The exchange of health information is a critical function in the delivery of care to patients in LTPAC organizations. All three site visits identified multiple clinical and administrative processes requiring the exchange of information. LTPAC providers and their partners use many different methods to exchange information -- face-to-face communication, telephone, fax, e-mail, access to EHR systems, and HIEOs.
A number of findings are consistent across the three site visit locations:
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LTPAC organizations are beginning to use electronic HIE, but in a very limited way.
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Communication and sharing of information occurs in multiple ways to support transitions and shared care. Increasing the use of electronic HIE methods will improve the timeliness and efficiency of communication, although it cannot completely replace face-to-face and telephone communication between health care providers.
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While HIEOs have some content that is useful for background information for admission, assessment, and care planning purposes, LTPAC providers require detailed medical record data prior to admission including narrative progress notes, assessments, and current medications that reflect changes. Access to the hospital EHR system often provides more timely and detailed information than what is currently available from HIEOs (as observed at two sites) to support the transfer of care process.
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The two sites that are IDSs have community care coordination programs to achieve improved health outcomes for specific target populations, and focus on reductions in ED use and hospital readmissions, as well as the costs of care. Community care coordinators and teams work with HCBS providers, with communication primarily by telephone and fax. There may be opportunities for improved efficiency through the use of HIEOs by and other electronic communication with home and community-based providers; however, these types of providers are not currently participants of the HIEOs.
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Some HIT messaging standards are embedded in LTPAC EHR systems and sometimes used to connect these providers with HIEOs. Further, the interoperability standards in Stage 2 of the EHR Incentive Programs (which will support more robust HIE for transitions in care or shared care with LTPAC/LTSS providers) are not yet used. Many of the standards required through the EHR Incentive Programs could be used to support HIE with and by LTPAC providers, but integration and use of these standards into LTPAC EHR products often requires additional investment of time, financial resources, and organizational awareness. Some standards are still early in their maturity level requiring a significant level of effort to implement.
A synthesis of the HIE findings from the three sites is summarized below using the framework developed for this project. The synthesis describes exchange activities to support transition of care, shared care, and other administrative functions from the perspective of the LTPAC organization. An expanded analysis of 35 identified information exchange workflows is detailed in Appendix K.
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4.2.1. Health Information Exchange for Transition of Care
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Health information is shared and exchanged to support a number of care processes as a patient transitions between care providers. The type of data shared to support transitions in care and the methods of exchange are summarized below. During transitions, information is typically exchanged face-to-face, by telephone, fax, and on some occasions, electronically.
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Referral and Preadmission Assessment. The information typically exchanged during referral and for preadmission assessments includes patient demographics, problems/diagnoses, medications, allergies, treatment orders, activity level, diet, isolation precautions, labs, progress notes (e.g., 3 days of narrative notes), recent H&P, operative reports and pertinent assessments/evaluations including cognitive and functional status. The referral and preadmission assessment information is exchanged using multiple methods -- face-to-face meetings potentially including participation in hospital discharge planning rounds, telephone, fax, access to the hospital EHR (depending on hospital policy) and if available access to community HIEOs.
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Referral for Community Services. The community care coordinators obtain information on patient goals and care plan information, patient demographics, problems/diagnoses, medications, allergies, treatment orders, progress notes, recent history, and physical and pertinent assessments/evaluations such as a cognitive status exam and functional status assessments. Setting up community services requires the exchange of information unique to the service provider. Typical information includes demographic and payer information, services requested, and when relevant, clinical information such as diagnosis and medications.
If the community care coordinator is an employee of the IDS, they access that information from the EHR system (hospital or physician practice) and communicate that information with the HCBS provider, typically by telephone, fax, and sometimes e-mail. If the community care coordinator is not an employee (e.g., they provide community care coordination through an AAA/Aging and Disability Resource Center (ADRC)), they have additional challenges in obtaining the necessary information from the hospital discharge planners by telephone or fax and relaying the information to HCBS providers by telephone, fax, and e-mail at times. In the Rush CCTP funded by CMS (discussed in the Rush Site Visit report in Appendix H), some of the BCCs are employees of organizations like the AAA and ADRC and are able to make special arrangements to access the hospital EHR to obtain necessary information on the patient.
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Transfer/Admission to LTPAC. The transferring provider (often an acute care hospital) sends a comprehensive set of updated health information at the point of transfer. The information may include an order for discharge to the LTPAC provider, a transfer summary, medication orders, updated medication administration records, treatment orders, key lab results, discharge summary, recent progress notes, special nursing care instructions (e.g., ostomy, wound, catheter care, dressings, IV), fall risk assessments, rehab/restorative progress and treatment plans, infection control/safety precautions, equipment and supplies needed, advanced directives and/or limited treatment orders and followup care contact information. The transferring provider usually communicates this information via paper documents, telephone, and fax. For hospital transfers, some information may be accessed by the LTPAC provider directly from the hospital EHR prior to admission when security measures and protocols have been established between the organizations.
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Transfer to Hospital or Another Health Care Provider from LTPAC. The LTPAC provider sends a comprehensive set of updated information at the point of transfer with the patient when they go to the hospital or to another health care setting. This information typically includes a transfer summary (which includes diagnosis/problems, medication orders, treatment orders, allergies, vital signs, functional and cognitive assessment data), pertinent recent labs, recent narrative progress notes, copies of current medication administration records, and advanced directive/do not resuscitate (DNR) orders. SNFs may send the items identified in the INTERACTII protocols when sending the patient to the hospital (e.g., transfer form, SBAR/nurses notes, recent physician orders and current medications, advanced directives). When sending to another LTPAC organization, they may also send the latest MDS or OASIS data set. This information is typically sent in paper format.
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Discharge Information from LTPAC Provider to Patient and Community Service Provider. When patients are discharged from LTPAC they are provided with a detailed discharge POC and instructions including information on discharge medications, self-care instructions, and followup care. As part of the discharge planning process, the LTPAC provider may also assist the patient with identifying and setting up community-based services to support a successful transition. In these circumstances, the discharging LTPAC provider typically communicates this information via telephone, fax, and sometimes e-mail to the community-based service provider.
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ADT Event Reporting to HIEOs. The two sites that participated in an HIEO electronically transmitted and received ADT events via an electronic interface with the HIE. The events reported included the patient identifier, the event (admission or discharge/transfer), date, and time. HIEOs use the ADT event reports to monitor changes and alert other treatment providers to a change in status.
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4.2.2. Health Information Exchange for Shared Care
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LTPAC providers frequently coordinate and share care with other health care and service providers. When sharing care, there are related HIE processes to support assessment, care planning, and ongoing monitoring. A summary of HIE activities to support shared care is described below along with the type of data shared. During instances of shared care, information is typically exchanged by telephone, fax/e-fax, or electronically such as via secure e-mail, use of HIEOs, or customized portals/data entry processes when available.
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Assess Needs and Goals. There are multiple processes related to assessing needs and goals at the start of care that require HIE.
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Initial assessment and development of admission care plan (such as at times of hospital discharge): To complete the assessment and initial care plan development, nurses, therapists and other interdisciplinary team members require recent hospital information and past medical history information to evaluate the patient. Information needed includes the hospital discharge summary, recent H&P, operative report, recent labs, summary of care records, past assessments, social history, and advanced directives. Typically, LTPAC receives the information needed to help complete the initial assessment and develop the admission POC via paper copies sent with the patient or via fax or telephone. In some cases, LTPAC providers electronically access the hospital EHR (if protocols have been established) and/or the HIEO. Medical record information needed, but not exchanged by the hospital or available from the HIEO must be requested from the hospital (e.g., discharge summary not sent at transfer) and is typically received via mail.
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Coordination with physician at start of care: The admission transfer summary, physician orders, medications, treatment orders, therapy evaluation, and home care POC content are all reviewed and signed by the physician. For a SNF patient, the physician completes a face-to-face visit, documents a progress note, and reviews and signs the POC and physician orders. Two sites were implementing customized physician portals to the LTPAC EHR to streamline information exchange. The physician logs into the LTPAC EHR portal to access and review patient information and sign their orders. When an HIEO was available with medication history information, it could be accessed electronically to help with the admission medication reconciliation process, although not a guaranteed source of complete medication history information.
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Communication with pharmacy, lab, and other service providers: The LTPAC provider communicates physician admission orders to the pharmacy, lab and/or other service providers as appropriate. Data exchanged includes demographic and payer information and the detailed orders for medications or services. Typically this is done via telephone, fax or custom web-based portal set up by the pharmacy or lab/radiology service provider. Results received from lab and radiology providers were sent via fax, dedicated printer to LTPAC, or available on the provider's web portal. One HIEO, HIN, was establishing an interface to route results from the lab/radiology provider through the HIE to the SNF's EHR using HL7 results reporting message standards.
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Create, Maintain, Update, and Implement Care Plan. After initial assessment, a care plan is established and maintained over time. The care plan is typically developed by the interdisciplinary team and communicated to the attending physician and the patient/family initially and with updates. The physician may review the POC during routine patient visits to a SNF. In home care, the care plan updates are communicated via the home care POC document. Care plan information and updates are communicated to the family in person, via telephone or through a narrative summary mailed to the representative.
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Monitor, Followup and Respond to Change. LTPAC providers monitor the ongoing care needs of patients, respond to changes in the patient's condition and followup on care and services required. HIE is required to support multiple care processes.
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Transmission of telehealth data: Patient's transmit telehealth data from their device and base station in their home to a cloud-based application. The telehealth nurse in home care accesses clinical data including blood pressure, weight, blood sugar, pulse, oxygen saturations, and responses to individualized questions. Home care nurses monitor the telehealth data on the cloud-based telehealth system. The data was not available in the home care EHR (although an interface was being developed at one site). The use of telehealth in an SNF was not observed during the site visits. EMHS had a telepsychiatry pilot program that could not be maintained due to reimbursement issues.
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Ongoing communication and coordination with physicians: LTPAC providers update the physician with status changes. Information exchanged includes test results, requests for new or revised orders, telephone orders, physician order renewals, home care POC recertification, and physician visit progress notes. These types of updates occur by telephone, fax, and/or secure e-mail. Two sites established physician portals to their LTPAC EHRs to facilitate the review and signature process.
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Order changes for medications, labs, and radiology tests: When the LTPAC provider communicates change in patient status, the LTPAC provider may obtain from the physician a new order or an order to change a medication (or another intervention). The LTPAC provider typically receives these order changes verbally from the physician via telephone. The physician signs the telephone orders in person, sent via mail, or through the physician portal to the LTPAC EHR.
For SNFs, there is also a communication process in which medication and other order changes are sent to the long-term care pharmacy. The pharmacy receives the physician order information from the SNF, often via telephone or fax. The pharmacy verifies the medication prescription with the ordering physician. The long-term care pharmacy enters the order in the pharmacy's electronic medication order system and dispenses the medications to the SNF.
New or changed orders for labs and radiology tests are communicated via telephone, fax, or through a custom web portal as a requisition to the appropriate ancillary service provider by the LTPAC provider. In home care, the nurse may draw the lab. In a SNF, a facility nurse or lab technician draws the lab or gathers the specimen. Results are returned from the lab and radiology provider to the LTPAC provider often by fax or dedicated printers or custom web portal. In Western New York, the HIEO was in the process of developing and implementing an electronic results delivery process to route results from the lab/radiology service providers through the HIEO to the LTPAC EHR.
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Change of Status and Updates with Patient and Family. When there is a change in status, the patient and/or their family is notified by the LTPAC provider of the change and related care/treatment plans. This is frequently communicated in person, by telephone or e-mail based on preference.
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Specialist Visits, Evaluations, and Referrals. LTPAC providers may identify and schedule visits with specialists (cardiologist, audiologist, psychologist, etc.) or set up a referral for community services to support the patient in their home. Information is exchanged to set up the service including demographic, payer, and service requirements. When applicable, progress notes or visit summary records are shared with the LTPAC provider.
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4.2.3. Other Administrative Health Information Exchange
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LTPAC providers exchange health information in support of administrative processes such as billing and required reporting.
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Quality Measure Reporting. LTAPC sites are collecting and/or submitting quality measure data to support grants and initiatives. EMHS Pioneer ACO is required to report 33 quality or performance measures electronically to CMS (see Appendix L for detailed measures). The data is collected through various mechanisms depending on the data elements -- through the EHR or abstracted from medical records and reported through a defined facility process.
CMS also requires electronic submission of federally mandated data or item sets (MDS, OASIS, inpatient rehabilitation facility-patient assessment instrument [IRF-PAI], Hospice Item Sets,p LTCH Care Data Setq). The CMS electronic transmission requirements for assessments do not leverage available HIT standards. CMS uses assessment data for several purposes including calculating quality measures.
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Mandatory Reporting. Public health authorities and state agencies may maintain registries or repositories for reportable public health data. The type of data to report varies by community and state. For example, immunization data or influenza and pneumonia data may be reportable information to public health agencies to detect outbreaks. Some states, such as New York, have customized electronic web portals to enter and submit reportable data.
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Payment. LTPAC providers may exchange electronic health information with payers to support their case management and claims adjudication processes. Payers may request, in electronic formats, relevant medical record documentation to assess continued coverage, validate services billed, or determine medical necessity. Requested documentation may include physician orders, certification/recertifications, progress notes, flow sheets, medication and treatment administration records, assessments, and other relevant data determined by the payer.
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