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C-CDA Direct Messaging: Are We There Yet?
Baylor Scott and White Health
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PresentersCherie Price, RN, CTT+, IQCIBaylor Scott & White Healthcare at GrapevineRN Care Manager and Care Management Informatics
Cindy Sunderman Neese, MSN, RN-BC, CPHIMSBaylor Scott & White HealthcareNurse Informaticist, Manager — eQuality MeasuresStrategy and Operations, STEEEP Analytics
Oscar Glorioso, RN, MSNBaylor Scott & White Healthcare Clinical Application Specialist IIAllscripts EHR — Clinical Documentation Team
Abeezar Shipchandler, MD, FACPInternal Medicine/HospitalistBaylor Regional Medical Center at PlanoClinical Assistant Professor Texas A&M HSC COM, Dept. of Internal MedicinePhysician Clinical Informatics Leader, Baylor Scott & White Health
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Special Thanks
Joseph H. Schneider, MD, MBA, FAAP
David Nickel, PMO
Linda Hodges, PMO
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Introduction
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Learning Objectives
• Identify pre-implementation considerations and potential challenges to implementing inbound/outbound direct messaging of C-CDA visit summaries
• Discover methods of C-CDA data exchange for outbound direct messaging of C-CDA documents
• Learn about the benefits of implementing inbound/outbound direct messaging of C-CDA documents
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The Road Ahead
Baylor Scott & White decided to implement C-CDA not only to avoid steep penalties from Medicare, but also as part of our goal to achieve strong transitions from the inpatient setting to the next level of care.
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The Journey
• Resource planning
• Development
– Technical configuration
• C-CDA document data mapping and configuration
• HISP configuration
• MU2 dashboard development
– Workflow development
• Implementation
• Monitoring and Meaningful Use attestation
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Resource Planning
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C-CDA Document Configuration
• Patient Information• Reason for Referral• Reason for Visit• Functional Status• Treatment Plans• Instructions• Discharge Diet• Hospital Discharge
Instructions
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C-CDA Document Configuration
• Vital Signs• Medications• Problems• Hospital Admission
Diagnosis• Hospital Discharge
Diagnosis• Allergies• Results• Procedures• Immunization• Social History
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C-CDA Document Configuration
• Encounters• Health Care Provider• Patient Contacts
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Data MappingCXD_Functional_Status
Extremity Movement
298331001^Normal motor response to command (finding)^SNOMED CT
MAE on command, no obvious deficits noted
225606002^Abnormal movement (finding)^SNOMED CT
MAE on command, no obvious deficits noted except
225606002^Abnormal movement (finding)^SNOMED CT RUE
225606002^Abnormal movement (finding)^SNOMED CT LUE
225606002^Abnormal movement (finding)^SNOMED CT Bilateral UE
225606002^Abnormal movement (finding)^SNOMED CT RLE
225606002^Abnormal movement (finding)^SNOMED CT LLE
3915700^Flaccid paralysis (finding)^SNOMED CT
Flaccid
26544005^Muscle weakness (finding)^SNOMED CT Weakness
163605002^On examination - quadriplegia (disorder)^SNOMED CT Quadriplegic
163604003^On examination - paraplegia (disorder)^SNOMED CT Paraplegic
163660009^On examination - flexion contracture
(disorder)^SNOMED CTContractures
6077001^Foot-drop (finding)^SNOMED CT Foot drop
298222004^Active range of joint movement reduced
(finding)^SNOMED CT Limited ROM
• Allergies = UNI code• Problems= CPT, ICD 10 and
SNOMED CT• Functional status= SNOMED
CT• Social History = SNOMED
CT
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HISP Configuration
• Primarily done by vendor engineer– URL– Direct address
• Smoke testing in non-production environment
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Workflow DevelopmentOutbound
Care Coordination use report to
identify patient
Disclosure Note saved on account and
triggers C-CDA Visit Summary
transmission via Direct Messaging
Vendor Cloud
HISP Receiving EHR
Average 80 outbound transmissions/day
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Workflow DevelopmentBSWH
partners and other Referring Practices sends C-
CDA
Sender’sHISP
Receiving HISP
Vendor Cloud
InboxCorporate
HIM matches C-CDA to patient
(Name, DOB, Address)
C-CDA saved to patient’s
chart
Clinicians views C-
CDA under the
documents tab or viewer
Inbound
Average 100 matches/day
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Implementation
3-4-14 C-CDA Discharge Summary Document (Inpatient) Go Live
4-29-14 C-CDA Summary of Care Document (Outpatient) Go Live
9-16-14 C-CDA-Visit Summary Document Go Live
1-23-15 Inbound Messaging Go Live
6-2-15Sending C-CDA Visit Summary via
Direct Messaging Go Live (Outbound)
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Monitoring and Meaningful Use Attestation
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Monitoring and Meaningful Use Attestation
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Monitoring and Meaningful Use Attestation
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Monitoring and Meaningful Use Attestation
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• Galvanized focus workgroup– Identified providers/groups who were high admitters
at each facility– Involved Clinical Informatics at each facility– Pursued addition of post-acute care facilities via
vendor portal– Daily monitoring, weekly update meetings
Monitoring and Meaningful Use Attestation
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Monitoring and Meaningful Use Attestation
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The Bumps Along The Way• People
– HIPAA Privacy office and/or Health Information Management department was engaged late in the planning
• New requirements were added to align with Legal/ Compliance
• Direct Messaging was added on existing HIM workflow
– Leadership changes slowed decision making and escalation of issues
• Logistics– Several hospitals would not meet the MU threshold with only
sending C-CDAs to the one physician group
– Other primary physician groups maintains a one to one Direct Messaging address versus practice Direct Address
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The Bumps (cont.)
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The Bumps (cont.)
Technical: Outbound
Occasional C-CDA transmission failures
• 10MB limit (includes document data as well as message information)
• Cloud and/or network failures
• Misspelled Direct Addresses
Functional Status 80% captured
• Discrete vs free text• More Nursing and Allied Health
data than Physician dataMedication Dictionary • Brand vs Generic1
Problem Management • Discharge Dx• Historic vs Current2
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The Bumps (cont.)
Technical: Inbound
Matching C-CDA documentation to patients
• limited demographic
Extra document being sent besides C-CDADifferent C-CDA naming convention for every organization
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The Destination
• No direct benefit for inpatient physician, the C-CDA provides outpatient providers a snapshot of key information and assume care without combing through hundreds of pages of records
• Next providers of care were able to quickly identify patients in need of additional intervention to prevent readmissions and other issues
– Decrease in readmission rates since July 2015
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Lessons Learned
• Conduct an analysis early on in the project to estimate reach for proposed solutions
• Regular meetings, clear communication and detailed documentation are essential to success
• Teamwork is critical
• Development of a report to quickly identify targeted patients is critical to time management
• HIM needs to be at the table• Automation of the process is ideal, but still requires additional
technical work to avoid release of PHI to inappropriate resources
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Looking Forward
• Logistics– Facility/hospital ownership of
outbound Direct Messaging workflow (decentralization)
– Leveraging Direct Messaging to build partnership across the country
– Integrate Direct Messaging with other IT initiative
• NSQIP• Breeze
– Measure Direct Messaging patient care outcome
• Workflow– PAMI data reconciliation
(Meaningful Use Stage 3)– Problem list management
• Meaningful Use– 50% threshold for Stage 3
(2018)• Vendor Enhancement
– Show Brand and Generic Drugs
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Contact Information
Cherie Price, RN, CTT+, [email protected]
Cindy Sunderman Neese, MSN, RN-BC, [email protected]
Oscar Glorioso, RN, [email protected]
Abeezar Shipchandler, MD, [email protected]