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Continuity of Care Adoption

Guide for Victorian Public Health Services

FINAL - DRAFT

Version Amendment History

Version Author Date Nature of Amendment

0.1 Health Design Authority 12/12/2012 Document Creation

0.2 Health Design Authority 5/02/2012 Updated following internal review

1.0 Health Design Authority 6/02/2012 Final for HDF release

OCIO Health Design Authority

Health Design Authority Report

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Table of Contents

1. Executive Summary.................................. ............................................................. 3

1.1 FINDINGS ...........................................................................................................................................5

2. Introduction....................................... ..................................................................... 8

2.1 BACKGROUND ....................................................................................................................................8 2.2 SCOPE ...............................................................................................................................................8 2.3 OBJECTIVES .......................................................................................................................................9 2.4 ASSUMPTIONS ....................................................................................................................................9

3. Continuity of Care Adoption ........................ ....................................................... 10

3.1 THE CONTINUITY OF CARE COMMUNITY .............................................................................................10 3.2 CONTINUITY OF CARE INTRODUCTION................................................................................................11

4. Continuity of care Analysis........................ ......................................................... 16

4.1 INFORMATION SHARING MODELS .......................................................................................................16 4.2 INFORMATION MODELS .....................................................................................................................22 4.3 FOUNDATION ELEMENTS ...................................................................................................................24

5. Conclusion ......................................... .................................................................. 26

5.1 SUMMARY ........................................................................................................................................26

6. Glossary ........................................... .................................................................... 28

7. Bibliography....................................... .................................................................. 29

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1. Executive Summary

The provision of healthcare has changed considerably in the last decade. Patients are commonly moving across various care settings within an organisation, or attending a variety of organisations for an episode of care. A number of services are now being provided in the home and the diversity of specialist organisations is increasing. This change has created a shift in the way that healthcare is traditionally delivered. As a result of this patients and service providers report significant fragmentation in the availability of information, communication and provision of care in this distributed environment.

Medical and personal information is typically collected from the patient and recorded at each service entry point. This is generally contrary to consumer expectations that information and communication regarding their medical condition, personal treatment preferences, and medical history is readily available to all service providers. Due to these changes and additional advances in service provider technologies, continuity of care has gained a high level of focus.

Continuity of care is often described in terms of a framework that gauges the provision of informational, management and relational continuity for the patient and provider. Informational continuity encompasses details of medical conditions, healthcare events, handover (particularly through documentation) and review of notes from previous consultations but also takes into consideration patient preferences. Management continuity relates to complex or chronic disease cases where many providers are involved in the care planning and delivery. Relational continuity addresses the link from current to future care as well as referring to a sustained long term relationship with doctors or health professionals. All three elements of this framework are key to improving patient outcomes and should appear seamless as health professionals share information to ultimately provide the best care to the patient, despite organisational and jurisdictional boundaries.

A key benefit that is associated with addressing continuity of care is improved patient care and a noticeable reduction of adverse clinical outcomes. Discontinuity of care has shown that there is lower quality of care follow up and significantly higher risk of re-admission to inpatient, emergency and other settings. International studies show approximately 50% of patients experience the impacts of discontinuity of care. (JAMA, 2007)

Continuity of care adoption and improvement are continuing activities at local, national and international levels. This document focuses on the relevant information sharing approaches and associated standards that will support continuity of care processes. There are many other key enablers that are required to ensure that a robust continuity of care environment is fully established, however interoperability is well recognised as a key priority. Continuity of care has a strong alignment with co-ordinated services, planning and communication across multi-disciplinary care teams, and is highly focussed on patient awareness, empowerment and satisfaction for care outcomes.

Key enablers for adoption include:

• Partnerships and networks

• Funding and incentives to enable continuity of care initiatives

• Cultural change and training needs

• Service boundaries

• Application functionality in referral, clinical and administration management systems

• Community consultation.

The NEHTA Care Continuum diagram below represents a graphical view of the patient journey through the health sector. It highlights the overall patient focus, the breadth of the processes, and the ehealth solutions required to support an IT-enabled and efficient health sector.

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© NEHTA 2013, reproduced with permission

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As the diagram above illustrates, there are many components that need to be considered in order to enable more effective continuity of care, each one being complex and requiring detailed analysis. The primary focus of this analysis is aligned one of these components, ICT and the electronic information models that best support these goals. In order to provide quality improvement in care, a common theme is the need for standards to be developed for the electronic transfer of data and the quality and consistency of the information for this purpose (Centre for General Practice Integration Studies, UNSW. Feb 2005).

The continuity of care definition can be very broad and encompass any number of models and functions depending on the care setting needs. For the purposes of this paper information models for continuity of care include:

• Discharge summary: point-to-point from a health organisation to general practitioner or specialist and point-to-share from a health organisation to a shared repository with EHR like capability

• eReferral: typically point-to-point

• Electronic health summaries: point-to-share or point to point

• Other clinical document types, such as continuity of care documents, specialist letters, etc.

Sharing continuity of care information in an electronic form currently has a low level of adoption and adherence to standards in Victoria. This issue is compounded when electronic information is shared across jurisdictional boundaries. The level of continuity of care adoption is varied across the state and nationally. A national standard for a shared health summary has been proposed by NEHTA however; this is not specific to continuity of care and has very limited adoption at this point in time. The ability to send and receive eReferrals is limited within Victoria, messaging is non-standard and a variety of approaches have been used. In contrast, discharge summary distribution is well established and is gaining a high level of adoption.

NEHTA has recently proposed Clinical Document Architecture (CDA) standards for eReferral and discharge summary and funded a limited number of pilot projects:

• The Victorian Wave 1 Site Support Project

• The NEHTA Rapid Integration of PCEHR project.

Although there has been good engagement across jurisdictions, these implementations have shown that there are limitations to the standards that have been developed and approved to date and that implementation timeframes can be lengthy.

The main challenges identified with widespread adoption of NEHTA standards are:

• Funding for adoption of the relevant standards that have been proposed

• Appropriate roadmap for transition of adoption from current processes to proposed NEHTA standards

• Lack of foundation elements in place to support national health initiatives.

1.1 Findings A continuity of care solution should include electronic multi-team and team-to-patient communication capability. Although this is not the key analysis of this document, the benefits of communication in conjunction with sharing patient record details are shown to be key. Methods such as telecommunications, telemedicine, email, or social media tools have been used with success.

Analysis presented in this document shows that the highest level of patient care in relation to information sharing could be achieved by adopting a point-to-share (central repository) model, in conjunction with continuing adoption of point-to-point discharge summary and eReferral solutions. This is referred to as a

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hybrid information-sharing model. Enterprise healthcare applications such as mature EMRs may need to be established within health organisations to support this approach. International trends are also showing a tendency toward a hybrid approach.

Consideration of the use of the Personally Controlled Electronic Health Record (PCEHR) repository or a similar type of repository for continuity of care purposes is relevant to this analysis. There are limitations with the PCEHR for this purpose; the repository is personally controlled (and therefore summary details may not be complete) and the NEHTA Shared Health Summary specification shows inconsistent support for continuity of care requirements. The PCEHR has a document-centric approach and therefore provides a passive aggregation of information.

Improvements to electronic referral must continue, both within Victoria (Service Coordination Tools Template and the Victorian Statewide Referral Form), and nationally with NEHTA’s eReferral specification and the extensions necessary to support two way messaging (e.g. referral acceptance or rejection). This is fundamental to sector standardisation and delivering continuity of care benefits.

The current use of discharge summaries, mainly in HL7 2.x form, will continue and should be expanded wherever possible. Consideration should be given to the use of NEHTA CDA standards for discharge summary. This approach has a high level of standardisation for rendering and interoperability, a roadmap that aligns funding, timeframes for product enhancements, and production readiness are the main barriers at this point in time. The reach of discharge summary should be extended into other areas of the health sector, such as specialists and Community Health.

The following foundation elements need to be established in order for continuity of care information sharing to be achieved:

• A highly reliable and accurate means of identifying patients across the Victorian Health Sector (VHS) needs to be in place. Adoption of the national individual health identifier (IHI) should be considered for this purpose however there are limits to its use and at this point in time it is considered to be a secondary identifier, the implementation and adoption of a Victorian statewide patient master index may need to be considered in conjunction with the use of the IHI.

• Development and adoption of interoperability standards endorsed for the state of Victoria. A compliance and conformance process will need to be established in order to ensure compliance with standards is achieved. A consistent set of terminology needs to be agreed.

• A shared Victorian repository that includes comprehensive information for continuity of care could facilitate maximum benefits for the VHS and should be considered. The repository should act as an EHR, provide basic decisions support capability, portal access and the capability to present the information that has been gathered in an intelligent manner. This approach requires alignment with strategic directions for the sector, and feasibility assessment as the cost of implementation, maintenance and conformity for adoption may be high.

• A highly reliable and accurate means of identifying practices and practitioners participating in continuity of care processes. The National Human Services Directory and national provider identifiers should be leveraged to the maximum degree possible.

Continuity of care has been identified as a high priority item for many developed countries. The United States have a large scale “meaningful use” program examining how health information is systematically collected, shared, and ultimately utilised, in a patient-centric way. This program is providing valuable change and adoption learning for other health jurisdictions, especially around the development of processes and principles of care transitions.

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The Massachusetts State Quality Improvement Institute has identified a range of principles that would assist them to realise their vision for improving care transitions:

1. Timely feedback and feed forward of information through standardized care plans/transition records or other formats are essential to improving care transitions and reducing unnecessary costs.

2. Communication Infrastructure should support efforts to improve care transitions.

3. Patient and family engagement is essential to improving care transitions.

4. Accountability for care during a transition will remain with the sending set of providers until the receiving set of providers has acknowledged responsibility for the care of the patient.

5. Provider and Practice Engagement are essential to insuring safe, effective transitions.

6. Improvement in Care Transitions should be assessed using standardised process and outcome measures, based on nationally endorsed measures when available.

It is generally agreed these principles need to be in place in order to complement electronic information sharing.

Given the evolving change in the nature of healthcare practice and the increasing fragmentation in continuity of care, a strategic roadmap toward closing the continuity of care vision should commence.

An appropriate roadmap to establish the foundation elements that support continuity of care should be defined: funding and realistic timeframes (long term) for the adoption of the many foundation elements that have not been established to date need to be considered for any significant initiative of this nature. The analysis in this document leads toward an adoption roadmap of the following nature:

• Establish strong Victorian standards for continuity of care information based on the CCD

• Assist NEHTA to establish a complete eReferral CDA standard

• Continue to foster discharge summary in HL7 2.x and transition to NEHTA CDA formats

• Establish a information sharing conformance and compliance governance process

• Ongoing programs to foster and support elements described above

• Feasibility assessment of a continuity of care repository, including costs and roadmap

• Ongoing input and adoption of NEHTA programs

• As per the finding of the Massachusetts State QII, Victoria will need to identify a range of principles and supporting programs that would assist them to realise their vision for improving care transitions, that will support the informational elements defined below.

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2. Introduction 2.1 Background OCIO Health Design Authority

The Office of the Chief Information Officer (OCIO) Health Design Authority (HDA) has been established to collate local, national, and international insights to gain a holistic and vendor agnostic understanding of healthcare applications and their relationship to standard healthcare business processes. This view will lead high quality healthcare application solution approaches for the VPHS by taking into account national and international trends in health ICT design.

The HDA mission is to drive a common vision and understanding for healthcare applications in the Victorian Health Sector (VPHS). Healthcare applications and ICT rely on proven standards, guidelines and principles to enable and encourage good clinical practice and interoperability across health information hubs. Standards enable the environment to be flexible in its approach to the specific applications and technologies that are adopted, without restricting innovation.

The Victoria Department of Health is focused on encouraging innovation by establishing clear principles and standards that establish proven ICT and application solutions that act as a foundation for the future. This HDF will be used to assist in establishing these principles. Standards and principles in healthcare are often complex and open to interpretation. A clear understanding of this knowledge and a rigorous foundational approach to its application in the VPHS is critical for success.

The HDA acts as a central body for aggregating and sharing this type of knowledge. An ongoing commitment to increasing the level of expert healthcare ICT knowledge across the VPHS is fundamental to delivering healthcare outcomes through the use of ICT. Facilitating this capability is a core role of the HDA.

2.2 Scope The Health Design Forum has expressed an interest in examining continuity of care adoption for Victoria. Central to a shared understanding of continuity of care is that, ‘The unit of measurement of continuity is fundamentally the individual. Continuity is not an attribute of providers or organisations. Continuity is how individual patients experience integration of services and coordination. Continuity of care crosses disciplinary and organisational boundaries’ (Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfield, B.H., Adair, C.E. and McKendry, R. 2003).

The Victorian healthcare sector is typically highly capable of managing the exchange of patient information between healthcare organisations however there are many disparate enabling technologies based upon different standards. NEHTA has recently defined a number of national standards and terminologies supported by a change and adoption program that enables the sector to trial many elements of a continuity of care approach.

The HDA recognises the breadth of the challenge to bring substantive improvements to continuity of care practices in Victoria, or nationally. And this would involve changes to existing business processes and behaviours, both for clinicians, their support staff and patients and their families, among a host of similar environmental and cultural changes. The role of the HDA in primarily one of furthering interoperability within the health sector; accordingly the scope of this paper, as discussed within the HDF, focuses on the more technical enablers for continuity of care, i.e. interoperability, information, and standards that deliver improved health outcomes for patients.

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2.3 Objectives • To identify the key processes and information sets that support continuity of care across health

organisations in the Victorian healthcare sector for example:

o Diagnostic results, medications and diagnosis information, or other

o Referral, discharge, and other care planning and coordination processes

• Assessment of proven models that facilitate a common and interoperable approach toward continuity of care. Identify approaches to continuity of care that provide evidence based patient care benefits and outcomes

• Identify national and international directions that influence standardisation and interoperability in the continuity of care area

• Identify foundational capabilities that must be in place for effective continuity of care processes to be realised, provide a roadmap towards the desired future state.

2.4 Assumptions The following assumptions apply to this document:

• Victorian health services are separate legal entities. This has implications on the various continuity of care approaches that have been proposed.

• In Victoria, diagnostic systems such as pathology and imaging are typically independent applications, each product will vary between health services.

• It is anticipated that continuity of care solutions will also vary from state-to-state.

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3. Continuity of Care Adoption 3.1 The Continuity of Care Community

© NEHTA 2013. Reproduced with permission

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The diagram above shows the range of stakeholders in the health sector. The complexity of the environment in which healthcare is delivered is significant, with many different types of organisations and people, which have vastly different characteristics and capabilities. Continuity of care involves interactions between these different organisations and people and mirrors the complexity of the sector as a whole.

It is important to note that the patient is placed at the centre of the Community Architecture, and this is consistent with local views of continuity of care – the patient is always the primary participant.

3.2 Continuity of Care Introduction Ongoing change in healthcare practice has promoted significant development in the manner in which healthcare is delivered. Often drivers such as cost efficiencies, funding models or new advances in medical procedures have influenced this change. Mental health services in Australia have moved toward community and home care, length of stay had decreased in the inpatients setting and day surgery services have been promoted. Patients are moving across settings within one organisation or increasingly attending a growing number of organisations for a single episode of care. A number of services are now being provided at home, and the diversity of specialist organisations is wide (Coleman, E.A, JAGC 2003).

This is a distributed health care environment where patients and service providers experience a significant fragmentation in the availability of information, communication and provision of care. Often common information such as medications details, alerts, allergies, next of kin, cultural requirements, diagnosis and advanced care directives are typically re-queried and re-entered at each service entry point. Tests are often re-ordered. Consumer expectations have also recently changed given the widespread adoption of information technology in many other service industries. It is easily assumed that information and communications about a patient’s medical condition, their preferences and history is readily available to all service providers.

Continuity of care is often described in terms of a framework for the provision of informational, management and relational continuity for the patient and provider. Informational continuity encompasses details on medical condition, but also takes into consideration patient preferences. Information accumulates as a patient care progresses. Management continuity relates to complex or chronic disease cases where many providers are involved in the care planning and delivery. Services need to be provided in a manner that is complimentary and timely. Relational continuity addresses the link from current to future care.

Victoria has applied independent organisational approaches to continuity of care processes most are currently manual. The distribution of electronic discharge summaries has been the most recent change that has enhanced continuity of care capability. Although there is a mature referrals program (SCTT), this content is generally managed using manual forms. eReferrals are also limited and the distribution of electronic summary care information is not present.

The meaning of continuity of care can differ greatly from one organisation or service provider to another, making related benefits difficult to measure. While there seems to be a lack in definitive measures on the direct benefits of continuity of care programs, current literature sights a number of articles that repeatedly target the benefits and evidence of continuity of care programs targeting chronic disease management, maternity services, child health and development groups, and a decreased attendance at emergency departments. In conjunction, continuity of care improves the uptake of preventative care, enhances adherence to therapy and increases patient and provider satisfaction. (Shultz, K. Rosser, W., 2007), (NSW DH, AHMAC, 2008).

There are a limited sets of approaches that can be used to implement information sharing for continuity of care. This paper focuses on three feasible approaches for distribution and access continuity of care information.

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This document assesses various information sharing adoption options including:

• Option 1: Point-to-point information sharing. Continuity of care information is distributed electronically from one organisation to the next at the point in which a patient in transferred for care

• Option 2: Point-to-share information sharing. Continuity of care information is sent to a central Electronic Health Record repository (an EHR that includes a viewing portal), every time that a patient concludes care within an organisation. In this model the repository (share) is assumed to have a level of passive decision support capability, portal access for active access to information, and the capability to present the information that has been gathered in an intelligent manner

• Option 3: A hybrid approach, information is shared using both options above.

It is important to clearly define the purposes for the continuity of care process in order to determine the relevant situations in which care continuity is required. Given a patient centric view of continuity, the need to access summary information from and recent care event may be very disjointed. A care organisation or provider may typically be focussed on handing on summary details to a named care organisation, e.g. a discharge summary upon discharge, or in situations where a patient is transferred to another organisation to continue treatment for a given condition/episode.

The common informational processes that are used to support continuity of care are listed below:

• Discharge Summary/Summary Letter : It is currently a very common practice to send an electronic inpatient discharge summary or emergency summary letter to general practitioners. There is an ongoing trend toward uptake, approximately 40% or more of discharge summaries are now sent electronically to general practitioners in the VHS. Discharge summaries are generally sent as textual documents within a Health Level 7 (HL7) 2.x framework. General practitioner systems are not currently highly capable of receiving and processing this detail in an atomic format. Many of the systems that produce discharge summaries have yet to be configured to send atomic information electronically.

• eReferral: There is limited use of standardised eReferral in the VHS. Often the mechanisms in place are not standards based and do not address the full requirements of an eReferral solution. Significant application enhancements is required in order to process eReferral information, describe clinical pathway information within the eReferral, match patient details and accept or reject referrals with notification back to the requesting provider. NEHTA standards address some of the terminology and messaging standards required, however the full eReferral messaging acknowledgement processes have yet to be defined and is key to the eReferral process.

• Shared Health Summary: There are no known electronic health summaries that are currently distributed in the VHS. NEHTA is currently funding Medicare Local Networks across Australia to trial this capability, i.e. distributing shared health summary details from a general practitioner to the PCEHR. Although there is some basic adoption of this capability in primary care, health sector software is generally not capable of sending or receiving this information.

It is important to be clear about the definition of interoperability and capabilities such as health information exchanges (HIE) for the purpose of this document. These terms are often used interchangeably in articles and in every day health discussions. The concepts are however very different, and render separate key capability and requirements for the continuity of care information sharing process. Integration engines and HIEs are technologies are middleware that are used to assist in achieving information sharing between applications.

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Interoperability is an end-to-end process, the following definition assists in the delineation of this definition.

“There are two parts to the definition of interoperability: 1) The ability of two or more systems to exchange information 2) The ability of those systems to use the information that has been exchanged This means that health information exchange is different than health information interoperability. Exchange is a necessary for interoperability, but it is not sufficient by itself to achieve health information interoperability.” (Fridsma, D. 2013)

The options above have been assessed on compliance to the benefits framework detailed below, this information is used as the criteria to measure the strengths and weaknesses of each option. The following benefits table has been used to assess the options above. This information is referenced and adapted from (NiHi, 2010).

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Key measures and benefits assessment Option 1: Point-to-point information sharing. Continuity of care information is distributed electronically from one organisation to the next at the point in which a patient in transferred for care Option 2: Point-to-share information sharing. Continuity of care information is sent to a central Electronic Health Record repository, every time that a patient concludes care within an organisation Option 3: A hybrid approach, information is shared using both options above.

Class Benefit eHealth Intervention Performance Measures HDA Importance

HDA Rating Option 1

HDA Rating Option 2

HDA Rating Option 3

Productivity Improved efficiency Short Term

Comprehensive continuity of care solution encompassing: Implementation of, eReferrals, discharge summary

Long Term

Comprehensive continuity of care solution including: State-wide PACS, shared health summary, common business processes and application integration.

Cost reduction, cost containment and avoidance, increased productivity, reduced duplication of test/procedures and administrative data duplication, and sharing of key patient information across entities

High 8 8 9

Support program reform or health system change management

Interoperable Health Information Systems supporting information sharing, support for programs such as SCTT and VSRF, change management programs

Impact on success of reform or change initiative

High 7 7 7

Access Improved service Telemedicine, Information systems, care pathways, eReferral support for Continuity of Care, service availability and capacity planning

Easier access to health services in remote areas, reduction in wait-times/lists for medical and surgical procedures

High 7 8 9

Improved quality and access to data for research

EHR, Victorian registries and repositories, data governance and standards programs

Increased availability of data, improved quality of data

High 6 8 8

Quality Improved patient health outcomes

Access to common clinical pathways, input to Clinical Decision Support, access to patient medications, and history

Reduced mortality (specific causes), reduced morbidity (clinical events, physiologic and metabolic measures), level of disability, functional status, symptom status, quality of life

High 7 8 9

Improved population health outcomes

Public health surveillance systems, crisis communications systems, public health portals, adherence to

Rapid response to threat situations

Reduced mortality (specific causes), reduced morbidity (clinical events,

Medium 5 8 8

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terminologies and codesets physiologic and metabolic measures)

Improved safety EHR, VEMR, Clinical Decision Support, access to common clinical pathways

Reduction in preventable adverse events High 6 8 8

Patient empowerment Patient-oriented web portals, email, patient access to personal electronic health record

Patient satisfaction surveys, rate of access to electronic services (e.g. hits on website)

High 5 8 8

Patient satisfaction All eHealth interventions Patient satisfaction surveys, level of patient inquiries and complaints

High 5 8 9

Improved privacy and security

Strong authentication, logging of system interventions (access, add, modify, delete), non-repudiation

Reduction in privacy and security incidents, effective response to privacy and security incidents

High 8 6 6

Costs Positive cost benefit outcomes

Cost benefit analysis, staff and administrative support systems. ABF measurement capability

Performance and benefits measurement, Return on Investment (ROI) measurement

Reduced patient assessment processes

High 7 5 5

Note: Measurement scale is from 1 to 10. 10 is high compliance and good/high benefits (Productivity, Access and Quality). The information in this table assumes an end state for options proposed, and does not factor the costs associated with building or refining the solutions proposed.

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4. Continuity of care Analysis

The Massachusetts State Quality Improvement Institute has identified the following barriers to implementing and facilitating effective care transitions:

• Lack of integrated care systems

• Lack of longitudinal responsibility across settings

• Lack of standardised forms and processes

• Incompatible information systems

• Ineffective communication

• Failure to recognise cultural, educational or language differences

• Compensation and performance incentives not aligned with goal of maximising care coordination and transitions

• Payment is for services rather than incentivised for outcomes

• Care providers do not learn care coordination and team based approaches in school

• Lack of valid measures of the quality of transitions.

While these items reflect the US healthcare system, the issues identified are universal and directly relate to adoption both in Victoria and Australia. This information highlights a number of common issues and has a direct correlation to the analysis on information sharing models below.

4.1 Information Sharing Models All the information-sharing models described below assume a high level of standardised interoperability. The messaging (packet of information) definition and terminology use requires a strong level of standardisation in order for continuity of care information to be processed electronically and interpreted correctly (UNSW, 2005, P29). Interoperability across applications is categorised by two levels:

• Atomic information: the discrete individual elements of information that are grouped into categories. E.g. individual elements that make up patient details: name, gender, address. This type of information can be processed and utilised by another application effectively providing for true interoperability capability

• Document information: this is typically a textual document of information, e.g. a Portable Document Format (PDF). Information of this type provides a diminished level of information sharing, and is a limited form of information sharing.

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4.1.1 Option 1 – Point-to-point Information sharing

In this option, information for the purposes of continuity of care is always shared from one organisation to another. Information would be sent or requested at the time that a patient is booked for a service. This process is well aligned to co-ordinated care models or where patient care is transferred from one known organisation to another known organisation. Currently electronic discharge summary and some eReferral information is shared under this arrangement. It should be noted while this is common practice, the Victorian Health Sector (VHS) (as a whole both public and private health organisations) has no known instances of sharing health summary details electronically across organisational boundaries in a standards based form.

The last organisation that collated continuity of care information for a patient is generally unknown to the general provider community. It is therefore very difficult to make a request for the most recent instance of a patient’s health summary within this point-to-point paradigm. Sharing health summary details in a point-to-point model will continue have this ongoing limitation.

Benefits and functional capability assessment

A point-to-point information sharing approach for continuity of care has limited benefits over and above current practice. Electronic discharge summary processes currently exist and are relatively standardised. eReferral processes are in use, and although some open standards are also used, e.g. Service Co-ordination Toolset Templates and HL7, vendors are still using non-standardised eReferral approaches that restrict other entrants into this market.

Shared Health Summary (SHS) information is not distributed well electronically. These processes do not provide general access to information for a patient or general access at any point in time to a service provider. Some patient and efficiency benefits are realised for specific and fixed care pathways, e.g. chronic disease management, however general access to information for continuity of care is not readily accessible.

Business Process alignment

Point-to-point information sharing is more aligned to discharge summary and eReferral processes. Discharge summaries are specifically designed to send to the patient’s general practitioner or specialist. eReferral processes are also designed for referral to a specific clinic and or provider for a designated service, therefore eReferral processes are highly aligned to a point-to-point information sharing model. Shared health summary information is not well aligned to a point-to-point information sharing model, ideally this information would be available at any point in time for patient centred continuity of care needs. It is not always clear as to when the patient or service provider may need this information for continuity of care processes. (UNSW, 2005).

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Option 1 - Strengths and Weaknesses The following strengths and weaknesses have been identified for Option 1: point-to-point distribution of continuity of care information:

Strengths

• Facilitates continuity of care benefits for specific patient care scenarios, particularly pre-determined pathways

• Facilitates alignment to state-wide and national information and interoperability standards for continuity of care details, given a standards based approach

• Improved and consistent technology implementation approaches

• Facilitates active decision support capability as a result of standardised information sharing and processing

• High productivity efficiencies, no manual duplication of continuity of care information, information is duplicated electronically

• Reduced health service ICT training needs

Weaknesses

• Does not facilitate a single consolidated and consistent patient record for the VHS. Data is only shared as required, and is not easily accessible on demand

• Limited patient satisfaction for care outcomes, patient access to information is not facilitated, and consumer choice is not facilitated

• Strong alignment to a fixed set of protocols for clinical practice, potentially stopping innovation

• The current VHS allows multiple pathology vendor applications to be adopted across the state. This prohibits consistent levels of results reporting given the variety of measures, and reference ranges experienced across multiple laboratories. A standardised continuity of care process does not resolve this issue

• This model requires strong governance and a compliance and conformance framework to ensure interoperability and information standards. This capability is not currently established

Opportunities

• Can facilitate alignment toward state-wide statutory reporting, foundation for appropriate business intelligence reporting, KPIs, and benchmarking in the future

• Capability to adopt a common and consistent pathology results across the VHS in the future

• Alignment toward a single Victoria/National patient identifier

• Strong alignment and compliance for interoperability standards to external systems: for eReferrals, shared health summary information and discharge summary details

Threats

• Vendor directions in the future do not align with the strategic directions of Victoria or Australia. Capacity to change multiple vendor solutions for this purpose in the future

• Continued divergence with terminology, information and interfacing standards, without strong governance and compliance processes in place

• Inherent risks should vendors not experience sustainability in the market

• A whole of state approach will align best practice, however, this can also stifle innovation

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4.1.2 Option 2 – A Point-to-share Information distr ibution model

In this option, information for the purposes of continuity of care is shared from any organisation to a central repository (share) with common for access to Victorian care providers. Information would be sent to the repository every time that a patient has had service provision (episode) at an organisation. This process is well aligned to all care models as information will be readily available at any point in the patients care journey. There are no known approaches of this nature currently utilised in the VHS.

A key component of this approach is the assumption that the repository (share) will have passive decision support capability, portal access for active access to information, i.e. a EHR with portal viewing capability, and the capability to present the information that has been gathered in an intelligent manner.


A point-to-share information-sharing approach for continuity of care has a number of increased benefits over and above current practice. Improved access to continuity of care information for care providers and patients as the most recent continuity of care details can be accessed as required, reduced manual duplication of information. Continuity of care information can be retrieved from the share (repository) and viewed via a portal arrangement or stored in local systems as required.

It is anticipated that if this functionality is available patient satisfaction and empowerment may increase, complaints and inquiries on current healthcare information will be reduced as patient would have more access and control of their data. Data quality improvements can only result if there are appropriate information and data quality standards in place.

Process alignment

Point-to-share information sharing is more aligned to the distribution of shared health summary detail. Summary data will be readily available as required, rather than in specific care processes. There is limited value in distributing eReferral information to a central repository, eReferral detail is more aligned to managing the referral process. Discharge summary details are specific to general practitioner workflows and design for this set purpose.

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Option 2 - Strengths and Weaknesses

The following strengths and weaknesses have been identified:

Strengths

• Facilitates Continuity of care benefits for all patient care scenarios. Provides for a single consolidated and consistent patient Continuity of care record for the VHS. Data is only shared as required, and is not easily accessible on demand

• Facilitates alignment to state-wide and national information and interoperability standards for Continuity of care details

• High patient satisfaction and care outcomes. Easy and consistent access to electronic clinical information for a patient in Victoria

• Facilitates productivity efficiencies alleviating manual duplication of information. Facilitates easier access to some patient record information

• Facilitates a single consolidated and consistent summary patient record for the VHS. Data is accessed on demand

• A number of patient satisfaction and care outcomes are enhanced

• Information does not need to be stored in local systems, the shared repository will store the most recent Continuity of care information for access

Weaknesses

• A point-to-share model has increased cost, a state-wide Continuity of care repository with view access for the VHS needs to be designed and built

• Strong alignment to a fixed set of protocols for clinical practice, potentially stopping innovation

• This model requires strong governance and a compliance and conformance framework to ensure interoperability and information standards. This capability is not currently established

• The current VHS allows multiple pathology vendor applications to be adopted across the state. This prohibits consistent levels of results reporting given the variety of measures, and reference ranges experienced across multiple laboratories. A standardised Continuity of care process does not resolve this issue

Opportunities

• Strong patient satisfaction and patient care opportunities for Continuity of care processes

• Strong alignment for state-wide statutory reporting, foundation for appropriate business intelligence reporting, KPIs, and benchmarking

• Capability to adopt a common and consistent pathology results across the VHS in the future

• Alignment toward a single Victoria/National patient identifier

• Strong alignment and compliance for interoperability standards to external systems: for eReferrals, shared health summary information and discharge summary details

Threats

• Vendor directions in the future do not align with the strategic directions of Victoria or Australia. Capacity to change multiple vendor solutions for this purpose in the future

• Continued divergence with terminology, information and interfacing standards, without strong governance processes in place

• A whole of state approach will align best practice, however this can also stifle innovation

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4.1.3 Option 3 – A hybrid approach, information is shared using both options above

In this option information is shared for continuity of care using both options above. Information would be sent from an organisation to a central shared repository, as well as distributed to a named organisation (in the event that there is transfer of care to another organisation). In addition to the details provided above, a hybrid approach can provide the transitional step toward adoption of a point-to-share method. In both cases information must be generated from health systems at the end of an episode of care and enhancements are necessary for healthcare systems to have this capability. This information could initially be viewed as a document, rather than processing this detail and integrating the information into the receiving system. This would provide a basic level of continuity of care information to be shared, while a continuity of care repository is established. Option 2 & 3 are closely related to HIE approaches, continuity of care information is a subset of the information that is shared using a HIE. Further information on HIE and Hybrid HIE approaches referenced in (Health Information and Management Systems Society, 2009.)


A hybrid information sharing continuity of care approach has all the benefits of the two models defined above.

Option 3 Strengths and Weaknesses The following additional strengths and weaknesses (to Option 2) have been identified:

Strengths

• Ongoing support and evolution of key existing Continuity of care processes, eReferral and Discharge Summary

• Provides an interim Continuity of care path while a point-to-share approach is built

Weaknesses

• No further weaknesses identified

Opportunities

• No further opportunities identified

Threats

• No further threats identified

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4.2 Information Models A number of standards that support continuity of care currently exist both nationally and internationally. The most prevalent international standard is the USA continuity of care Record (CCR) and continuity of care Document (CCD). These are standards based specifications that have been developed by HL7 committees in collaboration with a number of technical and health professional bodies in the USA. The standards encompass the relevant information and technical details that support clinical practice and continuity of care processes. The standard is based on the HL7 Clinical Document Architecture (CDA) and the Reference Information Model (RIM) specifications, in conjunction with this a number of vocabularies have been mandated, e.g. SNOMED-CT. Evidence shows that take-up of the CCR has not been high, while the situation with the CCD is the reverse, i.e. it is being adopted fairly broadly, partly as a result of the Meaningful Use program.

The USA has established incentives for adoption of health records, termed as “Meaningful Use”, CCD was selected as the relevant messaging standard. At a high level it includes the following sets of information:

• Patient Demographics

• Family and social history

• Episode details, dates, treatment provided

• Alerts and Allergies

• Medications

• Problems and Diagnosis

• Advance Directives

• Diagnostic Results

• Plan of Care

• HealthCare Providers details

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A diagrammatic representation of the CCR and is show below:

Source: ASTM International

The most consistent Australian standards that support continuity of care are the NEHTA Shared Health Summary (SHS), discharge summary and eReferral specifications. These are standards based specification that have been developed by NEHTA in collaboration with a number of Australian technical and health professional bodies. The standards encompass the relevant information and technical standards that support the capability to enable clinical practice for a patient and healthcare provider. The standard is based on the HL7 Clinical Document Architecture (CDA) specifications, in conjunction with this a number of vocabularies have been recommend, e.g. SNOMED-CT. Standards Australia HL7 IT-014 is currently reviewing these specifications.

This SHS standard has similar elements to the USA CCD, however it there are variances as the content is specifically designed for the Australian PCEHR. There are some limitations for use in continuity of care context, patients must self register before any information can be sent to the PCEHR, access to the PCEHR is token based for service providers, and the portal provides a passive view of discharge summary and shared health summary details. A reasonably comprehensive, yet limited set of shared health information is available in the specification, for example diagnostic results are not currently part of the standard. The information that is in the NEHTA shared health summary includes (NEHTA, 2012):

• Patient Demographics

• Allergies and Adverse Reactions

• Medications

• Current and Past Medical History

• Immunisations

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• Problems and Diagnosis

• Procedures

• Healthcare provider details

The NEHTA discharge summary is a CDA document that aligns with HL7 V3 and is currently under trial. General practitioner systems have yet to be enhanced to receive CDA discharge summaries however adoption of this model is expected over the next 2-3 years.

A number of sources provide details on the degradation in patient care and adverse clinical outcomes without high quality information transfer.

“Research is beginning to show that poor information transfer and discontinuity are associated with lower quality of care on follow-up, as well as adverse clinical outcomes. Moore et al found that errors related to discontinuity of care occurred for about 50% of patients and that lapses in communication related to diagnostic evaluations were associated with a significantly higher risk of readmission.” (JAMA, 2007)

These sources also provide details on the most relevant types information that assist in reducing this occurrence. In addition to the USA CCD definitions, which also include some of the detail below, additional details that assist the continuity of care process are as follows:

• Details on the information provided to the patient and family

• The patients condition or functional status at discharge

• Details of follow-up arrangements, appointment or procedures to be scheduled, tests pending at discharge

• Care planning and care pathway details

• Advance directives

An Australianised version of the HL7 2.x is currently used to distribute discharge summary information from health services to general practitioners. Wide use of this process has been established in Victoria and across the nation. General practitioner systems have been enhanced to receive and process this data. The use of a Victorian services for this type of messaging is gaining acceptance.

Although there is some use of the HL7 2.x standard for eReferral, adoption has been limited due to the many application enhancements required for the many forms that relate to eReferral and the complexity of end-to-end application requirements in order to facilitate eReferral business requirements.

4.3 Foundation Elements

To realise the full potential of continuity of care capability for the VHS a combination of foundation elements and practices need to be established. The following core elements need to be in place for continuity of care information sharing to be achieved.

• Consistent state-wide patient identifier. Currently every health service in Victoria records an independent identifier for every patient that attends a healthcare institution. Ideally the NEHTA Individual Healthcare Identifier (IHI) could be used to address this issue. There are however limitations with the current IHI design, namely IHIs can be optional, cannot be allocated in a timely manner to newborns and will not be allocated to deceased or international patients. These criteria will generally provide an 80% match to existing patient records. Patient information across health services cannot be consolidated without this capability.

Given that continuity of care information impacts a wide range of organisations both private and public, although there are currently some issues with utilising the IHI as primary

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identifier within health organisations, a high percentage of continuity of care patient records could be distributed using this identifier. Further assessment of this option is required.

• Distribution of continuity of care information requires a comprehensive provider services directory in order to determine the relevant service, care provision, provider and clinical organisation to and from which services will be provided. This capability determines the relevant end point in which to send information, and established an authenticated and authorised sender.

• Secure delivery of information point-to-point and point-to-share. Secure access to continuity of care information for patients and care providers.

• Distribution of continuity of care information requires strong a strong Information, terminology and interoperability standards framework to be in place. The OCIO Design Authority should define standards in order to ensure that open and vendor independent interoperability approaches are in place.

• A common statewide and/or national Provider Services Directory is required in order to distribute continuity of care information from one organisation to another, this facility provides service details, provider identification and facilitates many other foundation elements in to distribute information. Victoria currently utilised the Human Services Directory for this purpose, this has recently been made available nationally as the National Provider Services Directory (NPSD). A large percentage of General Practitioners and other providers in Victoria are registered in this directory. Although a number of health applications utilise this directory, there are many more applications that do not.

• Change in culture and practice is required to support the distribution of information of Continuity of care. Standardised terminology, care planning, community and patient adoption and training, provider adoption training, and changes to current continuity of care business processes. The introduction of standards and information technology will require a large change management program to be established.

• A strong governance framework needs to be established to support the interoperability and information standards for sharing continuity of care information. In the past vendors have adopted variations to HL7 and other standards making point-to-point messaging for functionality such as discharge summary or eReferral difficult to achieve by being non standard. A variety of different vocabularies for the same purpose have also been used across vendor solutions, e.g. independent provider directories have been established when the state-wide Human Services Directory (HSD) has been available for this purpose. Messaging and terminology for Victoria requires agreement and endorsement, a conformance and compliance process with appropriate governance around version and change management is required to support and information and interoperability standards.

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5. Conclusion

5.1 Summary Continuity of care is a broad subject, there are many areas which require attention in order for complete and effective adoption to be in place across information, relational and management continuity.

Both local and overseas experience highlight trends toward the potential value of a portal based solution (for example the PCEHR repository with portal viewing capability) to support continuity of care functions, including eReferrals.

Overseas Scotland’s SCI Gateway (NHS Scotland) provides the health sector with a portal based eReferral solution, including the ability to book appointments as well as creating and sending a referral. Recent enhancements have included full support for HL7 messaging and documents, providing health IT system vendors with another connectivity option. Over 95% of GPs is Scotland use this solution, with nearly 100% of referrals being processed through the SCI Gateway (NHS Scotland). Health Boards in Wales have also adopted this solution.

In Canada (Ontario and Manitoba) there are care transition portals available, and these go well beyond the handling of referrals, though eReferral remains an essential element of the solution. Manitoba, under their Bridging General & Specialist Care program, has followed the Scottish model with integration of booking services in their portal, and has also achieved integration with the provincial EHR. The Ontario Health Links program is designed to deal with the more human aspects of care coordination, such as engaging the patient and their family and the needed healthcare providers (OMH).

While the need for data transcription remains less than ideal, the results achieved through these portals, and their planned enhancements to support HL7 messaging and CDA documents, provides both strong capability and a degree of flexibility to the healthcare practitioners. Across the world specialised care coordination portals remain common, with many different health areas being represented, from cancer (many countries represented) through to child development (ABCD II program) in 5 US states, for example.

Given these international trends and the (information sharing) analysis in this document the highest level of patient care would be achieved by adopting a point-to-share (central repository) model in order to share continuity of care details, in conjunction with continued and ongoing point-to-point adoption of discharge summary and eReferral solutions. In this document this is referred to as a hybrid information-sharing model. Given that the PCEHR does not currently provide passive decision support and an active consolidated view of information, the analysis indicates a direction toward implementing a Victorian EHR that includes the relevant capability to meet continuity of care functionality as well as other strategic initiatives. Information could then flow to the PCEHR from this repository, should the use of the PCEHR become a strategic direction for Victoria in the future. The PCEHR being the vehicle for consumer access to information, as per it designated purpose. A Victorian repository of this nature would however need to align with strategic directions of the sector. Significant cost associated to this approach and this should therefore be in the form of a feasibility assessment.

The NEHTA shared health summary (SHS) does not include all of the information that is required for continuity of care. The HL7 International continuity of care document (CCD) has a comprehensive set of detail that addresses information sharing. Victoria should consider adopting the Continuity of care Document (CCD) as the base standard for continuity of care information sharing. As the SHS is a subset of this information, this also facilitates providing SHS detail to the PCEHR with minimal effort should this information need to be sent to the PCEHR in the future. A full assessment of the viability of the CCD for continuity of care is required prior to progressing with this option.

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The standardisation and implementation of eReferral solutions is currently low. Application enhancements and alignment to Victorian standards such as SCTT are not prevalent. eReferral take up within vendor applications has been low due to the cost of enhancement, lack of clear national standards and funding incentives. The current NEHTA eReferral specifications are also not complete, with full bi-directional eReferral messaging required for this process to work. As there has been low adoption for the current HL7 2.x, SCTT and associated application enhancement, and as most general practitioner software is currently being enhanced to NEHTA specifications, it is proposed that:

• The NEHTA CDA eReferral specifications be funded to be completed and made comprehensive

• Funding incentives for application enhancements should be geared toward NEHTA CDA eReferral standards

• eReferral information sharing should continue to be shared in a point-to-point method.

Discharge summary distribution is currently well established utilising HL7 2.x formats across the sector. Health service applications provide the relevant functions to create and manage discharge summaries. Distribution and delivery services are well established and general practitioner systems can process and display this information. Discharge summary report details are currently sent in a document format and not as discrete data elements. Consideration should be given to adopting NEHTA CDA discharge summary specifications incrementally, they are mature and the relevant application enhancements required to adopt this standard are being implemented. It is recommended that HL7 2.x documents continue to be shared to general practitioners as NEHTA specifications are adopted, these format should also be sent to the a central repository (share).

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6. Glossary

Term Description

AMT Australian Medicines Terminology

CPOE Computerised Practitioner Order Entry

DH Victorian Department of Health

EHR Electronic Healthcare Record

EMR Electronic Medical Record

GP General Practitioner

HIE Health Information Exchange

HMO Hospital Medical Officer

HIMSS Healthcare Information and Management Systems Society

HSD Human Services Directory

IHI Individual Healthcare Identifier, national NEHTA patient identifier

NEHTA National eHealth Transition Authority

OCCC Organisation Centric Continuity of care processes

OCIO Office of the CIO, Victorian Department of Health

PAS Patient Administration System – a system used for the recording of patient and provider information to support management and coordination of service provision.

PDF Portable Document Format

PCEHR Personally Controlled Electronic Health Record

PCCOC Patient Centric Continuity of care processes

PBS Pharmaceutical Benefit Scheme

SNOMED CT Systematised Nomenclature of Medicine Clinical Terms

VHS Victorian Health System

VPHS Victorian Public Health Sector

VEMR Victorian Electronic Medical Record, state-wide medical record for Victorian patients

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7. Bibliography

Centre for General Practice Integration Studies, UN SW. Feb 2005. Integration and Continuity of care, 28th February 2005.

Coleman, E. A. JAGS 2003. “ Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs” Available: http://onlinelibrary.wiley.com/doi/10.1046/j.1532-5415.2003.51185.x/full [Accessed January 2013]

Department of Health Victoria, 2012. “Health Design Authority EMR Evaluation Tools and Core”.

Fridsma, D. Jan 2013. “Interoperability vs Health Information Exchange: Setting the Record Straight”

Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfiel d, B.H., Adair, C.E. and McKendry, R. 2003 . Continuity of care: a multidisciplinary review, in British Medical Journal, 327, 22 November, 1219-1221. Health Information and Management Systems Society, 2009. Topic Series: HIE Technical Models, from the HIMSS Guide to participating in HIE November 2009.

Journal of the American Medical Association, 2007. “ Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians – Implications for Patient Safely and Continuity of care”. Available: http://jama.jamanetwork.com/article.aspx?articleid=205790 [Accessed January 2013]

National E-Health Transition Authority, 2012 “ Shared Health Summary” https://vendors.nehta.gov.au/public/index.cfm (PCHER Sheared Health Summary) [Accessed January 2013]

National Institutes of Health Informatics Canada (N iHi). 2011. “Benefits Realisation”. Available: http://ehealthrisk.wikispaces.com/Benefits+Realization/ [Accessed 3rd October 2012].

NSW Department of Health, AHMAC 2008 “ Primary Maternity Services in Australia, A framework for Implementation”. Available: http://www.ahmac.gov.au/cms_documents/Primary%20Maternity%20Services%20in%20Australia.pdf. [Accessed 18th January 2013].

Shultz, K., Rosser, W., CMAJ Nov 2007. “Promoting continuity of care should be integral to any health care system”. Available: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072971 [Accessed 18th January 2013].

Massachusetts State Quality Improvement Institute , Massachusetts Strategic Plan for Care

National Transitions of Care Coalition (NTOCC). 201 0. “Improving Transitions of Care with Health Information Technology”, available at http://www.ntocc.org/Portals/0/PDF/Resources/HITPaper.pdf [Accessed 3rd December 2012].

HL7/ASTM Implementation Guide for CDA Release 2 Continuity of Care Document (CCD®) Release 1, available at http://www.hl7.org/implement/standards/product_brief.cfm?product_id=6 [Accessed 3rd December 2012]

New Zealand National Institute for Health Innovatio n “GP Empowerment through Pathways and Electronic Referral Management: Shifting health service provision from secondary to community”, Jim Warren, Yulong Gu, Karen Day, Malcolm Pollock, Sue White [Accessed 3rd December 2012]. NHS Scotland SCI Gateway product overview, http://www.sci.scot.nhs.uk/products/gateway/gateway_prod_overview.htm [Accessed 31st Jan 2013]

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NHS Scotland SCI Gateway 11.1 Sending Referrals User Guide (PDF), 2006, available at http://www.sci.scot.nhs.uk/products/gateway/gate_docs/user/Gateway%2011.1%20Sending%20Referrals%20User%20Guide.pdf [Accessed 31st Jan 2013]

NHS Scotland SCI Gateway 11.1 Receiving Referrals user Guide (PDF), 2006, available at http://www.sci.scot.nhs.uk/products/gateway/gate_docs/user/Gateway%2011.1%20Receiving%20Referrals.pdf [Accessed 31st Jan 2013]

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Ontario Ministry of Health and Long term Care (OMH) , Health Links Program, http://news.ontario.ca/mohltc/en/2012/12/about-health-links.html [Accessed 31st Jan 2013]

National Academy for State Health Policy , Oklahoma’s Web Portal: Fostering Care Coordination Between Primary Care and Community Service Providers, Larry Hinkle, Carrie Hanlon, available at http://www.nashp.org/sites/default/files/OK.Web_.Portal.pdf [Accessed 31st January 2013]

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