While leveraging patient assessment content and making it interoperable might be a low-cost and opportunistic approach to engaging LTPAC provides in HIE activities, it is not perfect for summary information needed at ToC. These assessments are completed at prescribed points in time during a person's LTPAC episode. Nursing home assessments can be up to 89 days old and home health agency assessments can be as old as 59 days. The concept of exchanging not just the full MDS 3.0 and OASIS, but also a more concise summary document (a subset of the most clinically relevant items) emerged from on the expert interviews and discussions with the Keystone Beacon Community.
Clinical advisers to this study indicated that: (1) having dated information was better than having no information; and (2) assessment documents include data elements that are likely to be stable over time and clinically relevant at times of transitions/shared care. While less ideal for ToC, submitting patient assessment summary information to an HIE organization each time the MDS and OASIS is completed provides valuable information to support care coordination, shared care and case management processes.
Content for the MDS and OASIS assessment summary was identified as part of this study with input from clinicians (i.e., nursing home and home health agency providers, representatives from hospitals and integrated delivery systems, physicians, and nurses) (see Appendix J: Patient Assessment Summary for Health Information Exchange). The Keystone Beacon Community will be piloting the exchange of interoperable patient assessment summary documents using the HIT content standards identified and linked, under this study, to the MDS 3.0 and OASIS. Document exchange specifications for the exchange of assessment summary documents are under development at Keystone Beacon Community and their vendor partner GE, as well as in the ONC S&I Initiative LCCWG. The Keystone Beacon Community and the ONC S&I Initiative LCCWG are using the MDS 3.0 and OASIS Rosetta Stone resources developed under this study (see Appendix D: MDS Rosetta Stone Spreadsheet, Appendix E: OASIS Rosetta Stone Spreadsheet, Appendix K: MDS Assessment Summary Rosetta Stone, and Appendix L: OASIS Assessment Summary Rosetta Stone).
Diagram 1 illustrates the information flow for bringing almost all nursing homes and home health agencies into HIE activities in a cost-effective manner. In this scenario, non-HIT sophisticated LTPAC providers (they do not presently use interoperable HIT/EHR products) could transmit the federally required PAIs to the HIE organization who could transform it into an interoperable document and/or assessment summary that would be made available to authorized users.
|DIAGRAM 1. Exchanging Interoperable Assessment Content by a Non-HIT Sophisticated LTPAC Provider|
The top half of Diagram 1 shows the current state of HIE for most nursing homes and home health providers where federally required assessments are electronically transmitted to CMS. This exchange uses a format specified by CMS rather than industry-accepted HIT content and exchange standards (i.e., the assessment exchange is not interoperable).
The bottom half of Diagram 1 shows:
How the LTPAC provider could transmit the same non-interoperable patient assessment document that is transmitted to CMS to a HIE organization.
The HIE Organization could:
- Transform the non-standard CMS assessment document into an interoperable assessment document (i.e., link the assessment items with HIT content standards); and/or
- Generate an interoperable Patient Assessment Summary Document (a subset of assessment items that clinical experts indicate would be clinically useful to exchange at times of transitions in care and/or shared care).
The HIE Organization could make available the standardized assessment document and/or the Patient Assessment Summary Document to authorized entities (such as physicians, hospitals, other LTPAC providers, patients/family members).
"StratEng.pdf" (pdf, 1.74Mb)
"StratEng-A.pdf" (pdf, 198.14Kb)
"StratEng-B.pdf" (pdf, 534.93Kb)
"StratEng-C.pdf" (pdf, 214.97Kb)
"StratEng-D.pdf" (pdf, 4.65Mb)
"StratEng-D1.pdf" (pdf, 12.32Mb)
"StratEng-D2a.pdf" (pdf, 3.62Mb)
"StratEng-D2b.pdf" (pdf, 3.58Mb)
"StratEng-E.pdf" (pdf, 3.66Mb)
"StratEng-F.pdf" (pdf, 162.5Kb)
"StratEng-G.pdf" (pdf, 340.24Kb)
"StratEng-H.pdf" (pdf, 173.91Kb)
"StratEng-I.pdf" (pdf, 194.52Kb)
"StratEng-J.pdf" (pdf, 311.03Kb)
"StratEng-K.pdf" (pdf, 4Mb)
"StratEng-L.pdf" (pdf, 2.33Mb)