Having learned a great deal from reviewing recent literature and from speaking with experts in the area of health information exchange (Task 5), the Division of Health Care Policy and Research (HCPR) team is well positioned to conduct on-site case studies at four health delivery systems and affiliated and non-affiliated post-acute and/or long-term care settings. The purpose of this deliverable is to outline the plan for these case studies (Task 7), during which we will address the following overarching research questions:
The original contract called for HCPR to adopt the use cases from the Federal Health Architecture Electronic Health Record work group as the basis for the data collection materials. Upon review of these use cases, the Task Order Manager (TOM), Principal Investigator, and Project Director concurred that they were not suitable to meet the needs of this project. As such, different clinical scenarios were established by the HCPR team, in collaboration with the TOM.
To address the four overarching research questions above, open-ended discussion guides and scenarios will be developed for the four site visits (draft versions of the questions that will make up the guides and scenarios can be found in Attachment A). The HCPR Research Team recognized that the guides needed to be sufficiently flexible and open-ended in order to capture the uniqueness of each systems' and PAC/LTC providers' information exchange processes. The guides and scenarios were designed to maintain a balance between the amount of clinical and technical information gathered at the site visits. Because so few skilled nursing facilities and home health agencies have adopted electronic health record systems (Kaushal et al., 2005), it is anticipated that there may be limited technical information at some sites. It also is possible that the unaffiliated PAC/LTC providers may predominantly rely on paper-based communication and this may result in a shift in focus toward a more clinically oriented discussion. Regardless, it will be important to understand what data are and are not exchanged through whatever medium is used.
The HCPR team will use various approaches to obtain the needed information. For example, at the selected health delivery systems and PAC/LTC providers, the HCPR site visit team will conduct discussions with different individuals (e.g., clinical, administrative, health information technology [HIT] staff); observe the use of HIT by the selected health care delivery system for the creation, storage, and/or exchange of information needed by PAC/LTC providers; and run through various scenarios these settings are likely to encounter, determining how the data exchange would be handled given these circumstances.
Each site visit will essentially be comprised of two site visits--one to the health delivery system and an affiliated PAC/LTC setting, and the other to three unaffiliated PAC/LTC providers in the area. This design has increased the complexity of scheduling and conducting the visits at all health settings. Time management while on site will be crucial for the success of the visit and the guides are developed to ensure that all requisite information will be successfully obtained. To this end, the two-part site visits will attempt to obtain as much information from the health delivery systems regarding their health information systems prior to the visit. These information systems also may be discussed during the site visit, but the HCPR team will be cautious that these discussions do not detract from the main purpose of the site visits or consume a disproportionate amount of time. The site visit team will attempt to strike a balance between the amount of time devoted to gathering information about the health care delivery system and the unaffiliated PAC/LTC sites. When pressed for time, the latter focus will receive higher priority.
INTRODUCTION
Four health delivery systems have been selected for participation as case study sites. Within these systems, three unaffiliated post-acute or long-term care settings have been identified. In this chapter, we describe the criteria used for site screening and selection, and the process through which we recruited the final four sites.
CRITERIA FOR SITE SELECTION
Identification of Candidate Health Delivery Systems
For the purposes of this study, a health delivery system initially was defined as an entity that included a hospital with one or more affiliated or owned physician office practice(s), outpatient clinic(s), laboratories, and/or pharmacies. After an interview with Erickson Continuous Care Retirement Communities (CCRC), some of which include a medical center, a certified home health agency, inpatient and outpatient rehabilitation services, a skilled nursing facility, and an assisted living facility, it was decided to broaden the definition to include this type of health delivery system.
Suggestions from the Agency for Healthcare Research and Quality (AHRQ) and the ASPE TOM, and the site's national reputation of HIT readiness informed the development of our list. We initially identified 14 candidate health delivery systems and prioritized them according to the following broad criteria:
The following were specific criteria used to further prioritize candidate sites:
PRIORITIZED LIST OF POTENTIAL SITES
Table A.1 shows the prioritized list of sites using the criteria noted above. Although attempts were made to contact representatives from the majority of these institutions, in some cases that was not possible. In other cases, we spoke with individuals who may not have had the organization's long view; that is, we did not always get to speak with the leaders at the organization. Finally, the places that we vetted did not have the opportunity to review the accuracy of the information provided in this document, including Table A.1 below.
| TABLE A.1: Potential Site Visit List | |||||
|---|---|---|---|---|---|
| Health Delivery System and Location | Exchange Across 2+ Settings? | Has Unaffiliated PAC/LTC? | 6 m. + Experience with Software? | Amenable to Site Visit? | Rural Area? |
| Intermountain Health Care, Salt Lake City, Utah | Yes | Yes | Yes | Yes | No |
| Maimonides, Brooklyn, New York | Yes | Yes | In transition to new software? | Not asked | No |
| Mercy Medical Center, Rural Iowa Redesign of Care Delivery with EHR Functions, Mason City, Iowa | Yes | Yes | Some sites yes, some are in process of rollout | No | Yes |
| Meridian Health, Jersey Shore University Medical Center, Jersey City, New Jersey | Yes | Yes | Yes | Not asked | No |
| Montefiore Medical Center, Bronx, New York | Yes | Yes | Yes | Yes | No |
| Indiana Health Information Exchange, Indianapolis, Indiana | Yes | Yes | Yes | Yes | No |
| Erickson Continuous Care Retirement Communities, Catonsville, Maryland | Yes | Yes | Yes | Yes | No |
| Taconic Independent Physicians Association, as part of the Taconic Health Information Network & Community (THINC), Fishkill, New York | Yes | Unknown | Yes | Not asked | No |
| Allina Hospitals and Clinics, Minneapolis, Minnesota | Yes | Yes | Yes | Not asked | No |
| Rhode Island HIE project, Providence, Rhode Island | Unknown | Unknown | Unknown | Not asked | Rural/Urban |
| Deaconess Billings Clinic, Billings, Montana | Yes | Yes | Yes | Not asked | Yes |
| Kaiser Permanente, Oregon | Yes | Yes | Yes | Not asked | No |
| Partners Healthcare System, Inc., Boston, Massachusetts | Yes | Yes | Yes | Not asked | No |
| PeaceHealth, Eugene, Oregon | Yes | Yes | Yes | Not asked | No |
SCREENING/RECRUITMENT PROCESS
A screening/recruitment process was used to determine if a site met the selection criteria, could devote sufficient resources for a site visit, and would provide access to key information and operational processes. The process included the following steps:
SELECTED SITES
Erickson Continuous Care Retirement Communities
(Site Visit Dates: July 12-14, 2006)
Erickson Retirement Communities, Catonsville, Maryland, owns and operates 13 Continuing Care Retirement Communities (CCRCs) in the United States. Four of their communities are considered "mature campuses" and include a medical center, a certified home health agency, inpatient and outpatient rehabilitation services, a skilled nursing facility, and an assisted living facility (personal communication with Daniel Wilt, March 23, 2006). Erickson does have some specialists on campus who are employed by Erickson and some that are not (e.g., podiatry, dentistry), however, they do not own or operate most specialty clinics and do not own or operate any acute care centers. Erickson has developed a chart summary, which is generated out of their electronic medical record and can be accessed via the web or at any of their facilities' workstations. The chart summary includes relevant current and historical information such as advanced directives, medication lists, laboratory results, problem lists, contact information for patient and caregivers, etc. Care coordination is facilitated as physicians can access this information on or off-campus and then can coordinate in a timely manner with the emergency department physician if a patient requires acute care. In November 2005, Erickson launched a website (https://myhealth.erickson.com), which is provided to their residents free of charge. Patients have read-only access to their own medical record including the chart summary discussed above and can download it to a USB memory stick (provided by Erickson free of charge) and take it with them (should they travel or be away for extended periods of time). Alternatively, patients can access this information via the web.
Unaffiliated PAC/LTC sites: St. Agnes hospital, St. Agnes hospice, Johns Hopkins Home Health Agency.
Montefiore
(Site Visit Dates: August 2-4,
2006)
Montefiore is an integrated delivery system in Bronx, New York, providing a full range of services, including specialty care to both local and outside populations. It serves a medically underserved population, a large number of whom are young, minority, and poor (Greg Burke presentation slides from November 2004). Montefiore owns a large home health agency and contracts with a number of skilled nursing facilities in the area. They are using information technology to support the use of clinical pathways and retrospective assessments of practice and outcomes to improve quality of care (Source: Greg Burke presentation slides from November 2004). Montefiore is one of several acute care hospitals involved in the creation of the non-profit entity called the Bronx Regional Health Information Organization (RHIO). The other collaborators include additional acute care hospitals, over 40 community-based primary care centers, two nursing homes, two home health agencies, payors, physician offices, and laboratories. They recently were awarded $4.1 million from the New York Department of Health (NYDoH) for seed money (called HEAL-NY) to start up a data exchange RHIO in the Bronx. The focus of the Bronx RHIO is to facilitate sharing of clinical data among providers with disparate systems and levels of sophistication in using EHR systems (personal communication with Greg Burke).
Unaffiliated PAC/LTC sites: Schervier Nursing Care Center, the VNS of New York, the Jewish Home and Hospital.
Intermountain Healthcare
(Site Visit Dates: August 9-11,
2006)
Intermountain Healthcare is a non-profit health care system that provides care to residents of Utah and Idaho. This institution is one of the pioneers in health information technology, with a long history of excellence in the area of quality improvement. Stanley Huff and others at Intermountain were among the first users and developers of electronic health record systems. Intermountain Healthcare is a member of the Utah Health Information Network (UHIN), a community health information network that began in 1993. UHIN is a coalition of health care providers, payors, and state government with the common goal of reducing costs by standardizing administrative data, particularly payment data. The network community sets the data standards that providers and payors voluntarily agree to adhere. The UHIN standards are then incorporated into the Utah state rule via the Insurance Commissioners Office and are required for provider payment.
UHIN operates as a centralized secure network through which the majority of health care transactions pass in the state. Nearly all payors and providers are participating in this project. UHIN developed a tool (UHINT), which they provide free of charge to providers for use in electronically submitting claims. The tool is provided so that even the smallest provider can submit claims and electronically receive remittance advices. This has drastically reduced the amount of paper processing required for payors and has streamlined the payment of claims and remits, which has resulted in providers receiving payment more quickly. Under an AHRQ grant, they will use what they have learned standardizing the administrative data and pilot test the exchange of a limited set of clinical data (medication history, discharge summaries, history and physical, and laboratory results) with a small number of providers. This pilot is scheduled to occur in the summer of 2006.
Unaffiliated PAC/LTC sites: Christus St. Joseph Villa (not confirmed as of June 23), Community Nursing Service, Mission Health Services, CareSource (not confirmed as of June 23).
Indiana Health Information Exchange
(Site Visit Dates:
September 13-15, 2006)
The Indiana Health Information Exchange (IHIE) is a non-profit venture connecting a number of health delivery systems in Indiana and led by Dr. Marc Overhage. The IHIE comprises over 48 hospitals and has approximately 3,000 physicians who access the network. With AHRQ funding and a variety of other sponsors including BioCrossroads, regional and local hospitals, and the Regenstrief Institute, the IHIE recently implemented a community-wide clinical messaging project. Each participating partner has access to patients' clinical results using a single IHIE-controlled electronic mailbox.
In November 2005, the HHS announced the award of contracts totaling $18.6 million to four consortia to develop a prototype for a Nationwide Health Information Network (NHIN) architecture. IHIE, MA-SHARE (Massachusetts), and Mendocino HRE (California) are involved in the Connecting for Health consortium that will launch a prototype of an electronic national health information exchange based on common, open standards. Components of these prototypes that are particularly interesting for this project are: (1) the prototypes will be designed to facilitate HIE using the Internet, not creating a new network; (2) they will allow for communication to occur between many different types of EHR systems; and (3) they will allow for different types of software and hardware that can be included in the system.
Unaffiliated PAC/LTC sites: Beverly Healthcare at Brookview, the VNS of Central Indiana, TLC Management (not confirmed as of June 23).
INTRODUCTION
This chapter provides more detail on how it is envisioned the site visits will be conducted. To minimize burden on any host site, HCPR staff will be as flexible as possible in terms of setting up interviews with key individuals at each site. In some cases, those individuals with whom a member of the HCPR team should speak may be unavailable during the visit. In these cases, phone calls (either before of after the site visit) will be set up to attempt to collect the salient information over the telephone.
Overall case study objectives, the site visit participants, the protocols for conducting the visits, and a description of the logistics for setting up the visits are included below. See Attachment A for a copy of the scenarios and proposed questions that will be or already have been distributed prior to the site visit.
CASE STUDY/SITE VISIT OBJECTIVES
Three overarching topic areas inform the manner in which the site visits will be conducted:
SITE VISIT TEAM COMPOSITION
Site visits are anticipated to require three days on site, and one day following each site visit to summarize in writing the site visit findings. The site visit team will include Dr. Eric Coleman and Rachael Bennett from the University of Colorado, both with clinical expertise, particularly in acute hospitals, PAC, and LTC services. The Contractor has subcontracted with Mark Tuttle, from Apelon, Inc., to be the HIT expert of the site visit team. Dr. Coleman, Ms. Bennett, and Mr. Tuttle will conduct all four site visits. Jennie Harvell, the ASPE Task Order Manager, has indicated she will attend two site visits, Montefiore and Erickson CCRC.
RESPONDENTS AT EACH HEALTH SETTING
A list of key "types" of individuals that should be interviewed and/or observed during the course of the site visit has been identified. Table A.2 provides illustrative examples of the variety of people with whom the HCPR team may wish to speak, but should not be considered a comprehensive list. Each health setting will have its own unique set of personnel and each setting at each site visit will have a schedule tailored to their unique circumstances.
| TABLE A.2: Illustrative Categories of Individuals to be Interviewed/Observed During Site Visit | |||
|---|---|---|---|
| Management | Information Technology | Clinicians | Other |
| Director of
Nursing/Administrator of Facility Medical Director Business Office Compliance Officer/Regulatory Staff |
Chief Information Officer
Information System Administrator Staff that implemented the EHR system Staff that provide technical assistance to the EHR system users |
Physician(s)
Supervising RN Therapist(s) (if appropriate for setting) Nursing staff (RN, LPN, as appropriate) Pharmacist (if appropriate for setting) Other clinical staff (nursing aide, if appropriate for setting) |
Data entry staff (if
appropriate) Medical records (paper) |
OBSERVATION AND INTERVIEW PROTOCOLS
The site visit protocols will be conducted using multiple types of data collection including interview, observation, and various sample clinical scenarios. In addition, general information about the health system will be collected from the administrator and/or system administrator prior to the site visit.
Participating sites are fairly complex health systems. With regard to visits to Intermountain HealthCare, Montefiore, and Indiana Health Information Exchange, the schedule is to visit an acute care hospital and one affiliated skilled nursing facility or home health agency the first day. The second and third days will be spent visiting unaffiliated SNFs/NHs and/or HHAs. At Erickson, the first day will be spent at the Charlestown Campus (in Catonsville, Maryland) where the HCPR team will visit the medical center, as well as the on-campus SNF and HHA. The second day will be spent visiting the local acute care hospital, St. Agnes, which provides acute care services to Erickson residents, as well as the St. Agnes hospice. On the third day, the HCPR team will visit Johns Hopkins HHA, as they receive some referrals from Erickson.
At each care setting, three types of staff will be interviewed: clinicians, information technology, and business office/managers. In some cases, we will have large group discussions and in other cases, we will break off and have the expertise of each HCPR site visit team member speak with someone one-on-one.
SITE VISIT SET UP
At the time of the writing of this report, all four site visits have been confirmed. There were a number of challenges faced when the prioritized sites were contacted. The first challenge was getting the health delivery system to commit to a site visit. One of the preferred sites initially agreed to a site visit and then tacitly refused by neglecting to respond to any further correspondence. Of the four sites ultimately selected, two of the four required an amount of persuasion before agreement.
A second challenge was identifying a date when key individuals would be available in both the health delivery system and the unaffiliated PAC/LTC providers. The schedules of these key individuals are not within the control of the Contractor and every effort was made to identify a time that maximized participation.
A third and related challenge is the time of year in which the site visits are scheduled, which is July-September 2006, a time when many health delivery system and PAC/LTC staff are on vacation.
A fourth challenge was non-responsiveness on the part of the site liaison. Although the initial assignment of a liaison at each health delivery system went smoothly, follow-up communication with each HDS liaison has proved to be problematic. Furthermore, a liaison not only is needed at each health delivery system, but also at each of the PAC/LTC settings visited (three per site visit). Because the PAC/LTC settings are not affiliated with the health delivery system, the staff at some of the unaffiliated PAC/LTC settings has been less responsive to our request for a site visit than we had hoped. We interpret their reluctance to respond as likely the result of not fully understanding the short time commitment we were asking of their institution.
HCPR Site Visit Coordinator
The Project Director will be responsible for facilitating and preparing for each site visit (e.g., working with the host liaison to schedule interviews prior to our arrival, setting the schedule, knowing how to maneuver around the city to get to the next appointment, keeping us on schedule, and collecting the appropriate information at each setting). Once the site visit schedule has been approved and dates have been scheduled, the Project Director will continue with the following preparations:
Distributing Information to the Site Prior to the Arrival of the HCPR Team
HCPR will develop and disseminate a packet of materials to the appropriate individual (e.g., the administrator, Director of Nursing) prior to the site visit for confirmation and completion. The following are some potential items that may be included in the packet:
Designation of Site Liaison
One person at each site will be designated as the site liaison and this person will be requested to take on the following responsibilities:
Travel Arrangements
Once the site is selected, dates will be confirmed with HCPR and site participants. A HCPR staff member will set up the travel and lodging arrangements for the travelers, including a rental car, as appropriate for off-site travel.
Duration of Site Visits
The goal will be to conduct the site visits as expeditiously as possible to minimize the burden on the host sites. We estimate that each site visit can be completed in two and a half to three days. Appointments at each health care setting will be set up prior to our arrival and will require each site visitor to conduct up to four interviews each day, along with observing various staff conduct their routine tasks.
The following assumptions were made regarding the schedule and duration of a site visit:
Summary of Findings
Each of the HCPR site visitors is responsible for writing a site visit report, following a standard format (to be created). They also are responsible for participating in a phone call with the TOM within one week of the site visit to discuss key findings. The Project Director is responsible for preparing a one-page report to be used in conjunction with this debriefing phone call.
To ensure the accuracy of the report, we will ask a designated person at each visited health setting if s/he would be willing to review the site visit report summary for accuracy. Findings from the site visits will be included in the draft final report, due mid-November 2006.
Kaushal, R., Blumenthal, D., Poon, E.G., Jah, A.K., Franz, C., Middleton, B., Glaser, J., Kuperman, G., Christino, M., Fernandopulle, R., Newhouse, J.P., Bates, D.W. (2005). The costs of a national health information network. Annals of Internal Medicine, 143(3):165-73.
This first table would be converted into a data collection form we would send to all sites (acute care hospital and PAC/LTC settings) prior to the visit.
| General Information about Health Care Setting |
|---|
| Area served (urban, rural, both) |
| Year established |
| Ownership (gov't, for-profit, nonprofit) |
| Number of full-time employees |
| Number of nursing homes--owned |
| Number of nursing homes--affiliated |
| Number of home health agencies--owned |
| Number of home health agencies--affiliated |
| Physician practices--owned |
| Physician practices--affiliated |
| Do you have an inpatient pharmacy (yes/no) |
| Does SNF use a dedicated pharmacy or does it contract with large/retail pharmacies or multiple pharmacies? |
| Number of Pharmacies--outpatient |
| Do you have an in-house laboratory? |
| How many outside laboratories are used? |
| Do you have an in-house radiology department? |
| How many outside radiology centers/MR centers do you work with? |
| Number of affiliated physician practices |
| Main software vendor |
| Are your physicians affiliated with your HDS or are they independent? |
| Clinical EHR system differentiate from appointment or billing (yes/no) |
| Short-term (6 months?) HIE future plans |
| Long-term HIE future plans |
The following tables represent potential questions in various areas that we anticipate we will ask. Once we receive approval from the TOM, we will convert these questions into data collection guides.
| Health information exchange: | ||||
|---|---|---|---|---|
| Electronic Exchg | Manually (fax [F], hardcopy [HC], or phone [P]) | Standards-based? (yes/no) | What is exchanged, comments | |
| HDS and pharmacy inpatient or community? | ||||
| HDS and laboratory inpatient or community? | ||||
| HDS and radiology inpatient or community? | ||||
| HDS and physician practice | ||||
| HDS and SNF 1 | ||||
| HDS and SNF 2 | ||||
| HDS and HHA 1 | ||||
| HDS and HHA 2 | ||||
| Other HDS (hospitals, clinics) | ||||
| HDS and unaffiliated HHAs/SNFs | ||||
| Other: | ||||
| SNF and pharmacy (dedicated or contracted) | ||||
| SNF and laboratory (dedicated or contracted) | ||||
| SNF and radiology (dedicated or contracted) | ||||
| SNF and physician practice | ||||
| SNF and HDS(s) | ||||
| SNF and ED | ||||
| Other PAC/LTC settings | ||||
| Other: | ||||
| HHA and pharmacy (dedicated or contracted) | ||||
| HHA and laboratory (dedicated or contracted) | ||||
| HHA and radiology (dedicated or contracted) | ||||
| HHA and physician practice | ||||
| HHA and HDS(s) | ||||
| HHA and ED | ||||
| Other PAC/LTC settings | ||||
| Other: | ||||
| Acute Care Hospitals & Medical Centers/Clinics |
|---|
| What information is necessary to exchange at time of transfer from acute care hospitals to PAC/LTC? |
| focus on physician referrals, consultation reports, meds, lab work |
| Caregivers & coordination of care (including family) |
| What information actually is exchanged? |
| focus on physician referrals, consultation reports, meds, lab work |
| Caregivers & coordination of care (including family) |
| What medium (phone, fax, paper, electronic, a combination of all) is used to exchange information? |
| Who has access to and uses the information? |
| How is this information accessed? |
| Do all
clinicians (physician, nurse, social worker, therapist, and nutritionist) have
the same access to the information? Probe: between disciplines vs. within disciplines. |
| How is
information communicated to the different clinicians (physicians, nurse, social
workers, therapists, nutritionists, etc.)? Probe: between disciplines vs. within disciplines. |
| Do unaffiliated providers (e.g., PAC providers) have the same access to health information as affiliated providers? If not, how does access differ between affiliated and unaffiliated providers? |
| When is health information exchanged to PAC/LTC facilities? Is there a delay and if so, how long? |
| Is time-sensitive information exchanged in a timely manner with PAC/LTC? (Define what we mean by time-sensitive, then ask if this information is transmitted specially or separately, then what percentage of the time is the info transferred in a timely manner (e.g., by the time the patient arrives at your health setting) |
| Has this changed with the use of electronic health information exchange (e-HIE)? |
| What information is not being communicated/exchanged at time of transfer from acute care hospitals to PAC/LTC? |
| What are the plans for the future in terms of HIE including when/how/where HIE will become automated/become more automated? |
| What are the workflow/communication issues (positive and negative) with having (1) automated or (2) non-automated HIE? |
| What are the facilitators/barriers to (1) automated and (2) non-automated HIE? |
| Who were/are the advocates/champions for embracing e-HIE in your HDS (if applicable)? What did these champions have in common across all the sites? Did you use push or pull strategies (or both)? |
| How did the champions get others to embrace the concept that HIE was valuable? What points were most compelling? |
| Does your EHR system use CHI-endorsed content and messaging standards, and do these standards support electronic HIE? If so, which standards are used and how do these support HIE? |
| Who is responsible for ensuring data are up to date upon the patient’s arrival? |
| Who reconciles the information from the previous health care setting with the current care setting? (e.g., medications)? How long does this take on average? |
| What policies would promote information exchange (including electronic information exchange)? |
| Are the policies HDS? State? Federal? Accreditation? |
| Skilled Nursing Facilities--Home Health Agencies |
|---|
| Define the clinically relevant information at times of transition into and out the facility/agency? |
| How is
information exchanged with (i.e., to and from) the hospital (acute care)?
Probe: What % of the time does this happen? |
| How is information exchanged with (i.e., to and from) physicians (both in and outside of your health care setting)? |
| How is information exchanged with (i.e., to and from) pharmacies (inside and outside)? |
| How is information exchanged with (i.e. to and from) laboratories (inside and outside)? |
| How is information exchanged with (i.e., to and from) other PAC/LTC providers? |
| What data are exchanged with acute care? |
| What data are not exchanged with acute care? |
| What data are exchanged with physicians? |
| What data are not exchanged with physicians? |
| What data are exchanged with pharmacies? |
| What data are not exchanged with pharmacies? |
| What data are exchanged with laboratories? |
| What data are not exchanged with laboratories? |
| What data are exchanged with other PAC/LTC? |
| What data are not exchanged with other PAC/LTC? |
| Is the flow of info different if you are working with a provider that is not affiliated? How is it different? |
| Have you invested in an EHR system/applications? |
| If so, what functionalities are supported by the EHR system/applications? |
| To what extent and how are these applications adhering to CHI-endorsed standards for content and format? |
| Does the EHR-S support HIE? If so, w/ whom and how? |
| If you haven't already done so, what are your future plans in terms of adopting an EHR system? What criteria are you using to select one? |
| Are standards considered when implementing EHR systems or choosing vendors? If so which standards? |
| What kind of staff turnover do you experience? How difficult is it to get new staff trained on the EHR system (if applicable)? What other issues does staff turnover greatly affect? |
| How technologically savvy are the NHs/HHAs we visited? (opinion of site visit team member) |
| What policies
would promote information exchange (including electronic information exchange)?
Probe for things such as the greatest technological challenges (financial, integration of services, network security, electronic signature/ensuring person is who s/he says she is, others) |
| What are the facilitators/barriers to (1) automated and (2) non-automated HIE? |
| Technological--Electronic exchange of information |
|---|
| Interoperable internal information exchange |
| Interoperable information exchange with external parties |
| What can be exchanged |
| CHI-endorsed |
| Messaging standards |
| What EHR system, vendor, etc. |
| What hardware |
| What software |
| e-prescribing capabilities |
| Description of each EHR system |
| Architecture of EHR systems at PAC/LTC (if applicable) |
| How are the data stored? Shared? Accessed? Transmitted? Accepted at other setting? Entered? Etc. |
| How are you addressing any interoperability issues using standards-based EHR systems? Also includes (1) within each HDS, and (2) in terms of the broader context, including how HIE happens with unaffiliated providers (including e-HIE). |
| How does electronic health information exchange (E-HIE) vary between affiliated and unaffiliated providers within a single HDS? |
| How does e-HIE vary when exchanging to outside entities? To what extent could the e-HIE mechanisms being used with each HDS easily support e-HIE across HDS? If so how? If not, why not? |
| What are the
facilitators/barriers to (1) automated and (2) non-automated HIE Probe for things such as the greatest technological challenges (financial, integration of services, network security, electronic signature/ensuring person is who s/he says she is, others) |
| Short-term plans (0-6 months) |
| Long-term plans |
| Organizational Issues/Business/Managerial |
|---|
| Have you articulated a business case for electronic HIE in PAC/LTC? |
| How was this
business case developed? Probe: We are after clinical data that needs to be exchanged as well as billing data or MDS |
| When EHR system was implemented, was the adoption of a product that had CHI-endorsed standards a high, medium or low priority? |
| How did you choose your vendor(s) and which vendor did you choose? |
| When considering an EHR system, was interoperability with other systems a high, medium, or low priority? Please explain. |
| Approximately, what percentage of your overall annual budget is allocated to health information technology (HIT)? |
| Are any of your staff involved in SDOs? If yes, which ones? |
| How has staff turnover affected the training on the use of the EHR system? |
| Number of specific/dedicated information technology staff |
| Are any portions of the HIT outsourced? If so, what? |
| Is this part of a large chain or is it a freestanding health care setting? |
| Are they using CHI-endorsed and other HIT content and messaging standards? If so, which ones are they using? Messaging? Vocabulary? Direct care FM? |
| Is the organizational culture open to the idea of exchanging information to "outside entities" or is it more of a closed system? |
| What are the
facilitators/barriers to (1) automated and (2) non-automated HIE? Probe for things such as the greatest technological challenges (financial, integration of services, network security, electronic signature/ensuring person is who s/he says she is, others) |
| Short-term plans (0-6 months) |
| Long-term
plans Probe for top three information technology priorities. Examples might be creating a data warehouse, developing better network security, joining/expanding a RHIO or other data exchange group, reducing medical errors/increasing patient safety, upgrading existing clinical systems, implementing/choosing/vetting and EHR system, adopting technology-driven devices such as handheld PDAs for data collection or "smart pens" or whatever. |
Draft Clinical Scenario
Script: We believe that illustrative cases are one of the more effective and efficient ways of learning more about how you exchange information with health care clinicians in other settings.
For
the purpose of this exercise, we have selected an 82-year-old woman. The key
elements of her history include that she:
|
Now, let’s say this patient suffers a fall while bathing and is taken to the acute care hospital where her hip fracture is diagnosed and repaired without complications. Please help us understand how health information exchange either does or does not occur in response to each of the following questions.
We will begin by focusing on the acute care hospital:
Next, we will focus on the transfer from the acute care hospital to the skilled nursing facility
Next, we will focus on the transfer from the skilled nursing facility to emergency department [ED] located in the same acute care hospital from which she was recently released. Let’s say that the patient develops a swollen leg and becomes short of breath. The concern is that she may have suffered a deep venous thrombosis and possibly a pulmonary embolus despite being on an anticoagulant.
Next, we will focus on the transfer from SNF to the home health agency
Awareness and support for the need of interoperable, standardized electronic health records (EHRs) have greatly increased. To date, these efforts have largely focused on hospitals and ambulatory settings. Post-acute care (PAC) and long-term care (LTC) settings have unique needs for health information exchange (HIE). This project will examine how HIE is occurring between health delivery systems and unaffiliated PAC/LTC settings and the factors that promote or hinder this exchange. These research questions will be addressed:
Project activities will include a literature search and discussions with stakeholders involved in the development of EHR architecture and standards. Based on the information learned, a plan will be developed for conducting site visits, modifying previously developed tools to gather information. In the Summer of 2006, four site visits will be conducted. Progress presentations to the Office of the Assistant Secretary for Planning and Evaluation will be made in months 7 and 15 of the project. The information gathered through all the sources will be summarized and presented in the final report, which will identify policies that could promote information exchange and propose next steps on to how to support information exchange with PAC/LTC settings.
AT HOST HEALTH DELIVERY SYSTEM
We are pleased that your organization has agreed to participate in our study of health information exchange (HIE) in post-acute and long-term care. This project is examining how HIE is occurring between health delivery systems and unaffiliated post-acute and/or long-term care settings and the factors that promote or hinder this exchange. A better understanding will allow us to make informed recommendations to the Department of Health and Human Services about what needs to be done to facilitate more exchange with these often overlooked health care settings.
This document provides you with the objectives we would like to accomplish during the site visits as well as our expectations of you as a host sites. Our research team at the University of Colorado at Denver and Health Sciences Center (UCDHSC) is excited to visit your health setting; we will make every effort to minimize the burden placed on your staff and be as unobtrusive as possible. We also hope that members of your organization find the visit rewarding and stimulating.
Although our site visit will be three days, we plan to conduct the visit at your organization in one day. During the course of the site visit we plan to visit an acute care hospital and an affiliated home health agency (HHA) or skilled nursing facility (SNF) and three unaffiliated HHAs or SNFs.
Following is a summary of your organization's responsibilities as a participant in this research study:
All information gathered at each health care setting through this research will be held in the strictest confidence. No patient-level information will be collected or accessed. Only provider-level information will be provided in any study publications.
AT HOST POST-ACUTE/LONG-TERM CARE SETTING
We are pleased that your organization has agreed to participate in our study of health information exchange (HIE) in post-acute and long-term care. This project is examining how HIE is occurring between health delivery systems and unaffiliated post-acute and/or long-term care settings and the factors that promote or hinder this exchange. A better understanding will allow us to make informed recommendations to the Department of Health and Human Services about what needs to be done to facilitate more exchange with these often overlooked health care settings.
This document provides you with the objectives we would like to accomplish during the site visits as well as our expectations of you as a host sites. Our research team at the University of Colorado at Denver and Health Sciences Center (UCDHSC) is excited to visit your health setting; we will make every effort to minimize the burden placed on your staff and be as unobtrusive as possible. We also hope that members of your organization find the visit rewarding and stimulating.
Although our site visit will be three days, we plan to conduct the visit at your organization in one-half day (no more than three or so hours). During the course of the site visit we plan to visit an acute care hospital and an affiliated home health agency (HHA) or skilled nursing facility (SNF) and three unaffiliated HHAs or SNFs.
Following is a summary of your organization's responsibilities as a participant in this research study:
All information gathered at each health care setting through this research will be held in the strictest confidence. No patient-level information will be collected or accessed. Only provider-level information will be provided in any study publications.
Health Settings visited: Erickson Retirement Communities (including the medical center, Renaissance Gardens [skilled nursing facility], home health agency, and administrative center), St. Agnes Hospital, and the Johns Hopkins Home Care Group.
Erickson Retirement Communities is a non-profit, continuous care retirement community (CCRC), founded and led by an articulate visionary named John Erickson. This Chairman and CEO enthusiastically believes that both health care providers and patients need timely, non-redundant, anytime/anywhere access to patient health data. He is especially focused on removing the remaining impediments to achieving what he regards as seamless care, and he keeps informed about how healthcare and other community services are provided by observing and visiting the various buildings on the campus. His ambitious, forward-thinking approach is shared by other leaders within the organization, including Matt Narrett, MD, the Chief Medical Officer, and our host, Daniel Wilt, Vice President of Information Technology and Security Officer.
Originally, the Erickson model was designed to serve lower to middle income residents who owned their own homes and had a pension. A substantial deposit is required to reserve space or become a resident; this deposit is returned to heirs upon death of the resident. In addition, residents pay a fee based on the level of service (and care) they receive. More recently, the Erickson market has broadened socio-economically because of the quality and competitiveness of their care provision in this market.
The Charlestown campus--former home of a religious order on spacious grounds overlooking suburban Baltimore--is Erickson's flagship location and national headquarters. Currently it has 2,300 residents, five physicians, three nurse practitioners, and 1.4 FTE in mental health. The Erickson community is highly integrated and largely self-contained--the main exception being that residents who need acute care or hospice services are sent to nearby non-Erickson health delivery settings. The average Erickson resident's tenure is 12 years. They implemented Erickson Advantage (a CMS Medicare Advantage demonstration) about three months prior to the site visit, and enjoy a 7% penetration; the other 93% of residents are fee-for-service.
Erickson has an on-campus outpatient pharmacy that serves approximately 80% of the residents and their skilled nursing facility, Renaissance Gardens, uses them exclusively.
As observed, the Erickson campus does not provide hospice care nor does it have an acute care hospital. The majority of residents that need acute care go to St. Agnes Hospital, a few miles from the Charlestown campus. The Johns Hopkins Home Care Group receives a few referrals per month from Erickson.
Erickson’s EHR (GE Centricity) serves all sites, currently in 13 states and expanding to 16 states in the near future. A single installation of the GE Centricity EHR, managed from the Charlestown Campus, serves all Erickson sites, nationally. Administrative and billing (reimbursement) functions appear to be paperless. The Centricity “problem list” makes use of the ICD-9-CM codes used for reporting and billing. Incremental deployment of additional Centricity clinical functions is physician satisfaction driven; for the moment, this means that computer-based provider order entry (CPOE) is not deployed, although it is being piloted. At present, the Erickson system does not interoperate with non-Erickson systems when Erickson patients receive care at nearby emergency departments, although Erickson-associated physicians are allowed read/write remote access. At present, this access is supported through dial-up connection; web-based access is being contemplated but is not yet scheduled. Some internal nursing and home care information is kept using HealthMEDX’s product CareMEDX, which also produces MDS and OASIS submissions.
St. Agnes is a teaching hospital with the third busiest Emergency Department (ED) in the State of Maryland. They began looking at information technology strategies nearly a decade ago, before electronic health records were widely marketed and deployed by software vendors in the hospital market space. This planning led them to purchase and deploy a Meditech hospital EHR. They have a volunteer medical staff and hospitalists on service. Usually, Erickson doctors take care of Erickson patients while they are at St. Agnes.
St. Agnes information technology staff built their first portal to allow Erickson physicians access to St. Agnes data in the Meditech system in 1999. Erickson and St. Agnes have been discussing building a local, custom peer-to-peer interface to allow for the exchange of data between Meditech and Centricity, but the costs and risks associated with the project are a barrier to completing this effort. Part of the technical challenge facing such an effort is the fact that the Meditech (hospital) EHR is care episode-based and the Centricity (outpatient-centric) system is organized longitudinally.
Because Erickson Retirement Communities are able to provide most post-acute and long-term care services (with the exception of hospice), they rarely make referrals to outside providers. Johns Hopkins Home Care Group receives only a few referrals annually from Erickson, which is why they were included in this study. Johns Hopkins makes use of the McKesson Horizon health information system. See Table B.1 at the end of this appendix for a comprehensive compilation of the information requested from and supplied by each site, prior to their scheduled site visit.
1. What data are shared? What data should be shared but aren’t?
Access to information regarding medications, laboratory results, and clinical notes has been identified as the highest priority data at Erickson. Additional data discussed include allergies/intolerances, advance directives, medical problem list, and radiology reports. As part of a falls reduction program, a patient’s fall-risk status is being explored, using data currently collected. Interventions are being planned based on conclusions drawn from this analysis.
The one area noted where information should be shared but is not is the transfer of clinical information from the physical therapist in the SNF to the physical therapist in home health care.
2. How are the data shared?
Data sharing is accomplished through a combination of strategies. Erickson sends an electronically generated paper transfer summary with all patients who are referred off campus (e.g., acute care hospital, specialist, emergency department [ED]). This summary is printed from the Erickson GE Centricity system and accompanies the patient. St. Agnes ED physicians provided input during the development of this summary document. In spite of the fact that information from one computer system was being re-entered in another system, care providers seemed pleased with the paper reports, especially given their relative currency, completeness, and readability. This paper transfer of information may be an advantageous differentiator for Erickson relative to other sources of ED admissions. However, one reason this exchange works as smoothly as it does is the presence of Erickson associated physicians on both ends of the transfer.
The St. Agnes ED and Erickson home care nurses and administrators have read-only access to GE Centricity. Erickson physicians have read-only access to the St. Agnes health information system and also can remotely access it. They also will print out information from St. Agnes when they are on-site and bring it back to Erickson, where the hardcopy is kept.
St. Agnes ED physicians call the Erickson physician prior to sending the patient back to Erickson. For ED and hospital visits that do not result in Part A SNF admission at Erickson, the Erickson physician is responsible for updating the medications and the problem list in GE Centricity.
3. Timeliness and completeness of the data.
Timeliness, non-redundancy, and anytime/anywhere access have been established as a high priority by Erickson CEO John Erickson and have been a primary driver for innovation. It is believed, and internal evidence supports this, that better health information technology will improve customer satisfaction and safety, and ultimately favorably influence the bottom line. Within Erickson, care and the information about care received, appears to be relatively seamless.
4. Specifics about medications, laboratories, and radiology.
Quest Diagnostics, Mobile X radiology, and Omnicare/Neighborhood Pharmacy (located on the Erickson campus) are the three primary vendors. Quest Diagnostics is used by the outpatient clinic, home care, and the Renaissance Gardens (their SNF and assisted living facility [ALF]). Eighty percent of the independent residents and 100% of LTC residents use Omnicare/Neighborhood Pharmacy on campus, which creates opportunities for collaboration. For example, a pilot program is under development between the Renaissance Gardens at Erickson and the Omnicare campus pharmacy to initiate an e-prescribing program. Currently, prescribing is done on paper or by fax.
Laboratory, radiology, and medication data are re-entered manually into either or both of CareMEDX or Centricity. One side effect of this re-entry process is a sense of information “trust” and “ownership” for those doing the data entry.
5. Areas under development (e.g., CPOE, decision-making tools).
Meditech’s Provider Order Entry function is being piloted at St. Agnes. However, because St. Agnes does not employ their physicians and thereby cannot mandate its use, use is voluntary for the time being. CPOE is being explored at Erickson but was not in full operation at the time of the site visit.
St. Agnes and Erickson are exploring the bilateral development of a peer-to-peer HL7-based link that would support limited clinical information exchange (primarily discharge summary and medication lists) between these two settings. Both Erickson and St. Agnes would rather have their respective EHR vendors implement appropriate national data exchange standards, so that patient information could be exchanged automatically between the two systems, but they are concerned that this will take too long. Instead, they are contemplating investing in a custom bilateral exchange mechanism. One anticipated impediment to either a standard or custom exchange mechanism is the differences in the Centricity and Meditech data models. Centricity, as would be appropriate for an ambulatory care practice, supports a longitudinal patient-centric data model. Meditech, as is the tradition for inpatient care, supports an encounter-based model--that is, patient information is archived once that patient is discharged after an acute care episode.
6. Barriers to clinical data exchange.
At present, the Erickson (Centricity+CareMEDX) and St. Agnes (Meditech) systems do not interoperate and the amount of effort invested to re-enter information already represented in one system into the other is enough to warrant the exploration of a bilateral solution. However, perhaps because each system is relatively high function, neither Erickson nor St. Agnes staff view the lack of interoperation as something to complain about. Instead, the fact that each system has current, accurate, and relatively complete information is seen as a positive feature of the care environment.
The clinical documentation and notes for the SNF are electronic, but the majority of ancillary information such as laboratory and radiology reports are paper. The medications and nurse practitioner notes are in GE Centricity but are not available outside of the SNF/LTC. In general, all of the Renaissance Gardens information is electronically available to Erickson business lines, but is not electronically available to unaffiliated providers such as acute care hospitals.
Erickson utilizes relatively highly trained clinical professionals to transfer information manually across electronic systems as well as between paper and electronic systems. The time devoted to the clerical rather than clinical portion of this task was not perceived as onerous, nor was the possibility of transcription errors a concern.
7. Facilitators to clinical data exchange.
Erickson is unusual in that the primary care provider (PCP) or an associate physician from the same practice follows each Erickson patient when he or she is hospitalized. This creates opportunities for the attending physician to gather more complete information, sometimes using remote access while managing the patient across the various levels of care. Put differently, continuity of care is supported primarily by physicians and less so by the technology in place.
In addition, Erickson has a full-time “care coordinator” who follows Erickson patients at St. Agnes and arranges their discharge back to Erickson as well as all services including Part A SNF and home health care. This coordinator collects pertinent information, including the hospital course of treatment and the discharge summary, and faxes it back to the Erickson PCP, HHA, or SNF. Just as having physician continuity across care sites improves continuity of care, the care coordinator provides a channel and safety net for critical information as it moves across levels of care. One practical result of the care coordinator position is more timely coordination of information and resources, so that “everything is ready” when a patient is transferred, an example of integrated management of workflow and information transfer.
When specialists see Erickson residents (including when on campus), the dictated notes are not entered into GE Centricity but rather are faxed back to Erickson. An outpatient nurse has been hired to read the referral letters and use her clinical judgment to ascertain action items and new diagnoses and then transcribes this information into GE Centricity.
Erickson has developed an electronic chart summary, which is generated out of their electronic medical record and can be remotely accessed via the web or at any of their facilities' workstations. The chart summary includes relevant current and historical information such as advanced directives, medication lists, laboratory results, problem lists, contact information for patient and care providers, etc. This chart enables health information exchange between the physician and other providers in all of the health settings available to Erickson residents. Care coordination is facilitated as physicians can access this information on or off-campus and can then coordinate in a timely manner with the emergency department physician if a patient requires acute care.
In November 2005, Erickson launched a website, http://myhealth.erickson.com, which is provided to their residents free of charge. Patients can have read-only access to their own medical record including the chart summary discussed above. Patients can download it to a personal USB device (that Erickson provides free of charge) and take it with them (should they travel or be away for extended periods of time). Alternatively, patients can access this information via the web. Ideally, an ED physician or specialist could access this information via the portal upon obtaining the resident’s permission.
1. Hardware and software.
Erickson deploys a single copy of GE Centricity managed centrally from their Baltimore site. They also make use of a single copy of CareMEDX system for documenting home care, rehabilitation, and SNF care. St. Agnes Hospital, which provides acute care services for Erickson Charlestown patients, deploys a Meditech inpatient EHR.
2. Description of EHR system at Erickson, Johns Hopkins HHA, and St. Agnes.
Use of CHI standards is incidental only, if their use is required for other means such as reimbursement. No integration of different systems was observed. Inter-system information transfer is done manually, usually from paper generated by the originating system, or through “mind-ware” supported by remote access.
The EHR system at Johns Hopkins Home Care Group currently does not interoperate with any outside entities, including Johns Hopkins Hospital. Except for the aforementioned plans for a potential link between Erickson and St. Agnes, there are no immediate plans at Erickson, Johns Hopkins, or St. Agnes to modify or expand upon their existing EHR systems to promote the exchange of health information with either affiliated or unaffiliated health care settings.
3. Data storage, sharing, and access.
At each of the visited health settings, the data entry observed was manual, typically from paper copies of the information. Usually the paper copies were computer-generated. Within these limitations, health information technology usage seemed high-function, widely accepted, and relied upon. In-house access seemed readily available; remote access was available to select personnel, usually through dial-up connections. Gaps in this information umbrella were filled by transferring paper copies of records from one location to another.
4. Interoperability using standards-based EHR systems or other HIT solutions for HIE.
Ad hoc interoperation is being contemplated, though such custom interoperation may take advantage of a local version of HL7v2 messages. Other standards are not part of the planning process except as they are required for other reasons.
There is no electronic exchange of data between unaffiliated providers. At Erickson, because care provision on campus includes the medical clinic, skilled nursing, rehab, and home health, and the same physician follows the patient through all modalities of care, the data collected at each health setting are accessible to the physician. However, specialists submit reports in writing, and communication with pharmacies is via paper prescriptions or faxes. Physicians may use remote access to gain information about a patient that resides in a non-local system.
5. Health Information Exchange with outside entities.
Both Erickson Charlestown and St. Agnes would like to make use of standards-based data exchange between their two systems if appropriate standards existed and if those standards were implemented by their respective vendors. Because both sites are contemplating custom interoperation, presumably they would be willing to expend some funds to achieve standard interoperation in its place. However, a representative from St. Agnes noted that they did not want to take the financial hit of being an early adopter, but rather, were willing to wait until the dust settles and standards were more widely adopted before committing future resources into any type of HIE mechanisms. Erickson believes interoperation with St. Agnes, whether standard or bilateral, is a current priority, although no decision has been made regarding development of a link between the two systems.
1. Business case for PAC/LTC.
No formal business case was described; however, there is sufficient business interest to consider developing a custom exchange with St. Agnes. Erickson has the long-range vision of what adopting technology can do for their care provision as well as their bottom line, and although they have sought partners in the community to discuss interoperability, they have faced apathy or indifference from potential collaborators. No future plans to include other settings in an electronic HIE network were described.
2. Adoption of EHR systems.
Erickson, St. Agnes, and Johns Hopkins Home Care Group did not consider CHI-endorsed standards when selecting their EHR system(s) largely because they made these decisions years ago before standards had been put into place. Johns Hopkins Home Care Group uses McKesson’s Horizon, St. Agnes hospital uses Meditech, and Erickson uses GE Centricity (Medical Offices) and HealthMEDX (home health and SNF/NH).
Interoperability with outside entities was not a driving force in the selection of software vendors. In addition to functions supported, price of initial roll out and ongoing maintenance were the most frequently noted high priority criteria. Other criteria mentioned included access to technical support, ease of use for end user, meeting regulatory requirements (e.g., OASIS, MDS reporting or billing). The tradeoffs implicit in the incremental rollout of the next EHR function (e.g., CPOE), are being weighed carefully.
Unlike other regional care contexts, there is not a push from St. Agnes hospital's ED physicians (main referral source) to have electronic data readily available. Relatively speaking, it is working the way it is now.
3. Staffing.
Unlike many other long-term and post-acute care settings, Erickson has a very stable workforce, with an 82% retention rate. This consistency has benefited Erickson as a whole because the training and re-training of staff is kept to a minimum. Existing electronic patient information systems at Erickson seem to be well regarded by Erickson Staff. Johns Hopkins Home Care Group and St. Agnes experience a relatively high turnover rate, typical in the home health and hospital sectors, respectively.
With regard to training, representatives from the Erickson and St. Agnes information technology departments indicated that compared to the nurses, aides were more receptive to using technology (e.g., PDAs, laptops). The ability to have a mouse and click option and/or touch screen kiosks made the aides' workflow much easier. With the nurses, there had to be some computer competency training (e.g., how to enter notes into the record). At Johns Hopkins Home Care Group, the nurses and therapists are computer-literate and receptive to using technology to streamline their workflow; anytime/anywhere access is seen as a major productivity enhancer.
No one from St. Agnes or Johns Hopkins Home Care Group currently is or has been involved in standards development organizations (SDOs). Erickson information technology personnel participate in professional and standards organizations, but not as a central priority.
Erickson is a very high functioning retirement enterprise. They would readily make use of interoperation with pharmacies, laboratories, and other levels of care if standards and Commercial-Off-The-Shelf (COTS) products supported it. Their workforce seems very happy with the completeness of information in the Erickson EHR and with its anytime/anywhere accessibility. Erickson is an example of an enterprise that is ahead of the National Health Information Network (NHIN) exchange standard development. Further, if such standards are not created and deployed soon, Erickson (at Charlestown) may expend resources on the development of a custom exchange capability with its acute care provider.
| TABLE B.1: General Information Supplied by Visited Sites* | |||
|---|---|---|---|
| Name of Health System | Erickson Retirement Communities | St. Agnes Hospital | Johns Hopkins Home Care Group |
| Location | Catonsville, MD | Baltimore, MD | Baltimore, MD |
| Relationship to Host Site | Host site | Main referral for acute care | Referral recipient |
| Year established | 1983 | 1876 | >10 |
| Area served (urban, rural, both) | Urban | Urban and Rural | Both, mostly urban |
| Ownership | Non-profit, privately held, CCRC | Non-profit, hospital-based | Non-profit, freestanding |
| No. full-time employees | 11,000 | 2,200 | 450 for all lines of business; specifically for home health ~100 |
| No. of Nursing Homes (owned, affiliated) | 8 owned | 0 owned | 0 owned |
| No. of Home Health Agencies (owned, affiliated) | 13 owned | 1 owned | 1 owned |
| No. of Physician Practices (owned, affiliated) | 13 owned | 12 owned | 0 owned |
| Are physicians affiliated with health delivery system or are they independent? | Affiliated | Both | n/a |
| Inpatient pharmacy? | We have a pharmacy in the communities that is not affiliated | Yes | No |
| Does SNF use dedicated pharmacy or contract with large/retail, or multiple pharmacies? | We use an institutional pharmacy, OmniCare | n/a | n/a |
| No. of Pharmacies--outpatient | Two outpatient pharmacies on campus | 1 | 4 |
| In-house laboratory? | No | Yes | No |
| How many outside laboratories? | One, Quest | 2 | Many, based on pt’s insurance |
| In-house radiology department? | No | Yes | No |
| How many outside radiology centers/MR centers do you work with? | Refer to local centers | 1 | n/a |
| Electronic Health Record (EHR) system--scheduling, billing, or claims? | Yes. Medical Manager for the Medical Center & Keane for all other care | Yes | Limited |
| Clinical Electronic Health Record (EHR) system? | Yes. GE Centricity POE EMR 2005 for the Medical Center & HealthMEDX CareMEDX for our SNF, ALF, Home Health, & Rehab | Yes | Yes |
| Primary software vendor for electronic health information system (if applicable) | GE Centricity POE EMR 2005 and HealthMEDX CareMEDX | Meditech | Horizon/McKesson |
| Short-term (6 months?) HIE* future plans | We are focused on getting a few local hospitals and specialists integrated with our electronic medical records through HIEs | RHIO development with Erickson | Electronic referral |
| Long-term HIE* future plans | We are focused on getting all local hospitals and specialists integrated with our electronic medical records through HIEs | RHIO development with Erickson | On-line physician order/referral process with signature of forms |
| Miscellaneous notes | JHHCG include home care, infusion, home medical equipment, respiratory services, and outpatient pharmacies. | ||
| * Information in this table was collected from a “General Information About Health Care Setting” form sent to all sites prior to the scheduled site visit. | |||
Health Settings visited: Montefiore Medical Center, Montefiore Home Health Agency (MHHA), the Visiting Nurse Service of New York (VNSNY), the Jewish Home and Hospital Agency (JHHA), and Schervier Nursing Care Center (Schervier).
New York State, and especially New York City and surrounding counties, have a relatively long history of collaboration in health information technology; this is one reason NY leads all other states in public health functionality and public health information technology and is among the leaders in the use of in-patient health information technology (HIT).
The majority of the site visit was located in the Bronx, a densely populated urban area with circumscribed geography. The Bronx patient demographics are characterized as “young, poor, minority, disease burdened, and underinsured.” For these and other reasons, Bronx residents tend to receive healthcare in the Bronx as opposed to the other New York boroughs and Montefiore is self-defined as the preferred acute care and primary care provider by the community, and the only Bronx academic medical center. Increased awareness of fragmented, multi-institutional,1 and multi-level care and a long-standing sense of medical community have helped promote collaborative participation in the newly-funded Bronx regional health information organization (RHIO). One informant matter of factly stated that "geography is destiny," meaning that the Bronx is six miles by six miles and this geographic reality is one explanation for why there is a greater proclivity for collaboration with other health settings in the Bronx. Another informant observed, “capitated care led the way,” meaning that capitated care provided clearer incentives for information sharing and use of HIT to support that sharing. Included in the population examined as part of Bronx RHIO planning were 27,000 “Medicare lives.”
Despite this advantage, of the high concentration of nursing homes located in the Bronx (53), only one (the Jewish Home and Hospital Agency [JHHA]) has so far agreed to be involved in the Bronx RHIO, which is moving from a planning and study phase to a deployment phase now that it has received $4.1 million in HEAL NY funding. Not coincidentally, the Bronx has an excess of nursing home (NH) beds, at present. The Schervier Nursing Care Center (Schervier) was initially involved in the Bronx RHIO, but the Administrator determined that they were not ready, at present, to fulfill the technological requirements for participation so they dropped out. For an unknown reason, another large skilled nursing facility (SNF) in the area also dropped out of the RHIO, despite being involved in the planning stage discussions. Studies done prior to RHIO planning included attention to NH admissions, opportunities for hospital to NH-care coordination, avoidable hospital readmissions, and the distribution of hospital to long-term care transfers (49% of transfers to post-acute care from Montefiore Medical Center during the study period were to five NHs). Since the initiation of the Bronx RHIO, another four nursing homes have expressed interest in joining as institutional members.
Currently, the fact that the myriad of health care enterprises in the Bronx can communicate--person-to-person--at multiple organizational levels has not translated into electronic communication--or even person-to-computer communication. However, there seems to be some expectation that settings receiving patients should have remote access to patient information from where the patients came from, but at present, such hand-offs of electronic information are the exception rather than the norm.
The Bronx RHIO has a number of committees involved in various aspects of its design and implementation management. One committee is focusing on clinical issues and is in the process of defining an initial core data set of "normalized" information about individual patients that would be ready to be exchanged with all RHIO participants and be available at the point of care. Another part of the RHIO process links patient identifiers. The creation of a standardized patient transfer form for use in the Bronx and in the larger area covered by the VNSNY was discussed at several visited sites. Representatives at each site expressed interest in and some level of readiness for this transfer dataset to be finalized.
See Table C.1 at the end of this appendix for a comprehensive compilation of the information requested from and supplied by each site, prior to their scheduled site visit.
1. What data are shared? What data should be shared but are not shared?
New York State requires that hospitals complete the Patient Review Instrument (PRI) for all patients being referred for Medicare Part A SNF care. This document scores the patient on the intensity of care required.2 Its domains include physical and cognitive function, medications (last seven days), recent laboratory tests, x-rays, physical therapy (PT) and occupational therapy (OT) notes, and wound care. Ideally, this tool would help facilitate an appropriate match between patient care needs and care settings. Nursing staff must be certified on how to complete the PRI.3
More generally, the two nursing homes (NHs) we visited, JHHA and Schervier, made concrete suggestions for how Montefiore Medical Center could improve hospital to post-acute care information transfer. These suggestions included more frequent PT notes and especially greater documentation of mental status alteration and psychiatric/behavioral symptoms. NHs also would like the “look-back” period for medication reporting to extend to a full 14 days prior to NH admittance to help support completion of IV medication use required by the RUGs, thereby ensuring they are adequately reimbursed for more expensive services.
When a patient leaves JHHA (to go back to the hospital or discharged home), a discharge packet is prepared that includes a medical summary of recent events completed by the physician, a handwritten medication list, immunizations (to conform to current hospital quality initiatives), EKG, and laboratory tests.
When NH staff at Schervier transfer a patient to an emergency department (ED) or hospital, they attach a paper-based Schervier-standard patient summary including a transfer form (which describes the reason for transfer), physician transfer sheets, laboratory results, x-rays, and ECG.
The VNSNY has pilot projects underway that will implement data sharing with selected physician offices and, separately, with Weill Cornell Medical Center. The Montefiore HHA (MHHA) has a pilot project in place to share information with physicians via a web portal. (See Section III.2 for more details.)
2. How are the data shared?
The Patient Review Instrument (PRI) and supplemental information are distributed from Montefiore Medical Center to local area NHs via Extended Care Information Network (ECIN),4 which is a web-accessible application designed to facilitate the discharge process. ECIN is an Internet-based automated PRI that is HL7 compliant. Nursing homes pay $300/month to subscribe and, at present, 30 Bronx NHs make use of ECIN. Patient information is sent to a list of NHs selected from an on-line pick-list. When a referral arrives at a selected NH, an e-mail or page alerts the staff. The receiving NH then has the opportunity to e-mail back or call to ask questions and/or indicate its interest in accepting the patient. NHs without ECIN access may receive the PRI via fax. According to informants at Montefiore, their use of ECIN has helped reduce hospital length of stay (LOS) for nursing home bound patients from ten to eight days--in a context where a half-day reduction in LOS would pay for incremental use of information technology.
At Montefiore, PRI fields such as demographics and insurance can be auto-populated using information from other information systems, while other fields such as laboratories, medications, and physical therapy notes can be completed by copying and pasting from data fields in the Montefiore EHR. Prior to automation (auto-population), tool-supported creation of the PRI required 30-40 minutes to complete, whereas after automated pre-population and manual copying and pasting, it reportedly is completed in 10-15 minutes.
The MHHA uses MISYS for documentation and charting. If a patient is admitted to Montefiore Medical Center while actively receiving home health care, the home care coordinator based in the hospital can print a summary from MISYS and place that summary in the hospital paper record. Aside from this, emergency department (ED) and hospital nurses and physicians do not have access to MISYS. At present, the only way that MISYS and the Montefiore EHR (IDX LastWord) “interoperate” is via e-mail. MHHA has a field dedicated to capture the patient’s Montefiore Medical Record Number. All documentation that is generated to the physician (e.g., orders, discharge summary, admission notice) will include the Medical Record Number to make patient identification for documentation for the medical record seamless. MHHA has a process in place that auto-e-mails the physician when her or his patient is admitted to home care. The e-mail contains contact information of the team caring for the patient as well as the date the patient was admitted. In general, e-mail appears to be used increasingly often for fulfillment of non-time-critical information needs, much as voice mail is still used today. MHHA staff have read-only access to Montefiore Medical Center’s clinical information system (CIS). Montefiore representatives also commented that the JHHA physicians have limited read-only access to CIS, and these physicians would like to expand their access. For example, informants at JHHA indicated that care providers cannot always get access to laboratory results or radiology images in Montefiore’s CIS and they cannot access the medication list, although this access has been requested for several years.
When a patient is discharged from home health services, a discharge template in MISYS is used that is populated in part by MISYS and in part completed by a nurse who manually types in the remaining fields. The information typed into the EHR could be blood sugar ranges if the patient is a diabetic, wound status if the patient is being seen by the wound care team, or care providers at home. This type of information is patient-specific and is not captured via check boxes. The resulting summary is then sent to the attending physician via email.
The VNSNY pilots are implementing “back population” of EHRs at selected physician offices; this data transfer will make use of a web portal and HL7 messaging. The application being developed in collaboration with Weill Cornell Medical Center is web-based. The MISYS Physician Portal also is web-based and MHHA recently received a grant to modify the portal to allow the physician to access telehealth reports.
3. Timeliness and completeness of the data.
NH staff at JHHA and Schervier both commented that despite the fact that nursing staff require special certification to complete the PRI, the data contained within the PRI can be of inconsistent quality and is often incomplete. The information available from ECIN is similarly variable.
JHHA reports that the hospital discharge summary arrives with the patient (rather than prior to nursing home admission) and occasionally is misplaced or lost during this transition.
Schervier staff create their own paper medical record using some of the data received from the hospital. Staff commented that they would like to receive a discharge summary ahead of time but it frequently arrives with the patient, which reduces their ability to prepare to meet the patient’s needs upon arrival. They also mentioned that the PRI does not always adequately describe the patient. For example, NHs are particularly interested in the mental and psychiatric status of referred patients. The discharge summary from Montefiore often is illegible, as it is a carbon copy, and the Schervier informants mentioned that about 80% of the time, the primary care physician information is not included in the discharge packet.
The VNSNY tries to re-synchronize all patient information between care provider tablet and laptop computers and backend databases at least once every 24 hours. MHHA care providers (e.g., nurses, social workers, therapists) are required to synchronize their laptops once every 24 hours. MHHA recently deployed 50+ broadband wireless cards allowing staff to connect to the office while in the field.
4. Specifics about medications, laboratories, and radiology.
The Montefiore EHR integrates access to a medication list (Montefiore has a single in-patient pharmacy), lab results (if done by the Montefiore laboratory), and imaging reports. At present, none of these data elements are represented using national standards; when the relevant decisions were made there was no reason to use these standards. However, to better support re-use of such data elements by RHIO participants, such standards are an objective for the Bronx RHIO.
All MHHA laboratory results go to the Montefiore Medical Center’s clinical lab, thereby enabling timely access to results by ordering staff physicians.
JHHA has an in-house pharmacy and uses a single lab. JHHA staff have read-only access to a patient’s laboratory results performed at Montefiore Medical Center prior to transfer as well as radiology reports, but they do not have access to medication data.
Schervier uses one outside pharmacy, Shore Pharmacy, and a single lab, Lawrence Laboratory. The nursing unit has view-only computer access to the laboratory results from Lawrence Lab.
5. Areas under development (e.g., CPOE, decision-making tools).
Through a New York State HEAL NY award, the VNSNY is developing a portal for physicians with a common data presentation. The goal is to improve communication and specifically to reduce complications, duplication, and need for re-hospitalization. Portal information will include data elements that the VNSNY routinely collects, including hospital discharge summaries, radiology/lab/ECG reports, name of PCP, names of family caregivers, advance directives (whether or not on file), and wound images. The information will go directly into the electronic health record (EHR), which the physician’s office is using as well as the VNSNY medical record. Currently, the VNSNY is piloting the web portal with seven regional physician practices that all use GE Centricity/Logician EHR. (Contemporary software features of the Logician EHR system reduce the difficulty of implementing this “back-population,” relative to other EHRs.) The VNSNY already is observing an anticipated change in their relationship with MDs using the portal--“the MDs are new users with new requirements.” While the current goal of this effort is to (greatly) improve access to information about patients common to the MDs and the VNSNY, this access could support use of standards in the future.
The VNSNY also is participating in a pilot project with Weill Cornell Medical Center to develop an electronic CMS 485 form where the doctor could begin to write orders on the 485 at the time of discharge.5 The physician can sign the original 485 and any subsequent additions electronically. This advancement also would allow them to map data elements to the Continuity of Care Record (CCR). One advantage for physicians is that this feature includes a timer that can count minutes spent on home care oversight to facilitate documentation for billing. The electronic 485 has led to enhanced data completion. For example, the physical function section went from 28% complete to 94% complete and mental status went from 6% complete to 100% complete in a pilot study of four physician practices.
The VNSNY also is piloting a home monitoring project. In January 2007, they will be able to take results from the telehealth devices in the home and incorporate these data into the current database. They then would be able to trend these data with other data their clinicians have collected to get a more complete, accurate picture of the home care patient’s health status.
MHHA currently has a home monitoring project in place with Cardiocom. MISYS has partnered with Cardiocom to build a bi-directional HL7 interface that will allow information to flow seamlessly from the devices to the MHHA EHR.
JHHA is developing a database to establish a unique identifier that will be the basis for sharing information among all JHHA programs and services. Not coincidentally, this identifier will make it easier for JHHA to share patient information through the Bronx RHIO.
6. Barriers to clinical data exchange.
Montefiore Medical Center’s EHR (CIS) and the MHHA’s record system (MISYS) do not interoperate. For example, when a laboratory result appears in the CIS, the result must be entered manually into MISYS. Medications also are transferred manually from one screen in CIS to another in MISYS. HHA staff acknowledges the potential for transcription errors.
Representatives from the VNSNY indicated that communication streams that currently exist with Montefiore Medical Center are potentially subject to errors. For example, Montefiore liaisons have to fax the referral form to VNS headquarters and those data are then re-entered into the VNS electronic health record.
Challenges noted by Schervier staff are completeness of the information from the referring hospital (not necessarily just Montefiore Medical Center, but any referring hospital) and inaccuracy of the data that is sent, thereby reducing trustworthiness of the information. For example, descriptions of ongoing expensive medications or treatments (e.g., IVs, blood transfusions, chemotherapy) often do not accompany the patient and the SNF is forced to scour the information available to them to determine if the patient is on medications that will affect their RUG payments.
The biggest current barrier to clinical data exchange among the sites visited is a lack of electronic communication between existing information systems; not surprisingly, this is a major motivation behind planning for the Bronx RHIO. The next barrier will be the need to transform local electronic health information into the uniform patient summary required by the RHIO. After that, the biggest challenge will be the need to back-populate local health information with that available from the RHIO (e.g., to enable better local decision support through a more complete medication list, laboratory results, and problem list).
7. Facilitators to clinical data exchange.
As described above, the main facilitator to future electronic clinical data exchange is a regional organizational history of inter-enterprise (care provider-to-care provider) communication and inter-enterprise patient care. Beyond this, Montefiore Medical Center and MHHA plan to use a single patient identifier to track patients in their electronic health information system so that historical data in the Montefiore system are accessible and they can ensure that the patient they are treating is the correct patient. Among other benefits, this single identifier increases the utility of the Montefiore data warehouse. Because most Montefiore patients continue to receive care at Montefiore health settings for as long as they live in the Bronx, this creates an opportunity for a rich, life-long patient health record.
Montefiore Medical Center staff physicians (hospitalists) care for hospitalized nursing home patients. A different group of Montefiore staff physicians care for nursing homes patients in the nursing home (SNFists). Having organized physician groups employed by the regional provider creates an opportunity to develop more standardized protocols for patient care, including clinical protocols and higher expectations for information exchange.
MHHA has on-site care coordinators/liaisons in the Montefiore Medical Center to facilitate hospital-to-HHA referrals. It also has coordinators who visit two or three of the larger SNFs to help facilitate referrals from SNF to home care.
Another example of existing manual clinical data exchange across enterprises is weekly visits by HHA liaisons from Montefiore Medical Center and the VNSNY to JHHA to review and coordinate potential referrals. By being on site, these liaisons are able to collect and communicate needed clinical information to their respective employer (the VNSNY or JHHA) on soon-to-be discharged patients.
State-of-the-art information technology used by the VNSNY will be make it relatively easy to exchange patient data going forward with HIT systems at referring sites and with many EHRs used by primary care MDs who follow the patients during and after care by the VNSNY.
A fundamental facilitator of anticipated information exchange is the general computer literacy of regional care providers and their growing expectation that anytime/anywhere access to patient information should be supported.
1. Hardware and software descriptions of the main health delivery system and the affiliated PAC/LTC settings.
Back in 1995, after a year-long search, including visits to United States academic medical centers with EHRs, Montefiore Medical Center selected IDX’s LastWord EHR based on its ability to function in an integrated delivery system, and because it was perceived as user-friendly for physicians. Deployed initially as an in-patient EHR, LastWord was deployed for ambulatory care at 28 sites in 1996-1997. LastWord contains data from every Montefiore encounter for 1.8 million patients; currently this includes laboratory test results, medications, and images, but does not include notes and consults. Some scanned information also is represented. E-prescribing has been in place for close to a year. Currently, about 9,000 NH patients/year use Montefiore’s hospitals for inpatient care. Greg Burke, Vice President of Planning mentioned a recent study of Medicare claims data performed by Milliman that indicated that in the Bronx, two-thirds of the NH patients who die, die as hospital inpatients, and that about one-third of the Medicare-enrolled NH population die per year. As with several other deployed EHRs, LastWord was originally implemented in MUMPS. (IDX was purchased by General Electric in June 2006). Montefiore’s deployment of LastWord makes use of the proprietary physician-friendly problem-list vocabulary developed by James Campbell, MD. One feature of this list is the accompanying repertoire of links to SNOMED-CT. Primary care physicians “own” this problem list, and, at present, ED physicians do not have the authorization to update it. Because LastWord is not designed for population analysis and other aggregative data tasks, Montefiore Medical Center makes use of an adjacent Sybase data warehouse. The warehouse accumulates query-able patient information exported regularly from LastWord. The warehouse environment supports a growing repertoire of analytic reports, some of which were used as part of RHIO planning. Current RHIO plans call for use of a dBMotion product to extract the RHIO-standard information from EHRs and other patient information systems used by RHIO participants. One side of each dBMotion instance does the local extraction and the other side makes the patient information available in standard form to external RHIO users.
MHHA uses MISYS Homecare software for their EHR. Field clinicians can instantly access health care plans, patient demographics, medications, and other clinical information to improve quality of care. OASIS data collection is integrated into the patient health assessment. Assessments captured on laptops at the point of care are remotely synchronized to the EHR in minutes. Field staff is required to synchronize their laptops a minimum of once every 24 hours.
Fourteen years, ago the VNSNY began developing its own patient record system that continues to evolve to this day and currently supports more than 2,000 care providers. One reason that the VNSNY developed custom software is that there was so little available when they started. Currently, their system makes use of a three-tier architecture--an outer tier of software residing on care providers’ tablet computers and laptops, a middle tier of management and system applications and asynchronous communication support, and an inner tier of DB2 relational databases. The point-of-care (POC) component is written in Microsoft Visual Basic with a supporting Microsoft client Data Engine SQL database. Office-based management and analytic tasks are conducted either by using mainframe IBM Customer Information Control System (CICS) COBOL applications or web-based Java applications. Data are synchronized between the POC and host DB2 databases using internally-developed store and forward processing via an intermediary RISC-based processor. Thus, each morning each home health clinician has access to her or his caseload for the day. During the day, case workers record information on tablet computers. While unique, the VNSNY’s EHR system has been built whenever possible using commercial-off-the-shelf (COTS) systems and tools, such as SQL Server and Visual Basic. The VNSNY’s advanced information technology position was achieved at the cost of some less successful efforts along the way (e.g., premature attempts to get tablet computers deployed). However, their ability to contemplate participation in multiple RHIOs and to experiment with connections to physician practices is evidence of the soundness of their investment in scalable designs and components. They are in an increasingly better position to learn more about the appropriate use of information technology in home care settings. One important source of experiential learning is their current management of content and software updates; for example, formulary updates are pushed (sent) to the care provider laptops--the outer layer of the three tiered architecture--on demand, and twice annually these laptops are brought to headquarters for major updates to software and “geriatric decision support.” The latter generates a “problem” for each medication and therapy, and constellations of problems make explicit potential connections between congestive heart failure and depression. Currently, e-mail is not considered secure enough to use in home care provider communications involving patient information. Incrementally, the VNSNY system involves workflow management (e.g., management of lab tests, beginning with physicians currently phoning in orders, and ending with faxing the result to the physician). In between, the laboratories have access to the relevant work-lists and dispatching of phlebotomists. The VNSNY has a grant to implement the receipt of laboratory tests in HL7 messages containing LOINC codes.
MHHA decided against developing their own software product and instead purchased their EHR from MISYS Healthcare, a recognized leader in the homecare field. By partnering with MISYS, MHHA can utilize their clinical and process knowledge with their software expertise to build an efficient EHR that meets every one of their needs and can be used by other home care agencies across the county. MHHA is “Premier Partner” with MISYS, which allows them access to developers and other business partners. MHHA has used this status to request custom functions for streamlining the admissions process.
More recently, JHHA has been exploring different EHR alternatives but currently uses only “component” systems such as the QS1 Pharmacy System.6 Also used are the 3M Home Care program, and a scheduling and billing system--where indications accompany orders. The MISYS (formerly Per Se) Patient1 system was deployed during a recent trial but the expense of adapting the propriety database outweighed any other benefits of that system and the trial was terminated. The currently deployed ADT system stores a problem list with ICD coding and it can be used to generate a face sheet. The Lintech Comet system is used to complete and submit MDS, develop associated care planning, and support some order entry.7 OASIS submissions are handled using OCS.8 JHHA is networked, mainly for administrative purposes, with other affiliated sites in Manhattan and the Bronx, including community services and a primary care site. Another site supports redundant data that will be used for data disaster recovery.
Schervier uses American Health Care management software at present, and looks forward to the day when they will have a more robust EHR. They estimate that a satisfactory EHR will cost more than $750,000/year. The American Health Care software is specialized for long-term care and includes an MDS-reporting application. Their current extra-enterprise communication makes use of faxes and remote access for laboratory test results and they do not yet have computers available on care units.
2. Architecture of EHR system at main HDS.
a. Are they using CHI-endorsed and other HIT content and messaging standards? If so, which ones are they using? Messaging? Vocabulary? Direct care FM?
Current use of formerly CHI-endorsed and, prospectively Health Information Technology Standards Panel (HITSP)9 endorsed standards, such as ICD-9-CM and CPT, is incidental and not because of any perceived benefit of use of these standards, other than that they are required for regulatory or reimbursement reasons; again, decisions to use particular terminologies were made some time ago, before CHI existed. HL7 messaging is part of RHIO planning and HL7 capabilities (e.g., as part of ECIN) came up in discussion, but no use of HL7 messaging was observed. No site contemplated use of RxNorm for medication lists, and all sites made use of one or more proprietary formularies, such as First Databank or Micromedex.
Montefiore Medical Center created their lab codes before LOINC was available. They have been evaluating LOINC adoption along with the other RHIO participants and face the same challenge as other United States care enterprises in that they have homegrown coding systems, especially for lab tests.
b. Description of each EHR system and HIT solution(s) to support HIE
Each site visited had some deployed patient-care information technology. However, the only mode of HIE observed besides faxing and phoning was occasional remote access, usually by physicians. All sites have planned HIT enhancements; some of these are specifically focused on anticipated RHIO involvement, and others are unilateral.
All HIE observed was manual; sometimes this manual access was electronically remote, enabling users to create data in one system while viewing it in another. Usually, this step was described as “taking ownership” of the data (e.g., the patient’s medication list). Included in taking ownership is medication reconciliation.
3. Architecture of EHR systems at PAC/LTC (if applicable) and HIT solution(s) to support HIE.
All architectures observed were based on a central computer access through real-time networks, except in the case of the VNSNY, which used episodic (e.g., daily) network connections to tablet or laptop computers for resynchronization. As described above, Montefiore makes use of a Sybase warehouse that supports non-real-time access to patient information exported from LastWord. Web-based, anytime/anywhere connections were not observed at any site, although support for such applications was being contemplated as part of the Bronx RHIO and VNSNY pilots. Lack of any current deployment of HIE is a major reason behind the selection of dBMotion as a RHIO-common interface for Bronx RHIO members. dBMotion supports secure, virtual patient records.10 dBMotion is an architectural solution that supports a uniform interface to uniform extractions from each native system at each RHIO site. The dBMotion solution does not commit users to any particular HL7, CHI, or HITSP standard, instead it allows the RHIO to support an elective, collective repertoire of standards in the virtual patient record. This repertoire has yet to be defined. One reason for this delay is that each site would then be required to translate local information into RHIO-standard information. Currently, the degree to which dBMotion will support such translations has yet to be determined.
4. How are the data stored? Shared? Accessed? Transmitted? Accepted at other setting? Entered? Etc.
All sites observed store patient data in proprietary formats and databases in commercial applications, except for Montefiore, MHHA, and the VNSNY. The proprietary nature of how the data are stored was one reason why JHHA stopped deployment of a COTS EHR. The latter sites have information technology staff sufficient to support some storage and access via standard SQL. Montefiore Medical Center maintains a data warehouse of historical patient records accessible using (Sybase) SQL and this warehouse is updated regularly by exporting information from LastWord, the Montefiore EHR. The VNSNY uses backend (DB2) and laptop (Microsoft) client databases accessible using IBM and Microsoft SQL. Except for the JHHA use of read-only CIS terminals to access clinical information in Montefiore’s system and the VNSNY physician office pilots, we observed no extra-enterprise data sharing other than by paper, faxes, phone calls, and limited dial-up access.
Although the VNSNY certainly has the information technology expertise and capital to build interfaces with either ECIN or e-discharge, they have opted not to invest in this effort. As the largest home health agency in the county, they have a 25,000 patient load at any one time and are the home health agency many opt to refer to with "difficult” patients.
As observed earlier in this report, all sites reported re-entering patient information manually that came from a computer somewhere else. Each site saw this as taking ownership of the data.
5. How are you tackling any interoperability issues using standards-based EHR systems or other HIT solutions for health information exchange?
Although JHHA expressed interest in improving the bilateral exchange of data with care enterprises such as Montefiore, no site except the VNSNY described plans for bilateral interoperation. As previously mentioned, the VNSNY has pilots underway to exchange information with physician practices, and plans in place to interoperate with regional medical centers such as Weill Cornell. All sites visited anticipated being part of the Bronx RHIO either right away, or, in the case of Schervier, when facilities and funding permitted. The RHIO plans include anticipated potential use of a variety of standards, but no specifics are yet available.
6. How does electronic health information exchange (e-HIE) vary between affiliated and unaffiliated providers within a single HDS?
Of the sites visited, only the MHHA had a strong affiliation with another visited site, Montefiore Medical Center. This affiliation smoothed referrals, “most referrals are from our (Montefiore) system,” but these referrals did not include HIE. Instead, the MHHA employed 18 nursing FTEs to workup each patient prior to field care. Access variation is usually organizationally mediated; that is, affiliation determines who may have remote access to patient information from the “sending” care site.
Montefiore Medical Center plans to exchange summary information with Bronx RHIO members. Today, the only extra-enterprise data sharing of consequence, besides selective dial-up access, takes place through the PRI and ECIN.
JHHA is not affiliated with other care providers except through common training programs, such as with Mt. Sinai.
Schervier is part of the Bon Secours Health System, which is comprised of acute and non-acute care facilities but not affiliated with any New York City health care providers.
7. How does e-HIE vary when exchanging to outside entities?
Montefiore Medical Center’s information technology subsidiary, Emerging Health Information Technologies (EHIT), provides HIE services under contractual relationships to a number of other hospitals, including Bronx-Lebanon Hospital Center in the Bronx. EHIT also is the technology provider to the Bronx RHIO. It does not currently support e-HIE services with PAC/LTC beyond its organization, except for its use of ECIN.
MHHA does not support e-HIE beyond its organization except for its use of ECIN and planned participation in the Bronx RHIO.
JHHA does not support e-HIE beyond its organization, though it looks forward to participating in the Bronx RHIO.
Schervier does not support e-HIE beyond its organization, and has temporarily withdrawn from the Bronx RHIO. Schervier plans to purchase an EHR, but there is no schedule yet for doing so.
All sites found the current manual (fax, phone, or paper) bilateral exchanges of information inadequate and problematic, although some pairs of enterprises reported better paper exchanges than with other pairs. All sites found their use of ECIN an improvement over the way things were before it was available, but no site believes ECIN will be adequate indefinitely.
The VNSNY's future plans already have been extensively discussed in this report (see Section II.5).
1. Organizational Activities Supporting Electronic HIE.
Montefiore Medical Center has invested significant resources in the development of the business case for implementing and promoting electronic HIE across its extensive delivery system and within the region, as is evidenced by their leadership in promoting the Bronx RHIO, and being a key player in the grant writing process that led to the HEAL-NY award to form this RHIO.
JHHA and Schervier (the two NHs we visited) are both large, well-established skilled nursing facilities who have weighed the pros and cons of implementing an EHR, including one that has interoperable features with other health settings. Both SNFs are committed to providing quality care and are not averse to using technology to support or improve their care provision. That said, neither SNF has been particularly impressed with the software options available to SNFs in the current market. JHHA, for example, invested in an EHR, including all of the start-up hardware, software, and training costs, only to jettison it several years later when the leadership realized that the software capabilities were not as promised, and ultimately, it was not able to meet their organizational needs. At this time, JHHA currently is vetting other software options and is hoping to implement one in the next year.
Although Schervier was initially involved in the formation of the Bronx RHIO, the director declined to participate when commitments were being requested because she said they “were not ready.” They continue to collect most of their data on paper and enter the data into niche software--American Health Care Software--that does not interoperate with other systems.
The VNSNY, on the other hand, has a very sophisticated, well-funded information technology department that is involved in or planning a number of internally and externally funded standards-based initiatives to encourage and facilitate electronic HIE. These planned activities are discussed in detail in Section II.5 above. The bulk of their EHR system is homegrown and was built up over more than a decade of development, as they were and continue to be an early adopter of information technology.
2. Adoption of EHR systems.
None of the settings we visited necessarily selected their vendor(s) based on criteria such as use of CHI-endorsed standards or ability to interoperate with other systems.
Some health settings were early adopters of EHR systems (e.g., Montefiore, JHHA, VNSNY) and CHI-endorsed standards were not in place at the time they were selecting software. Montefiore Medical Center selected their EHR system in the mid-1990s, well before standards were being used in the development of EHR systems. The VNSNY found the home health software options wanting and opted to build their own EHR system.
As previously mentioned, Montefiore Medical Center and JHHA are heavily involved in the formation and implementation of the Bronx RHIO, having devoted significant resources to obtain the funding and persuading other participants to join. They are committed to and involved in efforts supporting interoperability among systems, albeit in the early stages. Montefiore has representation on some of the standards development organizations (SDOs). For example, the chief radiologist sits on the IHE standards board, others are involved with e-health Initiative, and others are involved in SDOs that focus on the financial/billing side of healthcare. The VNSNY has a very active, energetic, vocal information technology group, led by Tom Check, and they are educated on and involved in a number of SDOs.
In contrast, Schervier Nursing Care Center, which uses niche software (American Health), did not consider use of standards or interoperability when selecting this software vendor. Schervier is just one SNF in the Bon Secours New York Health System and the Bon Secours corporate office determined which software best met the organizations needs.
In general, most SNF clinicians and administrators we visited in New York (and elsewhere) have very modest, reasonable goals with respect to data exchange. They are most interested in having complete, accurate, legible, and timely data, regardless of the format. That is, a legible printout from a computer that is received prior to patient admission and contains complete accurate information would be considered a “big win.” Interestingly, all sites reported wanting more complete information, while admitting that there was an implied risk to getting “too much” information, because they would be liable for providing care in that context. Thus, receiving electronic data that are both machine and human readable, as opposed to just human readable, is not necessarily their immediate goal, or even a consideration in the near term.
Bronx RHIO participants are committed to a relatively advanced form of patient information exchange, through which providers in or affiliated with participating organizations will be able to access locally-generated electronic information--a specified core data set that abstracts what that site knows about the patient’s local encounters. The encounter might be a laboratory test result or it might be a visit to the local VA facility. For a given patient, at a given site, these distributed data sets form a series of virtual longitudinal patient records. A care provider at another site can retrieve and display a consolidated view of clinical information from all participating organizations as a “message” to be viewed locally. Further, in principle, each core data set has “normalized” data elements, potentially using standard terminology; therefore, in principle, a unified medication list could be created, for instance. While details remain to be determined and no testing has yet taken place, evidence of the extent of prior and current collaboration is the energy and planning that have gone into the RHIO proposal and plans.
The Bronx and Manhattan sites visited represent a significant opportunity for HIE. Currently, information about thousands of patients flows between care sites as part of relatively mature manual--fax, phone, and paper--processes. Thus, the collaborations necessary to support HIE exist or can be created, and there appear to be few competitive barriers to interoperation. That said, these enterprises face the myriad technical choices and tradeoffs required to start electronic information flowing between non-affiliated care enterprises using non-common HIT. However, over the last few decades, New York State and the New York Metropolitan area have demonstrated an ability to successfully undertake large health care projects, many involving the use of HIT, and this has created an expectation that they will succeed in deploying a useful, sustainable RHIO.
| TABLE C.1: General Information Supplied by Visited Sites* | |||||
|---|---|---|---|---|---|
| Name of Health System | Montefiore Medical Center | Montefiore Home Health Agency (MHHA) | Visiting Nurse Service of New York (VNSNY) | Jewish Home and Hospital Bronx Division** | Bon Secours New York Health System (Schervier Nursing Care Center) |
| Location | Bronx, NY | Bronx, NY | New York, NY | Bronx, NY | Riverdale, NY |
| Year established | 1882 | 1947 | 1893 | 1950 | 1938 SNCC 1983 Home Care |
| Area served (urban, rural, both) | Urban | Urban | Urban, suburban | Urban | Urban--SNCC
Both--Home Care |
| Ownership | Non-profit | Non-profit | Non-profit | Non-profit | Non-profit, freestanding |
| No. full-time employees | 10,000 | 266 | Approx. 11,700 | Approx. 1,000 in Bronx Division | 450 |
| No. of Nursing Homes (owned, affiliated) | 0 owned 30 Affiliated |
0--we have liaisons on site at 3 NHs | n/a | 3 owned | 1 owned |
| No. of Home Health Agencies (owned, affiliated) | 1 owned | 1 owned | 1 owned | 1 owned | 1 owned |
| No. of Physician Practices (owned, affiliated) | 21 Primary Care (owned) | 1 owned | 1 owned | ||
| Are physicians affiliated with health delivery system or are they independent? | Both 1,000 FT faculty 1,000 voluntary |
MHHA receives referrals from physicians who are employees of the health system and from physicians who have their own practices. | There are some MDs on staff in Hospice, our managed care plan, etc., but they are staff within programs. VNS obtains referrals from many MD practices and hospitals. They are independent and have only a referral relationship with VNSNY. | They are employees of JHHLS. | Independent |
| Inpatient pharmacy? | Yes | No | No | Yes--in-house pharmacy | No |
| Does SNF use dedicated pharmacy or contract with large/retail, or multiple pharmacies? | n/a | No | VNSNY does not own a skilled nursing facility. | See above. | Dedicated pharmacy |
| No. of Pharmacies--outpatient | 8 | 0 | 0 | 0 | 0 |
| In-house laboratory? | Yes | No | No | No | No |
| How many outside laboratories? | 4 major ones | 3, but we primarily use the vendor that links to CIS. | 3 | Mt. Sinai Hospital | 1 |
| In-house radiology department? | Yes | No | No | No | No |
| How many outside radiology centers/MR centers do you work with? | 4 major ones | n/a | n/a | Health Trac, Montefiore hospital | 1 |
| Percentage of overall budget dedicated to IT? | <5% | 2.2% of the home care budget is dedicated to IT. | |||
| Electronic Health Record (EHR) system--scheduling, billing, or claims? | Yes | EHR, Scheduling and billing is handled by MISYS. MISYS Healthcare Systems is one of the top HIT companies in North America, develops and supports reliable, easy-to-use software and services of exceptional quality that enable physicians and caregivers to more easily manage the complexities of health care. MISYS’s clinical products incorporate web-based technologies and are designed from the ground up to share patient data across all medical care settings. The Homecare system can exchange data with hospitals and other systems. | Billing: The CHHA
uses an internally developed billing system. Third-party software is used for
hospice, the Medicaid Managed LTC (MLTC) plan, and a pediatric program.
Third-Party Administrator is used for the new Medicare Advantage plan.
Claims: For the MLTC plan, claims are done via internally developed systems but will shift to third-party software. |
Site provided additional information in a separate document. | AHC is used for billing. |
| Clinical Electronic Health Record (EHR) system? | CareCast | MHHA uses MISYS Homecare software for our EHR. Clinicians in the field can instantly access health care plans, patient demographics, medications, and other clinical information to improve quality of care. OASIS collection is integrated into the patient health assessment. Assessments made on laptops at the point of care are remotely synchronized to our EHR in minutes. Field staff is required to sync their laptops a minimum of once every 24 hours. | VNSNY has developed an integrated EHR called the Patient Care Record System (PCRS), an accessible system via pen tablets by over 2,000 nursing and therapy staff. | Site provided additional information in a separate document. | No |
| Primary software vendor for electronic health information system (if applicable) | GE (IDX)--CareCast | MHHA utilizes MISYS for our EHR. The software was externally developed and is one of the top three home care software packages in use today. The software is housed on a MS SQL Server. | The system is internally developed and supported. PCRS uses three-tier system architecture. The mobile component is written in MS VB 6 with a supporting MSDE/SQL database. Office-based functions are done by either using mainframe CICS/COBOL systems or on web-based Java applications. Data is synchronized between the mobile and host databases using internally developed store and forward processing via an intermediary RISC-based processor. | Site provided additional information in a separate document. | American Health Care |
| Short-term (6 months?) HIE* future plans | Many | MHHA projects included the expansion of our Web-based Physician Portal for orders. Implementing an interface between our Telehealth devices and MISYS to incorporate the data into our EHR. Developing an interface between MISYS and the hospital’s EHR. Implemented auto-email to notify physicians when their patients are admitted to home care. | Planning for mobile-intake, MD web-based portal, RHIOs, and PCRS expansion to other clinical units, etc. | Participating in Bronx RHIO. We are developing a database to establish a unique identifier that will be the basis for sharing information within all JHHLS programs and services. | |
| Long-term HIE* future plans | Integrated expanded EMR spanning ambulatory, home health, and inpatient care, supported by online decision support. | MHHA will focus to ensure that 100% of all patient documentation will be captured in our EHR. MHHA will operationalize the HL7 interface to import information from referral sources automatically into MISYS. | Implementation of mobile-intake, MD web-based portal, RHIOs, and PCRS expansion to other clinical units, etc. | Electronic Medical Record | |
| * Information
in this table was collected from a “General Information About Health Care
Setting” form sent to all sites prior to the scheduled site visit. ** A division of the Jewish Home and Hospital Lifecare System. |
|||||
Health Settings visited: LDS Hospital (an Intermountain Health Care hospital), Christus St. Joseph's Villa, the Community Nursing Service (CNS), Hillside Rehabilitation Center, and CareSource Home Health and Hospice.
Intermountain Health Care is a not-for-profit health care enterprise that has over 60% of the acute care hospital market in Salt Lake City. Intermountain Health Care has more than 27,000 employees enterprise-wide, with approximately 4,700 at LDS Hospital, the hospital visited by the site visit team. Intermountain employs 550 physicians and has another 3,000 affiliated physicians with limited (read-only) access privileges to the enterprise electronic health information system (HELP system). The hospital employs hospitalists. Intermountain also has 92 clinics. According to one source, 17,000 people can access (with varying levels of permission) their Clinical Data Repository (CDR) that is part of the HELP2 system.11 HELP2 is the next generation of their CDR, and spans inpatient and outpatient settings, but it is not yet comprehensive in terms of clinical content. HELP2 is a single enterprise-wide longitudinal electronic health record (EHR) system that spans both inpatient and outpatient settings. The HELP2 database receives data from a heterogeneous collection of ancillary systems that communicate with the HELP2 database via HL7 interfaces. Currently, HELP2 houses over 2,000,000 patient records. Intermountain Health Care has a health plan division called “Select Health,” however, 35-40% of hospital admissions are traditional Medicare fee-for-service (FFS).
LDS Hospital and other Intermountain-owned hospitals have a decades-old tradition of ground breaking in-house development of information technology, and, more recently, they have entered into an alliance agreement with General Electric Healthcare to develop a next generation EHR system. The goal is to eventually run the enterprise using commercial-off-the-shelf (COTS) software. They have been and continue to be leading proponents and users of standard messaging.
Christus St. Joseph’s Villa (St. Joseph’s) is a non-profit skilled nursing facility (SNF) that receives the majority of their referrals from LDS Hospital, as well as two other local hospitals (Cottonwood and Altaview). St. Joseph's has 48 Medicare beds. They have a house physician who sees the majority of residents and a Medical Director who works at several SNFs in the community. None of St. Joseph’s staff, including the Medical Director, may access (even on a read-only basis) the Intermountain HELP system. They have begun a conversion to the Meditech EHR, starting first with billing, admissions, medications and treatment sheets, and MDS reporting. The decision to use Meditech at all St. Joseph’s sites was made at the corporate office based in Texas. St. Joseph’s Corporate is a healthcare enterprise that mainly focuses on hospitals, and has only three SNFs, of which St. Joseph's Villa is one.
Community Nursing Service (CNS) is a visiting nurse service. They receive about 45-50 referrals from LDS Hospital per year, and about the same from another area facility, Cottonwood Hospital. They have used Infosys/Homesys for four years. This software supports intake, staff scheduling, OASIS reporting, billing, and has a payroll interface. They indicated they are just beginning to roll out some of the clinical modules available with this software vendor.
Hillside Rehabilitation Center (Hillside) is a non-profit SNF and long-term care (LTC) nursing home with 120 beds, 82 of which are used. Their owner and administrator, Warren Walker, has a history of embracing technology focused on improving their processes, increasing staff satisfaction by reducing their workload, and promoting quality care. They are currently implementing an EHR developed by Utah-based Bluestep;12 it is being built on a core web application and the EHR is being designed for use in LTC environments. Thus, in contrast to Application Service Providers (ASPs), who provide web-accessible horizontal (generic) applications, Bluestep is a Vertical Service Provider (VSP); they have adapted their general purpose tools and applications to the specific needs of long-term care providers. Hillside has participated in the adaptation. A strength of the Bluestep LTC solution is its approach to the management of care workflow, including the management of tracking and acquisition of patient information such as a laboratory test result.
CareSource Home Health and Hospice is a home health agency (HHA) and in-patient hospice, the only in-patient hospice in Utah. They use McKesson’s Horizon and have modified it for use in both their home care program as well as in their hospice.
See Table D.1 at the end of this appendix for a comprehensive compilation of the information requested from and supplied by each site, prior to their scheduled site visit.
1. What data are shared? What should data should be shared but aren’t?
LDS Hospital discharge planners noted that most SNFs desire the same information on patients about to be discharged from the hospital, but in need of post-acute or long-term care. These requirements include: demographics, history and physical (H&P), therapy notes, and medication list. They report that the most patients have completed a Physician Orders for Life Sustaining Treatment (POLST)13 and that this follows the patient. Hospital staff report that many nursing homes transferring a patient to the hospital send the POLST. (Under Utah regulation, a POLST is optional, but if it exists, the POLST should follow the patient during a transfer of care.)
St. Joseph’s reports that patients received from Intermountain-owned hospitals come with a demographic sheet, H&P, consultant reports, medications used in the past 72 hours, labs, radiology, and therapy notes. However, St. Joseph Villa informants report that they rarely receive a POLST from an Intermountain-owned hospital, or from any of their other referring hospitals.
CNS estimates that approximately 5% of patients are admitted to home care with a completed POLST from the hospital.
When admitting a new patient, CareSource requests a H&P, the demographic sheet, medication list, and current progress notes. On average, they receive this information 75% of the time and it requires (on average) three follow-up phone calls. Physical therapy notes and prior Disposable Medical Equipment (DME) authorizations seem to be the most problematic data elements to obtain.
When Hillside residents are admitted from a hospital, they request and generally receive a face sheet, H&P, nursing notes, therapy notes, and a medication list. Hillside reports that they need to call the referring hospital ward clerk to get information on IV medication use, chemotherapy use, and ventilator use.
St. Joseph’s states that upon discharge to home, the nursing staff prepares a paper transfer packet to include a demographic sheet, H&P, therapy notes, wound care and a medication list. Upon transfer to the acute care hospital, nursing staff prepare the above information and add the POLST, recent labs and the MAR.
2. How are the data shared?
Electronic information exchange between unaffiliated levels of care was not observed during the site visit. All information transfer between the sites visited is by phone, fax, or paper accompanying the patient. Only rarely did post-acute care enterprises receive what they believed was sufficient information from the hospital on the first try; on average several phone calls were required to retrieve necessary information from paper or electronic records at the originating site. One exception was Cottonwood Hospital, another Intermountain Health Care enterprise; apparently, Cottonwood sends a complete printout of the patient’s hospital EHR.
In some cases, the information is transmitted via a phone call with the hospital discharge planner who manually abstracts the desired data elements from both the paper and electronic charts.
CNS intake care coordinators enter information received from the hospital into HomeSys.
Hillside intake coordinators scan hospital information and upload into their Bluestep system.
St. Joseph’s is beginning to enter patient information received into their newly-deployed Meditech system.
3. Timeliness and completeness of the data.
At LDS Hospital, the discharging physician dictates the complete discharge summary after the patient in discharged. The lag between when the patient is discharged and the dictation is complete varies depending on the physician and ranges from one day to three weeks. As observed, this means that the LDS Hospital discharge planner is the source of patient information provided to NHs until this summary is available. That said, LDS personnel have access to all current information.
4. Specifics about medications, labs, and radiology.
LDS Hospital has its own laboratory, radiology, and pharmacy services, and these services are supported by a mixture of locally developed and COTS applications that use a combination of local and national standards. LOINC codes are used for laboratory results and First Databank is used for medications.
St. Joseph's uses Intermountain’s laboratory, and the lab results are communicated via fax or phone (in the case of urgent results). Nursing staff then re-enter and send results to the medical director via her Blackberry®. St. Joseph's uses a single pharmacy (not Intermountain’s pharmacy) and generally gets admission medication 4-6 hours after arrival.
CNS uses multiple labs, largely governed by insurance or geography.
CareSource works with a single pharmacy and communicates via fax or phone.
Hillside uses Schrieber lab and results are faxed (urgent results are called). Results do not populate Blue Step, that is, they will be (are) entered manually. Hillside has made a financial investment in a single pharmacy and can electronically send medication information. This information auto-populates the pharmacist’s queue. However, scheduled “C-II” (Schedule 2 Controlled Substances) medications require a paper prescription in the State of Utah.
5. Areas under development (e.g., CPOE, decision-making tools).
LDS Hospital continues to improve the integration and interoperation of its many in-house software applications.
CNS is developing a physician portal that will allow physicians to sign orders electronically and modify the care plan.
Hillside is implementing decision support tools for nurses and CNAs within the framework of the BlueStep EHR. (Bluestep claims “knowledge management” as a feature of their core technology.)
6. Barriers to clinical data exchange.
At present, LDS Hospital physician progress notes are all in the paper chart. Intermountain does not allow home care or SNF coordinators into the hospital unless invited. Thus, they are not able to collect information on site.
St. Joseph's staff and Hillside’s staff do not have access to the Intermountain electronic health record.
CNS identifies their biggest information barrier to clinical data exchange is identifying the patients' primary care physician in the community.
Current SNF information exchange goals were almost always expressed in the form of the desire for the completeness of a paper record from the hospital. Some sites acknowledged that a complete record might be “too much,” or introduce accountability and liability concerns, but on balance all sites wanted more information that was commonly available.
7. Facilitators to clinical data exchange.
Placement decisions for Intermountain patients requiring post-acute care seems to be done almost exclusively by personal relationships--in the form of voice-to-voice communications between hospital discharge planners and the post-acute care intake coordinators. These personal relationships have taken years to develop and are the backbone of the referral process. One example of when such placements are over-ridden is a family request for geographic proximity. These personal relationships also support information exchange--from acute-care hospitals and emergency departments to post-acute care--both prior to and after a NH accepts the post-acute patient. At present, the two processes--placement and conveyance of patient information--are conjoined.
In sharp contrast to the personal relationships supporting post-acute care placement, the Utah Health Information Network (UHIN) is a community health information network that began in 1993. It is a coalition of health care providers, payors, and state government with, initially, the common goal of reducing costs by standardizing the transmission of administrative data, particularly payment data. The network community sets the data standards to which providers and payors voluntarily agree to adhere. The UHIN standards are then incorporated into the Utah state rule via the Insurance Commissioners Office. UHIN operates as a centralized secure network through which the majority of administrative health care transactions pass in the state. Nearly all payers and providers are participating in this project. UHIN developed a tool (UHINT), which they provide free of charge to providers for use in submitting electronic claims. The tool is provided so that even the smallest provider can submit claims and electronically receive remittance advices. The exchange of standardized electronic transactions has drastically reduced the amount of paper processing required for payers and has streamlined the payment of claims and remits, which has resulted in providers receiving payment more quickly. Under an Agency for Healthcare Research and Quality (AHRQ) grant, UHIN is pilot testing the exchange of a limited set of clinical data (medication history from payer to hospital), discharge summaries, history and physical, and laboratory results) with a small number of providers. The results of this pilot study are not yet available, but developers note evidence of demand for this service.
UHIN developers also are noticing an acceleration of development and feature requests given current software best practices--such as messaging and web-based connectivity. This is in contrast to formerly used “object-based” standards. Evolution of the UHIN is now more rapid, and more responsive to evolving user requests.
1. Hardward and software descriptions of the main health delivery system and the PAC/LTC settings.
The HELP2 system at LDS Hospital is a single large longitudinal EHR that integrates data across all care settings. It receives data from a heterogeneous collection of ancillary systems via HL7 Version 2 messaging that is standard across the enterprise. The HELP2 system was initially deployed in the outpatient environment but is now seeing widespread use within Intermountain hospitals. HELP2 desktops need support only a web browser with adequate computing power.14 HELP, (the first version of the system), is implemented on Tandem hardware, using the Tandem Application Language (TAL) programming language and PTXT Application Language (PAL), and uses the proprietary Tandem file system (Enscribe). The HELP system is still the primary system used in all Intermountain hospitals. Thus, HELP2 is intended as a complete replacement for the HELP system, but the transition from HELP to HELP2 enterprise wide will be a very long process.
2. Architecture of EHR system at main HDS.
a. Are they using CHI-endorsed and other HIT content and messaging standards? If so, which ones are they using? Messaging? Vocabulary? Direct care FM?
Perhaps to a greater degree than in any comparable large acute care hospital, internal inter-system communication is done using internally standard HL7 Version 2 messages. LDS Hospital and other Intermountain enterprises have pioneered such use, and incremental economies of scale were claimed for recent integration efforts. In contrast to most acute care medical centers where standards adoption is incidental to other considerations, LDS Hospital has adopted standards both because they are standards and because of perceived benefit.
Not unexpectedly, other than LOINC and HIPAA required terminologies CHI standards were not visible. For example, there was no visible use of SNOMED.
b. Description of each EHR system and HIT solution(s) to support HIE.
Currently, LDS Hospital has a rich and heterogeneous mixture of internally developed and COTS systems centered around core systems developed internally or in partnership with 3M. As of this writing, Intermountain has expanded the scope of its partnership with GE to further develop HELP2 capabilities.15
St. Joseph’s, CNS, and CareSource run their locally-deployed, proprietary applications on mini-computers, accessible from Local Area Networks (LAN) and dial-up lines. Hillside is making use of the web-based (remotely hosted) Bluestep product. CareSource uses McKesson Horizon, and they indicated that although they have not necessarily taken advantage of this fact, McKesson does have the flexibility to have custom programming done at a cost. McKesson’s future plans include going “platform independent,” much like today’s web browsers. It was unclear whether or not CareSource would immediately be taking advantage of these innovations when they become available.
c. If they have used "best of breed" how are these different software integrated?
Integration at LDS Hospital is via locally standard HL7 Version 2 messages using locally developed content standards, except for LOINC, some HIPAA standards, and occasional use of proprietary content solutions such as drug knowledge base (First Databank).
At Hillside, Bluestep achieves functional integration by implementing all functions using Bluestep core components and tools; thus, at present the Hillside system does not interoperate with other systems--though, because of its use of software “best practices” there is no reason why it could not easily do so in the future.
UHIN is achieving integration through the incremental deployment of state-wide data standards, that local systems “program to.” At present, these standards are largely Utah-specific, but work is underway on the deployment of content standards. One example appears in a Utah State Rule16 that describes use of national standards for claims-related transactions as an objective.
2. Architecture of EHR systems at PAC/LTC (if applicable) and HIT solution(s) to support HIE.
As described above, heterogeneous components inter-operate within LDS using internally standard HL7 Version 2 messages. Many components make use of a central patient data repository (another component) in addition to or instead of their own component-specific databases.
Hillside makes use of the Bluestep’s Vertical Service Provider (VSP) architecture, a variation on the web-based Application Services Provider (ASP).
3. How are the data stored? Shared? Accessed? Transmitted? Accepted at other setting? Entered? Etc.
The main LDS (current) patient record store is a proprietary database developed jointly by 3M and Intermountain. Archival (older) patient information is still stored in the LDS-developed HELP system.
At present, this information is not shared electronically outside LDS. Instead, the relevant information is transferred either voice-to-voice by the discharge planner, via fax, or paper copies accompanying the patient.
4. How are you tackling any interoperability issues using standards-based EHR systems or other HIT solutions for health information exchange?
Interoperation at LDS is currently aimed at integrating all information technology components used in LDS in-patient and outpatient care. Once intra-LDS integration is achieved, UHIN involvement will be one path by which both LDS, specifically, and Intermountain, in general, interoperate with other Utah healthcare enterprises including SNFs.
5. How does electronic health information exchange (e-HIE) vary between affiliated and unaffiliated providers within a single HDS?
Among LDS-affiliated providers, there is one method of interoperation--HL7v2-based messaging; currently the only non-affiliated interoperation is through the UHIN.
Other sites visited did not interoperate with non-affiliated sites.
6. How does e-HIE vary when exchanging to outside entities?
Exchange using the UHIN is currently limited to administrative transactions; as described above, limited clinical exchange is being piloted.
At Hillside, the Bluestep system being deployed will make it possible, technically, to develop bilateral interoperation (e.g., to get lab results), and to communicate with the UHIN.
The applications employed at the other sites--St. Joseph’s, CNS, and CareSource--are not designed with interoperation in mind; thus, exchange of information with the UHIN will become more difficult as the scope of doing so increases--from administrative data to clinical data.
1. Business Case for PAC/LTC.
With the exception of LDS Hospital, the settings visited were unaware of the UHIN, and its efforts to support and facilitate health information exchange. The exception to this is at Hillside where they did recognize that Medicaid claims now were solely done electronically, but were unaware that they were transmitted through the UHIN. Stan Huff is a consultant on the AHRQ-funded UHIN pilot, but no one else, including LDS Hospital staff, was aware that the UHIN project was in progress.
None of the post-acute or long-term care settings visited had any immediate or future plans to implement HIT to improve and/or facilitate HIE. Although LDS Hospital has the technical infrastructure in place to share data with other settings, when asked about sharing data with community PAC/LTC settings, Stan Huff’s response was “standards are not widely used with outside entities because no one has made it a priority…[the business case for LDS Hospital] is population driven. There is a limited amount of money to devote to EHR systems, and we use scarce HIT resources where they will have the greatest benefit for the largest number of patients. PAC/LTC is not the highest priority because they have few medical events or patient visits when compared to outpatient facilities or the acute care hospitals.” Stan Huff went on to say that “…most SNFs/NHs do not have the IT expertise to accept electronic data, and they are only a small piece of the pie. The individual institutions are not large enough to support IT staff that can deal with electronic data exchange.”
2. Adoption of EHR systems.
LDS Hospital developed its own EHR system unilaterally and later in collaboration with their software vendor 3M. They used their own vocabularies and when standards became available they used them opportunistically; however, when they first implemented the HELP system when few if any standards were available.
For all the post-acute and long-term care settings visited, vendor selection was not based on if they used standards or if they had an interoperable EHR system. With the exception of LDS Hospital and Hillside, none of these settings is involved in standard development organizations; none are they members of the UHIN.
LDS Hospital has a long history of groundbreaking HIT development. More recently, their technical leadership has included an intra-enterprise commitment to use messaging--currently their implementation of the HL7v2 standard--for all inter-component communication.
Perhaps inspired by this example and by the early use of the internet in Utah, former Governor, now HHS Secretary, Michael Leavitt, led the creation of a state-wide network to support state services and educational institutions--Kindergarten through grade 12 as well as post-secondary institutions. This popular and highly successful effort raised consciousness around the state and may have laid the ground work for the collaboration necessary to launch the now successful RHIO (Utah Health Information Network [UHIN]), and the fact that it includes erstwhile (network) "competitors."
Medicaid reimbursement is incrementally moving to the UHIN, as we saw at Hillside Rehabilitation that is now using UHIN to submit their Medicaid claims, as six months ago, Medicaid suspended their use of bulletin boards to submit the claims.
The RHIO is already clearly a success today--as measured by use and demand for services--although post-acute and LTC use does not seem to be a current priority, excepting use for Medicaid reimbursement. Initial drivers are: (1) patient eligibility; (2) provider credentialing and enrollment with payers; and (3) reimbursement. They have started a pilot on the exchange of clinical data, but it began in late summer, so it is too early to discuss findings. While serving the specific needs of post-acute and long-term care may not be a current RHIO priority, these care settings may derive significant benefit from general (planned) RHIO activities such as the uniform reporting of lab tests and e-prescribing.
Finally, while all sites wish they had a patient-centric longitudinal record, there is little if any movement to meet that goal. There is awareness of the possibility and potential of patient-accessible/writable health records, especially if they were UHIN accessible but the site visitors did not know of any plans, either short-term or long-term to facilitate this concept.
| TABLE D.1: General Information Supplied by Visited Sites* | |||||
|---|---|---|---|---|---|
| Name of Health System | Intermountain Health Care, LDS Hospital | Community Nursing Services | Christus St. Joseph’s Villa | Hillside Rehabilitation Center | CareSource Home Health and Hospice |
| Location | Salt Lake City, UT | Midvale, UT | Salt Lake City, UT | Salt Lake City, UT | Salt Lake City, UT |
| Year established | 1975 | 1925 | 1947 | 1970 | 1997 |
| Area served (urban, rural, both) | Intermountain--both
LDS Hospital--urban, major referral center, established in 1905 |
Urban and rural | Urban | Urban | Urban |
| Ownership | Non-profit | Non-profit | Non-profit | Non-profit | For profit, privately held, freestanding |
| No. full-time employees | Intermountain has 27,000
total employees LDS Hospital has 4,700 |
161 full-time (plus 195 part-time) | 75 | 66 | |
| No. of Nursing Homes (owned, affiliated) | 0 owned | 0 | 1 owned | 0 owned 3 affiliated |
0 |
| No. of Home Health Agencies (owned, affiliated) | 1 owned | 1 owned | 0 | 0 owned 0 affiliated |
1 owned |
| No. of Physician Practices (owned, affiliated) | 96 owned | 0 | 0 | 0 owned 0 affiliated |
1 owned |
| Are physicians affiliated with health delivery system or are they independent? | Affiliated, employed, and independent | n/a | Independent | n/a | Affiliated |
| Inpatient pharmacy? | Yes | n/a | No | No | No |
| Does SNF use dedicated pharmacy or contract with large/retail, or multiple pharmacies? | n/a | n/a | Dedicated | Dedicated | Dedicated |
| No. of Pharmacies--outpatient | Intermountain has 19
LDS Hospital has 1 |
Home infusion only | 1 | 0 | 0 |
| In-house laboratory? | Yes | n/a | No | No | No |
| How many outside laboratories? | 3 | 1 | 1-2 | 2 | |
| In-house radiology department? | Yes | n/a | No | No | No |
| How many outside radiology centers/MR centers do you work with? | 0 | n/a | 1 | 3 | 0 |
| Percentage of overall budget dedicated to IT? | |||||
| Electronic Health Record (EHR) system--scheduling, billing, or claims? | Yes | Yes | Yes | Yes | Yes |
| Clinical Electronic Health Record (EHR) system? | Yes | No | No (in process of development) | Yes | Yes |
| Primary software vendor for electronic health information system (if applicable) | In-house developed | Infosys/ Homesys | Meditech | American Data | McKesson and Resource Systems |
| Short-term (6 months?) HIE* future plans | Discuss at interview | In process of implementing clinical software | Developing Meditech for clinical records | New system | |
| Long-term HIE* future plans | Discuss at interview | Maintain | |||
| * Information in this table was collected from a “General Information About Health Care Setting” form sent to all sites prior to the scheduled site visit. | |||||
Health Settings visited: Indiana Health Exchange (IHIE), Regenstrief Institute, Indiana University (IU) School of Medicine, Wishard Health Services, Lockefield Village Rehabilitation and Healthcare Center, the Visiting Nurse Service (VNS) of Central Indiana, Kindred Long-Term Acute Care Hospital, Beverly Enterprises at Brookview, and Briarwood Rehabilitation.
Indiana Health Information Exchange/Regenstrief/Indiana University School of Medicine. Indianapolis, Indiana has several major hospital systems including the Indiana University hospitals, St. Vincent, St. Francis, Community Health, and Westview. The five Indiana University hospitals are Wishard Hospital (part of Wishard Health Services, the county-managed system that serves vulnerable populations of Marion County, Indiana), the Roudebush VA Medical Center, Riley Children's Hospital, Methodist Hospital, and the Indiana University Hospital. The latter three are owned by Clarian Health Partners.
Our primary host for the site visit was Dr. Michael Weiner, MD, MPH, Associate Professor of Medicine, IU School of Medicine, Scientist at Regenstrief Institute, and Center Scientist at the IU Center for Aging Research. Many of the other individuals we spoke with the first day are dually appointed as faculty at the University as well as research scientists at the Center for Aging Research or Regenstrief Institute.
Dr. Weiner is leading a new program at Indiana University called Gero-Informatics (defined as the application of medical informatics to geriatrics care). The mission of this program is to advance research, clinical care, and education related to gero-informatics.
Under the leadership of Clement McDonald, MD, Indiana University deployed an early (1973) electronic medical record system (the Regenstrief Medical Record System), evolutionary descendents of which are still in use today. Again with leadership from Dr. McDonald and with assistance from J. Marc Overhage, MD, PhD, success with the medical record system led to the formation of the Indianapolis Network for Patient Care (INPC), which permits emergency department (ED) physicians at all major Indianapolis hospitals to retrieve patient information stored at one of the other hospitals. A simple example of the utility of this arrangement was a recent patient being seen in an Indianapolis hospital ED for “chest pain.” Because the ED physicians could retrieve patient history information and see that the patient recently had a cardiovascular workup at a regional hospital a few months before, as well as read the results that showed the workup had at that time ruled out cardiovascular disease, they were able to diagnose a pulmonary embolism more quickly and at less cost and risk to the patient. While there are many factors that led to the current success of the INPC, regional ED physicians were the primary drivers and early users of this health information exchange and are credited with both pushing the concept of health information exchange within the Indianapolis community of health care settings and with being the early adopters who participated in its development.
Steven R. Counsell, MD, Director of IU Geriatrics, described current plans to build on the elements of regional "informational continuity of care" achieved to date; specifically, his goal is to build and maintain an increasingly complete, up-to-date, longitudinal patient-centric record. An early sub-goal is to exchange data with local primary care physicians, pharmacies, and laboratories. Dr. Counsell and his colleagues are positioned to formulate and pursue these ambitious goals because of the decades of effort in collaborative processes and infrastructure invested by Drs. Clement McDonald, Marc Overhage, and regional co-workers, and also by early adopters and users. Development of the INPC has demonstrated to the regional health care community that an incremental approach to a patient-centric record is both possible and the best way to proceed.
Because of these and other past successes, the physicians presently leading the Indiana Health Information Exchange are overwhelmed with opportunity relative to other regional care sites; their challenge and opportunity--per Dr. McDonald’s legacy17--is to identify real, solvable health information technology (HIT) problems, and then solve them. An example of the application of this method is Regenstrief’s early focus on the processing of laboratory test results. Their development paradigm enables them not to worry about the big picture, nor about painting themselves into a corner--as, for instance, they have done by continuing to use an unsupported version of the Microsoft OS for some of their order entry interfaces. (For skilled users, however, these interfaces are very high function--making use of fast keystroke-based commands.) Instead, they can invest their finite resources working on what they perceive to be the next most useful system function, learn from that effort, and go on to the next problem that is both important and solvable.
Part of Regenstrief’s repertoire of “lessons learned” is that they have sufficient accumulated experience processing data feeds, such as laboratory data, from other hospitals that they prefer to take the remote data "as is" and deal with things like undetected duplicate patient records later. This is a tradeoff that few others are in a position to make. Because of their hard-won experience and their associated investment in tool development, they have “lowered the bar” for the next hospital, medical practice, or other source of encounter data to join the Network. That is, they take the data stream from whatever system the next care setting has in place and then they develop the software transformations and mappings required to integrate that data into the IHIE. Again, they can do this easily and productively because of the economies of scale resulting from decades of experience and tool investment. The alternative--requiring that each hospital or other care setting develop its own transformations and mappings into some abstract data model--is so expensive and fraught with delays and risk that few regions have succeeded in achieving clinical data exchange using this approach. An important, but little appreciated feature of the IHIE approach, is that the integration team is focused only on the “next” data stream; it is not burdened, yet, with the necessity of solving the problem for rest of the region, the state of Indiana, the Midwest, or the nation. By focusing on the next data stream, they do not take on problems that are too large, and they can benefit--learn--from each step completed. Another little appreciated feature of the IHIE paradigm is that collaborative organizational energies can be focused on data issues--sharing, re-use, security, and the like--and not on technical details, which participants typically defer to the McDonald-Overhage Regenstrief leadership.
The deliberate focus on data as opposed to software has led Regenstrief to invest in the representation of transferred text-based information using formatted ASCII and to avoid using scanned images or unformatted text, wherever possible. This means that laboratory test result names can make use of the LOINC standard and, potentially, lab test results from different sites can be compared and aggregated.18 It also means that the IHIE may someday be able to “interoperate by meaning” using medication and problem list data. That is, patients may one day have a unified medication list. For instance, the daily dose of acetaminophen in combination drugs can be computed with a resulting unified problem list, showing both chronic and acute diagnoses. Thus, even if the goal and benefit today is uniform human readability of exchanged clinical data, IHIE is in a position to explore use of other computer-empowering terminology standards such as RxNorm (medications) and SNOMED (problem list) in the future.
IHIE is in the early stages of implementing a portal called Docs4Docs19 that provides access across care providers to admission and discharge transcriptions, laboratories, radiology, EKGs, and pathology. At present, medications are not included. Physicians see Docs4Docs as a "glorified mail service," giving them web-based (anywhere, anytime) access to health care transaction reports. It is supported by the large hospitals in the Indianapolis metro area. There are a few places currently using this technology, including Kindred Long-Term Acute Care (LTAC) Hospital.
The Docs4Docs portal is very new, and potentially revolutionary. Those in charge do not feel pressure yet to open it up to patients, as Kaiser Permanente health care has accomplished, but they will feel this pressure soon. Right now, Docs4Docs is, as the name suggests, very physician centric. The portal leverages the experience and good will that has been generated by long-standing regional ED physician collaboration and interoperation among the five hospitals currently participating in the Network portal. One novel aspect of the portal is that physicians manage--create and maintain--their own patient links. This approach overcomes the challenges of physicians having multiple affiliations (and thus multiple identifiers) and it allows physicians to track down encounter records for the same patient that the master patient index has failed to link.
Kindred Long-Term Acute Care Hospital. The purpose of our visit to Kindred was to see a demonstration of the IHIE’s Docs4Docs portal. This LTAC site receives patients from all surrounding hospitals, including Wishard. Their average length of stay (LOS) is 25 days, with an average census of 30 patients. The demonstration emphasized the utility of Docs4Docs--instead of rummaging through a paper-based in-box, or (less likely) a not always up-to-date paper chart, physicians can find the lab (or other encounter) result they want and display it. Optionally, the result can be displayed in the context of all recent encounters. The fact that the portal made these results accessible from any Web browser and displayable along with past results over time is viewed as a powerful feature; again, the principle early benefit of the portal is that a physician can retrieve recent results (from subscribing hospitals) for any patient (known to the system) from any web browser, and display them, aggregated in a graph, if appropriate. We were told that demand to have feeds available from the portal exceeded current personnel resources, and that the project--funded initially by grants--was modestly cash-flow positive from hospital subscription fees.
Wishard Health Services and Lockefield Village Rehabilitation and Healthcare Center. Wishard Health Services provides a spectrum of health care for older persons, including sub-acute care, extended/long-term care, outpatient/ambulatory care, and house calls for seniors, under one umbrella, the Acute Care for Elders (ACE) unit. It is a county-managed system staffed by university faculty and surrounded by other hospital chains, including Clarian (which also is part of the IU campus). By its mission, but to some extent also by patients’ choice, Wishard’s patient population is largely low-income. Their payor mix is 35.7% uninsured, 27.3% Medicaid, 22.5% Medicare (mainly FFS), 9.7% commercial, and 4.8% other. Wishard Hospital has an ACE Unit and an SNF (Lockefield Village), which also was visited by the team. The electronic Regenstrief Medical Record System was first developed in the Wishard system, and Wishard is unsurprisingly a participant in the IHIE. Wishard will complete deployment of mandatory e-prescribing processes for its physicians in January 2007.
Beverly Enterprises at Brookview is a nursing home with a Part A SNF, a dementia unit, and long-term care services. It is one of hundreds of facilities that are part of the national Beverly chain. The LOS for Part A patients is 37 days and occupancy is usually in the mid-90%. The IHIE was in communication with a Beverly Corporate representative concerning potential participation in the IHIE until that representative left Beverly during a recent reorganization. At the time of the writing of this report, there is no action being taken by either the IHIE or by Beverly Brookview to join the Network. However, Beverly Brookview has reported renewed interest in participating in the IHIE.
Beverly Brookview uses an EHR called VistaKeane that is used throughout all corporate facilities and maintained by corporate headquarters in Fort Smith, Arkansas. Floor staff entries--created by entering data on touch screens located outside of patient rooms--are monitored closely by supervisors within the facility as well as within the corporate office. The corporate office keeps a tight rein on each of the facilities. Beverly Brookview’s copiers and fax machine have digital scanning capabilities and are able to create, receive, and transmit digital documents for representation in a corporate document repository (Documentum).
Reportedly, Beverly corporate information technology can and does deploy enhancements to their information technology systems nationally if they are of sufficient importance.
VNS Healthcare System of Central Indiana is the largest HHA in Indiana. Established in 1913, it has 212 full-time employees. The VNS is the preferred provider for seven hospitals (i.e., there is a formal affiliation with these hospitals). At Wishard, they have a clinical liaison in the hospital who has access to the hospital’s EHR. The liaison also can access information for referrals that come from the ambulatory clinic and begin the process of populating the home health agency’s electronic record using a laptop.
The VNS recently upgraded to the MISYS system, previously having used McKesson. They are exploring a physician portal but this is not imminently available. They are heavily invested in telehealth (currently with 101 units) and plan to have 200 Honeywell units in operation by the end of 2007.
When asked about the IHIE, John Pipas, the CEO was familiar with the HIE’s activities in general, but to date, they have not been asked to participate, nor have they indicated to the IHIE group that they are interested in participating but would consider options if offered.
Briarwood Rehabilitation is a for-profit, long-term care facility with a Part A SNF. They have 113 skilled beds and an average LOS of 60-90 days. They use MDI for their MDS reporting and claims submission and do not have any future plans to implement an interoperable EHR system.
See Table E.1 at the end of this appendix for a comprehensive compilation of the information requested from and supplied by each site, prior to their scheduled site visit.
1. What data are shared? What data should be shared but aren't?
Wishard Hospital considers the discharge summary, insurance information, medication list, allergies, problem list, and advance directives among the core information needed at time of transfer.
SNF staff at Lockefield Village comment that they rarely receive information about a patient's mental status and behavior prior to transfer. When it is provided, it is sometimes incomplete.
The most common information that Beverly Brookview does not always receive from referring hospitals including Wishard is the discharge summary (again because it may be dictated later by the attending physician). Beverly Brookview has a full-time “recruiter” who visits acute care facilities to obtain patient information regarding potential Beverly Brookview patients. The information obtained is passed to an RN in charge of Brookview admission (or denial of admission).
When an urgent problem requires that a patient be transferred to a hospital, the Beverly Brookview person in charge of medical records helps to complete a handwritten form that includes a current medication list, recent laboratory results, insurance status, skin status, code status, physician name and contact, and facility contact. Many of these data elements are gathered from the Beverly Brookview computer but are handwritten onto the form. Beverly Brookview's patient records are reviewed once every 24 hours by remote care providers who can contact Beverly Brookview care providers if something in the record signals a potential problem.
Briarwood commented that the two data elements found to be missing with the highest frequency from referring hospitals are wound status and behavioral status.
2. How are the data shared?
The Wishard Hospital EHR can produce an abstract/clinical summary for patients as they enter an ED. The summary includes the reason for visit, a problem list, medications prescribed (that may or may not match what medications actually are taken), recent dictations available, recent laboratory results, recent radiology results, and immunizations. Advance directives are not part of the summary. An unusual feature of the system is a means by which the ED can update the ED summary and then send it with the patient back to the facility, but updating happens only infrequently.
At Wishard’s Lockefield Village extended-care facility, the EHR is available to retrieve data and also has integrated provider order entry in part of the facility, which is physically located on the Wishard campus, adjacent and connected to Wishard Hospital. Physicians, physical therapists (PTs), and nurses (RNs) can access information from the hospital prior to transfer and during transfer as needs arise. Some of the MD and RN charting is in the EHR but physical therapists only enter the final note/discharge summary. On Lockefield Village floors without provider order entry, SNF medications are not managed via the EHR. Lockefield Village also provides long-term care, but most of the charting is paper-based and separate from the EHR.
When patients leave the Part A SNF at Lockefield Village, communication with the receiving HHA is via phone and fax. This is an example of the lack of “informational continuity of care” that the Regenstrief gero-informaticians would like to overcome. Beverly Brookview made a related observation indicating, for example, that patients sent to the emergency department with potential internal bleeding sometimes were returned with the bleeding stopped but without information on what was done during the stay in the emergency room.
Extended Care Information Network (ECIN) is used by some of the referring hospitals, but referrals are largely made based on personal relationships between discharge planners and intake coordinators.
At Briarwood, a paper "standard transfer summary" is prepared when patients are transferred to the ED and a verbal report is called into the ED. This summary includes the reason for transfer, demographics, problem list, medications, allergies, and recent laboratory results.
When patients are discharged from Beverly Brookview to home health, information is printed from their EHR or photocopied from the chart.
The VNS does not share data contained in their MISYS with Wishard Health Services or any other hospital.
3. Timeliness and completeness of the data.
In general, the SNFs and HHA visited indicated that the Indianapolis area hospitals provide relatively complete data at the time of discharge. The exceptions to this would be that behavioral issues, wound assessments, and the other locations in which the patient/resident were recently treated often are missing. For home care, the Primary Care Physician (PCP) information often is not there, making it more time-consuming for the home health agency to locate and interact with the patient’s primary physician.
The staff at the VNS also mentioned that the discharge summary is faxed to them--if it is coming from the medical side of the hospital it generally has good documentation; if it is coming from the surgical side, the documentation is often incomplete. Their biggest issue, however, is that the discharge summary often is not available at the time of discharge (e.g., the physician having not yet dictated her/his orders).
As observed on other site visits, securing information about potential patients on a timely basis is a high priority task, the successful completion of which often depends on long-standing personal relationships between acute care and long-term care personnel.
4. Specifics about medications, labs, and radiology.
The IHIE Docs4Docs portal provides access across care sites to discharge transcriptions, laboratory results, and radiology. At present, medications have not been configured. The portal is supported financially by the large hospitals in the Indianapolis metro area. Kindred LTAC has access to the IHIE Docs4Docs portal and recently has begun to use it.
For Wishard Hospital patients, 80% of outpatient medications are dispensed from the Wishard-based pharmacies.
Beverly Brookview uses a single pharmacy, Pharmerica, (a national chain). Communications with the pharmacy are via fax. They also contract with a single laboratory, DCL Laboratories. The initial order is faxed, but staff can dial in to get results. The lab results also are provided via fax, but the results are not entered into VistaKeane.
At Briarwood, laboratory tests are ordered via fax and results are received via fax. Pharmacy orders are faxed.
At the VNS, communication with pharmacies is currently by fax; however, this will change once e-prescribing is initiated. Lab results are obtained via fax and placed in a paper chart.
5. Areas under development (e.g., CPOE, decision-making tools).
Beginning January 2, 2007, all prescribing will be electronic in the State of Indiana.
The VNS is exploring a physician portal but this is not imminently available.
The IHIE is working with the Centers for Medicare and Medicaid Services (CMS) to import Medicare claims data (encounters, tests, procedures) that could support multiple efforts including performance measurement reporting. Reportedly, this also would include MDS, OASIS, and Part D data.
Doc4Docs will increase its coverage of regional health care encounter records. Currently, most information comes from the five initial participating hospitals. Aside from the fact that they help provide financial support, their pre-processing (homogenization) of the data makes it easier for Doc4Docs to perform its processing. However, gradually Docs4Docs will start collecting the information from the original source (e.g., a laboratory, instead of from the hospital that ordered the lab test, or from a pharmacy instead of the enterprise that ordered the medication). The portal has regional completeness as a goal for both laboratory results and medications.
6. Barriers to clinical data exchange.
The primary barriers to clinical data exchange identified were the general lack of access to another provider’s existing electronic health record system, as all sites had some access to the Internet and all sites had at least some level of electronic record keeping. As all sites can support web-access, even if only by (rarely) dial-up, Docs 4 Docs should help reduce this barrier.
The post-acute and long-term care providers were largely unaware of the IHIE initiatives and activities. They have not been invited to join, nor have they initiated joining, largely because of the lack of knowledge that this exchange exists.
7. Facilitators to clinical data exchange.
Referrals from Briarwood to home health often involve an on-site evaluation by the home health liaison who is permitted to collect information concurrently.
At Wishard Hospital, the VNS has a clinical liaison who has access to the EHR. The liaison begins the process of populating the MISYS record using a laptop.
Beverly Brookview has a highly developed manual, paper, and fax-based patient recruiting and admission process supported by two full-time employees (FTEs).
The IHIE is starting to facilitate data exchange, at least with the five major hospitals in the Indianapolis area. These hospitals collect and refine information from a variety of other sources, such as clinical laboratories.
The VNS care providers, often deployed from home, use laptops to upload patient encounter information and to download visit assignments. Currently, care providers tend not to make use of laptops when they are with patients.
All sites make use of HIT to at least some degree, all sites are connected to the Internet (though not all have high-speed connections), and all sites make use today of phone, fax, and paper-based access to remote information.
1. Hardware and software descriptions of the main health delivery system and the affiliated PAC/LTC settings.
The IU (Regenstrief) EHR makes use of commodity servers that run a dialect of MUMPS; order entry via these servers is accessible through hospital Local Area Networks (LANs) by early generation (commodity) PCs running a now obsolete version of Microsoft Windows, or increasingly via Windows-based Citrix sessions for remote deployment and management. Data retrieval via EHR can be accomplished via the older text-based interface or by the web, using common web browsers with a Secure Sockets Layer or Virtual Private Network.
Docs4Docs makes use of a server-based data repository of data loaded from the EHRs of five hospitals; this server is accessible through web-based browsers.
2. Architecture of EHR system at main HDS.
a. Are the sites visited using CHI-endorsed and other HIT content and messaging standards? If so, which ones are they using? Messaging? Vocabulary? Direct care FM?
Except for the use of LOINC in the Indiana Network for Patient Care (INPC), use of CHI-endorsed standards is incidental at all sites (i.e., such standards are used only for regulatory or reimbursement reasons).
b. Description of each EHR system and HIT solution(s) to support HIE.
As described, IU makes use of a legacy, locally developed, MUMPS-based EHR. Beverly Brookview uses VistaKeane; the VNS uses MISYS; and for the present, Briarwood is content to continue to make use of largely paper-based processes.
INPC supports emergency department results retrieval from the EHRs at five hospitals to the emergency departments at the five hospitals; feedback of encounter or summary information from the emergency departments to the relevant remote EHR is not generally implemented.
Docs4Docs permits hospital-associated physicians to retrieve results residing in the EHRs of the five participating hospitals. Often these physicians are associated with more than one hospital or care site.
The nursing homes visited do not yet participate in either the INPC or Docs4Docs, though they might wish to if they had the opportunity.
c. If the sites visited have used "best of breed," how are these different software integrated?
The INPC and Docs4Docs process “streams” of data from hospital EHRs; sometimes these streams contain HL7v2 messages. No other inter-site integration was observed.
3. Architecture of EHR systems at PAC/LTC (if applicable) and HIT solution(s) to support HIE.
Both INPC and Docs4Docs make use of a central data repository. INPC is accessible from emergency department terminals. Docs4Docs supports web-based access.
4. How are the data stored? Shared? Accessed? Transmitted? Accepted at other setting? Entered?
All data are stored in MUMPS file systems (in the case of IU) or in the proprietary databases of the EHR or other record keeping applications for the other sites. Data from INPC and Docs4Docs make use of evolving messaging and web technologies specifically selected by Docs4Docs developers to be the best near-term solution. While the Docs4Docs application will be a very powerful demonstration of the utility of “anytime, anywhere,” access, it is not being designed to be a national solution; instead, continued local success and growth is its objective.
5. How are the sites visited tackling any interoperability issues using standards-based EHR systems or other HIT solutions for health information exchange?
Both the INPC20 and IHIE21 make use of HL7v2 messages and LOINC. The remaining aspects of these interoperation solutions make use of pragmatically determined, local “best practices.”
6. How does electronic health information exchange (e-HIE) vary between affiliated and unaffiliated providers within a single HDS?
The IU and Wishard use a single integrated EHR system. The five major hospitals in Indianapolis participate in the INPC and the IHIE. At present, neither the INPC nor the IHIE are available to NHs.
7. How does e-HIE vary when exchanging to outside entities?
“Outside” entities must, at present, obtain information from IU and other IHIE hospitals through the traditional methods--fax, paper, and telephone.
1. Adoption of EHR systems and Electronic Health Information Exchange with PAC/LTC.
Regenstrief Institute and IU were trailblazers with regard to developing their EHR system, the RMRS (Regenstrief Medical Record System). They established the INPC, which is the cornerstone of the IHIE model for data exchange. The EHR and INPC systems were established well before CHI-standards were selected.
The business case for the IHIE is relatively simple. Physicians and other clinicians value having access to previous encounters because it allows them to provide better care and because it will reduce costs by minimizing the duplication of tests and procedures, and it will enable physicians to determine more accurate diagnoses because they will have a more complete picture of the patient’s recent medical history.
Today, it is not a major goal for the IHIE to get an EHR into physician offices or post-acute/long-term care settings. The IHIE has plenty of work to do with the current and planned participants in the network, and although our impression is that they would welcome involvement by the PAC/LTC community, they are not going to actively recruit them into the HIE at this time.
For Beverly Enterprises, their EHR system was selected by the corporate office and all 300 facilities are required to use it. Likewise, any interfaces with other systems at the local level (e.g., Indianapolis), would first need to be approved and paid for by the corporate office. The Administrator did note that in vetting the software companies, use of standards was a criterion, which is one reason they selected VistaKeane. However, interoperability with other systems does not appear to be a current feature, or an immediate concern for Beverly Enterprises.
The VNS enjoys the status of being the largest home health agency in the area and is the preferred provider for many feeder hospitals. Interoperable EHR systems have not been a consideration to date, nor does it appear to be a near-future goal for John Pipas and his staff at the VNS.
Briarwood expressed no future plans to improve upon their current MDI software. Interoperability and the exchange of electronic data between their LTC facility and other health settings is not a priority at this time. They would be very happy to receive complete, legible, timely information via fax or phone.
2. Standards Development Organizations
With the exception of faculty and staff at IU, the Regenstrief Institute, and the IHIE, no other group reported being involved in any standards development organizations (SDOs).
The Indianapolis INPC and IHIE form the leading RHIO in the United States, a lead that may only increase once the IHIE obtains medication information and primary care encounter reports. The coverage of the IHIE appears to be scalable to the region and should achieve this coverage within a few years--at least for area physicians. A critical requirement for the success of the INPC, and later for the IHIE, was the trust originally cultivated by Dr. McDonald that information from one hospital would not be misused by another (e.g., competitive uses). Once this trust was established, the remaining problems were technical, and therefore solvable.
The Regenstrief software and system development paradigm has enabled the timely creation of incremental utility sufficient to produce and sustain Indianapolis’ current pre-eminent position. When combined with the use of commodity hardware, powerful systems can be built quickly and inexpensively. Were such systems built using current CHI-endorsed standards, they would be a replicable model for RHIOs throughout the country. Regardless, the INPC and IHIE are a model that can raise consciousness nationally regarding what can be accomplished given the organization will and resources to do so.
Finally, “a rising tide carries all boats.” While the INPC and IHIE are not aimed at nursing homes and/or home care, their success should help these enterprises. The latter are already making local use of HIT and were appropriate standards in place, the cost of connecting to the INPC and IHIE would be modest.
| TABLE E.1: General Information Supplied by Visited Sites* | |||||||
|---|---|---|---|---|---|---|---|
| Name of Health System | Indiana Health Info. Exchange/ Regenstrief Institute | Wishard Health Services | Lockefield Village (Wishard-owned SNF) | Kindred Long-Term Acute Care Hospital | VNS Healthcare System | Beverly Healthcare Brookview | Briarwood Health and Rehab. Center |
| Location | Indianapolis, IN | Indianapolis, IN | Indianapolis, IN | Indianapolis, IN | Indianapolis, IN | Indianapolis, IN | Indianapolis, IN |
| Relationship to Host Site | Host Site | Host Site | Application Demo Site | ||||
| Year established | IHIE Feb 2004 Regenstreif about 35 years ago | 1992 | 1913 | 1967 | 1998 | ||
| Area served (urban, rural, both) | Both | Both | Urban and rural 30 counties | Urban | Urban | ||
| Ownership | Non-profit | Corporately owned | Non-profit, freestanding | For profit, privately held | For profit | ||
| No. full-time employees | 16 IHIE | 113 | 212 FTE | 89 FTE | |||
| No. of Nursing Homes (owned, affiliated) | 0 | 0 owned 7 affiliated |
0 owned 0 affiliated |
0 owned 0 affiliated |
0 owned 14 affiliated |
||
| No. of Home Health Agencies (owned, affiliated) | 0 | 0 | 1 owned 7 preferred providers affiliated |
1 owned 0 affiliated |
0 owned 1 affiliated |
||
| No. of Physician Practices (owned, affiliated) | 0 | 0 | 0 owned 0 affiliated |
0 owned 0 affiliated |
0 owned 0 affiliated |
||
| Are physicians affiliated with health delivery system or are they independent? | n/a | Practicing physicians are with Indiana University | Independent | Independent | Independent | ||
| Inpatient pharmacy? | 0 | Yes | No | No | No | ||
| Does SNF use dedicated pharmacy or contract with large/retail, or multiple pharmacies? | n/a | Unknown | Hospice program contracts with one pharmacy | 1--Pharmerica Pharmacy | Dedicated | ||
| No. of Pharmacies--outpatient | 0 | 0 | 1 | 0 | 0 | ||
| In-house laboratory? | 0 | Yes | No | No | No | ||
| How many outside laboratories? | n/a | Unknown | Minimum of 20 outside labs | 1--DCL Laboratories | 1 | ||
| In-house radiology department? | n/a | Yes | 0 | No | No | ||
| How many outside radiology centers/MR centers do you work with? | 1 or 2 | 1 | 8-12 centers | 1--Mid-West Radiology | 1 | ||
| Percentage of overall budget dedicated to IT? | Not answered | Unknown | 5% | ||||
| Electronic Health Record (EHR) system--scheduling, billing, or claims? | Working towards that throughout the community--many of these services are in place at Regenstrief/ Wishard | 0 | Yes | Yes, EDS | Yes--billing/ claims submission for MDS purposes only | ||
| Clinical Electronic Health Record (EHR) system? | See above | In-house system | Yes | Yes | MDI--for MDS reporting only | ||
| Primary software vendor for electronic health information system (if applicable) | Developed internally | Internal | MISYS Telehealth Honeywell HomMed | VistaKeane | MDI--for MDS purposes only | ||
| Short-term (6 months?) HIE* future plans | Continue expansion of clinical messaging | Continue utilizing current internal system and available community resources | Having an internal EMR set up and interfaced with disease management and telehealth programs. Looking for potential web access by physicians, patients, and families to the telehealth program. | No | No formal plans | ||
| Long-term HIE* future plans | Same as above with further development of clinical quality initiative | Not established | To have web access portal for patient information to be reviewed by physicians | No | No formal plans | ||
| * Information in this table was collected from a “General Information About Health Care Setting” form sent to all sites prior to the scheduled site visit. | |||||||
9,000 Bronx residents were admitted to two or more hospitals in 2004, accounting for 30,000 admissions.
Website: http://www.health.state.ny.us/funding/rfp/0608071010/questions_and_answers.pdf.
Website: http://www.qs1.com/qs1home.nsf/Web+Pages/RxCare+Plus?OpenDocument.
Website: http://www.ansi.org/standards_activities/standards_boards_panels/hisb/hitsp.aspx?menuid=3.
Website: http://www.hospitalmanagement.net/contractors/it/dbmotion/dbmotion3.html.
Website: http://intermountainhealthcare.org/xp/public/documents/institute/faculty_clayton_building_system.pdf.
Website: http://intermountainhealthcare.org/xp/public/physician/help2/learnmore/requirements.xml.
Website: http://egems.gehealthcare.com/proom/internet/NewsandEvents.jsp?release_id=11972.
Website: http://www.rules.utah.gov/publicat/code_rtf/r590-164.rtf.
Dr. McDonald has just recently been named the Director of the Lister Hill Center at the National Library of Medicine.
As reported by Dr. Overhage, an aggregation of data from different emergency rooms was use to detect a recent outbreak of gastro-intestinal illness caused by food-born bacteria.
Website: http://www.regenstrief.org/medinformatics/i3/clinical-care/docs4docs.
Website: http://www.tkgnet.com/conference/summer2005/presentations/Clem_McDonald.pdf.