This study developed a framework to describe key care coordination constructs and functions, and selected HIE activities. Two frameworks were used and adapted to describe and characterize HIE models, interventions, and activities, as well as facilitators and barriers. These frameworks were used to guide and structure the literature review, environmental scan, site visits, and the resulting study findings. One framework was largely based on the HIT organizational framework developed by Westat researchers27 that identifies five major, interrelated facets (aspect of a particular feature, similar to a dimension) that provide a structure to organize and capture information on the implementation and use of HIT such as HIE. The framework in Rippen et al. (2013) was supplemented with the framework used by AHRQ for care coordination functions or mechanisms as discussed earlier8 (e.g., support care transitions and care planning), and was used to help characterize the care coordination processes and purpose of information exchange (e.g., to reduce rehospitalizations, coordinate post-discharge support services, improve medication safety). This study framework also uses the concept of care coordination constructs (coordinate between and across teams, providers, and family and caregivers).9 The care coordination functions and constructs were modified for this study to capture and characterize how HIE supports care transitions and shared care for persons receiving LTPAC care services.
The care coordination functions/mechanisms used for this study are: (1) to support care transitions or hand-offs (e.g., medication reconciliation, referrals); (2) to support shared care (e.g., assessment, monitor, develop POC); and (3) to support other functions such as public health reporting, quality reporting, and legibility determination. The care integration mechanisms used to describe HIE for this study are: (1) across members of the care team within affiliated organization; (2) between staff in an organization and other non-affiliated care providers including community services; and (3) between staff in an organization and patient/family members. Table 2-1 presents these care coordination constructs and functions, and examples of key HIE activities.
TABLE 2-1. Care Coordination Constructs and Functions Based on Study Framework, With Selected Examples Describing HIE
|Care Coordination Constructs -- HIE Across/Between|
|Across members of the care team within affiliated organization||Between staff in an organization and other non-affiliated care providers including community services||Between staff in an organization and patient/family members|
|Care Coordination Functions Supported by HIE:|
|Support Transitions in Care|
|Referral/Assessment||Preadmission assessment process: gathers information to evaluate the patient for appropriateness of admission and to obtain clinical, demographic and financial information for communication with care team|
|Transfer/Discharge||LTPAC/LTSS to Acute Care|
|SNF charge nurse sends admission/discharge/ transfer (ADT) form via secure e-mail to hospital ED intake manager|
|Acute Care to LTPAC/LTSS|
|Hospital case manager notifies affiliated primary care physician via e-referral software of patient transfer to LTPAC/LTSS||Hospital sends home health nurse wound care notes, ostomy notes, social worker notes, physical therapy (PT), occupational therapy (OT), via e-referral software used by both settings. This information is automatically integrated into the HHA EHR, and populates some fields, including demographics. Notes have to be printed and scanned into HER.
LTPAC/LTSS (e.g., skilled nursing) intake manager queries and access HIE virtual data repository of hospital data prior to admission
|LTPAC/LTSS to Subsequent Placement|
|Followup Post Transfer/Discharge||Hospital case manager follows up by secure e-mail with affiliated primary care physician to ensure patient has scheduled followup appointment||Patient/family/ caregiver portal access to HIE data in virtual data repository|
|Support Shared Care|
|Assess Needs and Goals||Aging Services receives information about patient living alone at home from hospital case manager in electronic formats, fax, and hard-copy|
|Create and Maintain Plan of Care||HHA receives notification of patient admission to hospital from HIE, initiate services planning for return to home|
|Monitor, Followup, and Respond to Change||Primary care physician receives notification of patient admission to hospital from HIE, monitors and plans for discharge|
|Support Other Administrative Functions|
|Quality and Public Health Reporting||LTPAC provider sends e-mail via Direct to local public health agency of reportable infectious disease|
|Payment authorization and eligibility determination||LTPAC providers submit required documentation for Medicaid authorization via HIE to state Medicaid agency|
HIE approaches, interventions, and tools can be implemented through many processes and mechanisms, which are related to and vary with respect to the other facets including the participants, organizations, setting, technology, and contextual factors. Five facets based on the HIT framework were used to describe and characterize the HIE interventions and frame the study findings:
HIE Technology captures elements relevant to HIT applications that enable electronic HIE. Key information captured includes the technology functionality, purpose of design, performance, and how technology facilitates the exchange of information.
HIE Data captures the characteristics of the data being exchanged.c
HIE Use and Workflow characterizes the use and users of the electronic or HIT-enabled HIE information, within and across exchange partners. For this study, this facet was expanded to also include manual, non-electronic, traditional means of exchanging information. It focuses on the workflow involved in exchanging information, the workflow insertion points for the HIE, and who has access to the information within and across the organization.
HIE Environment addresses the environmental and contextual factors including the settings exchanging information, their affiliations, and facilitators and barriers such as organizational support for care coordination, resources, and local factors.
HIE Outcomes describes outcomes from HIE to support care coordination, including care coordination measures, health care utilization such as hospitalizations, and patient safety and care quality measures such as medication-related errors, and adverse events.
These facets were originally conceptualized to characterize and understand HIT implementations, but, with the exception of the technology facet, for purposes of this study were applied to all forms of HIE, electronic and other forms. Appendix B provides the HIT frameworks, care coordination constructs and the HIT facets, with examples that are relevant to LTPAC/LTSS.
8. McDonald K, Schultz E, Albin L, et al. Care coordination measures atlas version 3. Rockville, MD: Prepared by Stanford University under Subcontract to Battelle on Contract No. 290-04-0020 for the AHRQ; 2010. AHRQ Publication No. 11-0023-EF.
9. Singer SJ, Burgers J, Friedberg M, et al. Defining and measuring integrated patient care: Promoting the next frontier in health care delivery. Medical Care Research and Review; 2011; 68(1):112-127.
27. Rippen HE, Pan EC, Russell C, et al. Organizational framework for health information technology. Int J Med Inf; 2013; 82(4): e1-e13.
c. According to the Rippen framework, data and interoperability are a sub-category under the Technology facet. For purposes of this study the data sub-category was treated as another facet and describes the characteristics of all data exchanged, electronic and other forms.
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
"HIEengageB.pdf" (pdf, 132.47Kb)
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