Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 3.3. Initiatives to Support Adoption of Health Information Technology and Electronic Health Information Exchange

10/29/2013

Health Information Technology for Economic and Clinical Health (HITECH) Act

There are other facilitators for LTPAC/LTSS providers to engage in HIE, some of which are a result of program initiatives targeting other health care providers that are involved in care coordination for the LTPAC population, such as hospitals and physicians. The HITECH Act,e enacted as part of the American Recovery and Reinvestment Act of 2009, promotes the adoption and meaningful use (MU) of certified EHRs. This legislation was the foundation of the EHR Incentive Programs for eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs); the development of criteria for what constitutes MU of EHRs; and the EHR certification criteria and standards that must be integrated into certified EHR technology (CEHRT) used by eligible providers in the EHR Incentive Programs.

The goal of MU is to support the use of certified EHRs to improve health care in the United States.69 The focus of Stage 1 of the EHR Incentive Programs has been on EP, EHs', and CAHs' adoption of certified EHRs, and the MU of data captured by EHRs. The Stage 2 MU requirements, effective fiscal year 2014, add to this foundation and require electronic exchange of health information and will support electronic coordination of care efforts by EPs, EHs and CAHs. Stage 3 MU requirements are expected to include requirements to support the interoperable exchange of additional content at times of transitions and referrals in care.

LTPAC/LTSS providers such as HHAs, inpatient rehabilitation hospitals, long-term acute care hospitals, and SNFs are not eligible for the Medicare and Medicaid EHR Incentive Programs.70 Nonetheless, the ability of LTPAC providers to exchange health information electronically with EPs, EHs, and CAHs could affect the ability of EPs, EHs and CAHs to qualify for incentive payments, and could impact the success of the EHR Incentive Programs to improve care coordination.1 LTPAC/LTSS providers that want to use EHRs and participate in HIE must either pay for the costs of EHRs or find other sources to offset these costs such as the shared savings ACO programs or the State Innovation Model.

Selected MU Stage 2 criteria related to care coordination and HIE include the following:58

  • Care Transitions. When transitioning a patient to another care setting, the EP, EH, or CAH should provide a summary of care record for each transition of care or referral. The Summary of Care Records is to include, if known, a care plan.

  • Patient Visits. Provide a clinical summary for patients for each office visit.

  • Reminders. Use clinically relevant information to identify patients who should receive reminders for preventive and/or followup care with patients on relevant health information.

  • Communication. Use secure electronic messaging to communicate with patients on relevant health information.

  • Data Use. When a patient transitions from one provider to another, medication reconciliation should be performed. The EP, EH or CAH who receives a patient from another setting of care or provider of care, or who believes an encounter is relevant should perform medication reconciliation.71

  • Data Portability. Patients must be able to view and download their own health information and also be able to transmit that information to a third party.

Stage 2 MU measures that will be required in Stage 2 and are particularly relevant to LTPAC are:

  • EPs, EHs, and CAHs requirement to provide a summary of care document for more than 50% of transitions of care and referrals, with 10% sent electronically across vendor and provider boundaries (i.e., between recipients using different EHR technology vendors for transitions of care and referrals).7273

  • Other MU criteria and measures include the capability to generate and transmit permissible prescriptions electronically, submit electronic data to immunization registries or Immunization Information Systems electronic syndromic surveillance data to public health agencies, and identify and report cancer cases to a state cancer registry. For more information see: http://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2.

  • As the Healthcare Information Technology Policy Committee74 continues to consider requirements for Stage 3 MU, there will be a greater focus on transitions/referrals of care.

Federal HIT Principles and Strategies

HHS is committed to realizing a patient-centered, value-driven health care system supported by the secure exchange of information across all providers of care. HIT serves as a foundational building block for achieving better health outcomes at lower costs. HHS recently released its HIE Principles and Strategy report, which notes that a "critical part of enabling the secure flow of information across the system is advancing the adoption of HIT standards through voluntary certification of HIT and HIE products and services."75 As part of this strategy, ONC said in a webinar that it will move forward with determining the potential scope and criteria for a HIT certification program and criteria for providers not eligible for the EHR Incentive Programs, starting with LTPAC (and behavioral health). In addition, CMS is considering ways in which Medicare and Medicaid payment policies can advance interoperable HIE by providers not eligible for the EHR Incentive Programs. Policymakers hope that by specifying EHR certification criteria for products needed by LTPAC providers that adoption of certified technology will increase and support interoperable HIE.7576

LTPAC providers were included in the 2011-2015 federal HIT Strategic Plan released by the ONC in March 2011. The Strategic Plan describes the need to support HIT adoption and information exchange in LTPAC, behavioral health, and emergency care settings and describes why continued investment is needed to fully support HIE.76

ONC Roadmap

ONC has developed a Standards, Interoperability, and Certification Roadmap that recommends establishing LTPAC (and Behavioral Health) HIT certification; and disseminating open source toolkits for Admission/Discharge/Transfer (ADT) alerts.75

3.3.1. Facilitators of HIE -- HIT Standards, Specifications, and Certification

EHR Certification for LTPAC

Some of the EHR technology certification criteria used for the EHR Incentive Programs are applicable to care transitions and coordination in LTPAC settings.70 The ONC Final Rule for Standards, Implementation Specifications, and Certification Criteria for EHR Technology encourages EHR technology developers of products for providers who are not eligible for the EHR Incentive Programs to certify their projects to: (1) transitions of care module and other appropriate modules; and (2) other certification criteria that make it more efficient for EPs, EHs, and CAHs to electronically exchange health information.77 MU Stage 2 transitions of care certification criteria require that EHR technology: (1) receive, display in human readable format, and incorporate transition of care/referral summaries according to specified standards; and (2) create and transmit transition of care/referral summaries according to the standard adopted. At the time of this report, approximately six LTPAC EHR vendors had products certified by ONC Authorized Testing and Certification Bodies.78

In addition, a private sector organization, Certification Commission for Health Information Technology (CCHIT), has also established LTPAC EHR certification criteria. At the time of this report, six LTPAC EHR vendors have CCHIT certified products.79

To date, LTPAC provider use of these certified EHRs is believed to be low. Nonetheless, some LTPAC providers are reportedly using HIT applications that incorporate ONC-adopted standards that support the Patient Summary Record (i.e., Health Level 7 (HL7) Clinical Document Architecture (CDA)/Continuity of Care Document (CCD)/C32 (MU Stage 1 requirement).

E-Prescribing

Persons receiving LTAC services are often prescribed multiple medications. E-prescribing is complicated for a number of reasons. E-prescribing typically involves multiple parties -- both the prescriber and the pharmacy. However, in certain institutional settings such as SNFs, e-prescribing will involve at least three parties -- the prescriber, facility, and pharmacy -- and may include other entities such as payers. The 2014 MU requirements issued by ONC include a standard for e-prescribing that once adopted will support this three-way information exchange. Use of interoperable e-prescribing technology solutions in SNFs will likely require changes in the current prescribing workflow and technical assistance to support implementation of e-prescribing in SNFs.

Standardizing Interoperability Specifications

There are specific workgroups sponsoring work on HIT and HIE standards that support care for persons receiving LTPAC, including these workgroups managed under the S&I Framework and HL7.80 These HIT and HIE standards include the Consolidated Clinical Data Architecture (CCDA) (exchange standard referenced in MU Stage 2), a more robust, implementable standard.f Relevant workgroups include:

  • S&I Longitudinal Coordination of Care (LCC) Workgroup (http://wiki.siframework.org/Longitudinal+Coordination+of+Care).

    • The S&L LCC Workgroup is advancing the electronic exchange of information at times of referrals and transition of care and exchange of care plans. The LCC Workgroup consists of two active sub-workgroups (SWGs): the Longitudinal Care Plan and LTPAC Transitions in Care SWGs. The Longitudinal Care Plan SWG has developed the Use Case for the interoperable exchange of the care plan, and identified the functional requirements to support its exchange. The LTPAC Care Transition SWG is developing a requirements-driven view of data elements required for information exchange based on a set of user stories related to transitions and referrals in care.

    • The S&I LCC Workgroup is working with HL7 to refine the CCDA Implementation Guide (a requirement in MU Stage 2) to support the exchange of more robust documents for transitions and referrals of care, and care plans. The updated CCDA Implementation Guide (being balloting in Fall 2013) includes new and enhanced document templates for the Transfer Summary, Consultation Note, Referral Note, and Care Plan.

    • The S&L LCC Workgroup is also reviewing the Domain Analysis Model developed by the HL7 Patient Care Workgroup (see HL7 below), providing input around care plan exchange (http://wiki.hl7.org/index.php?title=Domain_Analysis_Model).

  • The ONC S&I Electronic Signature for Medical Document Initiative (http://wiki.siframework.org/esMD+Initiative).

    • This CMS initiative will identify a standard for digital signatures for medical documents (such as care plans).

Facilitator -- Other ONC HIT Initiatives

As described below, ONC has directed some resources to engage LTPAC providers in state HIE activities and now has some programs and resources for LTPAC providers.

Challenge Grants

The ONC Challenge Grants are engaging LTPAC providers in HIT, EHR, and HIE activities at the federal, state and regional level to improve transitions of care. Federal Challenge grants to support LTPAC are operating in four states -- Oklahoma, Massachusetts, Colorado, and Maryland.8182

  • Oklahoma's Challenge Grant program is focused on HIE for care transitions, and is based on real-time Activities of Daily Living (ADL) documentation. The HIE partner is SMRTNET -- Secure Medical Records Transfer Network -- a robust HIE network serving Oklahoma's health care systems. SNFs were provided with access to the Internet and computers and then a clinical documentation tool, a "lite" EHR called CareTracker that allows caregivers to record required resident documentation and scans for changes in resident conditions and provide alerts when the conditions change. CareTracker helps to create a Situation, Background, Assessment, and Recommendation (SBAR, see Appendix A for more information), one tools in the INTERACT program, for communication and the Universal Transfer Form (UTF) if the patient is transferred to the ED or hospital. SMRTNET worked with providers to determine what information should be transferred via the UTF. SMRTNET supports an enhanced version of Direct, a low-cost HIE solution. LTPAC providers can query for patient information and securely send information to providers such as hospitals and physicians. Some of the partner sites with EHRs (e.g., hospitals) can click a link that connects directly to a web-based SMRTNET view, and structured data from the LTPAC providers can be imported to populate a patient's chart.

  • Massachusetts' IMPACT project is "meeting LTPAC providers where they are" by providing the Local Adaptor for Network Distribution (LAND) and Surrogate EHR Environment (SEE). LAND allows organizations with fully implemented EHRs capable of generating the newly specified transition of care and care plan data elements to create, transmit, and receive these new document types. SEE, intended for organizations without an EHR and lacking the ability to create these documents, allows providers to view, edit, and send documents to the receiving facility via Direct message transmission from a web browser. The IMPACT project is working to create tools to generate, translate, and view UTFs via the HIE. At the time of this study, there were 11 LTPAC facilities participating in IMPACT, all in Worcester County, Massachusetts, with plans to continue to expand as the state's HIE structure improves.

  • Colorado's HIE and program participant, the Colorado Regional Health Information Organization (CORHIO), is working in four targeted early adopter communities toward integrating HIE to improve care transitions. CORHIO is working with LTPAC organizations, including home health, hospice, SNFs, assisted living, long-term acute care hospitals and residential care facilities for the developmentally disabled to improve care transitions to and from acute care settings through HIE. The goals of the program are to facilitate adoption of HIE by the LTPAC community, develop a community protocol for information sharing across care transitions, and measure the impact of HIE on quality of patient care and rates of hospital readmissions. HHAs receive resources and training as part of their participation in this program.

  • Maryland and its partner, an operational regional HIEO called the Chesapeake Regional Information System for Our Patients (CRISP) are leveraging Maryland's statewide HIE to electronically share critical pieces of clinical information, including information on advance directives, in near real-time as residents of LTPAC facilities transition from one care setting to another. The project seeks to deploy new scalable technology among LTPAC providers and geographically proximate hospitals that will enable the exchange of care transition data. Three LTPAC facilities have been awarded funds for the adoption and use of HIT to support improved transitions of care for their patients as they transition between hospitals and their facility. These LTPAC providers are or will be able to use CRISP's encounter notification service to alert physicians and care coordinators in real-time when one of their patients has an encounter with a Maryland hospital, such as an ADT. These alerts are sent via a direct secure message or HL7 message to an EHR system.

Beacon Communities

ONC provided funding to 17 selected communities that are considered beacons for their communities in the development of secure, private, and accurate systems of EHR adoption and HIE.83 Some of the Beacon Communities included participation with LTPAC providers such as HHAs and SNFs. Beacon Communities in Rhode Island, Western New York, and Bangor, Maine are connecting HIEOs with LTPAC providers. The Rhode Island Beacon Community has targeted up to 84 nursing facilities across the state and engaged them in CurrentCare, a secure electronic network that gives health care providers access to the patient information. The Keystone Beacon Community in Pennsylvania developed an HIE tool that allows SNFs and HHAs to share a patient's information inexpensively and securely, with or without an EHR. The KeyHIE Transform tool is an all-inclusive, web-based service that transforms the electronic nursing home Minimum Data Sets (MDS) and home health Outcome and Information Assessment Set (OASIS) into an HL7 CCD so that SNFs and HHAs can share this information with other care providers (see Appendix A for more information about KeyHIE).

Community of Practice

ONC initiated a new long-term care community of practice (CoP), supported by the state HIE initiative, which provides opportunities to discuss areas of interest, collaborate, and share knowledge, information, experience, and best practices. This CoP is engaging with policymakers and implementers to identify opportunities to expand HIE in LTPAC and prioritize future advancements such as medication management, lab results integration, and advance directives.

Direct Project

The Direct Project (http://directproject.org/)28 was launched by ONC in 2010 "to support the use of standards-based protocols for an easy-to-use, secure, and scalable method of sending encrypted and authenticated health information over the Internet such as clinical summaries, CCDs, and laboratory results, to other providers who also own a DIRECT address."684 The most basic implementation of the Direct Project is secure e-mail via an e-mail client or web portal, which works just like regular e-mail, but with an added level of security required to transport sensitive health information. The Direct Project can serve as a solution for simple, point-to-point HIE around specific use cases. This tool can help LTPAC/LTSS providers to send and receive secure messages and electronic attachments with others in their network quickly, easily, and at a low cost, and facilitates referrals and transitions of care.33 Limitations of Direct include limited or low uptake, in part due to a lack of a provider registry.


  1. Dougherty M, Harvell J. Opportunities for engaging long-term and post-acute care providers in health information exchange activities: Exchanging interoperable patient assessment information. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy; 2011. Available athttp://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm.

  2. Affordable Care Act. National pilot program on payment bundling. Public Law 111-148 and Public Law 111-152. 2010: Section 3023.

  3. Engquist G, Johnson C, Johnson W. Medicaid funded long-term supports and services: Snapshots of innovation. Center for Health Care Strategies, Inc.; 2010.

  4. Woodcock C. Long-term services and supports: Challenges and opportunities for states in difficult budget times. National Governors Association; 2011.

  5. National Alliance for Health Information Technology. Report to the Office of National Coordinator for Health Information Technology on defining key health information technology terms. Washington, DC: U.S. Department of Health and Human Services, Office of the National Coordinator of Health IT; 2008.

  6. eHealth Initiative. 2012 report on health information exchange: Supporting healthcare reform. Washington, DC: eHealth Initiative; 2012.

  7. LTPAC Health IT Collaborative. A roadmap for health IT in long term and post-acute care, 2010-2012. Available athttp://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047579.pdf. Accessed July 25, 2013.

  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.

  10. Office of the National Coordinator for Health Information Technology policy framework RFTOP. Solicitation No 12-233-SOL-00615; 2012.

  11. Informed Medical Decisions Foundation. What is shared decision making? Available at http://informedmedicaldecisions.org/what-is-shared-decision-making/. Accessed January 12, 2013.

  12. Gruneir A, Bronskill S, Bell C, et al. Recent health care transitions and emergency department use by chronic long-term care residents: A population-based cohort study. J Am Med Dir Assoc; 2012; 13(3): 202-206.

  13. Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff; 2010; 29(1): 57-64.

  14. Naylor MD, Kurtzman ET, Pauly MV. Transitions of elders between long-term care and hospitals. Pol. Polit. Nurs. Pract.; 2009; 10(3): 187-194.

  15. Boling  PA. Care transitions and home health care. Clin in Geriatr Med; 2009; 25(1): 135-148. 

  16. Bayley KB, Savitz LA, Rodriguez G, et al. Barriers associated with medication information handoffs. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation. Rockville, MD; 2005.

  17. Chhabra PT, Rattinger GB, Dutcher SK, et al. Medication reconciliation during the transition to and from long-term care settings: A systemic review. Res Soc Admin Pharm; 2012; 8(1): 60.

  18. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med; 2003; 138(3): 161-167.

  19. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med; 2009; 360(14): 1418-1428.

  20. Thorpe KE. The Medicare advantage experience: Lessons for reform to original Medicare. Atlanta, GA: Emory University Rollins School of Public Health; 2012.

  21. Clancy CM. Commentary: Reducing hospital readmissions: Aligning financial and quality incentives. Am J Med Qual; 2012; 27(5): 441-443.

  22. Barnsteiner JH. Medication reconciliation: Transfer of medication information across settings-keeping it free from error. J Infus Nurs; 2005; 28(2 Suppl): 31-36.

  23. Sentinel events statistics for 2011. Jt Comm Perspect; 2012; 32(5): 5.

  24. Office of the National Coordinator for Health Information Technology. Getting to impact: Harnessing health information technology to support improved care coordination. In State HIE Bright Spots Synthesis: Care Coordination Part 1. Washington, DC: ONC; 2012. Available at http://statehieresources.org/wp-content/uploads/2013/01/Bright-Spots-Synthesis_Care-Coordination-Part-1_Final_010913.pdf.

  25. Murray LM, Laditka SB. Care Transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc; 2010; 11(4): 231-238.

  26. LaMantia MA, Scheunemann LP, Viera AJ, et al. Interventions to improve transitional care between nursing homes and hospitals: A systemic review. J Am Geriatr Soc; 2010; 58(4): 777-782.

  27. Rippen HE, Pan EC, Russell C, et al. Organizational framework for health information technology. Int J Med Inf; 2013; 82(4): e1-e13.

  28. Office of the National Coordinator for Health Information Technology. Update on the adoption of health information technology and related efforts to facilitate the electronic use and exchange of health information. Washington, DC: Office of the National Coordinator for Health Information Technology; 2013.

  29. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. Int J for Qual Health Care; 2004; 16(2): 125-132.

  30. Gleason K, Brake H. Medications at transitions and clinical handoffs (MATCH) toolkit for medication reconciliation. Rockville, MD: AHRQ; 2012; 11(12)-0059.

  31. Siefferman JW, Lin E, Fine JS. Patient safety at handoff in rehabilitation medicine. Phys Med Rehabil Clin N Am; 2012; 23(2): 241-257.

  32. Lucian Leape Institute. Order from chaos: Accelerating care integration. Boston, MA; 2012.

  33. Kripalani S. Care transitions. In Perspectives on Safety. AHRQ Web M&M; 2013.

  34. Allen J, Ottmann G, Roberts G. Multi-professional communication for older people in transitional care: A review of the literature. Int J Older People Nur; 2012; 7(4).

  35. Burton R. Improving care transitions. Health Aff and Robert Wood Johnson Foundation; 2012; 10.1377/hpb2012.17.

  36. U.S. Department of Health and Human Services. Roadmap to better care transitions and fewer readmissions. Available at http://www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html#BackgroundonCareTransitions. Accessed August 6, 2012.

  37. Terrell KM, Miller DK. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc; 2006; 7(8): 499-505.

  38. National Transitions of Care Coalition. Improving transitions of care: The vision of the national transitions of care coalition. Washington, DC; 2008.

  39. Brown RS, Peikes D, Peterson G, et al. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff; 2012; 31(6): 1156-1166.

  40. Bez A. Preventing unnecessary hospitalizations for nursing home residents. Podcast on Internet; 2012.

  41. Metzger J. Preventing hospital readmissions: The first test case for continuity of care. Falls Church, VA: Computer Sciences Solutions Global Institute for Emerging Healthcare Practices; 2012; WA12_0155 HCG.

  42. Rutherford P. Reducing readmissions -- First, for the patient. Cambridge, MA: Institute for Healthcare Improvement; 2012.

  43. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med; 2013; 368(13): 1175-1177.

  44. Agency for Healthcare Research and Quality. Medication Reconciliation. Available at http://www.psnet.ahrq.gov/primer.aspx?primerID=1. Accessed January 27, 2012.

  45. Centers for Medicare and Medicaid Services. Eligible professional meaningful use menu set measures, measure 7 of 10: Medication reconciliation. Available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/7_Medication_Reconciliation.pdf. Accessed August 28, 2013.

  46. Frisse ME, Johnson KB, Nian H, et al. The financial impact of health information exchange on emergency department care. J Am Med Inform Assoc; 2012; 19(3): 328-333.

  47. Kind A, Jensen L, Barczi S, et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff; 2012; 21(12): 2659-2668.

  48. Health Information Exchange Roadmap: The landscape and a path forward. ONC Grant #7U24AE000006-02. Washington, DC: National eHealth Collaborative; 2012.

  49. Hansen LO, Young RS, Hinami K, et al. Interventions to reduce 30-day rehospitalization: A systematic review. Ann Intern Med; 2011; 155(8): 520-528.

  50. Phillips CO, Wright SM, Kern DE, et al. Comprehensive discharge planning with post-discharge support for older patients with congestive heart failure. J Am Med Assoc; 2004; 291(11): 1358-1367.

  51. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc; 2011; 59(4): 745-753.

  52. Coleman EA. The care transitions program. Available at http://www.caretransitions.org/. Accessed August 6, 2012.

  53. Boston University. Project RED. Available at http://www.bu.edu/fammed/projectred/presentations.html. Accessed August 6, 2012.

  54. Institute for Clinical Systems Improvement, Minnesota Hospital Association and Stratis Health. Reducing avoidable readmissions effectively (RARE). Available at http://www.rarereadmissions.org/resources/collaboratives.html. Accessed November 19, 2012.

  55. Boult C, Green AF, Boult LB, et al. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's "retooling for an aging America" report. J Am Geriatr Soc; 2009; 57(12): 2328-2337.

  56. Healthcentric Advisors. Safe Transitions Project. Available at http://www.healthcentricadvisors.org/safe-transitions-cp.html. Accessed August 6, 2012.

  57. Society of Hospital Medicine. Project BOOST: Better outcomes for older adults through safe transitions. Available athttp://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&CONTENTID=27659&TEMPLATE=/CM/HTMLDisplay.cfm. Accessed August 6, 2012.

  58. Centers for Medicare and Medicaid Services. EHR Incentive Programs: Stage 2. Available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html. Accessed June 14, 2013.

  59. Metzger J. Preparing for accountable care: Coordinated care. Falls Church, VA: Computer Sciences Solutions Global Institute for Emerging Healthcare Practices; 2012; WA12_0280 HCG.

  60. eCaring LLC. Preventable readmissions: A prime target for healthcare innovation. Available at http://blog.ecaring.com/preventable-readmissions-a-prime-target-for-healthcare-innovation/. Accessed July 18, 2013.

  61. McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff; 2010; 29(5): 982-990.

  62. Pioneer Accountable Care Organization Model: General fact sheet. CMS, Center for Medicare and Medicaid Innovation; 2012.

  63. American College of Physicians. What is the patient-centered medical home? Available athttp://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/understanding/what.htm. Accessed August 30, 2013.

  64. Centers for Medicare and Medicaid Services. State Demonstrations to Integrate Care for Dual Eligible Individuals. Available athttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/StateDemonstrationstoIntegrateCareforDualEligibleIndividuals.html. Accessed October 28, 2013.

  65. Centers for Medicare and Medicaid Services. Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Available at http://www.innovations.cms.gov/initiatives/rahnfr/index.html. Accessed November 20, 2013.

  66. Centers for Medicare and Medicaid Services. New program to increase quality in nursing facilities. Available athttp://www.cms.gov/apps/media/press/release.asp?Counter=4454&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed November 20, 2012.

  67. Centers for Medicare and Medicaid Services. Details for Regulation #CMS -1600-P. Available athttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-P.html. Accessed August 8, 2012.

  68. Colorado Foundation for Medical Care. Links/resources/tools for providers -- care transitions improvement efforts. Available athttp://www.cfmc.org/integratingcare/provider_resources.htm. Accessed July 14, 2013.

  69. Office of the National Coordinator for Health Information Technology. Meaningful use -- What is meaningful use? Available athttp://www.healthit.gov/policy-researchers-implementers/meaningful-use. Accessed July 14, 2013.

  70. Dougherty M, Williams M, Millenson M, et al. EHR payment incentives for providers ineligible for payment incentives and other funding study. Washington, DC: Prepared for Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 2013. Available athttp://aspe.hhs.gov/daltcp/reports/2013/EHRPI.shtml. Accessed July 14, 2013.

  71. LTPAC Collaborative, State HIE Toolkit Module: Vulnerable populations and HIE. 2010.

  72. Harvell J, Harr M, Hall EP, et al. Implementing health information exchange in the long-term and post-acute care community -- Perspectives for LTPAC providers and their affiliated organizations. Webinar, December 12, 2012.

  73. ECRI Institute and s2a. Crossing the connectivity chasm: Pinpointing gaps in readiness to exchange health information. Plymouth Meeting, PA; 2012.

  74. Office of the National Coordinator for Health Information Technology. Health IT Policy Committee. Available athttp://www.healthit.gov/policy-researchers-implementers/health-it-policy-committee. Accessed June 13, 2013.

  75. Office of the National Coordinator for Health Information Technology. Principles and strategy for accelerating health information exchange (HIE). Washington, DC: Office of the National Coordinator for Health Information Technology; 2013. Healthcare Information Technology Standards Panel. HITSP enabling healthcare interoperability. Available at http://www.hitsp.org/about_hitsp.aspx. Accessed August 6, 2013.

  76. Office of the National Coordinator for Health Information Technology. Federal health information technology strategic plan, 2011-2015. Washington, DC: Office of the National Coordinator for Health Information Technology; 2011.

  77. Office of the National Coordinator of Health Information Technology. Initial set of standards, implementation specifications, and certification criteria for electronic health record technology. 2010:45 CFR Part 170.

  78. LeadingAge Center for Aging Services Technology. EHR for LTPAC: A primer on planning and vendor section. Washington, DC: LeadingAge Center for Aging Services Technology; 2013.

  79. Certification Commission for Health Information Technology. CCHIT certified products. Available at https://www.cchit.org/find-cchit. Accessed June 14, 2013.

  80. HL7 International. HL7 EHR system long-term care functional profile, release 1 -- U.S. realm. Available athttp://www.hl7.org/implement/standards/product_brief.cfm?product_id=134. Accessed August 28, 2013.

  81. Alwan M. Personal communication about LeadingAge members and participation in health information exchange of electronic medical record data. LeadingAge; 2012.

  82. Metz K, Russell W. Improving transitions of care in LTPAC: An update from the theme 2 Challenge Grant awardees. Washington, DC: Office of the National Coordinator for Health Information Technology; 2013.

  83. Office of the National Coordinator of Health Information Technology. Beacon Community program. Available athttp://www.healthit.gov/policy-researchers-implementers/beacon-community-program. Accessed December 20, 2012.

  84. Smith L. "Direct" your attention to Mass Health Information Exchange (HIE). Massachusetts eHealth Institute (MeHI) Newsletter; 2012.

  1. See http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.html.

  2. CCDA was developed through the joint efforts of HL7, Integrating the Healthcare Environment, the Health Story Project, and the ONC. CCDA is a more robust, implementable standard, and provides a single source for CDA templates for different document types including the discharge summary and CCD documents and is now the exchange standard referenced in MU Stage 2.

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