or similar. Prior to the single patient identifier, Montefiore used algorithms to develop possible matches, requiring more time for the clinician to verify they were reviewing the chart of the patient currently being treated. The ability to require the use of a single patient identifier and have all participants agree to this is another example of how the establishment and nurturing of interpersonal relationships has helped establish trust and a willingness to be a part of a HIEN.

2. Barriers

a. Lack of interoperability. Once health care partners agree upon the need to exchange information, perhaps the greatest barrier to e-HIE witnessed during the site visits was a lack of interoperability between EHRs and other health information systems. The lack of interoperable health information systems was a leading contributor to the inefficient practice of manually re-entering data, which was observed at all sites. This was observed whether the two EHR systems were owned by the same institution or owned by separate institutions. For example, Erickson (Maryland CCRC) has invested in two EHR systems, GE Centricity and CareMEDX. GE Centricity functions as the primary record for residents in independent living who see physicians in the on-campus clinic, while CareMEDX functions as the primary record for patients in home health care, Part A SNF, and LTC. Erickson staff manually transfer information between its two electronic systems (as well as between paper and electronic systems). At the time of EHR selection, Erickson was not able to identify a single EHR solution that could address the care needs of the various types of patients treated throughout the campus. Erickson staff noted that because of this, they were forced to purchase two separate systems and plan to pay additional costs to build interfaces to allow the two systems to be interoperable (i.e., allow for electronic exchange and re-use of content). If a viable HIT product that met their needs had been available, they would have readily opted for a single EHR solution.

Similarly, despite common ownership, Montefiore Medical Center's EHR (CIS) and MHHA's EHR (Misys) do not interoperate (i.e., do not: (i) electronically exchange or (ii) re-use content). When a laboratory result appears in CIS, the result has to be manually entered into Misys. Medications also are copied-and-pasted from one screen in CIS to another in Misys. When a home health care patient is admitted to the hospital, there are no fields in CIS that can identify that this patient is actively receiving home health care services. MHHA staff commented that having this information in the ED might influence the decision as to whether the patient should be admitted or could be managed in the home with the HHA's support. Still, in general, providers were pleased that current, reliable information was available electronically "somewhere," even if it required them to copy and paste it into their EHR or local system--an observation that proved common during the site visits.

b. Lack of access to existing systems. A related barrier to HIE identified during all four of the site visits concerned a lack of access to existing EHR systems. In general, the sending institution did not extend user privileges to clinicians in the receiving institution to view, much less edit or add content to their EHR system. In rare instances, physicians, nurse practitioners, and physician assistants practicing in the NH are given privileges to remotely access clinical information in EHRs in either the hospital or ambulatory settings. Under these circumstances, clinicians can care for patients in NHs or in patients' homes with the benefit of the information available from these sources. However, it should be noted that other PAC and LTC health professionals (e.g., nurses, CNAs, physical and occupational therapists) are not usually granted this same access. For example, in Utah, staff in two NHs (St. Joseph's Villa and Hillside Rehabilitation) do not have access to the LDS Hospital HELP2 EHR.

c. Health Insurance Portability and Accountability Act (HIPAA). The site visits confirmed that whether real or perceived, the implementation of HIPAA poses a barrier to information sharing across care settings in general or granting access to information contained in EHRs in particular. HIPAA allows the exchange of patients' health information for purposes of treatment, payment, and health care operations without patient authorization. However, misinterpretations of these HIPAA regulations were common. Clinicians were reluctant to share information or grant access to EHRs for fear of violating HIPAA laws and facing accompanying penalties. The site visitors were unable to determine the degree to which HIPAA concerns masked deeper concerns about competitiveness and liability that information sharing might elicit.

d. The referral process. Finally, the site visits highlighted the fact that in general, NHs and HHAs are dependent upon hospital for referrals. Within this context, NHs/HHAs expressed a reluctance to confront the hospital when the hospital did not supply necessary information at the time of transfer for fear that the hospital would choose to refer patients elsewhere. These providers acknowledged that a more objective third party might be needed to afford oversight of the referral process to ensure that NH referrals are not at risk should they speak up as to what they need from the discharging acute care hospital.

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