Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Overview of Health Information Exchange to Support Long-Term Care Services and Supports at Rush University Medical Center

10/29/2013

The availability, use and exchange of information are crucial to providing LTSS. As noted in the programs above, Rush has been dedicated to improving the transition of care process for a number of years. To accomplish this goal they have engage various departments/staff within the hospital system, affiliated providers such as physician practices owned by Rush, and non-affiliated providers.

This section describes the non-affiliated providers that were interviewed during the site visit, describes the technical infrastructure at Rush including the availability of a community HIEO, and describes the health information exchanged at transition of care and during shared care using a framework designed under this project.

Rush University Medical Center LTSS-Related Non-Affiliated HIE Partners

During the site visit, three community (non-affiliated) partner organizations were interviewed to discuss the types of HIE/sharing that occurs as well as the challenges and opportunities. They are not the only LTSS community partners, but selected for study purposes.

  • Health Resource Solutions (HRS) Home Care.12 HRS, a Medicare-certified HHA, serves the Chicago area (an 11 county region) providing nursing and therapy services including: 24-hour telemonitoring, geriatric care, psychiatric care, neonatal care, pediatric care, pediatric infusions, IV therapy, high tech infusions, physical therapy, occupational therapy, social work, and disease statement management.

    Specific to this project and LTSS, HRS is the preferred home care provider for the 3026 Grant (CMS CCTP) and Rush HHA Transitions in Care Program. They actively participate in pre-discharge planning at the hospital with the interdisciplinary team for high-risk Medicare beneficiaries. Under the Bridge Program they utilize the PERFECT tool to improve the success of transitions. In addition, HRS has found that their use of telemonitoring for select cardiology conditions has reduced hospital readmissions resulting in preferred provider status for RUMC and other Chicago-area hospital cardiologists.

    An HRS staff member is at the hospital receiving referrals, assessing the patient, and interacting with hospital case management staff. HRS uses Allscripts EHR for home care and receives their referral information through the AllscriptsCare Management tool for sharing relevant information at the point of transfer from the hospital to home with home care services (such as demographics, financials, referral, medication information, equipment needed and clinical information related to care needs). Some of the information in the Allscripts Care Management tool can be integrated into the HRS EHR such as demographics. Other information is printed and scanned into theAllscripts EHR.

  • Warren Barr Pavilion.13 Warren Barr is a SNF that has partnered with Rush in their Skilled Facility Rush Coordinated Care Program. They provide sub-acute rehabilitation services, orthopedic rehabilitation, a specialized chronic heart failure transitional cardiac care program, advanced wound care, IV therapy, and other specialized skilled nursing service.

    At the time of the site visit Warren Barr was just in the process of implementing an EHR system -- Point Click Care (PCC). They used Allscripts Care management for referrals from Rush which also provided relevant information (history and physical [H&P], labs, therapy, progress notes, social work notes, durable medical equipment [DME], demographics and financial data). Because information in Allscripts Care management is not interoperable and PCC does not support interoperable information exchange, information from Allscripts Care management cannot be automatically incorporated into the PCC system -- it must be re-entered if it is to be incorporated into Warren Barr's EHR. Warren Barr utilizes the Interact tools including the Situation, Background, Assessment and Recommendation Report (on paper now, but electronic once PCC implemented).

    When Warren Barr sends patients to the hospital (typically through the emergency department) they send by hard-copy a packet of information (demographics, diagnosis, medication list, labs, H&P, etc.). Warren Barr does not create an electronic, interoperable transfer form to support the transition. They have found that information often does not make it to the medical unit where the patient eventually stays. Another challenge is finding the patient in the hospital and ensuring that the staff are aware that they are a Warren Barr patient.

    A Rush physician and nurse practitioner sees patients at the SNF and will document in the SNF's EHR. For Rush patients these clinicians will also have to document in the Rush EHR system. The physician can access the Rush EHR to obtain any information needed for shared care.

  • Aging Care Connections.14 Aging Care Connections (the suburban Chicago AAA, and ADRC) offers programs and social services to adults age 60 and older and their family members to enhance their ability to remain as independent as possible in their own community. There are over 80 different programs and services available in these categories:

    • Information and assistance coordinated point of entry (resources, benefits, assessment, etc.);
    • Comprehensive care coordination;
    • Homemaker services;
    • Transportation;
    • Home-delivered meals;
    • Community Care Program;
    • Respite;
    • Elder Abuse (authorized by Illinois Department of Aging and AgeOptions, the AAA in suburban Cook County, to conduct case work services to investigate reports of suspected abuse, neglect or exploitation);
    • Benefits assistance;
    • Support groups; and
    • Caregiver support program.

    Aging Care Connections is funded in part by federal and state government agencies, the local AAA, local municipalities and townships as well as private funding like the United Way. They maintain an electronic client management information system (CMIS) and paper-based client records to records (but not an EHR). The information system maintains client records such as demographic records, results of screenings/qualifications for services, limited medical information such as medications and assessments, and service utilization records. The CMIS is not integrated with other community partner information systems/EHRs. In their role to investigate Elder Abuse, they must maintain a specific computer to access the state database to upload reports.

    When Bridge social workers and/or case managers identify the need for the HCBS listed above, they share via phone, fax and e-mail demographic information, and other initiation of service information. The social workers spend significant time moving information manually, following up by phone or e-mail to make sure information was received, and following up to make sure services were implemented. Aging Care Connection has data sharing agreements to access medical record information at some area hospitals to support the transition planning process. Where agreements are in place, staff at the Aging Care Connection may access the hospital EHR to review relevant information such as the discharge plans, diagnosis, medications and assessments.

Rush University Medical Center's Technology Infrastructure

To understand the technology infrastructure and future plans, Dr. Julio Silva was interviewed during the site visit. In addition to Dr. Julio Silva being a vice president and the CMIO at Rush, he is also the Medical Director for MetroChicago HIEO which is under development.

Electronic Health Record System

Rush University Medical System has a tag line for the EHR -- "one patient-one record." Both the hospital and ambulatory care practices use Epic EHR system for all patient care documentation in the hospital and ambulatory care sites. There are approximately 1,000 physicians in the Rush system -- 6% are employed by Rush and 40% are affiliates. Rush also extends Epic on a fee-for-services basis to some non-Rush physicians and manages the IT infrastructure for a management fee. Epic supports the Care Transition Program by providing the ability to route information to staff or affiliated provider (e.g., results delivery, routing to an in-box). Rush utilizes Epic's HIE platform Care Anywhere. Care Anywhereis only available to Epic EHR system users, however, and the use of Epic is limited in the LTSS community.

The Patient Care Managers at Rush use a different application document their narrative care management notes. At this time there is not an interface between the care managers' application and the Epic EHR. Rush is working on an electronic Bridge template in the EHR system. This template would enable the electronic incorporation of the BCCs documentation including their assessment of post-discharge risk elements in the Epic EHR and viewable by all authorized users of the system.

Health Information Exchange Organization

The State of Illinois is developing a federated HIE model with a record locator services that will reach out to regions and bundle and route information. One of the regions in Illinois is the Chicago area. There is currently not an operational HIEO in the Chicago area; however, there has been a big push to support HIE in the region since many different EHR systems are deployed -- none of which talk to one another. As a result, a MetroChicago HIEO is under development with Dr. Silva serving as the Medical Director.

A Metropolitan Council comprised of 120 hospitals and communities are working together to establish the HIE. The Council began with addressing governance. In April 2013, they selected a HIE vendor. Dr. Silva indicated during the interview that the MetroChicagoHIE platform will support care coordination efforts. The HIE will have functionality to support Direct messaging, event notification for primary care providers, results routing, referral management, and eventually population management, analytics and case management.

AllscriptsCare Management System and Web Referral

To communicate with LTSS providers, LTPAC providers and some community partners, Rush uses the Allscripts Care Management application for communication/referrals with community partners. The secure communication includes non-structured messages and attachments for information such as demographics, financials, services recommended, medication information, equipment needed and limited clinical information related to care needs. Subscribers have full access to information exchanged while non-subscribers could access some minimal limited amount of information. For providers who have the AllscriptsEHR program, some information such as demographics can be integrated/populatedinto the EHR application. Otherwise information must be printed and scanned or re-entered into the EHR application. Users of the AllscriptsCare Management application find that it has significantly helped with the timely transfer of information to support transition of care. However, communication is not bi-directional. Information is sent only one way from the hospital. Some of the challenges of the system include the limited content exchanged and the cost for community partners to subscribe.

About 80% of patients are not in the Rush network of providers (or preferred partners) who use Epic and/or AllscriptsCare Management, resulting in the majority of communication around transitions occurring by phone, faxing and e-mail.

Health Information Exchange Information Flow

Table H-1 describes the information exchange activities for Rush and their LTSS services as they coordinate transition planning services. The exchange scenarios are not limited to electronic exchange.

HIT Standards Used

It was not possible to determine the level or type of health information technology (HIT) standards used to facilitate exchange. Epic is a certified EHR application and therefore meets the applicable standards required for Stage 1. Allscripts Care Management does not appear to use interoperability standards (such as a continuity of care document or clinical document architecture) since content and attachments could not be incorporated. However, it appears that Health Level 7 v2 messaging standards for demographics are used to move data from Allscripts Care Management into Allscripts EHR.

HIE Related Measures

Rush did not report or discuss any specific HIE measures, but they do collects data in their EHR and other systems to track outcome measures. They have metrics related to outcomes with transition and coordination of care under the case management department, which may be related to their exchange of information:

  • Rates of readmission (readmission to any hospital in 30 days over the total number of hospital discharges);
  • Increased physician followup(completed visits by 30 days post-discharge);
  • Increased understanding of medications and discharge POC;
  • Decreased patient and caregiver stress; and
  • Nursing home placement.

TABLE H-1. HIE by Care Coordination Function and Partners, Rush University Medical Center Bridge Program

Transitions of Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Assessment/Referral
Referral for Community Services Patient is assessed for risk factors, discharge plans are being evaluated. A referral for LTSS evaluation is made.    
  • Access Rush EHR
  • Verbal
  • Communication during multidisciplinary team meetings
  • Paging/Text
  • Paging physicians
  • Epic daily reports to support transition
  • Risk Screen (meds, diagnosis, pain, fall risk, psychosocial needs, depression, ADLs, cognitive, etc.)
  • Demographics
  • Problem List
  • Medication List/Orders
  • H&P
  • Op Report
  • Case management notes in Maxus system (not Epic)
Case Managers to Bridge Social Workers
  Case managers make referral to appropriate HHA provider.    
  • Demographics
  • Problem List
  • Medication
  • Allergies
  • Supplies
  • List/Orders
  • H&P
  • Op Report
Case Manager to HHeA Nurse
  Case managers make referral to appropriate facility provider (e.g., SNF).  
  • Allscripts Care management
  • Phone
  • E-fax
  • E-mail
  • (Depending on Provider)
  • Demographics
  • Nurse snapshot (last 3 days of vitals, med administration, orders, diet, activity level, isolation, allergies)
  • Medications
  • Labs
  • Therapy Notes
Case Manager to SNF Nurse
  BCCs social worker assesses patient to determine services needed. Makes referral to community service provider if need is determined and/or followup to ensure services in place--pharmacy, DME, counseling, etc.  
  • Phone
  • E-fax
  • E-mail
  • Demographic information
  • Service requests
  • Additional information relevant for the service requested
  • ADL Assessment
  • Mini-Mental Exam
BCC to Home & Community Service Provider
Transitions of Care
Transfer/Admission to LTPAC/LTSS Obtain physician order or communication for discharge, services, and/or followup.    
  • Rush EHR
  • Verbal Communication during multidisciplinary team meetings
  • Paging/Text
  • Paging
  • Physician order or--physician progress note
Case Manager and/or BCC to Hospital Attending Physician
Prior to discharge, a pharmacy student reviews the discharge instructions sheet & completes a pre-discharge medication reconciliation.    
  • Rush EHR
  • Discharge instructions
  • Physician orders
 
  Patient transferred to HHA.  
  • Allscripts Care management
  • Paper printouts
  • Demographics
  • H&P
  • Op Report
  • DC Summary
  • Key Labs
  • MD Followup Contact
  • Advanced Directives
  • Physician Orders (including medications, treatments, & special skilled service orders)
  • Special nursing care (ostomy, wound, Catheter care, dressings, IV, trach, etc.)
  • Fall prevention
  • Rehab restorative care
  • Infection control/safety
  • Equipment/Supplies
Hospital nursing staff to HHA Nurse
  Patient transferred to SNF.  
  • Allscripts Care management
  • Paper printouts
  • Demographics
  • H&P
  • Op Report
  • DC Summary
  • Key Labs
  • MD Followup Contact
  • Advanced Directives
  • Physician Orders (including medications, treatments, & special skilled service orders)
  • Special nursing care (ostomy, wound, Catheter care, dressings, IV, trach, etc.)
  • Fall prevention
  • Rehab restorative care
  • Infection control/safety
  • Equipment/Supplies
Hospital nursing staff to facility Nurse
Discharge from LTPAC to Another Provider   Patient transferred from facility back to hospital.  
  • Paper
  • Transfer Form
  • Recent narrative progress notes
  • Copies of MAR
  • DNR order
Facility Nurse to hospital
Followup Post Transfer
LTSS Care Coordinator followup with Community Service Provider & Patient   Case Management makes followup contact within 24-48 hours on all home health & SNF transfers to assist in assuring services started, answer questions, etc.  
  • Phone
  • Clarifies any issues/questions
  • Additional information shared as needed
Case Manager to HHA or Facility
  Patient Care Coordinators and/or BCCs followup with referrals made for community services.  
  • Phone
  • E-mail
  • Verifies that services were delivered; follows up on issues.
  • Provides additional information as needed
Care Coordinator to Community Service Provider

TABLE H-2. Shared Care Information Exchange Activities

Shared Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Assess Needs and Goals
Admission Physician Visits/Evaluation (NH)   Rush physician & NP visit SNF patient 2 times during first week after admission & weekly until stable.  
  • On-site access to facility medical record
  • Electronic access to Rush EHR as needed
  • Order
  • Medications
  • Progress Notes
Rush physician/NP & SNF Nurse
Create and Maintain Plan of Care
Care Management/ CCT Meetings   Weekly case management meetings between Rush & HHA Provider.  
  • Sharing information on key indicator/risk data
  • Verify protocols followed from PERFECT
  • PERFECT form
Rush Care Coordinators, BCCs, Home Health Care Managers
  Quarterly meeting between Rush & Facility Provider (part of SNF Rush Coordinated Care Program).  
  • Sharing information on key indicator/risk data; verify protocols followed
  Rush Coordinated Care Director, Facility Representative, Case Management Director
Monitor, Followup, and Respond to Change
Ongoing physician visits/ evaluation (NH)   Rush MDs & NPs visit SNF patient for regular scheduled visits & as needed to meet medical needs of patient.  
  • On-site MD access to SNF medical record
  • MD remote electronic access to view Rush EHR as needed.
  • Order
  • Medications
  • Progress Notes
Rush MD/NP & SNF Nurse

TABLE H-3. Other Information Exchange Activities

Shared Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Mandatory Reporting
Elder Abuse Reporting   Elder Abuse Reporting by Rush Partner Aging Care Connection  
  • Electronic reporting to State Agency
  • As defined by state
Aging Care Connections Coordinator to State Agency.

  1. See http://www.healthrs.net/.

  2. See http://www.warrenbarr.com/.

  3. See http://www.agingcareconnections.org/index.html.

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