Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Barriers and Opportunities for Improved Health Information Exchange Practices

10/29/2013

Over the course of the two-day site visit, a number of issues were identified related to information exchange in support of care transitions and engagement of LTSS programs. Rush staff and community partners interviewed offered observations on both barriers and opportunities to improvement in improved HIE, communication and coordination practices.

Barriers

  • Need for an HIE Network Available to All Community Partners:

    • The lack of a referral application (that is affordable to all) to share information between the hospital and next care providers is a significant issue since 80% of Rush's discharges do not go to a provider within the system (or a preferred provider). Allscripts Care Management has been very helpful, but its use is limited to certain providers (i.e., those who have chosen to invest/acquire this software). AllscriptsCare Management is also limited because it does not allow bi-directional communication. Clinicians report a need for an electronic system that would allow routing of transition in care/shared care information to additional non-affiliated provider types.

    • The Chicago-area HIE has not considered how to engage community partners such as home and community service providers in the HIE. They are planning for supporting transition of care processes with providers such as HHAs and nursing facilities, but had not identified community service providers as target for the HIEO.

    • Home and community service providers find it a barrier that they cannot electronically access information from other providers EHRs, medical records, or client service records for implementation of services, assessment and care planning activities. Information (such as a mini-mental exam) completed by the various providers, if electronic and available on an HIE, would provide valuable information and reduce duplication.

    • An HIEO could provide the foundation for a longitudinal (community) care plan that would be invaluable for communicating patient goals and coordinating services across multiple care providers. Providers would have important information available reducing the need to "start from scratch" with each encounter, streamlining communication and aligning services.

  • Need to Redefine Traditional Case Management and Recognize Care Coordination Roles:

    • The traditional view of case management from a hospital discharge perspective needs to change to achieve a patient-centered approach to coordination and collaboration that extends beyond discharge, engages community partners and helps to support the patient in meeting their health care goals.

    • Rush representatives expressed a concern that current payment models did not cover care coordination/case management roles needed by some patients and include the provision of LTSS programs and HCBS. They saw an opportunity as new care delivery and payment models emerged (such as ACOs).

    • There were concerns expressed about the limited understanding of the importance of partnering and including LTSS and HCBS services in new payment models. Inclusion of LTSS and HCBS is beginning to emerge in some ACOs as a strategy to manage costs and improve outcomes.

Opportunities

  • Balancing the Amount of Information Sent Versus Information Needed:

    • Senders and receivers of information are often challenged to get the right information and the right amount of detail to support their clinical purpose. Either too much information is sent creating an overload for the receiving provider ("sleuthing") or too little information is sent -- it is often all-or-nothing. Redundant data is also common. Staff would like to see a portal that would allow a receiver to control the amount and type of information they can access to support the transition and shared care processes. This would be addressed with an HIE if it includes the information needed by receiving providers. Depending on its structure and governance, this request could be accommodated via the forthcoming Chicago-area HIE.

  • Development of Standardized Reports:

    • HIE tools such as Allscripts Care Management currently do not have standardized reports that for tracking and trending of data based on clinical content, risk assessment tools or other reporting requirements between Rush and their community partners.

    • Rush Case Management Department is talking to Epic about developing standard reports for their referral sources. Currently the capability is not available.

  • Integration of LTSS Needs in a Patient-Centered POC:

    • Early screening and identification of patients who may require LTSS is crucial. The lack of consistent screening across all relevant admissions can be problematic. Hospitals could address this by implementing a screening tool of the psychosocial elements and risk factors to determine early during a hospital stay which patients may need services. Establishing a care plan prior to discharge is crucial to ensuring appropriate services are set up and consistent with the discharge and teaching plans. This is very challenging when the referral is made after discharge. Similarly, implementation of such screening tools and shared care planning mechanism prior to a hospital stay; for example, in emerging service delivery reform models (e.g., ACOs) might also improve care and decrease costs.

    • Community care coordinators/social workers often establish a community care plan, but it is not integrated with a larger plan for the patient. A patient may have many care plans established by various providers that are not coordinated or reconciled with each other.

    • A sustainable vision for aging and disability services is needed that includes improved integration.

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