Adapting Modern Electronic Health Records to TeleHealthand new Healthcare Delivery Models

HIMSS Annual ConferenceChicago, Illinois

April 2015

Michael Minear, M.S., CHCIO, CPHIMSChief Information Officer

Speaker Disclosure

I have no personal financial relationships or interests in any entity producing, marketing, re-selling, or distribution health care goods and services consumed by, or used on patients.

Michael N. Minear, CHCIO, CPHIMS

Professional Affiliations

Chief Information Officer – University of California -Davis Health System

Associate Faculty - Johns Hopkins Bloomberg School of Public Health

Currently a member of - Board of Directors – California Telehealth Network (2012 – current)

Member - Healthcare Information & Management Systems Society (HIMSS)

Member - American College of Healthcare Information Administrators (CHIME)

Member - American Medical Informatics Association (AMIA)

Member of the American College of Clinical Engineering (ACCE)

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Presentation Outline

1. Overview of UC Davis and the UC Davis Health System

2. UCDHS Information Technology

3. UCDHS Telehealth Program

4. Online Clinical Knowledge

5. Stages of Telehealth

6. Questions

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1. Overview of the University of California Davis

Where is Davis California? A 1-4 hours drive from…

Napa image, winecountry.comLake Tahoe image, Tahoebest.comYosemite Valley image, NY TimesSan Francisco image, wall paper innBig Sur image, Stan Russell

SacramentoDavis

Lake Tahoe

Yosemite

Big Sur

San Francisco

Napa Valley

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California Drought

Image, cironline.orgDrought impact map, U.S. Drought Monitor weekly report Road sign image, NBC NewsCalifornia agriculture statistics, Beachcalifornia.com

California has been the number one food and agricultural producer in the United States for more than 50 consecutive years

Over half of America’s fruit, nuts, and vegetables Produce more dairy products than any other state Leading export crop is almonds 80% of US ripe olives Leading producer of strawberries Nationally, products exclusively grown (99% or more) in

California include almonds, artichokes, dates, figs, kiwifruit, olives, persimmons, pistachios, prunes, raisins, clovers, and walnuts

California Drought Produces Tastier Wine Grapes

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Member of 10-campus University of California system

Part of 6 campus UC health

UC Davis is the 9th ranked US public research university College of Agricultural & Environmental

Sciences ranked #1 in the world Ranked #1 in US for Veterinary Medicine Health System has 14 nationally ranked

clinical specialty programs

University of California Davis

UC Davis UniquenessHuman, Animal, Plant

UCDHS - ‘Improving lives and transforming health care’

Clinical Care− Leapfrog Hospital Group Top Hospital

award – 2013 and 2014

Research− $200+ million in annual funding− 34th ranking NIH research funding

(ranked 62nd in 2001)

Education− SOM ranked 24th for primary care Ranked 42nd for research

− Betty Irene Moore School of Nursing

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UC Davis Health System and Medical Center

National Cancer Institute ‘comprehensive’ designation cancer center, one of only 41 in the country

UC Davis School of Medicine ranks among the nation's top medical schools for rural medicine, primary care and research

UC Davis Medical Center is nationally ranked in 10 adult and 4 pediatric specialties

‘A’ rating on the Leapfrog Group’s most recent Hospital Safety Score

Leapfrog Hospital Group Top Hospital award – 2013 and 2014 as one of the nation’s highest performing hospitals

Magnet recognized for quality patient care, nursing excellence and innovations in professional nursing practice

2. UC Davis Health System Information Technology

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Information Technology

CCH

IT

Office of the National Coordinator

Cert

ifie

d EH

R

ICD-10-CM

phen

otyp

eEHR

LOINC

HITECH Act

EHR Certification

HIE

Accountable Care Act

Genotype

HL7

Meaningful Use

Online clinical knowledge

CPOE

UCDHS Information Technology Division

Annual operating budget of $105 million, annual capital budgets ranging from $11 million - $70 million depending on projects

Staffing - 430 FTE

Computing 1,314 servers (majority are virtual) 12,587 client computers 910 computers on mobile carts 620 mobile computers for BCMA 4,200 network attached printers

Networking and communications 45,000 IP network nodes 10 Gb links to CENIC, Internet, and Internet2 12,475 voice hand sets 4,195 Vocera VoIP badges, 4,105 pagers

Software Applications 488 applications in production use 220 interfaces

Primary and secondary data centers

13,500 faculty, staff, student customers

112,000 patient customers

2.3 million patient records

Half a billion clinic fact records

Shared 58,000+ medical records

Shared 6.5 billion ePrescription records

All types of clinical encounters

Clinical research

Clinical education

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UC Davis Health System – Clinical Software Infrastructure

Specialty Clinical Software Radiology information System Transcription / Voice Recognition Radiation Oncology Pathology Dietary Pulmonary Function Holter Muse EKG Echo EMG – orders Respiratory care – orders Treadmill CAPS TPN pharmacy admixture

Clinical Equipment Pyxis Drug cabinets Hemodynamic monitors Telemetry EKG Fetal monitoring Echo Glucose Point of Care Cardiac Cath Monitors Bar code medication admin Digital Infusion pumps Bladder Scanner Ventilators

Paper Medical Records Scanned and Linked into EHR

Consent formsOutside paper medical recordsOnBase document management system

Digital Clinical Images Radiology – Philips PACS Ophthalmology PACS – Anka Endoscope PACS – nStream Outside Clinical Images loaded to

Radiology PACS via PACSGear Non Radiology PACS images TeleHealth Store & Forward Radiation Oncology PACS - Teremedica Pathology PACS - Aperio

In Production | In Process | Not yet started

Secondary Use EHR Content NIH i2b2 Cohort Discovery Many disease Registries:

Cardiology Burn Trauma Cancer Many others…

Tethered Meta Registry

InterfacedWith EHR:

Legend

Epic Electronic Health Record

(EHR)

Tethered Personal Health Record

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UC Davis Health System – Clinical Software Infrastructure

Specialty Clinical Software

Clinical Equipment

Paper Clinical Records Scanned and Linked into EHR

Digital Clinical ImagesSecondary Use EHR Content

Epic EHR

2.3 million patient records

500+ million detail fact records

Fully digital Clinical records

3 PACS linkedto EHR

6 years of Experience

Tethered Meta Registry

Tethered Personal Health Record112,000+ patients

Millions of highly detailed

clinical data points

All clinical encounters in the EHR:inpatient, ED, ambulatory, home health, Telehealth

220 Production interfaces

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Key Measures of UCDHS EHR Use

Epic EHR Clinical Encounter Support− 100% of Inpatient, Ambulatory, ED, Home Health, and Telehealth encounters

supported by EHR Inpatient CPOE

− 94.6% of inpatient clinical orders entered via CPOE− 96.9% of ED clinical orders entered via CPOE− 761+ order sets in production use − Pediatric and investigational chemotherapy and TPN only orders not done via CPOE

ePrescribing− All 5 federally mandated ePrescribing interfaces in use 6.5 million+ records shared

Online Clinical Documentation− Over 409 templates in production use− Over 335 physicians use voice recognition to create their clinical notes− 93.5% of inpatient notes and 91.5% of ambulatory clinical notes are created

through online documentation templates Epic is the foundational system to store patient data

− Now have over 2.3 million unique patients stored in Epic

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UC Davis Health System is one of only 14 care providing organizations in the US that has earned both the Davies award and achieved Stage 7 in the EMR Adoption Model

UCDHS IT Awards

The HIMSS Nicholas E. Davies Award of Excellence recognizes outstanding achievement of organizations who have utilized health information technology to substantially improve patient outcomes while achieving return on investment

Healthcare organizations that attain Stage 7 of the EMR Adoption Model (EMRAM) demonstrate superior implementation and utilization of health IT systems. Their achievement has resulted in the true sharing, information exchange and immediate delivery of patient data to improve process performance, quality of care and safety

Most Wired hospitals have the highest level of Information Technology adoption. UCDHS has been named a Most Wired hospital in 2011, 2012, 2013, and 2014

3. UCDHS Center for Health and Technology

University of California Davis - Center for Health and Technology

The Center for Health and Technology's (CHT) Telehealth Program, was founded in 1992 by Dr. Thomas Nesbitt

CHT provides direct clinical care to patients at a distance

Since the inception of the program real-time consultation services have been offered in more than forty specialties linked to over 100 clinics and hospitals, the majority of which are located in, or provide services to rural areas

Dr. Nesbitt Center for Health & Technology

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Telemedicine

Medically underserved areas in California have historically had inadequate geographic access to health care specialists. This disparity in access has led to adverse results for patients who might have otherwise had excellent outcomes

Through telemedicine, patients do not have to leave their community and can gain access to specialists located hundreds of miles away− The consultative model provides a bi-directional education and

communication occurring between the primary care provider and the specialist

− The primary care provider remains responsible for the patient's treatment plan which results in an improved coordination of care.

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Pediatric Intensive Care Unit (PICU) Model

Telemedicine consultations from UCDHS specialists for critically ill pediatric patients in a rural ICU− Mortality and length of stay outcomes were equivalent to PICU

benchmarks− High satisfaction with the quality of care among physicians, parents,

and nurses

Marcin J, et al. (2004).Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatrics.144(3):375-80.

UC Davis PICU Rural California ICU

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Simulation-based Education

UC Davis has trained nearly 1,875 community-based health care providers and administrators at CHT facility in Sacramento− Trained over 1,500 participants who have taken courses at the American

Telemedicine Association (ATA) Conferences− Created ehealth curriculum used internationally

Over 100,000 simulation-based education hours and over 32,000 learners with 8,271 hours last year

Safe environment for inter-professional learning Problem-based learning to improve patient outcomes

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4. Evidence-based Clinical Knowledge Impacting Care

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Evidence-based knowledge

EHR and Process Change

ImprovedClinical Results+ =

UC Davis Sepsis Collaborative Project

Priority goal defined by leadership UC Health goal Funding by the Gordon and Betty

Moore Foundation Large team that met twice weekly

for 6 months− 50+ clinicians - MD, RN, PharmD− Non-clinicians - lab, IT, quality

improvement− Multiple care settings - acute, ICU,

ER) met twice monthly for 6 months

Clear goal and Support Leadership and Communication

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Sepsis Project Elements

Dellinger RP, et al. Critical Care Medicine. 2008; 36: 296-327

Evidence-based Knowledge Process / clinical workflow

Example clinical process changes Rapid turn around Lactic acid tests Nurses enter vitals into EHR 10 min or less Some clinical orders fire auto from data Clinical decisions made quickly or are escalated

17+ years to disseminate new knowledge… 23

Sepsis Project Elements

Policy changes EHR changes

Alerts Order setsRulesClinical documentation templates

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Sepsis Measurement

Population Data and Visualization Results

Sepsis Registry In Tethered Meta Registry4137332925211713951

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Observation (months)

Mor

talit

y Ra

te

_X=26.7%

2009 2010 2011 2012

SIC Mortality Rate by Calendar YearSevere Sepsis (995.92) and Septic Shock (785.52)

*Source Data from HIM

Since the 2009 baseline, UCDHS has reduced Sepsis Mortality by 36%...

The actual or observed rate for all sepsis related mortality was reduced over the course of about 1.5 years and has been maintained and still decreasing at a lower rate for 3+ years

Applying these techniques to other clinical goals… 25

5. Stages of Telehealth

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Phase 1 - Vison

In the February 1925 issue of Science and Invention,

Hugo Gernsback wrote an article sharing his vision of the ‘teledactyl’ to support doctors to see their patients through a view screen and also touch them via robot arms

He effectively predicted telemedicine

Novak, M. (2012). Telemedicine Predicted in 1925. Smithsonium.com. Accessed from http://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/?no-ist

1

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Teledactyl’s Distant Controls

Novak, M. (2012). Telemedicine Predicted in 1925. Smithsonium.com. Accessed from http://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/?no-ist

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Gernsback’s Vision of teledactyl vs. da Vinci Surgical Robot

Novak, M. (2012). Telemedicine Predicted in 1925. Smithsonium.com. Accessed from http://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/?no-istSurgery Robot Image – The Bethencourt Group. Cardiac & Thoracic Surgery, http://bethencourtgroup.com/500th-robotic-heart-surgery-performed-by-dr-bethencourt-on-his-birthday/

da Vinci Robotic surgery - 2015

Gernsback’s vison of the teledactyl - 1925

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Phase 2 – Piloting

For many years people and technologies were focused on delivering the vision of telemedicine

Value was created and lessons learned

Many technical barriers – did not have: − High speed ubiquitous networks− Client devices with high speed computing and quality

resolution− Mobile technologies− Security technologies to protect transmissions− Integration of clinical equipment integrated with video and

networks (stethoscope, otoscope, testing devices…)− Ability to share patient records − Scheduling and process support for follow-up care and referrals

across continuum− Low cost technologies

Top Image, EMSWORLDBottom Image, In the Center, employee and student publication, the University of Kansas Medical Center

2

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Piloting

Operational and legal barriers also existed: (at least in the US)− Clinician licensure across geographic boundaries (states)− Financial reimbursement for telemedicine encounters− Regulation and legal− Vested interests

The barriers limited the use of telemedicine

Right Image, ATT.comMiddle and Right Image, Howard Reis, Healthepractices 31

Nurse recording clinical encounter on TV camera at Boston Logan airport and transmitting to Mass General Hospital-1967

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Phase 3 – Conversion to Digital

Healthcare has been trying to eliminate the paper medical record for many years

For 30+ years most care providers still used paper records augmented by partial clinical automation

Care providers are now moving to a fully digital record and finally eliminating paper records and film based clinical images− UC Davis achieved fully digital records in 2012 − All paper records removed from hospital− When patients bring in paper records from other care providers they

are quickly scanned and linked to UC Davis EHR

Achieving fully digital records is critical to telemedicine and other new types of encounters− The foundation for digital encounters− For many years at UC Davis this highest cost of providing a

telemedicine encounter was copying and faxing patient records

3

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Phase 4 - Integration

Early clinical software was designed for one department− Pathology, Radiology, Ambulatory clinic, many others…

Niche software designs were the norm− Built to support a single function and/or department− Not designed to share data with other software

Huge challenges to share patient data within a single care provider With modern EHR software product suites, interface engines, and

improved standards – many organizations share clinical data well, typically using the EHR as the integration foundation

The UC Davis Health System has achieved almost total integration of clinical data − And an average of 127.4 million interface transactions per month− Takes a dedicated team of 21 FTEs UC Davis Health System

4

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Why is Sharing Clinical Data Important?

Patients have many clinicians and transitions of care

In American healthcare, clinical care is provided by many clinicians in many different locations. During the years 2000-2002, the typical Medicare patient was treated by a median of 7 different physicians (2 primary care physicians and 5 specialists) who were located in 4 different offices each year. Patients with chronic illnesses were treated by even more physicians (Pham, et al, 2007)

51% of primary care encounters involved care transitions (excluding radiology and pathology encounters) between individual physicians, where 36% - 41% of visits involved transitions between different medical groups (Rudin, et al, 2011).

A Canadian study found that patient information was often not shared with other physicians treating the same patient, and found that patient information about previous visits was not available 88% of the time (van Walraven, et al, 2008).

Only 19% of hospitals reported in 2010 that they exchanged patient clinical information electronically with providers outside their system (Kirtane, 2012).

Only 13% of US hospitals exchanged information with other hospitals (not in their system), and only 28% of hospitals exchanged with ambulatory providers outside of their system (Agency for Healthcare Research and Quality, 2011).

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But Current HIT Designs – Mostly Designed for one Organization

Many issues – separate organizational structures, competition, staff focus, standards, some legal barriers, software design…make it much harder to share data between organizations

All vendor EHRs are proprietary and closed software infrastructures

Data sharing standards only facilitate sharing clinical data between two different software applications – not fully integrate clinical data

Massive efforts have focused on creating effective clinical data sharing between organizations− Federal HITECH EHR meaningful use regulations− HITSP standards setting for US

HIT must support communities and populations not just an organization

Care Provider A Care Provider B Care Provider C

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UC Davis Patient Records Shared with Other Providers

Health Information Exchange critical to clinical workflows and to avoid duplicate testing (valuable for Telehealth, referrals, and transfers)

Required by Federal HITECH regulations

0

500

1000

1500

2000

2500

3000

3500

UC Davis Health SystemContinuity of Care Documents (CCD) or Equivalent

Shared with other ProvidersDecember 2010 through March 2015

OCHIN

Kaiser North

All Other Providers

Veterans Affairs

Sutter Health

Social SecurityAdministration

58,000+ full patient records shared36

Other Care Providers UC Davis has Shared Patient Records With

# Organization Location

Other Providers Initiated

Total

UCDHS Initiated

TotalTotal

1 SUTTER HEALTH and AFFILIATES Sacramento, CA 9,086 27,838 36,924

2 KAISER PERMANENTE NORTHERN CALIFORNIA Northern CA 4,249 4,143 8,392

3 U.S. SOCIAL SECURITY ADMINISTRATION Washington, DC 6,388 - 6,388 4 DIGNITY HEALTH, MERCY HOSPITALS IN SACRAMENTO Sacramento, CA 51 1,726 1,777 5 VETERANS AFFAIRS (VA) UNITED STATES 1,215 79 1,294

6 UCSF MEDICAL CENTER San Francisco, CA 540 331 871

7 OCHIN ACROSS U.S. 501 142 643

8 STANFORD HOSPITAL & CLINICS Stanford, CA 303 178 481

9 KAISER PERMANENTE SOUTHERN CALIFORNIA SOUTHERN CA 15 133 148

10 STANFORD CHILDREN'S HEALTH Stanford, CA 76 26 102 779 57,799 Total

Total for all other care providers

104 organizations

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Phase 5- Digital Clinical Care Environment

There has been a dream for many years to create a fully digital and integrated clinical care environment− There are many versions and opinions on what this may look like

Technology and care processes must be designed to support the full continuum of care

Home, WorkTraveling Nursing Home Clinic

EmergencyRoom

Hospital Critical CareUnit

Rural Urban

Poor Rich

5

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Move away from specialty and organization centric designs

1. Put the patient at the center and focus on HIT design and connect clinicians/care teams with patients/families

2. Integrate all clinical data about a patient to support each clinical encounter and analytics

3. Apply evidence-based clinical knowledge through advanced analytics and decision models to support every care encounter and to proactively assess a patient’s or population’s health status and support relevant interventions

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Future Care Scenarios

Cancer Diagnosis1. Patient receives a diagnosis of cancer2. Phenotype data fully integrated with genotype data3. Advanced analytics used to assess patient’s clinical data and unique

genotype to suggest optimal treatments fully tailored to that patient’s genotype mutations and create and help deliver am optimized plan of care

2 year old has sore throat at 3AM in the morning1. Patient has bad throat pain – parents use iPad to access child’s clinical data

and inputs new symptoms2. EHR uses guidelines to suggest parents use consumer home testing kit most

parents use at home to take throat swab, results transmitted to EHR3. EHR with embedded analytics diagnosis strep throat, suggests at home

treatment, automatically orders antibiotics to nearest all-night pharmacy, Dad drives to pharmacy to pick up the drug

Less about telemedicine, or mobile technologies, or EHRs…more about a complete digital health environment

or Digital Clinical Ecosystem40

Leverage EHR, PHR, Video, and Mobile Technologies

EHR to EHR telemedicine consult− Provider to provider, or to patient within one EHR

eConsult via video or messaging with urgent care type provider− Patient to urgent care center via video or secure message

Video encounters within tethered PHR− Patient to physician or nurse using PHR linked to EHR

Clinical call center encounters− Patient or family to clinical call center encounter

Patient and provider communication and data sharing through tethered PHR− Patient to Physician and care team via secure message

Store and forward − Specific clinical content such as retinal scan sent to ophthalmologist or

video psychiatric encounter sent to psychiatrist for review − Connection to Withings, Fitbit, or Apple Health Kit

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Other EHR, PHR, Video, and Mobile Use Cases

Remote monitoring of ICU or other care provision− Dedicated video and connections to clinical monitors to monitor critical care

patients

Inpatient consults− Physician to physician or nurse to support inpatient care

Specialty video support – Tele Stroke, Tele Psych, Tele Derm− Providers broader service coverage often replacing local specialty care often

to support emergency department environments

Home monitoring− Video connection and collection of targeted clinical data elements for patient

support at home

Tele interpretation service− Provides remote language interpretation support for a clinical encounter

Mobile telemedicine (iPad, iPhone, Android)− Multiple mobile platforms supporting patients & providers to access EHR/ PHR

Social media− Use of social media tools for patient education and group support

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Consumer Health Management Technologies

Scanadu Scanaflo™ - urine test kit in development that will empower people to monitor their health at home

AliveECG App

Electronic Sensors Printed Directly on the Skin

John Rogers, a materials scientist at the University of Illinois at Urbana-Champaign

Fitbit

Apple Health Kit

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Healthcare Moving to Digital Care Environment – Long way to go

FutureVision

Paper recordsDisconnected clinical careIsolated clinical data17+ years to disseminate new knowledge

Piloting Digital Integration Digital Clinical Care Environment

Full access to clinical resourcesClinical data fully digitalIntegrated clinical dataPhenotype linked to genotypeHigh speed ubiquitous networksEasy to use end points (tablets…)Privacy of clinical data protected

Legacy

Innovate - but focus less on specific technologies − Telemedicine, mobile computing, video technology, Fitbit, Apple Health Kit,

social media – all are attributes of the new paradigm

Focus on integration of data, leveraging clinical knowledge and community-level HIT − Leverage the emerging technologies that are relevant

US Healthcare

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6. Questions

?

References

Agency for Healthcare Research and Quality. (2011). National Healthcare Quality Report, 2011, Chapter 6, Care Coordination. AHRQ site on HHS website. Retrieved August 15, 2012 from http://www.ahrq.gov/qual/nhqr11/chap6.htm

Kirtane, J. (quoting the American Hospital Association - Hospital Survey, 2010). (2012) Putting the IT in Transitions: An Update from the Office of the National Coordinator for Health IT. Retrieved August 16, 2012 from http://www.techandaging.org/ASA_Care_Transitions_Technologies_Presentation.pdf

Pham, H., Schrag, D., O’Malley, A., Wu, B., Bach, P. (2007). Care Patterns in Medicare and Their Implications for Pay for Performance. The New England Journal of Medicine 356, 1130-1139.

Rudin, R., Salzberg, C., Szolovits, P., Volk, L., Simon, S., Bates, D. (2011. Care transitions as opportunities for clinicians to use data exchange services: how often do they occur? Journal of the American Medical Informatics Association. 18(6), 853-858.

Van Walraven, et al. (2008). Information Exchange among physicians caring for the same patient in the community. Canadian Medical Association Journal. 179(10), 1013-1018.

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End