To understand health information exchange (HIE) for long-term and post-acute care (LTPAC) providers, a site visit was conducted at Eastern Maine HomeCare (EMHC). EMHC is the home care and hospice division of the Eastern Maine Health System (EMHS). The health system is an integrated delivery network (IDN) with hospitals, ambulatory care practices, LTPAC providers (home health, hospice, nursing homes and assisted living) and ancillary services. The home care division includes three agencies and seven offices, serving both urban and rural areas covering two-thirds of Maine. EMHC also provides telehealth services to patients in the health system, and has been successful in reducing hospital admissions and emergency department (ED) visits.
EMHS is both an innovator and a leader in health care having received grants to test new models of care and payment, and industry awards and recognitions. Health information technology (HIT) has been a key factor in supporting their innovative practices and a strategy to manage health care for a population that covers a large urban and rural geography.
EMHS received an Office of the National Coordinator for Health Information Technology (ONC) Beacon Community Grant in 2010 to support improvements in the health of people with chronic conditions and reduce costs. The Bangor Beacon Community achieved these improvements through a care coordination program that was facilitated by HIT. LTPAC providers were an integral component of the grant particularly the use of home care services and telehealth technology. The grant provided an opportunity for EMHC to upgrade its electronic health record (EHR) platform to a single solution across all of their agencies and sites and increase the number of telehealth units available for use. To illustrate the effectiveness of the program, outcomes for patients on telehealth were tracked. In 2012 hospital and ED visits dropped from over 70% before telehealth to 8% while in the telehealth program. This drop in hospitalization and ED visits resulted in savings of over $2 million.
Maine has a statewide HIE called HealthInfoNet® (HIN). HIN was operational in 2009, but expanded its technology infrastructure in 2010 with the ONC Beacon Community Grant, ONC Regional Extension Center (REC) Grant and State HIE Cooperative Agreement Program funding. All of Maine's acute care hospitals are under contract to connect to the statewide HIE along with ambulatory providers, federally qualified health centers (FQHCs), mental health agencies, home health agencies (HHAs) and two nursing homes. HIN has select types of information available including medication history, allergies, lab and test results, vital signs, image reports, transcribed reports and a problem list. HIN also provides tracking for six admission/discharge/transfer (ADT) events and sends notifications to HIE participating organizations when they have a treatment relationship with the patient. EMHC utilizes HIN as part of the admission process to gather information on new patients and assist with the start of care assessment process. The agency also submits the patient's home care plan to HIN.
EMHS has been an incubator for testing new health care delivery and payment models participating in both Maine and Centers for Medicare and Medicaid Services (CMS) Patient-Centered Medical Home (PCMH) projects and launching one of 32 Pioneer Accountable Care Organizations (ACOs) in the United States. EMHS Pioneer ACO has 14,000 attributed Medicare participants. EMHC is an integral part of both programs working closely with patient care coordinators and community care teams (CCTs) to improve the health and outcomes for high-risk patients and reduce their costs. The use of telehealth for homebound patients has been an important tool for daily monitoring and interventions when clinical measures require attention. As noted above, the use of telehealth has resulted in dramatic reductions in hospital and ED visits for the 167 patients using the service in 2012.
EMHS maintains the technical infrastructure for the IDN including EMHC. The home care division has its own EHR application -- McKesson Horizon Homecare -- used by all of the home care and hospice agencies and sites. The hospitals and ambulatory sites use the Cerner Millennium EHR system. Cerner has a tool for known as PowerChart for multi-entity organizations. PowerChart pulls the most relevant patient information from the various entities together in one view and provides a link to HIN. EMHS physician practices use Centricity.
EMHC uses Phillips Healthcare Solutions for its telehealth program. Units in the home transmit data to a cloud-based clinical software application where it is recorded for monitoring, tracking and trending. Currently the telehealth data does not connect with the EMHC EHR, but an interface is under development.
Health information is exchanged in multiple ways (phone, fax, e-mail, customized portals, and HIN during clinical and administrative processes. HIE information flows occur in three categories: (1) transitions of care; (2) shared care; and (3) administrative processes. EMHC routinely exchanges information during preadmission assessment, at transfer and discharge, at start of care when assessing the patient and developing their plan of care (POC), with ongoing monitoring and maintenance of the patient's POC and recertification, and with status changes. EMHC developed a physician portal to their EHR to improve the exchange of information with physicians for reviewing and signing the patient's POC and orders.
A number of barriers and opportunities for improvements in HIE were identified over the course of the two-day site visit. The opportunities and/or barriers identified by EMHC representatives include:
Cost/reimbursement barriers to expand the telehealth program.
Policy barriers for engagement of LTPAC in new delivery models related to homebound status for home care patients and three-day hospital stay for skilled nursing facility (SNF) Medicare beneficiaries.
Use of a consolidated (community) patient-centered care and treatment plan to enhance care coordination.
Opportunities for improvements in medication reconciliation process after hospital discharge.
EMHS is an innovative organization that is demonstrating how LTPAC providers and technology can and should be integrated into new care delivery and payment models. Their patient-centered approach to care coordination embraces the spectrum of providers and integration of community services to provide the high-quality care in the most cost-effective setting. Technology plays an important role in supporting their coordination of care infrastructure and is viewed as a critical tool for future enhancements in their delivery and payment models.
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