Electronic Communication Across Provider Settings: Connecting NH Providers

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Electronic Communication Across Provider
SettingsConnecting NH Providers

• June 10, 2005
• Wendy Angelo, MD
• Dan Venecek, PMP

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Objectives

• Discuss Existing Systems
• Clinical Workflow Examples
• Gaps in clinical handoffs
• Proposed plan to address clinical information
  sharing

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Concord HospitalLead Partner in AHRQ Grant

• Second busiest acute care hospital in NH
• 205 beds
• Regional referral area 275,000
• 15,500 admissions in 2004

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Capital Region HealthCare

• More than 2,600 employees
• 300 physicians on medical staff
• 75 employed physicians
• Serves 5 counties in central New Hampshire
• Approx. 750,000 patient contacts/visits per year

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Located in Central NH
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Concord Area Partner Organizations

• Concord Hospital
• Concord Hospital Primary Care Practices
• Concord Hospital Family Health Center
• Dartmouth Hitchcock-Concord Clinic
• Concord Regional VNA
• Riverbend Mental Health Services

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Concord Hospital Technology

• Over 10 years experience with barcoded medication
  administration
• A decade of EMR experience
• PACS Medical Imaging System
• Physician Portal
• gt 25 systems communicating via Interface Engine
  technology
• Implementing Electronic Patient Record (Document
  Imaging)

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Concord Regional Visiting Nurse Association

• Horizon Homecare - McKesson
• Clinicians maintain coded medication lists
• Medications reconciled from patient home
• Centralized database updated with clinical
  information entered remotely
• Shared clinical information
• electronically (Physician Portal)
• Implementing Telehealth technology

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Riverbend CommunityMental Health

• TIER - Sequest technologies
• Communication tool for multi-disciplinary team
• Document visits
• Tracking federal and state required forms

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Over 170 providers accessing more than 125,000
electronic patient records
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EMR in the Concord Area
Laconia
70
8
5
6
3
Hillsboro
147
5
5
3
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• For a rural community we are fortunate to have a
  depth of EMR penetration and a culture of
  collaborative practice that enhances our ability
  to take on quality improvement at a community
  level.

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Current Electronic Communications

• Communication between hospital services and the
  practices
• HL7 interfaces between lab, radiology, hospital
  transcription, and the outpatient EMR
• Secure messaging of rehab progress notes to PCP
• Primary care to specialty care
• electronic outbound referrals from ambulatory EMR
  
• Secure messaging between providers
• Specialty care consult notes to primary care
• interfaced directly into ambulatory EMR

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Current Electronic Communications

• Providing the right information at the right
  time
• ED granted access to EMR
• Physician Portal brings together hospital
  experience (EKGs, images)
• Clinical data gathered by VNA can be viewed via
  Physician Portal

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Communication Between Inpatient and Outpatient

• Wrap-around EMR
• Using tools that directly pull information from
  the outpatient to the inpatient environment
• Discharge processes that facilitate the
  maintenance of the outpatient record
• Tools and processes used by hospitalists to
  smooth transition points

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Clinical Handoff Scenario Hospital Admission
Orders

• Hospital admission template in EMR
• Order sheet auto-populates with problems,
  allergies, and medications
• Decreases transcription errors
• Creating hospital admit orders within EMR

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Clinical Handoff Scenario Hospital Discharge
Dictation Placeholder for Hospital Course
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Clinical Handoff Scenario Hospital Discharge
Easy to read patient discharge instructions
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Even with our current technologies and
collaborative environment there are many examples
of difficult transitions
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The Biggest Risk at Any Transition Point is
Medication Error
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Our Current PilotPre-op Medication Reconciliation

• Pt is pre-op for lung surgery
• Surgery about to be canceled because of elevated
  liver functions of unknown etiology
• Going through pre-op process
• Clearance nurse realized that he was on two meds
  that PCP did not know about
• Letter faxed to PCP
• PCP had him discontinue meds
• Liver functions improved

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Barriers to Medication Reconciliation

• Varying Accuracy of Medication Lists
• Often does not represent what the patient is
  actually taking
• OTC, herbs, vitamins, meds stopped or started by
  patient
• Difficult, if not impossible, to share discrete
  data electronically
• Information not shared between episodes of care
  in different settings
• Provider push back on any workflow that increases
  their workload

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How do we overcome these barriers

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Its NOT about the technologyIt is about getting
the right people at the table

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Leadership

• Recognized Challenges
• A sense of urgency that this issue needs to be
  addressed
• Financial Match Commitment and Fair Distribution
  of Shared Costs
• Support for needed changes at each organization
• Liability concerns among partners
• Governance Structure

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Collaboration of the Clinical Community

• Clinical and Frontline Staff from each partner to
  address
• How to keep the project patient centered
• Patient Privacy Confidentiality Concerns (HIPAA
  Standards)
• Sensitivity to provider workload and Clinical
  Workflow Changes

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Our Vision of Success

• Organizational Success Defined by
• A cultural change has occurred
• Actively seeking collaboration between partners
• Workflows re- engineered to be more
  Patient-centric

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Our Vision of Success

• Technological Success Defined by
• All partner EMRs store medications in a discrete
  format
• Able to share the same medication list across
  provider settings
• Use Automated Technology to Broadcast
  Updates/Changes to all of a patients providers
• Measure number of updates/changes broadcast and
  number accepted

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Our Proposed Technological solution

• The creation of a community wide grid

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Technology SolutionNovo Innovations, Inc

• Information captured in local EMR
• Continuity of Care (CCR) record updated
• Changes securely broadcast to all nodes on the
  grid
• Provider notified of change and allowed to update
  EMR

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Development Considerations

• Events when is the information acquired and
  distributed?
• Extraction how is the data acquired from the
  local EMR?
• Patient matching who is the patient, who has
  interest in the patient?
• Intervention how do providers receive and
  accept data?
• Insertion how is data input into the local EMR?

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Why we will succeed

• Collaborative environment established
• Record of successfully implementing clinical info
  systems
• Focused on quality and patient safety
• Partner clinicians and IT
• Patient safety demands that we succeed