Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Overview: LTPAC Interoperability Toolkit

12/01/2011

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has been facilitating the further automation and interoperability capabilities of the long-term and post-acute care (LTPAC) community in part through the development of a LTPAC Interoperability Toolkit to support re-use of standards-enabled, semantically interoperable assessment content from the minimum data set (MDS) and Outcome and Assessment Information Set (OASIS) for patient care summaries (and other documents) that can be exchanged with physicians and other providers. These tools are needed to support the re-use of assessment content.

The LTPAC Interoperability Tool Kit provides a suite of tools that takes into account the current and widely varied electronic capabilities across LTPAC settings to make it as easy as possible for LTPAC systems to exchange interoperable information with health information technology (HIT)/electronic health record (EHR) systems used by other health care providers (e.g., physicians, hospitals, other LTPAC settings). In brief, the Toolkit links HIT content standards to the MDS and OASIS assessment and guides the creation of patient assessment summary documents that re-uses data from the LTPAC provider and can be exchanged with physicians and other providers.

FIGURE G-1: Current State: Data/Document Creation and Exchange in Most LTPAC Providers
Flow Chart: Non-interoperable Data in LTPAC EHRs & Medical Records (Demographics, Problem, Allergies, Medications, Immunization, Lab orders and results, Functional and Cognitive Status Assessments, Advance Directives, MDS data, OASIS data, Other). Leads to Exchange: LTPAC to CMS (Tools: Electronic Transmission to CMS using CMS MDS/OASIS data transmission specifications in EHR application), or Exchange: LTPAC to Other Providers (Tools: Mail, fax, image, email; Vendor and application specific software and tools to create various documents and reports). Exchange: LTPAC to CMS leads to Non-interoperable Electronic Assessments (MDS (CMS); OASIS (CMS)). Exchange: LTPAC to Other Providers leads to Paper-based or Non-interoperable Documents (MDS/OASIS; Face Sheet; Problem Lists; Allergy List; Physician Order (Medications and Treatment); Lab Reports; Progress Notes; Other documents and reports).

Implementation of the Health Information Technology for Economic and Clinical Health legislation, including requirements for the meaningful use of certified EHRs, and the Patient Protection and Affordable Care Act are creating opportunities for LTPAC providers to electronically exchange and re-use health information to support quality, improve coordination and continuity of care, and increase efficiencies.

Figure G-1 illustrates some of the data in records maintained by LTPAC providers that is used to create and exchange certain documents. As discussed more fully bellow, at present, this data often not digitized and is seldom linked to HIT content standards.

Figure G-2 highlights how data in LTPAC records can be linked with HIT vocabulary standards and re-used to create standardized documents for purposes of interoperable health information exchange (HIE) by LTPAC providers and other health care providers, HIE entities, caregivers, or other authorized entities. Use of HIT standards is expected to lower the cost and complexity of HIE activities. In some cases, the LTPAC provider may wish to directly exchange health information with other providers. Alternatively, HIE Organizations may wish to facilitate the exchange of information between LTPAC providers, other providers, and other entities. Whether the HIE is direct between providers or via HIE Organizations the tools highlighted in Figure G-2 could be used by the exchanging organization to support the exchange of this health information.

FIGURE G-2: Transforming and Exchanging Interoperable LTPAC Provider Data
Flow Chart: Non-interoperable Data in LTPAC EHRs & Medical Records (Demographics, Problem, Allergies, Medications, Immunization, Lab orders and results, Functional and Cognitive Status Assessments, Advance Directives, MDS data, OASIS data, Other). Leads to Exchange: LTPAC to CMS (Tools: Electronic Transmission to CMS using CMS MDS/OASIS data transmission specifications in EHR application), or Exchange: LTPAC to Other Providers (Tools for Transforming LTPAC Data into Interoperable Content: Rosetta Stone for MDS and OASIS; HL7 CDA Patient Assessment Questionnaire IG and Conversion/Validation Tools; Patient Assessment Summary Documents Rosetta Stone for MDS and OASIS; CCD Implementation Guide; Under Development: CDA/CCD Specifications that reuse assessment content and other EHR data for Patient Assessment Summary Documents, Transfer/Discharge Documents, Care Plans). Exchange: LTPAC to CMS leads to Non-interoperable Electronic Assessments (MDS (CMS); OASIS (CMS)). Exchange: LTPAC to Other Providers leads to Paper-based or Non-interoperable Documents (MDS/OASIS; MDS/OASIS Patient Assessment Summary; Discharge/Transfer Documents; Care Plans; Advanced Directives).

LTPAC EHR systems vary widely in existing capabilities. While most LTPAC settings have electronic means of capturing and communicating the MDS or OASIS assessment instruments, many do not have electronic problem lists, electronic allergy lists, electronic medication lists, etc. Many settings are entirely paper based while some a have full EHR implementations.1 Plans for implementation of electronic systems variesacross providers. Some centers have placed priority on digitizing order entry, problem lists, or allergies and some have implemented electronic nursing documentation. While some provider’s HIT system may include standardized vocabularies, those providers that do have electronic patient data, this data is more often supported by local codes.2

A transfer-of-care situation requires an optimal level of information to continue to provide quality care. Too little or missing information could lead to dangerous or life-threatening events, while too much information creates “information overload” that may cause the receiving provider to miss critical quality and safety concerns. In a patient population where recovery and progress is often slow and difficult, even minor delays in the exchange of needed health information can result missed medications, and continuing therapies and treatments that can cause costly weeks of rehabilitation and patient regression.

The stakeholder interviews (Appendix A) repeatedly stated that problem lists, current medications, allergies and recent vital signs were the most important elements in information exchange between settings. In addition, stakeholders felt that functional and cognitive status history would be valuable in continuing uninterrupted care.

LTPAC Interoperability Toolkit

To support LTPAC providers participation in HIE activities an Interoperability Toolkit was created. The Toolkit is expected to lower the costs that LTPAC vendors and implementers would otherwise incur with creating and reusing semantically interoperable assessment content:

  • MDS Rosetta Stone: A resource for the MDS 3.0 which links assessment items to applicable terminologies and code sets including Logical Observation Identifiers Names and Codes (LOINC), Systematized Nomenclature of Medicine (SNOMED), International Classification of Diseases (ICD-9-CM and ICD-10). (Appendix D)

  • OASIS Rosetta Stone: A resource for the OASIS-C which links assessment items to applicable terminologies and code sets including LOINC, SNOMED, ICD-9-CM, and ICD-10. (Appendix E)

  • Clinical Document Architecture (CDA) Patient Assessment Questionnaire Implementation Guide (IG): Describes how to represent a patient assessment questionnaire that includes functional status content as a standardized CDA compliant document. This IG was developed and balloted as a draft standard and includes the MDS as an example of how to format patient assessment questionnaires in a CDA-Extensible Markup Language (XML) compliant format. Health Level 7 is expected to finalize this standard in late 2011/early 2012. (Appendix G)

  • MDS Conversion/Validation Utilities: Various tools for transforming the MDS from the Centers for Medicare and Medicaid Services (CMS)-required and the CDA-XML format, validating that a MDS in CDA format is conformant, etc. (Appendix G)

  • Continuity of Care Document (CCD) Implementation Guide: Provides general guidelines on how to construct a valid CCD document. (Appendix G)

  • Patient Assessment Summary Rosetta Stone for MDS: A resource which identifies a subset of assessment content from the MDS 3.0 to provide a clinical summary or snapshot of the patient for the point in time that the assessment was completed. The Rosetta Stonelinks the subset of assessment items from the MDS 3.0 to applicable terminologies and code sets including LOINC, SNOMED, ICD-9-CM, and ICD-10. (Appendix K)

  • Patient Assessment Summary Rosetta Stone for OASIS: A resource which identifies a subset of assessment content from the OASIS to provide a clinical summary or snapshot of the patient for the point in time that the assessment was completed. The Rosetta Stonelinks the subset of assessment items from the OASIS-C to applicable terminologies and code sets including LOINC, SNOMED, ICD-9-CM, and ICD-10. (Appendix L)

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