the clinical and business case for interoperability direct trust mini conference, sunday, march 22,...
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The Clinical and Business Case for Interoperability
Direct Trust Mini Conference, Sunday, March 22, 2015
Holly Miller, MD, MBA, FHIMSSCMO MedAllies
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Agenda
• Transitions of Care (TOC) Current State• Financial Incentives Offered for TOC
Improvements• Developing a Patient Centered Medical
Neighborhood to Enhance Patient Care Transitions and Healthcare Value
• Patient Centered Medical Neighborhood In Action
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Transitions of Care:
Copyright, 2014 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Current State
Adverse Events (AE)
1. Forster AJMurff HJPeterson JFGandhi TKBates DW The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med2003;138161- 167
2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates D (2005) Adverse drug events occurring following hospital discharge. Journal of General Internal Medicine 20: 317–323
3. Coleman EASmith JDRaha DMin S Post-hospital medication discrepancies: prevalence, types, and contributing system-level and patient-level factors. Arch Intern Med2005;1651842- 1847
4. Kanaan AQ, Donovan JL, Duchin NP, Field TS, Tjia J, Cutrona SL, Gagne L, Preusse P, Harrold LR, Gurwitz JH. Adverse Drug Events After Hospital Discharge in Older AdultsJ Am Geriatr Soc. 2013;61(11):1894-1899.
5. Gandhi, TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger SL, Shu K, Federico F, Leape LL, Bates DW. Adverse Drug Events in Ambulatory Care. N Engl J Med 2003;348:1556-64.
6. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellie K, Seeger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289(9):1107-16.
• ~ 20% of patients discharged from hospital experience an adverse drug event (ADE) *1,2,3,4
• Similar rates of ADEs in ambulatory patients, particularly among the elderly* 5,6
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1/5
• Hospital Discharge1
– 1st Post discharge PCP visit ~ 75% no information about the hospitalization
– 4 weeks post discharge 51-77% discharge summary not available
1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41.
• PCPs and Specialists2, 3
– PCPs report sending information 70% of time; specialists report receiving the information 35% of the time
– Specialists report sending a report 81% of the time; PCPs report receiving it 62% of the time
2 O’Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med, 171 (1), 56-65.3. Mehrotra, A., Forrest, C.B., Lin, C.Y. (2011). Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly, 89 (1), 39-68.
Communication Deficits
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Adverse Events (AE)
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Root Cause Analysis of Serious Adverse Events (AEs) Most frequent attributable cause is ineffective
communication Most vulnerable parts the TOC process are the “hand-
offs” Most frequent AEs are ADEs due to medication errors
*Greenes, R. (2007). Clinical Decision Support: The Road Ahead. New York, NY: Elsevier, Inc.
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Transitions of Care:
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Financial Incentives
• Patient Protection and Affordable Care Act– Transitions of Care• CPT codes for Transitional Care Management
Services–Discharge from Hospital, SNF, Community
Mental Health Center, Outpatient Observation, Partial Hospitalization
Care CoordinationIncentives
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Patient Protection and Affordable Care Act– Transitions of Care• CPT codes for Transitional Care Management Services
Care CoordinationIncentives
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Code Medical Decision Making
Communication F2F Visit Reimbursement
99495 Moderate complexity
Within 2 business days of discharge
Within 14 calendar days of discharge
$163.99
99496 High complexity Within 2 business days of discharge
Within 7 calendar days of discharge
$231.26
Care CoordinationIncentives
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Chronic Care Management Fee – Medicare patients
• 2 or more chronic or episodic health conditions
– CPT code 99490 under Part B fee for service• $ 41.92 per patient per month• Only billed once per month per patient and by one physician• > 20 mins clinical staff time directed by a physician spent in
CCM services• Patient consent required: Medicare pays 80%, patient liable for
20% co-insurance• Comprehensive care plan is established, implemented, revised
and monitored
– Requirements
CCM Scope of Service Element Billing Requirement
Certified EHR or Other Electronic Technology Requirement
Structured recording of demographics, problem list, medications, medication allergies and the creation of a structured clinical summary record must inform the care plan, care coordination and ongoing clinical care
Structured recording of demographics, problem list, medications, medication allergies and the creation of a structured clinical summary record using CCM certified technology
24/7 Access to care management servicesContinuity of care Care management for chronic conditionsCreation of a comprehensive care plan for all health and health related issues. Share the care plan as appropriate with other providers
Electronic capture of the care plan available 24/7 within the practice and share care plan electronically (not fax) with other providers
Provide patient with a written or eCopy of the care plan Document provision in the EHR using CCM certified technology
Management of care transitions between and among providers and settings
Format and exchange clinical summaries electronically
Enhanced patient and provider communication including asynchronous communication
Beneficiary consent - for CCM services Document the beneficiary’s written consent and authorization in the EHR using CCM certified technology
Beneficiary consent – right to stop the servicesBeneficiary Consent – only one provider paid during a calendar month
• Patient Protection and Affordable Care Act, Transitions of Care (Cont.)– Value Based Purchasing• Accountable Care Organizations: 1/1/2012• Community-based Care Transitions Program
(CBCT): 1/1/2011• Comprehensive Primary Care Initiative (CPC): 2013
– Expanding Authority to Bundle Payments• Hospital penalties for preventable 30 day readmissions
Care CoordinationIncentives
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• American Recovery and Reinvestment Act (ARRA)– Health Information Technology for Economic
and Clinical Health Act (HITECH)• Meaningful Use Stage 2 Core– More than 10% of patients transitioning or
being referred have electronic transmission using CEHRT to recipient
Care CoordinationIncentives
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Transitions of Care:
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Developing a Patient CenteredMedical Neighborhood
Practice
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Developing a Patient Centered Medical Neighborhood
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Practice
Developing a Patient Centered Medical Neighborhood
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Practice
Developing a Patient Centered Medical Neighborhood
Hospital
HospitalHospital Behavioral
Health
Practice Practice
SNF
HISPHISP
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Home Health
Developing a Patient Centered Medical Neighborhood
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
• Clinical Leadership• Clinical Trading Partners• EHR Configuration• Establish Role Based Workflows• Training Materials
Developing a Patient Centered Medical Neighborhood
Identifying Clinical Trading Partners• Acute care facilities analyze most frequent:– Discharge destination points– Transfer destination points
• Ambulatory facilities analyze most frequent:– Referrals or referral sources– Planned admissions to hospitalists
• Readiness assessment of clinical trading partners– 2014 CEHRT upgrade complete– HISP strategy identified
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
It Has To Be Easy
Direct implementation shouldENHANCE existing clinical workflow
20Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Transitions of Care:
• Patient Centered Medical Neighborhood in Action
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Direct HISP
Hospital Primary Care
Discharge C-CDA to PCP
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Primary Care
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Patient Centered Medical Home
Care Manager
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Direct HISP
Hospital
Home
Primary Care
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Patient at Home
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Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Patient Centered Medical Home
Care ManagerPatient at Home
Medication VerificationMedication VerificationMedication Verification
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Primary Care
Patient at Home
Patient Centered Medical Home
Care Manager
Discharge Diet and Exercise InstructionsDischarge Diet and
Exercise Instructions
Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home
Patient at HomeCopyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
The Patient Centered Medical Neighborhood
Hospital HomeHealth
Specialist(s)
LTPAC Settings (SNF, Other
Professionals etc.)
Patient
Patient Centered Medical Home
Integrated Workflow Across the Community
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Patient Centered Medical Neighborhood
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
Thank You
30
hmiller@medallies.com
Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission
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