Achieving Meaningful Use: Transitions in Care

1. Achieving Meaningful Use: Transitions in Care Session 9 April 13, 2011

2. Agenda • Introduction • Overview of how Direct can be used to meet MU and State HIE Program requirements to exchange transitions of care documents • Panelists • Gary Christensen, CIO/COO, Rhode Island Quality Institute • Holly Miller, MD, MBA, FHIMSS, Chief Medical Officer, MedAllies Inc. • Q&A • Poll

3. Meaningful Use Requirements

4. State HIE Program Responsibilities The Program Information Notice to State HIE grantees (dated July 6, 2010) outlined key responsibilities that states and SDEs must address in 2011, specifically to address and enable three priority areas: e-prescribing, receipt of structured lab results, and sharing patient care summaries across unaffiliated organizations.

5. Why Direct for Transitions of Care? • MU-compliant. Direct use cases tied to MU priority areas, including patient care summaries. • Standardized. Direct provides a standardized transport mechanism for patient care summaries. • Simple. Simplicity helps adoption among low volume practices and small, independent providers. • Scalable. Direct can be utilized beyond 2011 in meeting future stages of meaningful use requirements and other business goals.

6. Provider Sends Patient Care Summaries to Specialist and Back Specialist HISP PCP Perspective: Primary care provider refers patient to specialist including summary of care record.Context: The provider has made the determination that it is clinically and legally appropriate to send the summary of care record to the specialist. Workflow Steps: Primary care provider refers patient to specialist including summary care record a. Physician interacts with EHR to create information packet for delivery across Directb. Information packet crosses Direct Project to specialist physician’s EHR Specialist sends summary care information back to referring provider through same workflow steps

7. Hospital Sends Discharge Information to Referring Provider Hospital PCP HISP Perspective: Primary care provider refers patient to specialist including summary of care record.Context: Hospital has completed care and is preparing to discharge patient Workflow Steps: At the time of hospital admission in the EHR, the PCP of record is verified with the patient Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information package to be transferred to the PCP of record within the Hospital EHR system Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g. medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.) When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions and medications with patient

8. Rhode Island Quality Institute Presentation

9. Rhode Island Direct Pilot – Objectives • Demonstrate the feasibility of levering Direct Project specifications as a vehicle for feeding clinical information from practice-based EHRs to the statewide HIE, currentcare • Demonstrate Direct Project User Stories: • Case 1: Primary care provider refers patient to specialist including summary care record • Case 2: Specialist sends summary care information back to referring provider

10. Rhode Island Direct Pilot – Summary • RIQI worked with EHR vendors, targeted practices, and Beacon practices to: • Integrate Direct reference code (one line) into EHR platforms • Trigger the automatic creation of a Direct message (through the reference code), the generation of a CCD and attachment to the message, and sending it to an HIE Direct mailbox • Connect targeted, participation practices that use this interoperability model (through Direct) to the Statewide HIE as a Data Sharing Partner for currentcare • Lever native Direct messaging as a means to improve PCP/Specialist coordination of care

11. Hospital Sends Discharge Information to Referring Provider Hospital PCP HISP Perspective: Primary care provider refers patient to specialist including summary of care record.Context: Hospital has completed care and is preparing to discharge patient Workflow Steps: At the time of hospital admission in the EHR, the PCP of record is verified with the patient Provider entering an order for patient’s discharge from the hospital prompts the creation of a discharge information package to be transferred to the PCP of record within the Hospital EHR system Discharging provider includes all necessary/relevant information in the Discharge information packet (e.g. medications at discharge, discharge instructions, allergies, imaging reports, relevant labs etc.) When patient is logged-out of hospital system, system is triggered to send this packet to patient’s referring provider Referring provider will receive prompts, upload the packet, schedule a follow-up, and review discharge instructions and medications with patient

12. Wouldn’t it be great if….

13. Exchange of Health Information from EHR (EHR to HIE ): Easy as 1

14. Beacon Intervention: Provider Notification

15. Beacon Intervention: Quality Reporting

16. Easy Exchange of Health Information from EHRs (Doc to Doc): Easy as 1,2,3

17. MedAllies Presentation

18. MedAllies Direct Pilot Objectives • Overview: Enhance patient care and safety across transition of care settings (hospital d/c and “closed-loop” consultation) by providing the real time transfer of pertinent clinical information across disparate EHRs in a fashion that is consistent with existing clinical workflows • Clinician adoption • Secure, fast, inexpensive and interoperable • Support small practices, large integrated delivery systems, and everything in between • Support advanced primary care and accountable care models

19. Hudson Valley – New York StateParticipants • HISP • MedAllies • Healthcare Organizations • Hospitals: Albany Medical Center, Health Quest Systems • Primary Care: Albany Medical Center, Community Care Physicians, Health Quest Systems, Institute for Family Health, Scarsdale Medical Group, • Specialists: Albany Medical Center, Asthma and Allergy Associates of Westchester • EHR Vendors • Hospital: Siemens, Cerner • Primary Care: Allscripts, Epic, NextGen, eClinicalWorks • Specialists: Allscripts, Greenway

20. Hudson Valley – New York State Hospital Discharge to PCP

21. Hudson Valley – New York State Closed Loop Referral (PCP to Specialist & Back)

22. MedAllies Direct Summary • Speed/difficulty of implementation • Two tracks: Technical and Clinical • Coordinated to deploy a technically excellent solution that included extensive clinical participation and insight in the design • Technical track focused on harmonizing the implementation of Direct messages and a common payload • Clinical track focused on leveraging existing inpatient and ambulatory EHR workflows to incorporate Direct transactions • Ease/difficulty of ongoing utilization • Training • Minimal • Project focused on integrating Direct messages into existing EHR clinical workflows and preserving the practice-specific roles and responsibilities of the end users at each provider organization • Ongoing utilization will require minimal additional training consistent with training for EHR upgrades

23. MedAllies Direct Summary • Speed/Latency • All of the Direct message exchanges in the MedAllies’ Direct pilot occur in real time • Speed of transactions is latency between the MedAllies’ data center and EHR locations - measured between 5 and 10 seconds • Data arrives to recipient prior to patient leaving last clinical area • Workflow and Clinical Adoption • Use cases used most common transfer of care events where patient at risk • Clinical adoption key measure of project success • Providers would only use the system if it were consistent with their established clinical workflows • Need for messages to be pushed to the providers within their EHR systems • “This is the Holy Grail of medicine.” • Dr. Ferdinand Venditti, the vice dean for clinical affairs at Albany Medical Center and a practicing cardiologist

24. Provider Testimonials • Applicability of the Direct integration for the closed loop referral use case: • “We struggle with the process of getting information to a consultant and getting it back. Being able to link and do it from inside our system is ideal. This is exactly what we would hope for in terms of being connected.” • Kenneth Croen, MD, Scarsdale Medical Group, LLC   • Impact on current clinical workflow: • (The Direct approach) “definitely mimics our workflow, but in a much more effective way, where we are much more likely to get the results from the consults and the information we are looking for.” • Sarah Nosal, MD, Institute for Family Health • Preferred mechanism for clinical messaging with respect to Meaningful Use:  • “An HIE, where you have data posted, is a circumstance where an unknown patient presents and you want to see what information is out there on this patient. The ED is the ideal circumstance for that use case. A patient shows up, they are complaining of belly pain. You want to pull the universe of data out there that might help you decide what is going on. Versus a very pointed direct exchange between two clinicians, which is what we are talking about here.” • Fred Venditti, MD, Albany Medical Center • Privacy – security:   • Direct approach “is one to one, physician to physician. There may be opportunities to share data that may be more restricted in an HIE.” • Patricia Hale, MD, Albany Medical Center 

25. Real Word Lessons – Enabling Transitions of Care with Direct • Standards • Process • Anticipate • Communicate • Partnership • “Eyes on the Prize”

26. Additional Resources

27. Using S&I Initiatives to Meet Meaningful Use • S&I Transitions of Care Initiative • Will focus on supporting all transitions of care with a common modular set of data that can be used both in a document context and to inform downstream clinical decisions (med rec, updating problem, allergy lists, decision support, etc.) • The S&I Framework will develop: • Use Cases and Requirements • Vocabulary • The communication/expression of specifications in CCR and CDA • Harmonization • Document differences in C83 and CCR

28. Additional Resources • Transitions of Care work plan should be completed in July 2011 • State HIE Program Website • http://statehieresources.org/hie-priorities/ • S&I Framework, Transitions of Care Initiative • http://jira.siframework.org/wiki/display/SIF/Transition+of+Care+%28ToC%29+Initiative • Direct Project Wiki • http://wiki.directproject.org/ • State HIE Program Website • http://statehieresources.org/hie-priorities/

29. Q&A

30. Poll