IMPACT - Connecting Long Term and Post-Acute Care Organizations to the Healthcare System of the Future

1
IMPACT - Connecting Long Term and Post-Acute
Care Organizations to the Healthcare System of
the Future

• February 2013
• Drs. Larry Garber and Terry OMalley

2
Agenda

• Problems with care transitions
• What is Long Term and Post-Acute Care (LTPAC)?
• IMPACT addressing LTPAC needs
• ONCs SI Framework - Developing national
  standards for transitions of care datasets
• LAND SEE software to facilitate integrating
  LTPAC into electronic health information
  exchanges (HIE)

3
Communication Adverse Events

• Poor care coordination increases the chance that
  a patient will suffer from a medication error or
  other health care mistake by 140 (Lu, et al.,
  2011)
• Communication failures between providers
  contribute to nearly 70 of medical errors and
  adverse events in health care (Gandhi,
  et al., 2000)
• 150,000 preventable ADEs (8 Billion nationwide
  wasted) each year occur at the time of admission
  due to inadequate knowledge of outpatient
  medication history (Stiell, et al., 2003)

4
Problems With ED Visits

• Physicians in the Emergency Department (ED) lack
  important or critical patient information 32 of
  the time
• 15 of ED admissions could be avoided if the ED
  had outpatient information (Stiell, et al.,
  2003)

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Problems After Hospital Discharge

• 1.5 Million preventable adverse events annually
  nationwide from discharge treatment plans not
  followed (Forster, et al., 2003)
• When multiple physicians are treating a patient
  following a hospital discharge, 78 of the time
  information about the patients care is missing
  (van Walraven, et al., 2008)
• 20 of Medicare patients are readmitted within 30
  days. Preventable readmissions waste 26B
  nationwide annually (McCarthy, et al.,
  2009)

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Ambulatory Care is Just as Bad

• 68 of specialists receive no information from
  the referring PCP prior to referral visits
• 25 of PCPs do not receive timely post-referral
  information from specialists (Gandhi, et al.,
  2000)

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Is Massachusetts Different?

• Preventable readmissions waste 577 Million in
  Massachusetts annually
• MA ranks 35th in the nation on measures of
  quality relating to coordination of care, such as
  preventable hospitalizations for chronic
  conditions and hospital readmissions (McCarthy,
  et al., 2009)

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• National care transitions experts overwhelmingly
  identified improving information flow and
  exchange as the most important tool to improve
  care transitions (ONC, 2011)

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An Odd Twist of Fate

• 2008 Economy crashed
• 2009 ARRA passes, including the Health
  Information Technology for Economic and Clinical
  Health
• 27 Billion for hospital and MD practice EHRs
• Must use the EHR in a Meaningful way, including
  improved communication with others that have
  EHRs
• But Long Term and Post-Acute Care was left out!

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Yet Post-acute Care Costs are
Rising faster than acute care costs
Source MedPAC, 2011
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• What is LTPAC?

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The Spectrum of Care
High
Acute Care Hospital
Psych Hospital
Emergency Department
PACE
LTACH
Home Health
Outpt. Rehab
Adult Day Care
CBS
Outpt. Behav. Health
IRF
Intensity of Care
SNF
Hospice Facility
Urgent Care
Physician Office
Nursing Home
Home Hospice
Outpatient Testing/Pharmacy/DME
Assist Living
Living at Home
Acuity of Illness
Low
High
Adapted from Derr and Wolf, 2012
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Traditional Long-Term and Post-Acute Care (LTPAC)
High
PACE
LTACH
Home Health
IRF
Intensity of Care
SNF
Hospice Facility
Nursing Home
Home Hospice
Assist Living
Living at Home
Acuity of Illness
Low
High
Adapted from Derr and Wolf, 2012
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IMPACTs View of LTPAC
High
PACE
LTACH
Home Health
Outpt. Rehab
Adult Day Care
CBS
Outpt. Behav. Health
IRF
Intensity of Care
SNF
Hospice Facility
Urgent Care
Physician Office
Nursing Home
Home Hospice
Outpatient Testing/Pharmacy/DME
Assist Living
Living at Home
Acuity of Illness
Low
High
Adapted from Derr and Wolf, 2012
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The Spectrum of Care
High
Acute Care Hospital
Psych Hospital
Emergency Department
PACE
LTACH
Home Health
Outpt. Rehab
Adult Day Care
CBS
Outpt. Behav. Health
IRF
Intensity of Care
SNF
Hospice Facility
Urgent Care
Physician Office
Nursing Home
Home Hospice
Outpatient Testing/Pharmacy/DME
Assist Living
Living at Home
Acuity of Illness
Low
High
Adapted from Derr and Wolf, 2012
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• How is LTPAC Different Than Acute Care or Typical
  Office-Base Care?

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Type of LTPAC Patient

• Closer to end of life
• Greater number of health concerns, meds,
  healthcare providers, and care settings
• Reduced cognitive capabilities
• Increased risk of adverse events
• Reduced mobility increased risk of falls
• Increased transportation issues/costs
• Less financial and social support
• More legal issues

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Type of LTPAC Organization

• Limited financial and human resources
• Fewer incentives for EHRs or HIE participation
• Less likely to have risk-sharing contracts
• Not part of HITECH/Meaningful Use
• Limited technological infrastructure
• LAN/WIFI
• IT Security/Policies/Backup/Redundancy
• EHR, if present, likely to be ASP model
• Being asked to care for increasingly more complex
  patients

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MUs Impact on LTPAC

• Meaningful Use defines the datasets that
  Hospitals send when patients are discharged
• 40 of Medicare patients are discharged to
  traditional LTPAC settings (SNF, Home Health,
  Inpatient Rehab Facility, etc)
• These patients are the sickest population and
  account for 80 of Medicare costs
• Sources http//aspe.hhs.gov/health/reports/2011/
  pacexpanded/index.shtmlch1
• http//www.medpac.gov/documents/Ju
  n11DataBookEntireReport.pdf

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IMPACT Grant

• February 2011 HHS/ONC awarded 1.7M HIE
  Challenge Grant to state of Massachusetts
  (MTC/MeHI)
• Improving Massachusetts Post-Acute Care
  Transfers (IMPACT)

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IMPACT Objectives Strategies

• Facilitate developing a national standard of data
  elements for transitions across the continuum of
  care
• Develop software tools to acquire/view/edit/send
  these data elements (LAND SEE)
• Integrate and validate tools into Worcester
  County using Learning Collaborative methodology
• Measure outcomes

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• Developing National Standards to Support LTPAC
  Needs

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Datasets for Care Transitions

• Traditionally What the sender thinks is
  important to the receiver
• Future Also take into account what the receiver
  says they need

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MA DPH Universal Transfer Form

• Started with DPHs 3-pg Discharge Form
• Sought input from LTPAC receivers
• Reviewed existing forms and datasets
• MDS
• OASIS
• IRF-PAI
• INTERACT
• Sought expert opinions
• Resulted in 7-page UTF

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Massachusetts Paper UTF Pilot
Too Long!
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14x14 Sender (left column) to Receiver (top)
196 possibly transition types
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Prioritize Transitions by Volume, Clinical
Instability and Time-Value of Information
Black circles highest priority Green circles
high priority
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Receiver Data Element Survey

• 1135 Transition surveys completed
• Largest survey of Receivers needs
• 46 Organizations completing evaluation
• 12 Different types of user roles

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11 Types of Organizations
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12 User Roles
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Findings from Survey

• Identified for each transition which data
  elements are required, optional, or not needed
• Each of the data elements is valuable to at least
  one type of Receiver
• Many data elements are not valuable in certain
  care transition

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A single paper form cant represent this
variability in data needs
49 Documents Is Too Many!
Black circles highest priority Green circles
high priority
32
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Five Transition Datasets

1. Report from Outpatient testing, treatment, or
   procedure
2. Referral to Outpatient testing, treatment, or
   procedure (including for transport)
3. Shared Care Encounter Summary (Office Visit,
   Consultation Summary, Return from the ED to the
   referring facility)
4. Consultation Request Clinical Summary (Referral
   to a consultant or the ED)
5. Permanent or long-term Transfer of Care to a
   different facility or care team or Home Health
   Agency

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Five Transition Datasets

• Shared Care Encounter Summary
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc

• Consultation Request
• PCP to Consultant
• PCP, SNF, etc to ED

• Transfer of Care
• Hospital to SNF, PCP, HHA, etc
• SNF, PCP, etc to HHA
• PCP to new PCP

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Five Transition Datasets
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Additional Contributor Input

• State (Massachusetts)
• MA Universal Transfer Form workgroup
• Bostons Hebrew Senior Life eTransfer Form
• IMPACT learning collaborative participants
• MA Coalition for the Prevention of Medical Errors
  
• MA Wound Care Committee
• Home Care Alliance of MA (HCA)
• National
• NYs eMOLST
• Multi-State/Multi-Vendor EHR/HIE Interoperability
  Workgroup
• Substance Abuse, Mental Health Services Agency
  (SAMHSA)
• Administration for Community Living (ACL)
• Aging Disability Resource Centers (ADRC)
• National Council for Community Behavioral
  Healthcare
• National Association for Homecare and Hospice
  (NAHC)
• Transfer of Care CCD/CDA Consolidation
  Initiatives (ONCs SI Framework)
• Longitudinal Coordination of Care Work Group (ONC
  SI Framework)
• ONC Beacon Communities and LTPAC Workgroups
• Assistant Secretary for Planning and Evaluation
  (ASPE)/Geisinger MDS HIE

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Two Care Plan Datasets
Transfer of Care
Consultation Request
Shared Care Encounter Summary
38
Situation-specific Data Elements

• Variable Base on Situations
• Setting
• Diagnoses
• Medications
• Treatments
• Procedures

39
Care Plan Permeates Datasets
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How do they compare to CCD?

• 175 element CCD
• 325 element IMPACT for basic LTPAC needs
• 480 elements for Longitudinal Coordination
  of Care

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• Testing the
• IMPACT Dataset

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Pilot Sites to Test the Datasets

• 9/2011 Applications sent to 34 organizations
• Selection Criteria
• High volume of patient transfers with other pilot
  sites
• Experience with Transitions of Care
  tools/initiatives
• 16 Winning Pilot Sites
• St Vincent Hospital and UMass Memorial Healthcare
• Reliant Medical Group (formerly known as Fallon
  Clinic) and Family Health Center of Worcester
  (FQHC)
• 2 Home Health agencies (VNA Care Network
  Overlook VNA)
• 1 Long Term Acute Care Hospital (Kindred
  Parkview)
• 1 Inpatient Rehab Facility (Fairlawn)
• 8 Skilled Nursing and Extended Care Facilities

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Nursing Facility Pilot Sites

• Beaumont Rehabilitation of Westborough
• Christopher House of Worcester
• Holy Trinity Nursing Rehab
• Jewish Healthcare Center
• LifeCare Center of Auburn (EMR)
• Millbury Healthcare Center
• Notre Dame LTC
• Radius Healthcare Center Worcester

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IMPACT Learning CollaborativeTesting the Care
Transitions Datasets 16 organization, 40
participants, 6 meetings over 2 months, and
several hundred patient transfers
45
Learning Collaborative Surveys

• Surveys directly on envelopes carrying IMPACT
  packet, filled out by sender as well as receiver.
• Online survey at completion of pilot

46
Analyzing data elements helped
47
Senders found the data
48
Receivers got most of their needs
49
Home Care needed even more!
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Comment from Pilot Site Survey
While we knew what ED's and hospitals required,
we didn't realize Home Health Agencies needed
much more than what we typically sent.
-Skilled Nursing Facility
51
Advancing Interoperable HIE
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New World of Standards Development
National Coordinator for Health IT (ONC)
Office of the Chief Scientist
Office of the Deputy National Coordinator for
Operations
Office of the Chief Privacy Officer
Office of Economic Analysis Modeling
Office of the Deputy National Coordinator for
Programs Policy
HIT Policy Committee Defines Meaningful Use of
EHRs
Office of Policy Planning
Office of Science Technology (formerly known
as the Office of Standards and Interoperability
(SI))
SI Framework convenes public and private
experts, and proposes HIT/HIE standards
HL7 ballots standards
Secretary of HHS makes standards part of
Meaningful Use and EHR Certification
Office of Provider Adoption Support
Office of State Community Programs
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SIs Longitudinal Coordination of Care WG
Longitudinal Coordination of Care Workgroup

• Providing subject matter expertise and
  coordination of SWGs
• Developing systems view to identify
  interoperability gaps and prioritize activities

Patient Assessment Summary Sub-Workgroup
LTPAC Care Transition Sub-Workgroup
Longitudinal Care Plan Sub-Workgroup

• Establishing the standards for the exchange of
  Patient Assessment Summary (PAS) documents
• Providing consultation to transformation tool
  being developed by Geisinger to transform the
  non-interoperable MDSv3 and OASIS-C into an
  interoperable clinical document (CCD)

• Identifying the key business and technical
  challenges that inhibit long-term care data
  exchanges
• Defining data elements for LTPAC information
  exchange using a single standard for LTPAC
  transfer summaries

• Near-Term Developing an implementation guide to
  standardize the exchange of the Home Health Plan
  of Care (former CMS 485 form)
• Long-Term Identify and develop key functional
  requirements and data sets that would support a
  longitudinal care plan

http//wiki.siframework.org/LongitudinalCoordinat
ionofCare
54
Original SI ToC Use Case

• Scenario 1 - Provider to provider
• User Story 1 - Hospital/ED to PCP
• Discharge Instructions
• Discharge Summary
• User Story 2 - Closed Loop Referral
• Consult Request
• Consult Summary
• Scenario 2 - Provider to patient
• User Story 1 - Discharge Instructions and
  Discharge Summary to patients PHR
• User Story 2 - Closed Loop Referral where copies
  of Consult Request and Consult Summary are sent
  to patients PHR

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Relationship to SI ToC Scenarios

• Type 3 Dataset
• Scenario 1 2/User Story 2 Consult Summary

• Type 4 Dataset
• Scenario 1 2/User Story 2 Consult Request

• Type 5 Dataset
• Scenario 1 2/User Story 1

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LTPAC Poster Child Scenarios

• Type 3 Dataset
• Scenario 1 2/User Story 2 Consult Summary
• ED to SNF

• Anticoagulation
• CHF

• Type 4 Dataset
• Scenario 1 2/User Story 2 Consult Request
• SNF to ED

• Type 5 Dataset
• Scenario 1 2/User Story 1
• Hospital to Home Health Agency
• HHA ?? PCP (HH POC Subset)

57
SI Care Plan Use Case

• Scenario 1 - Complete handoff of care from the
  sending care team to a receiving care team
  (Hospital to SNF)
• Scenario 2 - Between care team members during
  shared care
• User Story 1 Between PCP and Home Health Agency
  for HH Plan of Care (CMS-485)
• User Story 2 Between PCP and outside Physical
  Therapist
• Scenario 3 Between providers and patient

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Timeline for Standards Development

• October 2012 MA HIway go-live in 10 large sites
  with CCD and LAND
• February 2013 Preliminary Implementation Guide
  completed
• May 2013 Pilot electronic Transfer of Care
  Datasets between 16 central Massachusetts
  organizations using MA HIway, LAND SEE
• July 2013 Finish Implementation Guides using the
  SI Framework and Lantana, incorporating
  pilot feedback
• November 2013 HL7 Balloted/Reconciled/Published
  Implementation Guides in Consolidated CDA

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Getting ConnectedLAND SEE
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LAND SEE

• Sites with EHR or electronic assessment tool use
  these applications to enter data elements
• LAND (Local Adaptor for Network Distribution)
  acts as a data courier to gather, transform, and
  securely transfer data if no support for Direct
  SMTP/SMIME or IHE XDR
• Non-EHR users complete all of the data fields
  and routing using a web browser to access
  their Surrogate EHR Environment (SEE)

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Surrogate EHR Environment (SEE)

• Acts as destination for routed CCD documents
• Software hosted by trusted authority, accessed
  via web browser
• SEE is accessed via the HIEs web mailbox
• Non-EHR users able to use SEE to view, edit, send
  CDA documents via HIE or Direct to next facility
• Can select document type (e.g. Transfer of Care
  or INTERACT SBAR) to display section flags
  indicating their optionality
• Can reconcile 2 documents to create a third
• SEE users able to locally print copies of the
  documents or subsets of the documents

62
Using SEE for LTPAC Workflows

• SNF patient getting sicker
• Subset of Transfer of Care dataset that is in
  SBAR (INTERACT) is flagged for completion by
  nurse online
• Can re-use data received from hospital
• Can re-use clinical assessment data (function,
  cognition, wound) from last MDS
• Completed SBAR printed for chart
• Patient transfer to Emergency Department
• Can re-use hospital, MDS, OASIS or SBAR data
• Multiple users (nurse, social worker, clerk,
  etc) can work on different sections online at
  same time
• Completed ToC dataset sent electronically to ED
• Subset can be printed for ambulance team

63
LTPAC Communication Today Paper!
Home Health
Non-standard EHR OASIS
PCP
Hospital
Billing Program MDS
Nursing Facility
64
LTPAC Communication with LAND SEE
LAND SEE fill in gaps
Home Health
SEE CCD OASIS
Non-standard EHR OASIS

LAND
PCP
Hospital

LAND
SEE CCD MDS
Billing Program MDS
Nursing Facility
65
The Future with LTPAC EHR Standards
Home Health
EHR OASIS CCD
PCP
Hospital
EHR MDS CCD
Nursing Facility
66
Advantages of LAND SEE

• Most role-based authentication uses EHR, using
  work that local organizations have already done
• Most users (docs nurses) only work out of 1
  system
• Data re-used whenever possible
• No blended central clinical data repository
• Case/discharge managers or nurses can control
  when and where to route documents because theyre
  the ones that know when and where!
• Non-EHR users get same HIE transport
  functionality as EHR users
• Relatively low-cost to deploy and support
• Easily scalable and replicable

67
Standard Configurations of LAND

• Necessary to support some advanced
  characteristics of IMPACT
• MDS XML documents from Nursing Facilities
• OASIS XML documents from Home Health agencies
• Expanded data set beyond what is in a standard
  CCD

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Outbound LAND configurations

• Merge a standard CCD and a second XML document
  that contains additional data elements into a
  Transfer of Care CDA document
• Transform data element transmitted via an HL7 2.x
  Results interface from an EHR into a Transfer of
  Care CDA document
• Transform an MDS XML file into a CCD
• Transform an OASIS XML file into a CCD
• Exploring the use of Pennsylvanias KeyHIE
  Transform (AKA The Gobbler) as cheaper
  alternative

69
Inbound LAND configurations

• Transform a Transfer of Care CDA document into
  a free-text document
• Transform a Transfer of Care CDA document into
  a free-text document and transmit it to an EHR
  via an HL7 2.x Transcription interface
• Transform a Transfer of Care CDA document into
  discrete data elements and transmit them to an
  EHR via an HL7 2.x Results interface
• Transform a Transfer of Care CDA document into
  a standard CCD and a second XML document that
  contains additional data elements

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Next Steps for Pilot Sites

• Update gap analysis using expanded dataset
• Catalog which data elements are captured (and by
  whom using what vocabulary) electronically, on
  paper, or not at all with current standard
  process
• Of those captured electronically (including CCD,
  MDS OASIS), identify process (technology
  workflow) to make these available to LAND (for
  Phase 2).
• Identify workflow to review new documents in SEE
• Notification by email or text message, and to
  whom?
• View online vs. print? Who does it and where?
• Can any of the data elements received be
  electronically filed discretely for re-use using
  LAND?
• Identify workflow to update and send SEE document
  with current info when discharging to Home Health
  or ED transfer
• How can standard and non-standard data elements
  be collected and added online using SEE to the
  documents being sent?
• How will copies be printed for patient and
  ambulance?
• Additional computers, printers, or chairs
  required?

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IMPACT Timeline for Next Steps
Dates Activity
9/2012 3/2013 Integrate pilot sites into state HIE using LAND SEE
4/2013 5/2013 Pilot site Go-lives with state HIE using LAND SEE
2/2013 9/2013 Ballot updated datasets in SI Framework and HL7
6/2013 7/2013 Make SEE available under Open Source License
4/2013 9/2013 Evaluate hospital (re)admissions total cost of care
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Sharing LAND SEE

• LAND
• Orion Healths Rhapsody Integration Engine
• http//www.orionhealth.com/solutions/packages/rhap
  sody
• Well make some standard configurations available
• SEE
• Written in JAVA
• Baseline functionality software and source code
  that can connect to Orions HISP mailbox via API
  available for free starting July 2013 (Apache
  Version 2.0 vs. MIT open source license)
• Innovators can develop and charge for
  enhancements, for example
• Integration with other vendors HISP mailboxes
• Automated CDA document reconciliation

73
Disseminating the Seeds
IMPACT Advisory Committee Massachusetts Care
Transitions Forum Massachusetts QIO (MassPRO)
Worcester Galaxy
Worcester Galaxy
Another Galaxy
Another Galaxy
Pilot Sites
Core Project Team
Pilot Sites
Pilot Sites
Core IMPACT Team
Core ProjectTeam
Another Galaxy
Pilot Sites
Core Project Team
Another Galaxy
Another Galaxy
Pilot Sites
Pilot Sites
Core Project Team
Core Project Team
74
Questions?
TOMalley_at_Partners.org Lawrence.Garber_at_ReliantMedic
alGroup.org
75
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