The following opportunities were identified, based on the site visits, to advance the use of current state of information sharing and exchange involving LTPAC/LSSS.
Care Coordination for QIs and Reduced Costs must Engage LTPAC and LTSS
Health system transformation initiatives are placing focus on the need for improved information sharing and exchange capabilities. Findings from the site visits indicate that LTPAC and LTSS are instrumental in care coordination efforts to improve quality and reduce costs particularly for high-risk/high cost patient populations. For example, care coordination services across care settings and community services are important for improving quality of care and a key strategy for EMHS in achieving their needed health savings as an ACO. There are several opportunities that could support care coordination through information exchange related to these care delivery models including:
The exchange of a patient-centered care plan can support care coordination across providers and care managers. Using the standard for care plans (being balloted by HL7 in the Fall 2013) could enable the interoperable exchange of care plans across team members and over time. The exchange of care plans can support continuity and quality of care, and align multiple care plans across health care providers. HIEOs can play a critical role in supporting the exchange and alignment of care plans. Further, access to care plans could enable population health analytics by HIEOs.
Greater involvement of community-based services in HIE activities will support the care coordination models being developed. Integration of community-based services is identified as a key service to improve quality of care and reduce costs for target populations. Electronic exchange of basic health information (such as demographic, scheduling and messaging) with community-based service providers will improve continuity and coordination of care.
The availability of electronic LTPAC assessment data creates an immediate opportunity for HIEOs to access data that is ubiquitous across LTPAC providers. MDS data is available for all patients in Medicare or Medicaid certified SNFs, OASIS data is available for all Medicare patients receiving home health services, and IRF-PAI data is available for Medicare covered patients in inpatient rehab facilities. HIEOs may want to explore how to include federally required patient assessment data in their network particularly if they are performing advanced population analytics to help support new delivery and payment models. The low-cost technology solutions could transform the assessment data into interoperable and reusable summary content.
Explore Expanded Information Sharing and HIE Options for LTPAC
The nature of care delivery by LTPAC providers requires the exchange of health information with clinical partners, the patient, family and other stakeholders. Many of the current HIE processes are labor intensive and inefficient. Over 35 HIE workflows were identified using the frameworks applied in this study to support transitions of care, shared care, and other administrative functions. There are multiple strategies that could be explored to improve the HIE capabilities between LTPAC and other provider organizations such as the following:
Exploring partnerships between non-affiliated organizations to allow authorized providers to view data in EHRs, support point-to-point information exchange between EHRs and/or expanded use of Direct secure e-mail messaging of non-interoperable health information.
Identifying additional information, methods for obtaining this information, and opportunities to reuse the information to support care giving. For example, HIEOs at two of the sites identified pharmacies as a source of important electronic medication information. HIEOs could make available electronic medication information to LTPAC providers or pharmacies could deliver electronic medication directly to the LTPAC providers. Further, work is needed to explore the feasibility, benefits, and barriers of exchanging electronic medication information from pharmacies, including long-term care pharmacies.
Increased emphasis on development and testing of HIT standards would ease the implementation of interoperable HIE across the continuum including by LTPAC/LTSS providers.
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
"HIEengageB.pdf" (pdf, 132.47Kb)
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"HIEengageH.pdf" (pdf, 1.02Mb)
"HIEengageI.pdf" (pdf, 264.75Kb)
"HIEengageJ.pdf" (pdf, 663.47Kb)
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"HIEengageL.pdf" (pdf, 141.17Kb)