leveraging hie for release of information · • some information on the progress note will need to...

CHIA PRESENTATION HANDOUT 2018 CHIA CONVENTION & EXHIBIT

SAN DIEGO, CA

Leveraging HIE for Release of Information

Presented by: Dorothy O'Hagan, MNLM, RHIA, CCS

& Panelists

Presented on: Wednesday, June 06, 2018

© California Health Information Association, AHIMA Affiliate

5055 E. McKinley Ave, Fresno CA 95407 Tel: (559) 251 – 5038 [email protected]

CaliforniaHIA.org

Leveraging HIE for Release of Information 6/6/2018

California Health Information Association, AHIMA Affiliates 1

Leveraging HIEfor Release of Information

Cassi Birnbaum Dan Chavez Dorothy O’HaganUCSD Health San Diego Health Connect Rady Children’s

June 2018

1

Agenda

• HIE and Industry Update• Community of San Diego Update• HIM and HIE Discussion points

2



Source: Camden Coalition

The Goal…A Comprehensive View

Hepatitis A Case Example

• Homeless, age 30• 10 ED Visits (Mar–Aug)• 1 Hospitalization• 1 Hep A Vaccination• Hx ETOH

March

April

May

June

August

ED Visit 3/31

July

ED Visit 4/3

ED Visit 5/6

ED Visit 5/19

ED Visit & Hospitalization 7/16ED Visit 7/12

ED Visit 8/20

ED Visit 8/31

ED Visit 6/19 ED Visit 6/22

Hep A Diagnosis 7/16

Hep A Vaccination 6/7

Cellulitis & abscess of lung

Blisters on hand

Abdominal pain

Cough & brown phlegm

Vomiting

Convulsions

Rib pain

ETOH withdrawal

Weakness, cough, fever, chills

Onset of illness 6/16

ETOH withdrawal & Seizure



County Health Rankings Model

5

Driving Change

From a Sick Care System

To a Coordinated Healthcare System

To a Community Integrated Health System

6



Must Add an AIM

•Cost•Quality•Patient Experience•Provider Experience•Equity = Social Determinants of Health

7

Nationwide Interoperability Efforts

Key:Network-to-NetworkPerson-centricnetworkProvider-centricnetworkSecuremessagingnetwork/RLSConsumer-directednetwork

*Yearof launch** For purposesof this scan,HIMSS’sInterop & HIE CommitteeusedEPICtorepresentoneexampleof vendor-mediatedexchange.

eHealth

Exchange

Sequoia

2012*

Carequality

2014

Care

Everywhere

(EPIC)**

2008

CommonWell

Health Alliance

2013

NATE

2013

Surescripts

2008

Patient CenterData

Home™ (SHIEC)

2015

Community

HIEs

2005

DirectTrust

2011

CARIN

Alliance

2016

MEMBER



Key Findings from Environmental Scan

Multi-prongedapproach to exchange

Limited measurement of standards implementation, adoptionand use

Provider centric system of exchange

Semantic interoperability a barrier to dataexchange

Inconsistent quality lowers value proposition

No common solution onpatient matching

EXPANDING THE NETWORK

10

A program of



WHAT DOES DATA TELL US?

11

Decisions and

Actions

What Happened?

Why Did it Happen?

What Will Happen?

What Should I

Do?

Complete 360 degree view

DRIVING INTEROPERABILITY

Connecting All forBetter Health & Wellness

COMMUNITY INFORMATION EXCHANGE

@



Driving Interoperability

Connecting All forBetter Health & Wellness

COMMUNITY INFORMATION EXCHANGE

@

Patient identificationData qualityData provenancePHI and PIIPublic health to primary careProper presentation summaryClosed loop referral systemNotifications and alerts

Population Health is the Future of HIE

14

Patient Practice PublicPopulation

Informatics, standards, workforce, business drivers, governance

Source: AMIA, Fridsma



HIM and HIE

• Standard naming convention – update– Documenting preferred names

• Consent – moving to community-wide consent• Homeless addresses – number of ways, Hep A challenge• SOGI - LGBTQIA• Opioid crisis• Implementing the POLST eRegistry• Implementing image sharing• MPI workgroup facilitation

15

Linking IG & Patient Matching

• IG starts at the information point of origin

• Patient matching starts at registration

• Using industry standards to match patients

– The right patient, every time

• Patient merges and corrections are costly

• Unmeasurable cost is the cost of patient safety

• Developing a culture of accountability and high reliability

• Centralized process for access and MPI data integrity



Identity Management

• Prevention

– Patient Access

– Scheduling

– POC Registration

• Identifying Errors

– Nurses and other clinicians

– Access staff

– Coders

– MPI Integrity team

• Resolution

– HIM

– Compliance

– Ancillary Systems

Recent Sanitized Example

MRN 1234 – Daffy Ronald Duck is an 83y/old duck, born on 8/22/1932. He does not have any current activity with UCSD

MRN 5467– Daffy Albert Duck is a 77y/old duck, born on 2/22/1939. This MRN was created on 7/30/16 by user Sally from the Pond Clinic

On 8/24/16, user Sally Goose altered MRN 1411 to reflect Daffy Albert’s information at the Pond Clinic. There were also scanned documents by user Ugly Duckling, including a driver’s license for Daffy Ronald. The DL reflects Daffy Albert’s birthday, who is 7 years younger than Daffy Ronald. This alone should have raised a red flag before altering critical demographic fields.

Labs were ordered and a progress note resulted from Daffy Albert’s visit on 7/30/16.

Questions Raised

• Who are the correct contact staff members to notify of an encounter move from one MRN to the correct MRN for Pond Clinic-related errors?

• UCSD must notify lab information services so that they can update their system

• Pond Clinic charges will need to be moved – establishment of a contact person is essential

• Some information on the progress note will need to be changed to reflect the correct patient’s name, so the doctor will need to be notified to addend the note

• Patient Access Manager will need to assist in reverting back the correct demographics

Cost to UC San Diego to correct: $7,000



Governing the Integrity of Enterprise Master Person Index

• Establish an MPI Governance Committee– Teams for each clinical integrated network (CIN) “service area”

• Establish policies, procedures, guidelines, and education to facilitate accurate identity management

• Establish dashboard by service area

• Establish data correction procedures to assure integrity of the MPI and downstream ancillary systems

• Centralize access controls and decisions regarding ability to register patients and maintain MPI integrity

• Collaborate with IT to evaluate the state of the CIN’s MPI data prior to loading external data to MPI to mitigate organizational risk

• Lead data clean‐up initiatives

Enterprise Identity Management Governance

• Support administrative and clinical staff via hotline to correct patient data as

soon as possible

• Establishes a culture of accountability through analyzing, tracking and trending

of duplicate and overlay errors

• Promote a culture of high reliability which improves patient safety and

decreases cost

• Reporting of errors using SBAR method to impact change and increase

awareness

• Reporting of errors by department and service area to executive leadership



Set Target MPI Integrity Measures

Goal is to reduce overall duplicate rate to under 1%

Resource Management

• Due Diligence staffing to assess the state of new CIN sites:– Identify their duplicate rates,

– Enterprise vs. disparate MPIs,

– Capture of SSNs, conversion clean-up

– Training of new staff/new sites

– Intervention and remediation

• Consideration of system enhancements, testing and implementation

• Allocate Staffing for real time monitoring for all UC San Diego locations including CIN sites

• Timely correction of duplicate medical record numbers and potential overlays across domains, enrollee, and death master integration (new project)

• Actively work the potential duplicates and overlays

• Specialized, expert team performs Contact Mover and identity theft functions



Introduction of SOGI

23

What is SOGI?

24



Preferred Name and Pronoun

Defining Identity Management Standards

• Establish naming convention policy including newborns with multiple births based on best practice

• Introduced to San Diego Health Connect (Regional HIE for adoption)

• Establish legal name with verification process

• Define required data entry elements across the enterprise including ancillary systems

• Map data flows

• Incorporation of SOGI (sexual orientation/gender identity) into the patient access/clinical workflow process OSHPD Considerations Sex at Birth to accommodate clinical considerations LCD/NCD edits – NCCI edits – need to be aligned



Realizing the Value of MPI Integrity

Patient Satisfaction• Patient Centric – assuring the complete and right

information at the point of care

• Increased patient confidence

Treatment Benefits

• Assuring critical information necessary to treat the patient is available for care decisions and treatment and avoidance of another patient’s information being inadvertently used

• Decrease in incidence of repeat testing

• Avoidance of any medication or adverse reactions due to failure to identify medication history

• Access to the complete record

Electronic Secure Data• Improved continuum of care

• Ability to share data without costly and impactful delays while data is being merged or unmerged

• Avoidance of patients receiving appointments or bills for services provide to the mis-identified patients

Savings

• Centralized model enables 50% less FTEs – cost per task = $15 vs. $26

• Each duplicate costs $150

• Each confirmed overlay costs $4,500

Projected savings from a lower duplicate and overlay rate - $9,000/month - $108,000 per year

Patient Matching Update

• Fundamental to interoperability

• Continue to refine process with MPI and referential matching –

increased metrics, cause and effect, change workflow and process

• Will move beyond real time correction to a parallel MPI

• MPI diagnostic reports to participants

• Naming conventions convergence

• Exploration of sharing MPI as single source of truth for other

community infrastructures



Measuring HIE Value

1. Patient Matching – MPI/RLS

2. Public Health Reporting

3. Query/Response

4. Repatriation

5. ED and EMS

6. Image Exchange

7. POLST

• Total potential Annual Savings single enterprise: ~$647,000+

• Total potential Community Annual Shared Savings: ~$19,737,950+

29

Proving the Value of Health Information ExchangePOLST Registry

30

• Funded by California Health Care Foundation, in joint effort with EMS Authority and the Coalition for Compassionate Care of CA, San Diego Health Connect (SDHC) was selected to be one of two pilot communities to launch a Physician Order for Life Sustaining Treatment (POLST) registry in its region.

• The POLST registry will be a feature within the SDHC Health Information Exchange portal, utilizing its community Master Patient Index and will bridge with City EMS’s electronic patient care record.

• As a pilot project, SDHC has launched the registry tool and started to receive POLST forms from UCSD, SHARP, and Integrated Health Alliance who contracts with 8 skilled nursing facilities to date.

• By Q1 of 2018, SDHC will add additional participants to build the region’s POLST registry. • SDHC HIE users can now retrieve POLST forms. • This pilot project will run through December 2018 and hope to gather invaluable lessons to

the granting agency and counterparts.



HIE Effectiveness

31

HIE Access during a Patients

Emergency Visit

Healthcare Outcomes• Length of Stay• Readmissions• Multiple Doctors

Relationship between Patient & Doctor

Degree of Patient’s

Information Spread

Doctor’s Experience

on HIE

Control Variables• Severity• # of prior HIE access for a patient• MD’s recent HIE use• Patient’s demographics (age & gender)• Time variables (after walk-in hour,

weekend)

HIE Strategic Trajectory

32

PHASE IConnectivity

PHASE II CareCoordination

PHASE IIIPopulation Health Management

QuadrupleAim

PatientExperience

Lower Costs

Better Health

CollectConnect

TransitionsClose care gapsRemove redundancy

Optimize theHealth of ourCommunity

PopulationPatientProvider

ProviderExperience



What is SAFR?

• Search a patient’s health record for problems, medications, allergies, and end

of life decisions to enhance clinical decision making in the field

• Alert the receiving hospital about the patient’s status directly onto a

dashboard in the emergency department to provide decision support

• File the emergency medical services patient care report data directly into the

patient’s electronic health record for a better longitudinal patient record

• Reconcile the electronic health record information including diagnoses and

disposition back into the EMS patient care report for use in improving the

EMS system



SAFR Outcomes

• Number of received transaction messages from SD City EMS to UCSD’s two emergency departments is 3794, Hillcrest and La Jolla

• 808 paramedics and EMTs trained and utilizing

• Still evaluating the LOS measures

• Morbidity and Mortality outcomes for both trauma and ED patients

• Ancillary test ordering patterns

• Patterns of utilizers of 911

• Over $250,000 annual savings associated with the timely availability documents to enable charge capture of trauma activation and EMS transport level

EMS SAFR Project ROI Breakdown

Hard Cost Savings:• Revenue Integrity revenue reversals due to late/missing EMS documentation to enable us to obtain trauma activation charges $150,000/year• Cost of prepping, scanning documentation

$80,000/year• Total Hard Cost Savings: $230,000/yearSoft Costs: • Immediate availability of documentation including EKGs



SAFR Outcomes

• The project has improved emergency care and saved lives

• In May of 2017, 911 was called for a middle‐aged man with left shoulder pain. Paramedics found the patient pale, cool, diaphoretic and hypotensive with a blood pressure of 60/40 mmHg. An ECG in the field demonstrated potential heard attack (ST elevation MI or STEM).

• Through SAFR, this information including the ECG was sent to UCSD‐Hillcrest Medical Center and was in the hands of Emergency Physician and Cardiology before the patient arrived

• Staff were prepared and pre‐activated personnel were in place in the Cath Unit within 16 minutes of the patient’s arrival

• The patient was found to have a severe coronary artery thrombosis underwent angioplasty and stenting, and is now recovering and doing well

EMS Image Transmission

EKGsVitalsRhythm Strips



© 2017 California Health Information AssociationCaliforniaHIA.org

Standards - Temporary Newborn Names • There is no current national newborn naming convention for

newborns, specifically, patients who have not yet received their legal name and have a temporary name.

• Patients who are the product of multiple birth delivery present multiple challenges for interoperability and successful patient matching.

• Newborns do not have a Social Security Number (SSN) or governmental identification at the time of birth.

• SSN is often the highest weighted item used in patient matching algorithms.


Scenarios Inhibiting Interoperability• Newborn patients are often issued a temporary name which may not be

updated at the time of discharge

• Multiple birth patients are often named similarly– Same first name, different middle name – John David Smith, John Daniel

Smith– Reversal of first and middle name – John David Smith, David John Smith– Similar first and/or middle name – Sarah, Sarai– Different first name, same middle name – John James Smith, Joshua

James Smith




Scenarios Inhibiting InteroperabilityWhen a baby is born, the birth hospital usually assigns a temporary name, such as Baby Boy A or Baby Girl B.

When the legal name is decided by the parent, the temporary name is updated, but this update may not occur if the patient is discharged or transferred before the legal name is decided. When the child is later seen at a different healthcare organization and the name is still “baby” vs. the legal name, interoperability without manual intervention, i.e., verify and update the patient name, is compromised.


Scenarios Inhibiting Interoperability Children of a multiple birth delivery, issue is magnified as it can be difficult to identify which child was Baby Boy A vs. Baby Boy B.

• The non-birth organization would need to contact the birth hospital as well as research birth certificate information and diagnoses to prevent an overlay

• Parents may not know which child was assigned as Baby Boy A or Baby Boy B at the birth hospital and thus would not be able to answer that “John David” is Baby Boy A and “David John” is Baby Boy B.




Multiple Birth Designation • ~2.5 Million multiple birth persons are under 18

– Same address, telephone number and date of birth– ~89K Triplet + birth persons are under 18

• 2012 CDC data shows:– Twin Births = 131,269– Triplets = 4,598– Quadruplets = 276– Quintuplets+ = 45


Scenarios Inhibiting Interoperability • Many healthcare organizations use Social

Security Number as a unique patient identifier– In the pediatric population, the parent may not

know the SSN.– Facility may not capture SSN – Multiple birth children may have been issued SSN

with sequential digits• No government issued identification




Children’s Hospital Association Mission• The Children's Hospital Association (CHA) advances child health through innovation

in the quality, cost and delivery of care with our children’s hospitals.

• Representing 220 children’s hospitals, the voice of children’s hospitals nationally.• Children’s hospitals are essential providers, setting the standard for the highest quality pediatric care while

training the next generation of pediatricians. With its members, the CHA champions policies that enable children’s hospitals to better serve children; leverages its position as the pediatric leader in data analytics to facilitate national collaborative and research efforts to improve performance; and spreads best practices to benefit the nation’s children.

• CHA advances child health through innovation in the quality, cost and delivery of care with our children’s hospitals. Who we are Representing 220 children’s hospitals, we are the voice of children’s hospitals nationally. Children’s hospitals are essential providers, setting the standard for the highest quality pediatric care while training the next generation of pediatricians. With its members, the CHA champions policies that enable children’s hospitals to better serve children; leverages its position as the pediatric leader in data analytics to facilitate national collaborative and research efforts to improve performance; and spreads best practices to benefit the nation’s children.


Children’s Hospital Association CHA, Health Information Management association recognized the need and published a white paperincluding recommending standards to increase interoperability.

Unique patient identifier is not in place for adults and even if implemented, practically speaking would not help the pediatric population.

Fragile children are transported from general acute care birthing hospitals to pediatric hospitals within hours of birth with limited information. Clinical care may be impacted with lack of ability to access medical records.




Recommendation • Adoption of a national standardized naming convention for

temporary newborn names• Additional data elements:

– Mother’s first name– Mother’s maiden name– Gender– Birth order

• Capture newborn name as “alias”


Data Elements • Mom's name: Katie Smith• Mom’s maiden name: Katie Miller

Baby's name if she had a girl: Smith, Girl KatieBaby's name if she had a boy: Smith, Boy KatieBaby's name if she had an undetermined sex: Smith, Baby KatieIf the mom has twins: Smith, Girl A Katie and Smith, Boy B Katie




Newborn Naming Conventions


Fetal Care

• Register using Temporary Naming Conventions

• Date of Birth = estimated delivery date• Care delivered prior to delivery available




Data Makes a DifferenceSocial Security Administration Automated Disability Determination • Matching with Name, DOB, Address & Gender =

74% • Adding phone number and e-mail address is

anticipated to be 94% (August 2017 implementation)


Resolving the Problem

• Adopt Children’s Hospital Association Recommended Patient Naming Conventions




White Paper


Sample Policy



Summary

• HIM and HIE continue to collaborate and drive convergence

• HIE is moving the needle• Consent remains a challenge• HIE is interoperability• Support community based standards• Moving to 360 degree views• Continue to fully promote and support HIE• Thank you!

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”Atul Gawande



Questions?

ContactDan ChavezExecutive DirectorSan Diego Health [email protected]

Cassi BirnbaumSystem-wide Director of health Information Management and Revenue IntegrityUC San Diego [email protected]

Dorothy O’HaganDirector, Health Information, Interoperability, and Documentation ExcellenceRady Children’s Hospital – San [email protected]




References• Adelman, J., Aschner, J., Schechter, C., Angert, R., Weiss, J., … Southern, W. (2015). Use of Temporary

Names and Associated Risks. American Academy of Pediatrics, 136(2). Retrieved from http://pediatrics.aappublications.org/content/early/2015/07/08/peds.2015-0007

• Harris Health System. (2011.) Harris County Hospital District Puts Patient Safety in the Palm of Your Hand. Retrieved from https://www.harrishealth.org

• Lusk, K. (2015). Decade of Standardization: Data Integrity as a Foundation for Trustworthiness of Clinical Information. Journal of AHIMA 86(10), 54-57.

• Lusk, K., Noreen, N., Okafor, G., Peterson, K., Pupo, E. (2014). Patient Matching in Health Information Exchanges. Perspectives in Health Information Management, 1-24.

• Mandel, H., & Alam, S. Health Level 7 Web Service Search Success Rates in New York City’s Citywide Immunization Registry. [Abstract]

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