Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Discussions by Topic

12/01/2011

Topic: Meaningful Use

Stakeholders were asked to discuss their opinions regarding the impact on the LTPAC provider community of the CMS Meaningful Use (MU) requirements for Eligible Hospitals (EH) and Eligible Professionals (EP).

Themes from stakeholder group discussions are as follows:

TABLE A-3: Meaningful Use
Stakeholder Group Discussion Themes
LTPAC Providers Although Stage 1 MU criteria do not require EP/EH to electronically exchange information with LTPAC providers, opportunities exist for:
  • LTPAC providers to solicit information exchange with hospitals/physicians if the interoperability standards required by MU are deployed by the LTPAC clinical information system.
  • LTPAC providers to work with acute care providers, HIEs, and hospital/ambulatory EHR vendors to gain agreement on relevant information to be made available electronically during transitions of care across provider settings.
IDS Providers While there is no direct financial incentive to electronically exchange information in the LTPAC setting:
  • As EP/EH adopt technology, there will be more requests for LTPAC providers to exchange information electronically.
  • Efficiencies experienced by participants in electronic exchange of information will push the curve for adoption.
  • As a by-product of MU, there will be more electronic exchange of data at transfers of care with providers not affiliated with the IDS -- both in-bound and out-bound.
  • New, low-cost exchange models will emerge that recognize the benefits to providers of intermediate steps in information exchange (e.g., providers can view information even if they don’t contribute information to the exchange; clinic notes can be typed in Word and submitted to an HIE to apply a CCD wrapper).
Software Vendors
  • The exclusion of LTPAC providers from MU will have a negative impact on the adoption of technology in this care setting.
    • LTPAC providers are a very pragmatic group -- most actions are the result of a mandate, an incentive, or a compelling business driver.
    • The fastest way to promote electronic exchange of information is with money and education.
  • Despite the absence of federal incentives for adoption of technology, forward looking LTPAC providers will recognize the need to prove viability in a changing landscape:
    • Participation in electronic exchange of information is an indicator of a progressive provider.
    • Deployment of technology will impact the ability of a provider to recruit younger staff (who will expect and want computers).
    • Efficiency is critical with the ever increasing demands to do more with fewer dollars.
  • There are competing views regarding whether LTPAC providers will want to electronically exchange information if it cannot be reused in their systems. Even if LTPAC providers are only able to view information, it is a starting point and there is value in the information exchange.
CMS
  • The readiness of LTPAC providers to participate in electronic information exchange is very low.
    • Information garnered through the Continuity Assessment Record and Evaluation (CARE) Health Information Exchange Project (HIEP) -- a project engaging three advanced health information organizations (HIOs) with many members -- shows there is very little exchange of data amongst providers.
      • HIO members were surveyed regarding readiness to exchange information and what type of data they had the ability to either send or consume. Results showed minimal readiness or ability to exchange information.
  • The exclusion of LTPAC from federal HIT funding and mandates will result in a much slower uptake of technology in this care setting.
    • Absent funding and mandates, LTPAC providers generally do not feel they have the capital to invest in upgrading existing systems or acquiring new products that support the electronic exchange of health information.
FACAs
  • LTPAC is an important component to achieving the advantages of meaningful use and distributed health information exchange such as:
    • avoiding errors,
    • reducing complications,
    • anticipating treatments and interventions,
    • reducing resource expenditures (e.g., re-hospitalization, Emergency Room utilization and similar types of metrics)
  • Absent federal financial incentives, it is important to look for other motivators or enablers that promote HIT adoption and electronic exchange of information by LTPAC providers such as:
    • New payment models (e.g. Accountable Care Organizations (ACOs), payment bundling) necessitate accurate and timely communication of health information for efficient and effective coordination of care.
    • Resources such as the open-source versions of all IHE (Integrating the Healthcare Enterprise) components which allow vendors to easily embed those technologies in their products and reduce the cost of product development.
    • Incremental deployment of technology, (e.g., deploying the ability to receive and read a CCD even though a system does not have the data and/or ability to create a CCD).
State-Level HIEs Though LTPAC providers are excluded from meaningful use, inclusion of these providers in electronic information exchange is important due to:
  • The significant impact of LTPAC on health care costs and quality (e.g. re-hospitalizations, Emergency Room visits).
  • The need to support MU criteria such as medication reconciliation, transfer of care record and certain quality measures that where LTPAC data is needed for computation of the measure.
NQF
  • Though LTPAC providers are excluded from meaningful use, inclusion of these providers in electronic information exchange is important due to:
    • MU criteria that look at the exchange of information,
    • National focus on transitions of care
    • Payment reform models that look at bundled payments, ACOs, etc.
  • While process metrics that measure the occurrence of CCD/information exchange are likely for the foreseeable future, the metrics need to transition to outcome measures to be truly meaningful.

Topic: Health Information Exchange

Stakeholders were asked to discuss their opinions regarding what information was important to exchange and the benefits/challenges to exchanging the information. Themes from stakeholder group discussions are as follows:

TABLE A-4: Health Information Exchange
Stakeholder Group Discussion Themes
LTPAC Providers
  • Standards are needed to support the exchange of information of particular interest to LTPAC providers such as:
    • Reason for referral
    • Treatment goals
    • Actual treatment orders
  • While exchange of medication information is a high-value action, challenges related to data messaging and data content still exist that preclude automation of the reconciliation process such as:
    • Differences in the completeness of data made available when different versions of NCPDP standards are used by providers, pharmacies, data aggregators, etc. to transport medication information
    • Lack of information on medications that are not part of the pharmacy enterprise (e.g., OTC medications purchased out-of-pocket)
    • NDC codes
IDS Providers
  • Points of divergence regarding the value of exchanging computable information versus human readable information:
    • Making human-readable information available gets you 85% of the value of an electronic exchange proposition -- most clinicians feel a human-readable, current document is far better than nothing.
    • Questionable value to receiving an electronic “viewable only” form of information that is currently provided as hardcopy. If all the provider receives is electronically viewable information, it stills needs to be reduced to paper/printed for inclusion in the resident record in accordance with standards of practice for recordkeeping.
Software Vendors
  • Currently there is very little electronic information exchange -- especially with transfers of care.
  • Providers see the value of information exchange -- the sell needs to be on “standardized” exchange. Vendors get many requests for one-off interfaces.
  • High value information to exchange for LTPAC providers includes:
    • demographics,
    • medications,
    • reason for hospitalization (diagnoses), and
    • plan/orders for services on discharge
  • Barriers to LTPAC participation in electronic information exchange include:
    • Technical complexity and ambiguity of some aspects related to exchange of a CCD. (NOTE: Since the interviews were conducted initiatives are underway such as the Green CDA to reduce the complexity)
    • Lack of a standardized approach for electronic information exchange across individual HIEs becomes very problematic for large multi-state national chains.
    • Vocabulary standards are currently inadequate and not readily deployable.
CMS
  • Proof of concept trial launched with Regenstrief, Healthbridge, and MedVirginia to move Continuity Assessment Record and Evaluation (CARE) data from an HIE to CMS.
    • A subset of CARE data is exchanged using HITSP C83.
    • Data collection for the demonstration slated for June through December 2010.
FACAs
  • Regarding incremental interoperability (such as a Level 1 CDA with an embedded pdf), the following philosophies from the Mayo Clinic Beacon project were shared:
    • Exchanged electronic data must be put in front of the physician in the context of their native EMR, which means the data must be machineable, manipulatable, and manageable.
    • Physicians involved in routine primary care are fearful of receiving non-standard, difficult to interpret, unfamiliar layout, information.
    • High value information such as labs, meds, allergies and problems, MAY be appropriate to exchange in a human readable format -- but it must be efficiently consumable by the clinician.
State-Level HIEs
  • New efforts underway in Delaware, Indiana and Pennsylvania to explore how LTPAC providers can be included and serviced by the HIEs.

Topic: CDA to Transfer of Care

Stakeholders were asked to discuss the use of CDAs for transfer of care. Themes from stakeholder group discussions are as follows:

TABLE A-5: CDA to Transfer of Care
Stakeholder Group Discussion Themes
LTPAC Providers
  • LTPAC Providers need to closely look at how electronically exchanged information is identified, reconciled, and incorporated into the workflow of the interdisciplinary team. In the instance of a CCD, three key use cases to address in relation to workflow are:
    • Transfer of care
    • Shared care
    • Exchange with the consumer
Software Vendors
  • LTPAC clients have not requested CCD functionality from participant vendors.
  • One of four participating vendors had the capability of generating a CCD -- all other vendors had road mapped the functionality.

Topic: Data Reuse

Stakeholders were asked to discuss the reuse of MDS/OASIS data for transfer of care summaries. Themes from stakeholder group discussions are as follows:

TABLE A-6: Data Reuse
Stakeholder Group Discussion Themes
Software Vendors
  • Concern was voiced over the latency of MDS data
    • If MDS content is used in populating the CCD, the MDS date would need to be front and center so that recipient would be clearly aware if the information was 3 months old.
    • If MDS question(s) are replicated elsewhere in EMR system, there - may be a more current response to use in populating the CCD
    • MDS questions could be useful for CCD but probably not sufficient

Topic: Standards

Stakeholders were asked to discuss any gaps or other issues that impede the deployment of HIT standards.  Themes from stakeholder group discussions are as follows:

TABLE A-7: Standards
Stakeholder Group Discussion Themes
LTPAC Providers
  • A number of LTPAC organizations operate multiple facilities located in different counties or states. When faced with exchanging electronic information with multiple HIEs, the importance of standardized information becomes critical to any scalability within these organizations.
Software Vendors
  • LTPAC vendors and providers will require guidance and assistance with the deployment of standard terminologies such as LOINC and SNOMED.

Topic: Quality Measures

In light of the quality measures incorporated into the Meaningful Use rule, participants were asked to discuss the state of quality measures in the LTPAC setting. Themes from stakeholder group discussions are as follows:

TABLE A-8: Quality Measures
Stakeholder Group Discussion Themes
National Quality Forum (NQF)

 

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