This section describes some of the uses of HIE supporting care transitions with LTPAC/LTSS providers, specifically: (1) transfers from an LTPAC/LTSS to a hospital; and (2) transfers from a hospital to an LTPAC/LTSS provider. Interventions varied in how HIE was used to support care transitions. This section provides examples of the technology, workflow, data exchanges, and users.
Transition from LTPAC/LTSS to Hospitals (ED, Acute Care, Psychiatric)
Electronic exchange from LTPAC/LTSS to ED and hospitals was commonly implemented using directed, peer-to-peer, and query-based technology, with variations across providers.
For the small number of LTPAC/LTSS providers that have an EHR, a custom interface sent ADT data using secure HL7 version 2 messaging standards, usually using Direct. ADT messages are sent for specific types of events or use cases, such as inpatient admission. ADT messages typically include key information such as medications, lab test results, demographics, allergies, problems, diagnoses, discharge summaries, vital signs, and clinical notes. The ADT event updates are sent from the HIEO to specific providers through secure messaging, perhaps using a Virtual Provider network connection (e.g., Beechwood Homes, Western New York through HIN, and Cedar Living Nursing Home, Oklahoma through SMRTNET.
Direct exchange is being used to support a variety LTPAC HIE activities such as exchanging CCDs (e.g., CORHIO), sending ADT messages to hospitals supplemented with data from INTERACT and care paths with decision support (i.e., Oklahoma SMRTNET).
When a patient is admitted to the ED, the SBAR content is electronically sent to ED staff, and alerts ED doctors if more information is available in the HIEO about the patient (e.g., Golden Living Nursing Home through Indiana HIE).
The HIEO may send alerts to specific care providers such as the patient's primary care provider for events such as hospital admission or discharge.
More advanced functionality reported by a small number of interventions were real-time alerts upon hospital admission, sent to primary care physicians, mental health providers, and HHA staff.
Hospital ED admission staff can query for LTPAC patient information via a HIEO upon admission, and retrieve patient information, typically in a CCD format, and distribute to clinical staff.
At least one hospital automatically prints the CCD and other information and adds it to the patient chart (Indiana HIE).
The HIEO may send alerts to specific care providers such as the patient's primary care provider.
Hospital staff at some hospitals can access patient exchange information at the HIEO and import into their hospital EHR (e.g., Norman Regional Hospital, Oklahoma SMRTNET), which was reported to greatly increase physician use of the information.
Before electronic HIE was available, information exchange predominately occurred by paper and/or via fax, photocopying, mailing, and telephone calls. Most LTPAC/LTSS sites reported faxing additional information that could not be sent electronically to hospitals, HHAs, and other providers.
At one site, when the SNF sends patients to the hospital, typically through the ED, the SNF also send a packet of information in hard-copy (e.g., demographics, diagnosis, medication list, labs, history and physical [H&P]). However, the SNF found that this information is not accompanying the patient to the medical unit where they are admitted. Another challenge is locating the patient in the hospital and ensuring that the hospital staff know that the patient was admitted from a SNF.
Data Sent from LTPAC Providers at Transitions
The following types of data were found to be transmitted by LTPAC providers at times of transitions in care: INTERACT information (including SBAR), transfer form, face sheet, most recent H&P, recent hospital discharge summary, nurse's progress notes; orders related to acute condition, current medication list or administration record, advance directive, care limiting orders, relevant lab results, relevant x-ray reports, immunization records, and physical therapy notes.
Less frequently sent data from LTPAC providers at transitions included patient assessments including functional and cognitive status (e.g., from MDS, OASIS), wound care and other images, fall and other risks were also sent but less frequently.
HIE Recipients/Users at Hospitals
The types of hospital staff that most often reported to be users of the information sent by LTPAC providers included: hospital admission clerks, ED and hospital clinicians, emergency medical technicians, hospital social workers, and case and care managers. Patient's primary care providers and specialists were also identified as recipients of the information provided by LTPAC providers.
Transition from Hospital to LTPAC/LTSS
This section describes HIE from hospitals to the receiving LTPAC/LTSS provider. The flow of HIE from hospitals to LTPAC/LTSS providers was more common than the reverse direction.
Point-to-point exchange from the hospital to the LTPAC/LTSS sites using Direct or other means was not commonly reported. One of the case study sites, Rush University Medical Center, does send secure e-mail using their e-referral software to LTPAC/LTSS providers.
To prepare for the return of the patient, the LTPAC/LTSS sites typically are provided with access to web-based portals to query hospital information while the patient is hospitalized. When the patient's name is entered into the portal, data can be accessed from hospitals and other providers. The information is typically available via a community or virtual health repository.
Depending on the interface available through the EHR or an HIEO, SNF staff can view and use the hospital information in different ways. At least one site reported that they can view all records for the patient, or select only those from a particular facility. A sidebar provides a menu of types of information from which an authorized provider can choose (e.g., lab results, admission and discharge summaries, radiology notes, and a summary information sheet).
Often other data were available from outpatient providers, laboratories, and other LTPAC/LTSS providers.
Because this is a portal, information needs to be retrieved and repurposed rather than accessed directly from the LTPAC/LTSS's EHR system.
- Some HIEOs offer sophisticated applications to access and use the HIE information in data repositories.
- PatientCare360 used by CORHIO has the ability to create, view, and print a CCD into a Summarization of Episode Note.
There are many examples of non-electronic exchange of information when patients transition from a hospital to a SNF or home care (e.g., using fax and sending hard-copy documents).
Some SNFs and post-acute providers report using clinical liaisons (e.g., intake or admission nurses) to gather information and assess patients in the hospital prior to being transferred to the SNF or a rehabilitation center (e.g., Beechwood Homes, Chicago Rush University Medical Center referral SNF).
Rush University Medical Center, was working with their EHR vendor to develop standard reports that would be sent to their referral sources (e.g., LTPAC/LTSS providers), but not via electronic HIE as the Rush EHR does not have the capability to generate this standardized report.
Hospital discharge planners more often send hard-copy and fax discharge orders to LTPAC/LTSS providers.
HIE Recipients/Users at LTPAC
The LTPAC users of the information sent by hospitals include charge nurses, directors of nursing, care transfer coordinators, wellness nurses, physicians, and pharmacists.
Data Sent to LTPAC at Transitions
The following types of data may be transmitted by hospitals to LTPAC providers at times of transitions in care: updated hospital information; transfer form; medications; nurses notes; H&P; diagnoses; operative report and other relevant clinical data (e.g., functional status, therapy, skilled nursing services, and the hospital discharge summary).
Information that is less frequently sent from hospitals to LTPAC providers included nutrition, fall risk, physical inactivity rates, ADL, instrumental ADL (IADL), fall history, and self-management information collected in relation to conditions such as COPD, heart disease, diabetes, and asthma. In addition, one HIE intervention involved the hospital sending wound care images to the home care provider.
HIE Impact and Care Coordination Measures Used
Many of the identified HIE interventions reported efforts to measure the impact of their care transitions interventions. The most common measure was related to hospital readmission rates. Other measures reflecting care transitions were the rates of ED visits and hospital admissions. Three interventions reported that they monitored discharge disposition and two interventions measured length of hospital stay.