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

12/01/2011

Currently, there are three federally-mandated assessment tools used by the CMS for the purpose of compensating and assessing PAC4 -- the RAI, including the MDS, used in nursing facilities and swing-bed settings, the IRF-PAI, used in IRFs, and the OASIS, used by HHAs. Each of these instruments is a data collection tool designed to collect information in a format specified by CMS that can be submitted according to CMS’s electronic submission requirements. However, the assessment instruments require information that is not comparable across settings, require different and sometimes proprietary formats for reporting based on care setting, do not use standardized, interoperable HIT vocabularies, do not support standardized health information exchange (e.g., using HL7 messaging standards), and frequently are incapable of interfacing with an individual patient’s EHR.5

A 2004 report studying EHRs in LTPAC settings outlined some of the issues that make the collection and subsequent use of this data burdensome:

A final limitation to interoperability that also could be improved by standards development is the integration between the EHR maintained in the various LTPAC sites and the government-mandated data sets: MDS, OASIS, and IRF-PAI. In every case, the information systems for the mandated data set were completely distinct from the EHR. None of the sites was able to import information from the comprehensive clinical assessments contained in the EHR and populate mandated data sets. In most cases, the process for completing the mandated data sets was separate from the process used to maintain the EHR. Thus, the lack of integration between mandated assessments and the clinical information recorded in the EHR was a major impediment to integrated care delivery. Further, the EHR was dominated by orders and assessments written by the physician and/or nurse practitioner, and by nursing and therapy reports of medical care issues such as medications, vital signs, and treatments. However, linkage of mandated data sets and the EHR requires standardized content and messaging not only for the EHR, but also for the federally mandated data sets.6

A 2006 report on the viability of a uniform PAC assessment system, prepared for CMS and the Iowa Foundation for Medical Care, explained that the "domains, actual items, item definitions, scoring methods, and metrics differ across tools." Differences in the tools are partially due to the outcomes of care emphasized in a particular setting, so that "even when the domains of health and function are consistent across tools, many of the items used to measure them differ." This study further found that “None of the three existing CMS assessment tools for PAC (MDS, OASIS, IRF-PAI) adequately covers the spectrum of patients and the necessary domains to be used across settings, and mapping across instruments is complex.”7

A 2008 study attempting to map between the MDS and IRF-PAI, confirmed the difficulty of evaluating and tracking changes in functional status from one setting to another due to the lack of a single comprehensive assessment instrument for measuring patient outcomes, but noted that attempts to change or replace measures currently in place would face strong resistance from practitioners and administrators who use and rely on these instruments on a daily basis.8

In 2009, CMS published in the Federal Register ([74FR10050 (March 9)] and [74FR22208 (May 12]) plans for using revised versions of the OASIS and MDS data sets starting in 2010.9 In outlining plans for using a revised OASIS data set for HHAs, CMS stated:

In accordance with long-standing federal objectives, CMS ultimately plans to create a standard patient assessment instrument that can be used across all post-acute care settings. The revision of the OASIS instrument is an opportunity to consider various components of quality care and how patients might be better served as they (and information about them and their care) move among health care settings.10

In January 2009, anticipating the imminent move to a substantially revised version of MDS, the American Association of Homes and Services for the Aging, in a joint letter with other stakeholders, sent a letter to President-elect Obama’s transition team urging them not to go forward with a proprietary format for reporting MDS 3.0 data.11

In response to the Federal Register notices concerning OASIS and the MDS, a number of organizations reiterated concerns about the continued use of proprietary software for submitting data to CMS.

The National Association for Homecare and Hospice addressed the interoperability issues in comments co-signed by a number of other stakeholder parties:

The implementation of an updated OASIS data set is a unique opportunity to advance interoperability and make a significant impact on home care agencies/EHR products which is the direction healthcare is heading with a goal of widespread, interoperable electronic health records by 2014. The accepted standards exist, but CMS currently does not plan to adopt them for OASIS-C. Instead, CMS plans to continue to collect OASIS-C data using proprietary data exchange formats that are not interoperable -- this is inconsistent with the national agenda to advance EHRs and is short sighted in recognizing the opportunity with the OASIS-C rollout.12

AHIMA, in comments to CMS on proposed changes to the Skilled Nursing Facilities Inpatient Prospective Payment Systems published in the May 12, 2009 Federal Register [74FR22208], again addressed concerns about the continued use of proprietary resources for reporting data to CMS:

The proposed rule currently calls for custom transmission of MDS versus the use of HHS accepted standards. By requiring custom transmission of MDS, vendors and providers will be forced to slow their participation in national health information exchange initiatives by diverting resources and focus and develop programs for CMS compliance first, then focusing their efforts on health information exchange.13

CMS published the final rules for the skilled nursing facilities (SNFs) PPS [74FR40287, August 11, 2009] and HHAs PPS [74FR58077, November 10, 2009] and confirmed the 2010 implementation dates for MDS 3.0 and OASIS-C. In the final rule for the SNF PPS, CMS responded to stakeholder concerns by saying “CMS appreciates the comments that were submitted with regard to HIT standards and will consider these comments as the MDS 3.0 is implemented.”14

As CMS continues to improve upon PAC assessment instruments, it is clear that more work needs to be done in standardizing the data and data exchange formats to support continuity of care and interoperability of patient information maintained by the various care facilities.

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