Each year about 12 million medically complex and/or functionally impaired Americans need long-term and post-acute care (LTPAC) services in nursing homes, home health, or other settings. Persons receiving LTPAC services typically have multiple health care encounters with physicians and other clinicians. Transitions to and from LTPAC settings to emergency rooms and hospitals are common.
The need to improve care and care coordination for LTPAC patients is great. For example, about one in four Medicare beneficiaries discharged from a hospital to a skilled nursing facility is readmitted within 30 days.1 Clinical trials suggest that 20-50 percent of rehospitalizations are preventable. Preventable rehospitalizations and other suboptimal health care outcomes are detrimental to LTPAC patients and costly for federal and state governments as Medicare and Medicaid programs are the primary payers of LTPAC services.2 Most persons who receive formal LTPAC services are insured by these programs.
Definition of Interoperability
Interoperability in health care is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively and consistently, and to use the information that has been exchanged.
National Alliance for Health Information Technology
Health information technology (HIT) and health information exchange (HIE) among providers have the potential to improve the overall quality and continuity of care of LTPAC patients, reduce rehospitalizations, and control health care spending. Yet LTPAC providers do not have robust, interoperable HIT capabilities to support the electronic exchange and use of clinical information. Without these HIT capabilities, LTPAC providers face significant barriers in accessing patients' clinical information from other providers; further, hospitals, primary care professionals, caregivers and other providers cannot obtain timely and important LTPAC information. Ultimately, LTPAC providers' limited HIT capacity and engagement in HIE activities:
- Impedes care coordination and effective transitions of care;
- Retards improvements in the delivery of quality health care;
- Contributes to higher costs for payers and patients, and poor outcomes; and
- Will eventually stymie eligible professionals' and hospitals' ability to qualify for incentives for the meaningful use of HIT.3
Both the Patient Protection and Affordable Care Act (ACA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) aim to improve the quality and efficiency of health care. Many health care reform provisions depend on health care providers' ability to electronically exchange and use clinical information. Although HITECH supports the development of a nationwide HIT infrastructure for the electronic exchange and use health information, to date, limited resources have been directed to support LTPAC providers' participation in HIE activities. Although HITECH did not include financial incentives for LTPAC providers, market-driven pressures arising from payment and delivery reforms are expected to require investments in technology to coordinate care and exchange information with other providers to deliver high quality care in a safe and efficient manner. These pressures will extend to eligible providers (e.g., physicians and short-term acute care hospitals) as they attempt to qualify for their meaningful use electronic health record (EHR) incentive payments; as well as to providers ineligible for such incentives, including nursing homes and home health agencies, as they seek to position themselves in a reformed health delivery environment.
To achieve national health care reform goals, HIT policies and initiatives to advance the electronic use and exchange of health information must include LTPAC. This report describes the:
Policy rationale for engaging certain LTPAC providers (specifically nursing homes and home health agencies) in HIT activities, and describes activities underway that seek to engage these providers.
Opportunities to leverage federally mandated assessment instruments as an entrance point for engagement.
Tools to assist LTPAC providers in expanding their HIT capabilities.
Substantial gains in health care quality, efficiency, and outcomes will be potentially delayed if LTPAC providers do not adopt and use HIT and exchange capabilities. Concrete steps are needed to engage nursing homes and home health agencies and enable them to use HIT that supports electronic exchange across providers. As described later in this report, there is support for adding to future stages of meaningful use requirements that eligible professionals and hospitals have two-way electronic exchanges of clinical information with other providers -- including LTPAC -- in order for those eligible providers to qualify for federal incentives and avoid financial penalties. As hospitals and physicians -- both important referral sources for LTPAC providers -- increase their use of HIT they will exert more pressure on LTPAC providers to use standards-based technology to exchange information and coordinate care.
This report identifies opportunities and tools to support HIT adoption and use among LTPAC providers, particularly nursing homes and home health agencies by leveraging federally required assessment instruments used and electronically transmitted by almost 100 percent of these providers in the United States. The analysis and approach for engaging LTPAC providers in HIE activities result from a four-year study sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (HHS) and undertaken by the American Health Information Management Association (AHIMA) Foundation that involved input and technical expertise from a variety of public and private sector LTPAC stakeholders and experts in HIT and HIE.
The central opportunity presented in this report to engage LTPAC in HIE activities is to apply HIT vocabulary and document exchange standards to existing federally required patient assessment content thus enabling their interoperable exchange and re-use. Clinical and other experts consulted as part of this study indicated that:
Exchanging patient assessment information could improve communication between care providers and provides an important snapshot of an individual's clinical status at the time the assessment was completed.
Exchanging a summary of the patient's clinical status derived from each assessment completed provides allows for tracking and trending changes in condition over time and is useful to clinicians and case managers.
Exchanging a summary of an assessment completed prior to transition may be dated but still provides valuable information since some information is better than no information. (See discussion in the Exchanging Standardized Assessment Content for Patient Assessment Summary Documents section regarding the Keystone Beacon Community Program.)
Re-using some assessment content could provide clinically useful information to support more complex shared care and transition processes. (See discussion in Opportunities to Re-Use Standardized Patient Assessment Content and Link with Other Data section regarding the inclusion of assessment information in the creation and exchange of the Uniform Transfer Form in Massachusetts, and the creation and exchange of the home health plan of care in New York.)
In summary, an approach to accelerate LTPAC providers' adoption of more sophisticated types of information exchange and sharing capabilities would support meaningful use requirements. The exchange of patient assessment instruments (PAIs) and the re-use of assessment content could serve as the initial foundation for expanding LTPAC providers' HIT capabilities and participation in more sophisticated HIE activities. This report includes the following information and makes available a set of technical tools for LTPAC providers to begin participating in HIE.
Section II describes the methods and approaches used to conduct this study.
Section III describes the national policy priorities and the policy rationale for engaging LTPAC providers in electronic HIE activities, highlighting relevant parts of the ACA and HITECH.
Section IV provides an overview of the HIT capabilities in LTPAC and reviews existing PAIs.
Section V describes how standardized PAIs and content could be used to engage LTPAC providers in HIE activities. This section describes how interoperable PAIs and content could be used to accelerate LTPAC providers' readiness and ability to participate in the nationwide HIT infrastructure through the interoperable exchange of PAIs and patient assessment summary documents. This section also describes how standardized assessment content is being re-used in a variety of HIE activities.
Section VI describes the technical infrastructure needed to support an interoperable nationwide health information infrastructure that includes LTPAC and outlines the tools available to facilitate interoperable exchange.
Section VII discusses opportunities for expanding beyond patient assessments and advancing to more sophisticated types of HIE.
Section VIII, describes opportunities and options for next steps that could be undertaken to increase the LTPAC sector's and states' awareness of impending demands for electronic clinical information exchange.
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