Making an IMPACT on Care Transitions in Central

Massachusetts

January 16th, 2013

Larry Garber, MD

Medical Director for Informatics

Reliant Medical Group

Conflicts of Interest

None

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Learning Objectives

Attendees will be able to:1.Express the current medical and economic impact of poor care transitions

2.Discuss the software system for enabling providers across the continuum of care to participate in the health information exchange

3.Explain the role of the IMPACT project in developing national standards for care transition datasets

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Agenda

Problems with care transitions

IMPACT – working to improve care transitions

ONC’s S&I Framework - Developing national standards for transitions of care datasets

LAND & SEE – software to facilitate integrating LTPAC into electronic health information exchanges (HIE)

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Communication & Adverse Events

• Poor care coordination increases the chance that a patient will suffer from a medication error or other health care mistake by 140% (Lu, et al., 2011)

• Communication failures between providers contribute to nearly 70% of medical errors and adverse events in health care (Gandhi, et al., 2000)

• 150,000 preventable ADEs ($8 Billion nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history (Stiell, et al., 2003)

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Problems With ED Visits

• Physicians in the Emergency Department (ED) lack important or critical patient information 32% of the time

• 15% of ED admissions could be avoided if the ED had outpatient information (Stiell, et al., 2003)

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Problems After Hospital Discharge

• 1.5 Million preventable adverse events annually nationwide from discharge treatment plans not followed (Forster, et al., 2003)

• When multiple physicians are treating a patient following a hospital discharge, 78% of the time information about the patient’s care is missing (van Walraven, et al., 2008)

• 20% of Medicare patients are readmitted within 30 days. Preventable readmissions waste $26B nationwide annually (McCarthy, et al., 2009)

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Ambulatory Care is Just as Bad

• 68% of specialists receive no information from the referring PCP prior to referral visits

• 25% of PCPs do not receive timely post-referral information from specialists (Gandhi, et al., 2000)

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Is Massachusetts Different?

• Preventable readmissions waste $577 Million in Massachusetts annually

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

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National care transitions experts overwhelmingly identified

“improving information flow and exchange” as the most important tool to improve care transitions

(ONC, 2011)

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An Odd Twist of Fate

• 2008 – Economy crashed• 2009 – ARRA passes, including the Health

Information Technology for Economic and Clinical Health – $27 Billion for hospital and MD practice EHRs– Must use the EHR in a “Meaningful” way, including

improved communication with others that have EHRs

• But Long Term and Post-Acute Care was left out!

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Yet Post-acute Care Costs are

Source: MedPAC, 2008 DeJong 2010

Rising faster than acute care costs

IMPACT Grant

February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI):

Improving Massachusetts Post-Acute

Care Transfers (IMPACT)

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IMPACT Objectives & Strategies

• Facilitate developing a national standard of data elements for transitions across the continuum of care

• Develop software tools to acquire/view/edit/send these data elements (LAND & SEE)

• Integrate and validate tools into Worcester County using Learning Collaborative methodology

• Measure outcomes14

Developing National Standards to Support

LTPAC Needs

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Datasets for Care Transitions

• Traditionally – What the sender thinks is important to the receiver

• Future – Also take into account what the receiver says they need

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Stakeholders/Contributors•State (Massachusetts)– MA Universal Transfer Form workgroup– Boston’s Hebrew Senior Life eTransfer Form– IMPACT learning collaborative participants– MA Coalition for the Prevention of Medical Errors – MA Wound Care Committee– Home Care Alliance of MA (HCA)

•National– NY’s eMOLST– Multi-State/Multi-Vendor EHR/HIE Interoperability Workgroup– Substance Abuse, Mental Health Services Agency (SAMHSA)– Administration for Community Living (ACL)– Aging Disability Resource Centers (ADRC)– National Council for Community Behavioral Healthcare– National Association for Homecare and Hospice (NAHC)– Transfer of Care & CCD/CDA Consolidation Initiatives (ONC’s S&I Framework) – Longitudinal Coordination of Care Work Group (ONC S&I Framework)– ONC Beacon Communities and LTPAC Workgroups– Assistant Secretary for Planning and Evaluation (ASPE)/Geisinger MDS HIE– Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE)– INTERACT (Interventions to Reduce Acute Care Transfers)

Single dataset for all transitions?• 175 element CCD

• 325 element IMPACT forbasic LTPAC needs

• 480+ elements forLongitudinalCoordination of Care

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14x14 Sender (left column) to Receiver (top) = 196 possibly transition types

Transitions to (Receivers)In Patient ED Outpatient Behavioral LTAC IRF SNF/ECF HHA Hospice Amb Care EMS BH CBOs Patient/

Acute Care Services Health CommunityTransitions From (Senders) Hospitals Inpatient (PCP) Services Family

Inpatient Acute Care Hospital

Emergency Department

Outpatient services

Behavioral Health Inpatient

Long Term Acute Care Hospital

Inpatient Rehab Facility

Skilled Nursing/Extended Care

Home Health Agency

Hospice

Ambulatory Care (PCP, PCMH)

Emergency Medical Services

Behavioral Health Community

Community Based Organizations

Patient/Family

“Receiver” Data Element Survey

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• 1135 Transition surveys completed

• Largest survey of Receivers’ needs

• 46 Organizations completing evaluation

• 12 Different types of user roles

12 User Roles

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Findings from Survey• Identified for each transition which data

elements are required, optional, or not needed

• Each of the data elements is valuable to at least one type of Receiver

• Many data elements are not valuable in certain care transition

• A single paper form can’t represent this variability in data needs

• Can be grouped into 5 types of transitions22

1. Report from Outpatient testing, treatment, or procedure

2. Referral to Outpatient testing, treatment, or procedure (including for transport)

3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)

4. Consultation Request Clinical Summary (Referral to a consultant or the ED)

5. Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency

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Five Transition Datasets

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

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

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

Five Transition Datasets

Transitions to (Receivers)

In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family

In patient

ED

Out patient services

LTAC

IRF

SNF?ECF

HHA

Hospice

Ambulatory Care (PCP)

CBOs

Patient/Family25

3

5

5

5

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Five Transition Datasets

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Two Care Plan Datasets

Testing the

IMPACT Dataset

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Pilot Sites to Test the Datasets16 Worcester County Pilot Sites:

– St Vincent Hospital and UMass Memorial Healthcare

– Reliant Medical Group (formerly known as Fallon Clinic) and Family Health Center of Worcester (FQHC)

– 2 Home Health agencies (VNA Care Network & Overlook VNA)

– 1 Long Term Acute Care Hospital (Kindred Parkview)

– 1 Inpatient Rehab Facility (Fairlawn)– 8 Skilled Nursing and Extended Care Facilities

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

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IMPACT Learning Collaborative:Testing the Care Transitions

Datasets

16 organization, 40 participants, 6 meetings over 2 months, and

several hundred patient transfers…

Learning Collaborative Surveys

• Surveys directly on envelopes carrying IMPACT packet, filled out by sender as well as receiver.

• Online survey at completion of pilot31

Senders found the data

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Receivers got most of their needs

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Home Care needed even more!

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Office of the Chief Scientist

Office of the Chief Scientist

National Coordinator for Health IT (ONC)

Office of the Deputy National Coordinator

for Operations

Office of the Deputy National Coordinator

for Operations

Office of the Chief Privacy Officer

Office of the Chief Privacy Officer

Office of Economic Analysis & Modeling

Office of the Deputy National Coordinator for Programs & Policy

Office of the Deputy National Coordinator for Programs & Policy

Office of Policy & Planning

Office of Policy & Planning

Office of Science & Technology (formerly known as the Office of

Standards and Interoperability (S&I))

Office of Science & Technology (formerly known as the Office of

Standards and Interoperability (S&I))

Office of Provider Adoption Support

Office of State & Community Programs

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S&I Framework convenes public

and private experts, and proposes

HIT/HIE standards

HL7 ballots standards

Secretary of HHS makes standards

part of “Meaningful Use” and EHR Certification

IMPACT

HIT Policy Committee Defines “Meaningful Use”

of EHRs

New World of Standards Development

Getting Connected:LAND & SEE

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LAND & SEE• Sites with EHR or electronic assessment tool

use these applications to enter data elements–LAND (“Local” Adaptor for Network

Distribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR

• Non-EHR users complete all of the data fields and routing using a web browser

to access their “Surrogate EHR Environment” (SEE)

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Surrogate EHR Environment (SEE)

• Acts as destination for routed CCD+ documents• Software hosted by trusted authority, accessed via

web browser• SEE is accessed via the HIE’s web mailbox• Non-EHR users able to use SEE to view, edit, send

CDA documents via HIE or Direct to next facility• Can select document type (e.g. Transfer of Care or

INTERACT SBAR) to display section flags indicating their optionality

• Can reconcile 2 documents to create a third• SEE users able to locally print copies of the

documents or subsets of the documents

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Using SEE for LTPAC Workflows• SNF patient getting sicker

– Subset of Transfer of Care dataset that is in SBAR (INTERACT) is flagged for completion by nurse online

– Can re-use data received from hospital– Can re-use clinical assessment data (function,

cognition, wound) from last MDS– Completed SBAR printed for chart

• Patient transfer to Emergency Department– Can re-use hospital, MDS, OASIS or SBAR data– Multiple users (nurse, social worker, clerk, etc…) can

work on different sections online at same time– Completed ToC dataset sent electronically to ED– Subset can be printed for ambulance team

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Hospital

Home Health

PCP

Non-standard EHR OASIS

Nursing Facility

Billing Program MDS

LTPAC Communication Today – Paper!

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Hospital

Home Health

PCP

SEE CCD+

OASIS

Non-standard EHR OASIS

LAND

SEE CCD+

MDS

Billing Program MDS

LAND

CCD+

CCD+

LAND & SEEfill in gaps

LTPAC Communication with LAND & SEE

Nursing Facility

The Future with LTPAC EHR Standards

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Hospital

Home Health

PCP

CCD+

CCD+

EHR MDS

CCD+

EHR OASIS

CCD+

Nursing Facility

Timeline for Standards Development

• October 2012 MA HIway go-live in 10 large sites with CCD and LAND

• April 2013 Pilot electronic Transfer of Care Datasets between 16 central Massachusetts organizations using MA HIway, LAND &

SEE

• September 2013 HL7 Balloting of new Care Transition and Care Plan standards for inclusion in Meaningful Use Stage 3

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Disseminating the Seeds

IMPACT Advisory CommitteeMassachusetts Care Transitions Forum

Massachusetts QIO (MassPRO)

Worcester GalaxyWorcester Galaxy

Pilot Sites

Core IMPACT

Team

Another Galaxy

Pilot Sites

Core ProjectTeam

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

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TOMalley@Partners.orgLawrence.Garber@ReliantMedicalGroup.org

Questions?

Bibliography

• Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine 138: 161-167. 2003.

• Gandhi, Tejal K., Sitting, Dean F., Franklin, Michael, Sussman, Andrew J., Fairchild, David G., and David W. Bates. “Communication Breakdown in the Outpatient Referral Process.” Society of General Internal Medicine (September 2000): 226- 231. doi:10.1046/j.1525-1497.2000.91119.x. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/.

• Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007 Dec;40(6 Suppl):S40-5. Epub 2007 Sep 7.

• Lu, C. Y. and E. Roughead. “Determinants of Patient-Reported Medication Errors: A Comparison Among Seven Countries.” International Journal of Clinical Practice (April 6, 2011): 65: 733–740. doi: 10.1111/j.1742-1241.2011.02671.x. http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2011.02671.x/pdf.

• Overhage JM, McDonald CJ, et al. A randomized, controlled trial of clinical information shared from another institution. Annals of Emergency Medicine 39[1], 14-23. 2002.

• Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003 Nov 11;169(10):1023-8.

• Van Walraven, C., Seth, R., Austin, P. & Laupacis, A., 2002. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med, Volume 17, pp. 186-92.

• Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value of Healthcare Information Exchange and Interoperability. Hlth Aff (Millwood) 2005 Jan-Jun;Suppl Web Exclusives:W5-10-W5-18.