The findings and observations above begin to highlight a number of barriers or challenges related to HIE and advancing its use by LTPAC providers and the expanded use of electronic HIE. This section describes the barriers or challenges that were identified by the site visit providers.
Medication Reconciliation Challenges at Transitions of Care/Admissions
All three sites identified medication reconciliation as one of their biggest challenges during transition of care. Hospital discharge medications must be reconciled with the patient's pre-hospital regime and post-hospital POC. Exacerbating the problem is often the lack of primary or attending physician's historical knowledge of the patient and their overall POC, and the lack of complete and accurate medication history information, even when a HIEO is available. For example, some HIEOs use SureScripts for filled prescription history data. The prescription information from HIEOs may not reflect all of a patient's prescriptions and whether the patient filled them. In some cases there is a lag time for a pharmacy to report the information to SureScripts. While the information is useful to LTPAC providers, it cannot be considered the complete and accurate trusted source. Because medication reconciliation is critically important for patient safety and continued care, improvements are needed to ensure safe hand-offs at transition from the hospital to the LTPAC provider.
Need for Improved Efficiency in HIE Between LTPAC Provider and Pharmacy
For SNFs, there is also a communication process in which medication and other order changes are sent to the long-term care pharmacy. However, this process is typically not supported through electronic, interoperable transmission. Both Western New York and Maine's HIEOs have begun work to address this gap by connecting a long-term care pharmacy to their exchange.
Lack of Efficient Exchange of Information Between LTPAC and Attending Physicians
During a patient's stay in LTPAC, these provider organizations must frequently exchange information with attending physicians for status changes and updates, order changes, obtaining signatures, POC and certification updates, etc. Typical exchange processes include photocopying, making printouts, or scanning medical record information to mail, fax and send via secure e-mail. However, these methods are labor intensive and highly inefficient for both providers. Two of the LTPAC sites (Beechwood and EMHC) developed physician portals to their EHR applications in lieu of interoperable exchange between the physicians' EHR and the LTPACs' EHR. While this is a first step toward improved efficiency and information access, it does not provide a process for the exchange of information from physician's EHR and the LTPAC provider's EHR. This is an important issue because both the LTPAC provider and physician share responsibility for care and treatment, but the information continues to be maintained in silos, and is not reusable, resulting in data re-entry.
Even with Standards, Interfaces are not Easy to Implement and Must be Customized
As noted a number of times in this report, standards may be available, but they are challenging to use and require significant resources to implement. Barriers include the use of older standards which contributes to the need for vendors to support customized interfaces, the cost of developing the interfaces and the time to test and implement. While newer standards may facilitate exchange of information, one HIEO informant reported that some of the standards lack specificity, which has resulted in variations in implementation and requires that the HIEO transform reportedly "standardized" information into a consistent format. Further, vendors have been slow to adopt these newer standards, for several reasons including that they have not been tailored and tested for LTPAC implementation.
Lack of Awareness of HIE Standards
In general, there is little awareness among providers (including LTPAC providers) and others regarding the upcoming MU Stage 2 standards, or of the standards emerging through the S&I Framework or being balloted through HL7 to support the exchange of health information including on behalf of persons who receive LTPAC/LTSS services. In some cases there is awareness, but limited resources (time and money) to support implementation of these available/emerging standards. Several respondents, including representatives from HIEOs, health systems administrators, and LTPAC and other providers noted the lack of available resources to support various HIE implementations with LTPAC providers. Appendix L provides a table that identifies the standards that are available to support the types of LTPAC data frequently provided to or requested by other health care providers.
The findings from these site visits also informed opportunities to expand HIE to support care coordination for persons receiving LTPAC/LTSS, discussed in the next section.
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
"HIEengageB.pdf" (pdf, 132.47Kb)
"HIEengageC.pdf" (pdf, 62.72Kb)
"HIEengageD.pdf" (pdf, 64.52Kb)
"HIEengageE.pdf" (pdf, 71.74Kb)
"HIEengageF.pdf" (pdf, 67.17Kb)
"HIEengageG.pdf" (pdf, 128.62Kb)
"HIEengageH.pdf" (pdf, 1.02Mb)
"HIEengageI.pdf" (pdf, 264.75Kb)
"HIEengageJ.pdf" (pdf, 663.47Kb)
"HIEengageK.pdf" (pdf, 126.77Kb)
"HIEengageL.pdf" (pdf, 141.17Kb)