making an impact on care transitions in central massachusetts january 16 th, 2013 larry garber, md...
TRANSCRIPT
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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[email protected]@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.