A number of overall findings and impressions emerged from the three site visits which provide a snapshot of the current state of HIE by LTPAC to support the transition of care, shared care and care coordination processes. In addition, barriers to and opportunities for advancing HIE in LTPAC settings were also identified across the sites visited.
Transitions of care are complicated and require a multipronged approach to communication and information exchange. LTPAC providers receiving the hand-off of care from hospitals or other providers must gather information from multiple sources using multiple communication/exchange methods to accurately start care, assess the patient, and develop an appropriate POC. Electronic HIE can create efficiency in the process and improve the timeliness and availability of health information; however, communication in person and by telephone will continue to be necessary to ensure a safe hand-off in care.
New care delivery and payment models are highlighting the importance of care coordination including community services. Programs and initiatives that focus on improved care coordination across settings are highlighting the importance of a HIT infrastructure and financial support for establishing and implementing such infrastructures. The CMS Hospital Readmission Reduction Initiative, CCTP, Beacon Community grants, PCMH programs, and Pioneer ACO all provided an impetus to support coordination and information exchange processes and some funding to advance HIT infrastructures.
Both Rush and EMHS have programs to extend care management and coordination that include community-based services to improve health outcomes and reduce costs. EMHS leaders indicated that care management services along with a HIT infrastructure were critical strategies for helping reach their QI measures and achieve cost savings as a Pioneer ACO. While community care coordinators are instrumental in the care management process, many of the LTSS service providers (e.g., transportation and meal services) are generally not part of HIE activities. Integration of LTSS and HCBS are important to achieving health care goals and outcomes (and are being tested as part of some CMMI initiatives) for high cost/high-risk populations. However, these HCBS/LTSS providers do not use EHR systems and are not on the radar as potential contributors or users of data from HIEOs. The information systems they do use are not interoperable, which contributes to using time-consuming telephone, paper, and fax.
Electronic HIE in LTPAC may be contingent on additional funding sources or policy initiatives. Initiatives to improve care coordination and breakdown the silos between health care providers through electronic HIE were often driven by new policies and funding models. As noted at the site visits, several types of programs and initiatives spurred care coordination and improved HIE practices. Informants at one of the visited sites indicated that additional funding will be needed to support electronic HIE to improve care coordination.
HIE organizations are evolving and the value proposition for LTPAC providers is just beginning to emerge and has not yet been realized. HIEOs are beginning to collect information from different providers including ancillary service providers and maintain this information in one consolidated location. However, at this time, the observed HIEOs do not provide a complete picture of the patient nor include the level of clinical data needed to support LTPAC processes around care transitions. The information needed by LTPAC providers to support the transition of care/admission process requires detailed medical record data found in hospital EHRs. Timely access to HIEO data may be another limitation. A LTPAC provider's access to needed preadmission data may be delayed until a patient is admitted to LTPAC, a treatment relationship is established, and consent is obtained. Once the treatment relationship is established, information in the HIEO is often useful to LTPAC providers, particularly in terms of past medical history, services and medications. However, the data in the HIEO, while expanding, is currently not comprehensive; thus requiring other information sources to be accessed and information exchange methods to be used.
One of the emerging uses and potential values of the data maintained by HIEOs is the ability to perform population health analytics, which could support a variety of activities such as understanding health outcomes across populations, providers, service delivery models, advancing clinical decision support tools to support practices found to be effective, and supporting public health and safety. However, the realization of this value proposition was not observed during these site visits. The ability to perform these advanced analytics functions is contingent on several factors including the HIEO's structure and purpose, its technical infrastructure, the quality and comprehensiveness of their data, and the ability to reuse this data to support these analyses.
Adoption of electronic HIE applications by LTPAC providers is beginning, but interoperable exchange is non-existent. The primary mode of exchanging health information by LTPAC providers continues to be traditional methods -- telephone, fax, and secure e-mail with PDF attachments. New processes are emerging to improve the timely and efficient exchange of information including use of: secure access to the hospital EHR, shared network drives to house hospital information, proprietary electronic referral applications for subscribers to exchange information, customized portals for physicians to access LTPAC providers' EHRs, and access to community HIEOs.
When HIEOs are available, some LTPAC providers are participating, primarily by accessing medical history information after admission to assist in the assessment and care planning processes. In some limited instances, information is being sent from LTPAC providers to HIEOs (e.g., ADT messages and the home care POC). Some HIEOs such as HEALTHeLINK anticipate delivering results between ancillary service providers and LTPAC providers.
EHR applications used by LTPAC providers may include some basic HIT messaging standards (e.g., HL7 2.3 or 2.5); however, standards-based document exchange meeting MU Stage 2 requirements, such as the exchange of a patient summary record, was not observed to be sent or received by providers or the HIEO. When electronic exchange was implemented, the cost, complexity and lack of technology solutions that support "standardized", interoperable HIE were identified as barriers.
Quality and performance measure data are being collected. All three sites are collecting and reporting some type of quality/performance measurement data. None of the three sites collected measures specific to HIE activities; however, timely exchange was identified by the sites as a factor that contributes to improved performance. The following list summarizes the focus of pertinent quality measures at the three sites:
Number and rates of hospital admissions/readmissions over a period of time (e.g., for a SNF, home care, telehealth program).
Hospital readmission rates for target populations related to the CMS Hospital Readmission Reduction program, Beacon Community grant, and/or identified high-risk/high cost populations.
Rates of physician followup completed within 30 days post-discharge.
Increased understanding of medications and discharge POC.
Decreased patient and caregiver stress.
Nursing home placement rates.
Clinical data reporting/measurement for target populations (e.g., completion of labs with certain values for diabetes patients).
Cost of encounters for a target population.
Average cost savings over a period of time for target populations in accountable care payment arrangements.
Required CMS quality measurement/reporting data for SNFs, HHAs, and hospice.
As noted, EMHS collects 33 required quality measures as a Pioneer ACO (see Appendix J, Attachment J-1). EMHC also collects quality performance data on their telehealth program to quantify the reduction in ED, hospital admissions and associated costs. EMHS has been able to quantify a significant impact on key performance indicators and costs for the 167 patients in the telehealth program in 2012, reducing hospitalization and ED visits by an average of 65% for target diagnoses, resulting in an estimated $2.1 million in health care savings. EMHC also reports that for every dollar invested in home care during the first year of the pilot, they saved $3 as an ACO.