U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
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This report was prepared under contract #HHS-100-03-0028 between U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of Colorado. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.
The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
The Division of Health Care Policy and Research is an inter-disciplinary research organization based in the Department of Medicine at the University of Colorado at Denver and Health Sciences Center. The mission of the Division of Health Care Policy and Research is to improve health care services, organization, and policy through research and education. Division faculty conduct health services and health policy research in a range of areas, including: quality of care assessment, assurance, and improvement; Medicare reimbursement and regulations; clinical and system interventions aimed at improving nursing home care, home health care, transitions across sites of care, and end-of-life care; managed care alternatives; telemedicine and health informatics; cognition and behavior; and cross-cultural research to assess interventions aimed at improving health care services to ethnic minorities. Ms. Bennett, Ms. May, and Dr. Coleman are the contributors from the University.
Many of the world’s major standard health care terminologies are maintained with software developed by Apelon. Enterprise deployment of these and other terminologies is supported by an Apelon-built vocabulary server that is now open source. Users of this server include health care providers, government agencies, and biomedical research enterprises. Apelon’s TermWorks software is an inexpensive tool that adds functions to Microsoft Excel so that, connected over the web, a term or a column of terms in a spreadsheet can be matched and mapped using the tools and databases not previously widely available.
Apelon employees have been involved with many of the past decade’s significant terminology-related projects and continue an active consulting practice. The company also provides subscription content services to assist users of open-source vocabulary tools in handling updates and new releases of standard terminologies. Current development efforts include a web-based Wiki-model tool (and corresponding submission system) aimed at broadening participation in terminology development. Mr. Tuttle was a member of the site visit team and contributor to this report.
We would like to thank the health settings that participated in the site visits and allowed us to gather information on how they exchange data within and among their provider settings. We also are grateful to the experts in electronic health record systems and data exchange who provided advice on the initial design of the project and recommendations for next steps. Finally, we would like to thank our ASPE Project Officer, Ms. Jennie Harvell, MEd, for her commitment to and valued guidance throughout the project.
The study, entitled "Health Information Exchange in Post-Acute and Long-Term Care," was sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS), and conducted from September 30, 2005 through October 15, 2007. The purpose of the study was fourfold: (1) describe the current status of the use of health information technology (HIT) in existing state-of-the-art health delivery systems (HDSs) and how health information is or is not exchanged with "unaffiliated"1 post-acute care (PAC) and long-term care (LTC) providers and other components of the health care delivery continuum (e.g., physician offices, laboratories, pharmacies, and hospitals) that use HIT; (2) identify the factors that support or deter the timely exchange of needed health information to and from unaffiliated PAC and LTC providers and other components of the health care delivery continuum that use HIT; (3) identify ways in which policy makers can encourage information exchange by HDSs that use HIT with unaffiliated PAC/LTC providers; and (4) summarize and organize information learned and describe the next steps that could be pursued to extend HIT into PAC/LTC.
The study was divided into three phases. The first phase included a review the literature. The second phase involved speaking with stakeholders and national experts in the area of health information exchange (HIE). The third phase built upon these first two phases by conducting four site visits with exemplar health systems to obtain more detailed information to address the stated study objectives. Based on national reputation and willingness to host a site visit, four "hub sites" were selected. The study team then identified both affiliated and unaffiliated providers (i.e., "spoke sites") in each of these geographic areas that received patient referrals from the hub sites. As the four hub sites were not selected at random, the findings and recommendations of this study are limited and may not be representative of all PAC and LTC settings in the United States.
There is increasing recognition in both the public and private sectors that significant improvements in health care quality, continuity of care, and efficiency of care may be realized through implementation of HIT. The ability to share health data between and among health care providers is critical to providing high-quality, cost-effective, informed health care. The ability of health providers to act on timely information improves workflow efficiencies and may save lives. A paper medical record does not allow for such efficiencies to be fully realized; yet at this time, the vast majority of PAC and LTC providers (and other health care settings, also) still use a paper medical record for the authoritative record.
In acknowledgement of the increasing importance of HIT implementation, a number of initiatives have followed the April 2004 Presidential Executive Order 13335. This Executive Order recognizes the need for the development and nationwide implementation of an interoperable HIT infrastructure and established the position of the National Coordinator for Health Information Technology (NCHIT) in the HHS to provide leadership for this effort. Shortly thereafter, the Office of the National Coordinator for HIT released a report, "The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care" (Office for the NCHIT, 2004) that outlines a framework for realizing the goal that most Americans have an interoperable electronic health record (EHR) by 2014.
A previous study also conducted by the University of Colorado at Denver and Health Sciences Center (UCDHSC), entitled "Electronic Health Records in Post-Acute and Long-Term Care" found that health information shared across health settings (e.g., acute care hospitals, physician offices, nursing homes [NHs], home health agencies [HHAs], laboratories, and pharmacies) was inadequate to support high-quality patient care. When information was shared, it often was shared only with "affiliated"2 providers. The authors sought to understand if this trend had shifted in the three years since that study had concluded. This current study built upon those findings and posed additional questions: How is information shared across and between health care provider settings? Is information shared differently when shared with affiliated versus unaffiliated settings? Does involvement in a health information exchange network (HIEN) (e.g., a regional health information organization [RHIO]) make a difference in the types of or amount of data shared across health settings?
Four leading edge sites were chosen as "hub sites" for visitation based on the fact that each provider site: (a) was using a relatively robust electronic health information system; and (b) collaborated with a number of affiliated and unaffiliated PAC and/or LTC settings that treat their patients. Three of the four settings also were involved in some type of RHIO/HIEN.
The four hub sites were: Erickson Retirement Communities (Catonsville, Maryland), Montefiore Medical Center (Bronx, New York), Intermountain Health Care (IHC), specifically LDS Hospital (Salt Lake City, Utah), and the Regenstrief Institute/Indiana Health Information Exchange (IHIE) (Indianapolis, Indiana). Each hub site has earned the reputation for being a leader in promoting HIE, has strong ties to the community, strong local leadership, and an organizational and cultural commitment to enhancing quality of care and increasing efficiencies.
Each site visit was comprised of multiple components. On the first day, the site visit team visited a hub HDS (one was a continuous care retirement community (CCRC), two were acute care hospitals, and one was an academic health center). The second and third days of the site visits were spent visiting three or more LTC or PAC settings3 that receive referrals from the hub site. When possible the site visit team visited both affiliated (i.e., owned) and unaffiliated settings. In some cases, names of PAC/LTC settings were obtained from the hub site contact and in other cases the project team independently approached the PAC/LTC settings and requested their participation in the study.
Although there were geographic, socioeconomic, and organizational/structural differences at the four sites, a number of common themes emerged, which are highlighted below.
1. Limited Health Information Technology Adoption in PAC/LTC Settings
In general, the site visits revealed limited adoption of HIT in PAC and LTC settings. This finding is consistent with two studies on HIT adoption in PAC/LTC settings. A 2005 study by Kaushal and colleagues (Kaushal et al., 2005a; Kaushal et al., 2005b; Poon et al., 2006) estimated EHR adoption in 2005 for NHs to be 1% and less than 1% for HHAs. The authors projected that HIT adoption in five years will not increase much for either health sector (14% for NHs, and <1% for HHAs). The other study included a survey that was conducted by the American Health Care Association (AHCA) and the National Center for Assisted Living. Two of the key findings were: (1) paper continues to be the primary communication mechanism in NHs and assisted living facilities (ALFs); and (2) while respondents to this survey express that they are beginning to adopt more HIT, in three years, it is projected that these two settings will still be in the early stages of transitioning to HIT (American Health Care Association, 2006).
Because the project objectives included looking at state-of-the-art delivery systems, the majority of PAC/LTC sites visited were early adopters of HIT in some capacity. However, with a few exceptions, HIT use was generally limited, was not standards-based, and typically did not include data exchange capabilities. The visited PAC/LTC providers used information technology applications that met rudimentary regulatory requirements and billing needs, and were observed to be using HIT applications for some intra-facility functions. However, the use of HIT by PAC/LTC for HIE with other organizations (e.g., hospitals) was observed rarely. In some cases, there was no EHR used, nor were there future plans to implement HIT.
2. Poised for Interoperability
The Presidential Executive Order of August 2006 defines interoperability as "the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered" (Federal Register, 2006). At one hospital visited, a representative declared that health care enterprises in his region were "poised for interoperability." The same observation could be made at another hospital visited, and represented an important shift from only a few years earlier when interoperability was not of paramount concern. Although no site presented a schedule for achieving complete interoperability across all settings, each hospital had plans in place for some degree of data exchange outside of its enterprise. Moreover, each expressed some intent to include nearby LTC sites in those plans. The study team found that one of the biggest drivers for health data exchange was a desire to support "anytime/anywhere" access by physicians and other providers who practiced in multiple care settings. Care providers who had such access then wanted to be able to include information from the "remote" or referring system into the "local" or receiving system. Anytime/anywhere access often was supported by dial up connections, and, increasingly, by web interfaces. However, "electronic population" of the local or host system with information from a remote system was rare. Not surprisingly, once providers began having remote access in one care setting, they also wanted access in other care settings. However, staff at the various sites expressed various formidable challenges when they attempted to populate local or host electronic medical records (EMRs) with remote information.
The phrase "data exchange" was typically interpreted by the sites to mean the display of patient information on a local computer that originated from a computer at a remote, unaffiliated care site. Although it is implied that this involves a two-way data exchange method, more often than not, it was simply a one-way transaction.
Two clinical scenarios stood out for their ability to illustrate the demand for HIE and the inherent challenges: the transfer of patients from hospital to PAC or LTC settings, and the transfer of NH residents to the emergency department (ED). Care providers in NHs that receive patients from hospitals, and in EDs that receive patients from NHs want to know certain details about the patient's current status and medical history and they are willing to take the time to read this information on a computer screen if the information is current and trusted. The notion that, for example, the receiving provider's EHR would be able to represent information about the patient in a way that could feed into a decision support feature and influence the care plan was described as a goal by some sites, but not one that was expected to be achieved any time soon.
The three phases of this study helped inform a proposed framework for HIE that is illustrated in Table ES-1. One can think of these different kinds of data exchange arranged on a continuum or spectrum; at one end of the spectrum the phrase "data exchange" implies that computers can act as the informational equivalent of fax machines only; at the other end of the continuum, "data exchange" implies that information received by a computer can be used in the same way as information entered locally. An example of the latter would be an ability to import a medication list that had been reconciled in the hospital and represented in its EMR into an outpatient EMR that facilitated the local computer to analyze the synthesized list for drug-to-drug and drug-to-disease interactions.4
| TABLE ES-1: Levels of Health Information Exchange |
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Table ES-2 expands upon the Table ES-1 framework by proposing specific features for each level to suggest a progression from less to more sophistication of HIE. This table was constructed based on the literature review as well as the study team’s observations concerning HIE and use of EHRs across the sites selected for the study. Although none of the settings observed have reached Level 4 (i.e., completely interoperable EHR systems, using standards-based applications to share information with affiliated and non-affiliated providers), it is included as the purported “future goal.”
3. Data Exchange among Health Settings, Particularly Post-Acute and Long-Term Care
At every NH and HHA visited, the potential benefit from engaging in activities with external parties to support and increase HIE was observed. At Erickson, the local and national information technology staff are prepared to subsidize the implementation of HIE standards if such standards are available in the near future. In each of the other three visited locations, PAC and LTC enterprises are in a position to benefit from HIE efforts originating outside of their organizations. Although PAC and LTC sites are not leading HIE efforts and are not directly involved as collaborators; they will benefit nonetheless. As all PAC and LTC sites had some Internet connectivity and some local information technology systems (even if only to meet administrative data reporting requirements), the barriers to sending and receiving electronic patient information are lower than once observed. However, because the perceived and actual barriers to the simultaneous re-use of patient information remain high, driven by factors that include implementation and maintenance costs, mistrust of the data, a fear of litigation, and Health Insurance Portability and Accountability Act (HIPAA) and other privacy concerns, such interoperation is not yet in sight for any enterprise visited. Nevertheless, once human-readable electronic exchange is in place, the incentives for the automatic population of local systems from remote systems with computer-readable electronic health information will become more clear and measurable. For example, it will be easy to assess the amount of time, and therefore the cost, required to manually re-enter information in a local system that exists in electronic form elsewhere. In this sense, the fact that hospital is "poised for interoperability" will help expedite the incremental deployment of HIE at collaborating PAC and LTC sites.
a. Workflow. The four site visits reinforced the central role that workflow issues play in HIE. Information technology is a cross-cutting issue, an observation that permeated the site visit discussions at many levels. In general, relatively highly-paid professionals in hospitals, PAC, and LTC settings are expending a significant proportion of their time on clerical tasks rather than attending to patients' clinical needs. EHRs did not necessarily provide solutions to this inefficiency. Because of the lack of interoperable EHRs, it was common for sites to report that nurses and physicians read from a computer screen or print out a patient's health data from one electronic health application only to manually enter the information into another electronic health application (such as an EHR). Respondents described manually re-entering laboratory results received electronically into their own EHR system, because the two electronic systems did not have the capabilities of exchanging data. In most cases, the clinicians were not consciously aware of the amount of effort that was being expended. Rather, they had long accepted these tasks as inevitable.
Further probing revealed that manual data re-entry from one system or medium to another may add value in terms of improving quality and safety. For example, the process of printing the medication list from one electronic source and then manually entering into an EMR provided an opportunity for greater scrutiny than what would have been made had the medications been reviewed on a single computer screen. During these discussions, clinicians acknowledged that this manual re-entry activity was not simply a clerical process but rather something that provided an opportunity to cognitively assess whether the medications were in fact appropriate, whether any additional diagnostic testing was required, and whether the patient might be at risk for an adverse drug reaction. Alternatively, this process has the potential to introduce new errors due to transcribing errors (Brody, 2007). Thus, it remains to be determined how these vital tasks will be accomplished once more advanced (e.g., interoperable, standards-based) electronic solutions are forthcoming.
b. Majority of data sharing to and from PAC/LTC is done manually. Independent of the degree of EHR capability in place at the hub sites, the exchange of data between these hubs and affiliated and unaffiliated PAC/LTC settings is largely conducted manually (phone, fax, paper records that are mailed or accompanies the patient at the time of transfer). This information either is filed in a paper record and/or transcribed into the PAC/LTC setting's EHR. Phone, fax, and paper records continue to be used for patient referrals, discharge, and transfer documentation. Although some implementation efforts were underway, the study team did not witness any electronic transmission of data from PAC/LTC settings directly into the hospital's EHR systems.
| TABLE ES-2: Illustrative Examples of HIE Capabilities by Level | ||||||||
|---|---|---|---|---|---|---|---|---|
| Level 1 Paper-based Record/ No EHR |
Level 2 Combined Paper Record/EHR |
Level 3 EHR Used/Limited Electronic Data Exchange, Some HIT Standards Used |
Level 4 Completely Interoperable EHR System, Use of HIT Standards |
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| HIE Methods |
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| Features/Attributes of Patient Health Information and Electronic HIE1 | No Electronic HIE (i.e., not electronic data) | No EHR | Some e-HIE | Limited use of EHR | Data exchange limited to certain systems | Access to data limited to user role/ discipline | EHR is primary record | Standards-based EHR system (i.e., EHR content is standardized) |
| May have software for AR/AP, scheduling | No Anytime/ Anywhere Access | May allow for images to be imported | Clinical information collected on paper & entered into EHR | Continued but limited use of paper record | Some use of standards (messaging &/or content) | Interoperable with internal & external systems | Record can be electronically exchanged/ is transportable | |
| Meets minimum regulatory requirements2 | Limited Anytime/ Anywhere Access | Decision support features & alerts used | Anytime/ Anywhere Access | Computer Empowered Interoperable System | Anytime/ Anywhere Access | |||
| Facilitators of HIE | Limited involved in HIE Network (e.g., admin/claims data) | Some clinical content exchanged within HIE Network | Greater amount clinical information exchanged/shared within HIE Network | |||||
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c. Importance of personal relationships in referrals. Although HIT can and will expedite referrals from one setting to the next; it was observed that today, personal relationships superseded any technological advancement in place. In other words, the "human element" is well engrained into the process of data exchange. One observation that crystallized this point was hearing that despite implementation and acceptance of an electronic mechanism to facilitate post-hospital patient placement in skilled nursing facilities (SNFs), discharge planners often finalized these arrangements outside of this mechanism telephonically with admission coordinators with whom they had a personal relationship. They trusted these people more willingly than an "anonymous" source of data.
d. Lack of standards used. Two primary observations regarding adoption of standards-based HIT solutions in PAC/LTC were observed. Firstly, among those PAC/LTC providers that had purchased and implemented an EHR system, the use of standards as a vetting criterion for vendor selection was not considered. Respondents clarified that standards development and adoption are still in the early stages, which is why most of the systems used by the visited PAC/LTC settings did not use standardized terminologies, messaging standards, or documents for the electronic recording and exchange of health information. They would like to see greater consensus on some of the standards work before they invest the resources necessary to adopt/convert their systems. The other observation is that many PAC/LTC settings visited were unaware of the extent of activity in the standards development community, and therefore did not see the potential value of having a standards-based EHR system to facilitate HIE across health settings.
In other cases, the lack of standards was not synonymous with a lack of sophistication in EHR adoption. In fact, national health care leaders including the Regenstrief Institute, IHC, and the Visiting Nurse Service (VNS) of New York were early adoptors of HIT applications that support clinical care, and as a result they developed their own "homegrown" systems prior to the emphasis on using national standards. When asked if they were planning on adopting balloted, Consolidated Health Informatics (CHI)-endorsed standards, representatives from these early adopters indicated that it was financially prohibitive to reconfigure their systems.
e. Lack of financial incentives for HIE. The site visits did not reveal any real or perceived financial incentives for adopting HIT that supports HIE with outside entities. The initial outlays for hardware and software remain prohibitive, training costs can be quite high, particularly considering the historically high staff turnover in PAC/LTC, and ongoing maintenance costs may be difficult to justify when the short-term return on investment is unclear. Furthermore, the benefits of HIE do not necessarily accrue to the institution that makes the investment in hardware/software, including the time to input and maintain the information. These costs and uncertainties regarding the return on investment will likely be particularly problematic for small, independent PAC/LTC settings. The business case for the referring organization that would need to make the HIT investment remains underdeveloped.
A significant barrier to widespread electronic exchange of health information with PAC/LTC settings is that the majority of PAC/LTC providers and those health care organizations with which health information must be exchanged, have yet to implement EHR/HIT systems with the capacity to support interoperable HIE. It is not that leaders in those settings do not see the value in obtaining timely, accurate health data from a referring site (or providing it to other settings at discharge). It is possible that the functionality seems so far out of reach at this point, due to the lack of low-cost, reliable, well-supported hardware and software, and the lack of data available on the return on investment of adopting HIT, particularly in the PAC/LTC health sector. Thus, demonstration, dissemination, and education regarding the benefits of adopting an interoperable EHR system relative to the associated costs of not adopting these systems are imperative if providers and vendors are going to invest more heavily in EHRs for PAC and LTC.
The study team recommends that a thorough, targeted national survey of HIT adoption, use, and barriers to adoption in PAC/LTC should be conducted. There have been small-scale studies looking within a specific geographic region or market area (Continuing Care Leadership Coalition, 2006; Hudak & Sharkey, 2007), and the 2007 National Home and Hospice Care Survey includes, for the first time, questions on whether the responding HHA has an EMR, and if so, whether the HHA uses certain EMR functions or whether these functions are either not used or not available (personal communication with Jennie Harvell, ASPE Project Officer). Experts have convened and given their best impressions and projections for HIT readiness in all types of health sectors, including PAC and LTC (Kaushal et al., 2005a; Poon et al., 2006). However, to date, there has not been a scientifically-based, comprehensive survey on the specific types of HIT applications that are currently in use, or that are being considered for future implementation in NHs.
Continued development and adoption of standards-based work needs to take place. Recent developments are promising. For example, an important step forward is the recent letter from the Secretary of HHS to the National Committee on Vital and Health Statistics (NCVHS) that the CHI recommendations for HIT standards for the Functioning and Disability domains will be adopted for use in new federal health information systems and, to the extent possible, as existing health information systems are modified. Likewise, approval by Health Level Seven (HL7) and the Health Information Technology Standards Panel (HITSP) of the Continuity of Care Document (CCD) standard, a harmonized summary record standard is an important needed activity to facilitate interoperable data exchange across settings. These standards-based activities need to be built upon and expanded.
Related to the above point, PAC and LTC provider participation in standards development and encouragement of HIT adoption is paramount. The LTC provider and vendor communities were instrumental in the recent decision by the Certification Committee for Healthcare Information Technology (CCHIT) to include the certification of NH EHRs in its expanded scope of work. CCHIT certification can be a valuable asset for NH providers to reduce their risk when making costly HIT investments. Continued participation in standards development work is necessary to keep the LTC and PAC communities involved in the future directions that will evolve.
PAC and LTC settings' involvement in HIENs/RHIOs should be increased. Given the Federal Government's interest in moving the Nationwide Health Information Network (NHIN) to the next phase, it is clear that HIENs will be key players in that process. Education on the role that HIENs are playing in communities and encouragement of all setting types to get involved is important to ensuring their "voice" is heard in the design and development of HIE strategies.
The Federal Government and many state administrations see the broad implementation of HIT as an important lever by which to improve health care quality and safety, and reduce costs. Implementing HIT will support the exchange of data as patients move between health care settings, and such exchange will measurably decrease errors, enable more timely and productive clinical decisions, and allow for a more comprehensive patient-centric longitudinal electronic record (Coleman, May, Bennett, Dorr, & Harvell, 2007). To this end, hospitals and ambulatory settings are implementing EHRs that are increasingly compliant with national standards. However, adoption of HIT solutions in NHs and HHAs has lagged behind hospitals and ambulatory care settings.
This project set out to identify what information is exchanged between hospitals, physician offices, and ancillary health providers (such as laboratories and pharmacies), and NHs and HHAs. The project also asked how and whether HIT is being used to facilitate HIE with and between NHs and HHA providers. These questions were posed to several early adopters that have implemented HIT to support the exchange of health information as patients change care settings. In particular, this effort focused on whether there were any differences in the types, content, or format of data that were shared with affiliated as opposed to unaffiliated care settings. Further, the project asked whether HIE strategies employed by leading HDSs could be replicated elsewhere and what lessons were learned as implementers developed their information technology solution(s). Specifically, the project team sought to understand what worked and what did not work as expected at the sites visited. More generally, the team wanted to identify what facilitated and impeded both electronic and non-electronic HIE.
Ultimately, the answers to these key questions can provide information to health care leaders and policy makers on: (1) the patient health information that needs to be exchanged with NHs and HHAs; and (2) the use of HIT to support HIE. This knowledge may help to inform a national strategy to promote more widespread interoperability towards the ultimate objective of improving the quality of health care in this country.
The four goals of this project were to: (1) describe the current status of the use of HIT in state-of-the-art HDSs and how health information is or is not exchanged between "unaffiliated" PAC/LTC providers and other components of the health care delivery continuum (e.g., physician offices, laboratories, pharmacies, and hospitals) that use HIT; (2) identify the factors that support or deter the timely exchange of needed health information to and from unaffiliated PAC/LTC providers and other components of the health care delivery continuum that use HIT; (3) identify the policy levers that could be used to encourage information exchange by HDSs that use HIT with unaffiliated PAC/LTC providers; and (4) summarize and organize information learned and describe the next steps that could be pursued to extend electronic HIE (e-HIE) technologies into PAC/LTC.
All activities, which included a literature review, stakeholder interviews, site visits, and resultant case studies attempted to answer one or more of the following research questions:
In select health care delivery systems:
What type of health information is needed for summary documents of hospital stays, physician office visits, medication orders, and laboratory tests?
Within selected health care delivery networks, what clinical information is exchanged as part of the summaries of physician office visits and hospital stays, physician orders, and reports of test results?
What health information is exchanged between health care providers and unaffiliated PAC/LTC settings and what are the mechanisms used to exchange information?
What factors do PAC/LTC providers and representatives from the selected health care delivery systems identify as supporting or creating barriers to the timely exchange (in any form; i.e., electronic, fax, paper, etc.) of physician and hospital summaries, physician orders, and results reporting between HDSs and PAC/LTC providers?
The audience for this report is broad and varied, including federal and state officials, PAC and LTC providers, standards development organizations (SDOs), and potentially payors, vendors and other stakeholders interested in HIT. As such, the report is written with the expectation that the reader may have little knowledge of the current state of HIT development and the corresponding policies put forth and planned. Section II explains the methods used to select and recruit the participating sites for the case studies. Section III presents our findings and results, separated into major areas focusing on clinical and organizational/management of HIE and technical issues. The purpose of this division is to make it easier for readers to separate out these related, but different observations and findings from the site visits. Section IV presents our interpretation of the findings, as well as a discussion of possible next steps.
For the purposes of this study, a "health delivery system" (HDS) was defined as an entity that includes a hospital with one or more affiliated or owned physician office practice(s), outpatient clinic(s), laboratories, and/or pharmacies. The goal was to identify up to ten candidate HDSs, from which four would be selected for site visits.
The criteria used to select the HDSs was based on the type and scope of electronic health information creation, storage, and exchange believed to be implemented in the system; the anticipated level of effort required to gather data about the information exchange mechanisms at each system; and to the extent possible, how the HDS is representative of those around the country and/or provides an instructive contrast to the other sites selected.
More specifically, the following criteria were used to prioritize candidate sites. The HDS should: (1) have an electronic health information system that allows for the exchange of health information across two or more settings or providers (e.g., hospital and physician offices, laboratory, pharmacy, radiology), and preferably has documentation to explain the clinical/organizational and technical components and capabilities of the health information system; (2) refer patients to unaffiliated PAC and LTC settings (defined as SNFs, NHs, and HHAs) in the same general geographic location (unaffiliated, for the purposes of this screening was defined as not being owned by the HDS);5 (3) preferably have at least six months experience with the software application(s) that support information exchange; and (4) be amenable to a site visit by a three-person team of data collectors who would require access to a variety of staff (including clinicians, information technology specialists, and managers).
Although the criteria were established a priori, it was later recognized that provider arrangements often do not fall into neat categories of affiliated and unaffiliated. As noted above, in some cases, organizations may have a preferred provider relationship, although they are not officially affiliated. Rather, provider arrangements continue to evolve. For example, physicians with multiple affiliations have proven to be an impetus for data exchange across health settings. In fact, within many situations, physicians "follow" patients across settings muddying the waters as to what constitutes affiliated and unaffiliated relationships.
Because of the growing impact that RHIOs or HIENs are having in facilitating HIE, the criteria for selection also included sites with RHIO or HIEN involvement. The Healthcare Information and Management Systems Society (HIMSS) defines a RHIO as a group of organizations with a business stake in improving the quality, safety, and efficiency of (health) care delivery (Healthcare Informatics in collaboration with AHIMA and AMDIS, 2005). Because of the multiple issues (e.g., business, legal, legislative, technological, clinical, and cultural) involved in cross-organizational interoperable HIE, support for HIE organizations has become more attractive at both the state and federal levels. While grants are normally used for start-up and planning phases, recent surveys have indicated that additional funding sources for RHIO start-up and continuation is necessary (Healthcare Informatics in collaboration with AHIMA and AMDIS, 2005; HIMSS and the Center for Health Information and Decision Systems, 2006).
In response to this recognized need, federal programs have emphasized and increased the amount of funding for grants and demonstrations for RHIO and HIEN planning and implementation. Over 40 states are in some phase of planning, implementation, or have projects that are focused on HIE organizations (HIMSS and the Center for Health Information and Decision Systems, 2006).
As there are no "best practices" that a RHIO or HIEN can use to start itself, communities often have produced their own design, specific to their own needs, with funding or planned funding coming from a variety of sources, including hospitals; employers; physician groups; non-profit groups; insurers; local, state and Federal Government; user fees; financial incentives; and private investors. As such, involvement in collaboration with other area organizations was viewed as an important factor for inclusion in site selection.
The following list for potential site visits was created and reviewed by the project team and a group of leaders in the field of HIT identified by ASPE. Based on a review of the literature and recommendations from peers and grant-making organizations, 14 organizations were identified as being particularly innovative in the area of HIE. These sites did not ask to be considered, nor were they necessarily aware that their names had been put forth. Based on the criteria discussed above, the sites originally considered are listed in alphabetical order below:
Preliminary information was gathered by the research team through web searches and interviews with informants at each site. The expectation was that the team would gather enough information to determine if each site met the majority of the selection criteria and if they would be amenable to a site visit. This information was then shared with the ASPE Project Officer and together the project team and the ASPE Project Officer prioritized the list of candidates. The final list of sites was selected in January 2006. The approach was to first select the host site, and then determine if the main referral recipients from this site included three or more (affiliated or unaffiliated) PAC or LTC settings. The exception to this approach was Erickson Retirement Communities. Erickson is a CCRC and provides the spectrum of health care to the elderly, with the exception of hospital and hospice care. Therefore, for this site visit, we asked Erickson to provide us with names of hospitals and any community PAC or LTC settings that may serve Erickson residents.
The following four host sites were selected for site visits based on the preliminary background information obtained. More in-depth information was obtained later in the project as the site visit details were confirmed, as well as during the site visit. Specifics can be found for each site visit in Appendices B through E, and are in the order in which the site visits were conducted.
Erickson Retirement Communities
(Site Visit Dates: July
12-14, 2006)
Erickson Retirement Communities, Catonsville, Maryland, owns and operates 13 CCRCs in the United States. Four of their communities are considered "mature campuses" aimed at providing "total care" for retired individuals. One of the mature sites, the Catonsville campus includes a medical center that acts much like a physician's office for Erickson residents, a Medicare-certified HHA, inpatient and outpatient rehabilitation services, a SNF, and an ALF (personal communication with Daniel Wilt, Vice President Information Technology, March 23, 2006). Erickson employs certain medical specialists (e.g., podiatry, dentistry) and allows other independent clinicians to treat patients on campus. However, it does not own or operate most specialty clinics and does not own or operate any acute care centers. Three additional CCRCs are under construction and Erickson plans to establish additional communities throughout the country. Because Erickson's information technology approach is highly centralized--all campuses' EHRs are run out of the central office in Maryland and accessed using high speed network connections--they believe that their per site information technology costs will be reduced as they implement EHRs in new locations.
Erickson uses one EHR (GE Centricity) at the medical center on campus, and another (HealthMEDX) for the SNF (Renaissance Gardens) and the HHA. One forward-thinking, patient-centric advancement made by the information technology team at Erickson is the development of an electronic chart summary, which is generated from their EMR and can be accessed via the web or at any of their facilities' workstations. The chart summary includes, but is not limited to, relevant current and historical clinical information such as advanced directives, medication lists, laboratory results, problem lists, and contact information for patients and caregivers. Care coordination is facilitated as physicians electronically access this information on or off campus and communicate pertinent data in a timely manner to the ED physician when a patient requires acute care. In November 2005, Erickson launched a website6 providing residents access to their medial records for no additional cost. This and other online health information services are discussed in greater detail in Section III.G below.
At the time of the site visit, Erickson was not involved in a HIE organization in their area/region, although it is their desire to do so. They have initiated preliminary discussions with providers in their region on this topic.
Unaffiliated HDSs and PAC/LTC sites: St. Agnes Hospital and Hospice, Johns Hopkins Home Health Agency.
Erickson PAC/LTC sites: Renaissance Gardens (SNF and LTC NH), Erickson's on-campus HHA.
Montefiore Medical Center
(Site Visit Dates: August 2-4,
2006)
Montefiore Medical Center (Montefiore) is an integrated HDS in Bronx, New York, providing a full range of services, including specialty care to Bronx residents as well as patients outside of this borough. Montefiore serves a medically underserved population, a large number of whom are young, minority, and poor (Greg Burke, Vice President of Planning, Montefiore Medical Center, presentation slides from November 2004). The Montefiore HDS includes an acute care hospital (Montefiore Medical Center), a large HHA, and contracts with a number of SNFs in the area. Montefiore uses IDX's LastWord in both the inpatient setting as well as for ambulatory care at 28 sites. 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. Montefiore also is one of several acute care hospitals involved in the creation of the non-profit entity called the Bronx Regional Health Information Organization (BxRHIO). At the time of this report, the other collaborators in the BxRHIO include several hospitals, over 40 community-based primary care centers, one NH, two HHAs, payors, physician offices, and laboratories. A month prior to our August 2006 site visit, Montefiore was awarded $4.1 million from the New York Department of Health for seed money (called HEAL-NY) to commence 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, Vice President of Planning, Montefiore Medical Center).
Unaffiliated PAC/LTC sites: Schervier Nursing Care Center (SNF), the VNS of New York (HHA), the Jewish Home and Hospital (SNF).
Affiliated PAC/LTC site: Montefiore Home Health Agency.
Intermountain Health Care
(Site Visit Dates: August 9-11,
2006)
IHC is a non-profit health care system that provides care to residents of Utah and Idaho. This institution is one of the pioneers in HIT, with a long history of excellence in the area of quality improvement. Homer Warner, MD; Stanley Huff, MD; and others at IHC were among the first users and developers of EHR systems. LDS Hospital, one of IHC's hospitals in Salt Lake City was visited. Intermountain provides over 60% of the acute care market in Salt Lake City and has more than 27,000 employees enterprise-wide. LDS Hospital alone has 4,700 employees. Intermountain employs 550 physicians and has another 3,000 affiliated physicians with limited (read-only) access privileges to the electronic health information system (HELP system). Intermountain also has 92 clinics. According to one source, 17,000 people can access (with varying levels of permission) the Clinical Data Repository that is part of the HELP2 system.7 LDS Hospital 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, initially, the common goal of reducing costs by standardizing the transmission of administrative data, particularly payment data. The network community sets the data standards, using recognized national standards (e.g., HL7 messaging and NCPDP standards), to which providers and payors voluntarily agree to adhere. The UHIN standards are then incorporated into the Utah state rule regarding payment of health care via the Insurance Commissioners Office (UHIN, 2007).
UHIN operates as a centralized secure network through which the majority of health care administrative transactions pass statewide. Nearly all Utah 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 sized provider can submit claims and electronically receive remittance advices.8 State officials indicate that the exchange of standardized electronic transactions 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 Agency for Healthcare Research and Quality (AHRQ) grant, UHIN is pilot testing the electronic exchange of a limited set of administrative and clinical data (medication history, discharge summaries, history and physicals, and laboratory results with a small number of providers). This pilot involves the exchange of information form payer to hospital only, no PAC or LTC providers are in the pilot. The results of this pilot study are not yet available, but the UHIN developers note informally that health care providers involved in the UHIN are beginning to request and require these clinical and administrative data. For example, UHIN developers are noticing an increase in feature requests from users (e.g., setting a statewide standard for credentialing physicians, account reconciliation). Because of the adoption of emerging technologies such as messaging and web-based connectivity (in place of earlier less nimble, less scalable, and more expensive technologies), UHIN's ability to fulfill those requests is keeping pace (personal conversation with Jan Root, Standards Manager, UHIN.
Unaffiliated PAC/LTC sites: Christus St. Joseph Villa (SNF), Community Nursing Service (CNS) (HHA), Hillside Rehabilitation (SNF), and CareSource (HHA and Hospice).
Affiliated PAC/LTC sites: IHC does not own any PAC or LTC facilities.
Indiana Health Information Exchange
(Site Visit Dates:
September 13-15, 2006)
The IHIE is a non-profit venture connecting a number of HDSs in Indiana. The IHIE, led by Dr. J. Marc Overhage, 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,9 regional and local hospitals, and the Regenstrief Institute, the IHIE recently implemented a community-wide clinical messaging project to support e-HIE between physicians and hospitals. Each participating partner has access to a limited amount of patients' clinical results using a single IHIE-controlled electronic mailbox called Docs4Docs (discussed in detail in Section III.G.6 of this report).
The IHIE was a health care market member in one of the four consortia10 awarded a HHS contract in 2006 requiring the development of four prototypes for a NHIN architecture. All three health care market members within the Computer Science Corporation (CSC) consortia (IHIE, MA-SHARE [Massachusetts], and Mendocino HRE [California]) helped to develop, test, and demonstrate a prototype, based on common, open standards. Of particular interest for this project, required components for all four prototypes: (1) were designed to facilitate HIE using the Internet, not creating a new network; (2) allowed for communication to occur between many different types of EHR systems; and (3) allowed for different types of software and hardware that could be included in the system. As stipulated by HHS, the prototype architectures were submitted to HHS in January 2007 and on February 14, 2007, CSC announced their success with exchanging health information through their NHIN prototype. Health data were securely transferred between MA-SHARE, the IHIE, and the Mendocino Health Records Exchange, as well as local public health departments within those regions (CSC, 2007).
Unaffiliated PAC/LTC sites: Beverly Enterprises at Brookview (HHA), VNS of Central Indiana, Briarwood Rehabilitation, Kindred Long-Term Acute Care Hospital.
Affiliated sites: Lockefield Village Rehabilitation and Healthcare Center (SNF), Wishard Health Services (Hospital).
A case study plan was developed and submitted to the ASPE Project Officer in June 2006, outlining the plan for how the site visits would be conducted (see Appendix A for the complete report).
The site visit team asked for assistance from each selected HDS in identifying which LTC/PAC agencies/facilities received their referrals, and also asked the HDS to provide contact information for these referral sites. The recommendations received from the host HDS were supplemented with additional PAC/LTC settings11 that were identified based on national reputation, ASPE Project Officer suggestion, and referral from industry associations (e.g., National Association for Home Care [NAHC], American Association of Homes and Services for the Aging [AAHSA], AHCA) and RHIOs.
Each of the four site visits consisted of multiple locations, which meant coordinating the review of four to five different providers at their separate locations. The site visit team visited an acute care hospital; three or more HHAs, NHs, or SNFs; and often another setting (e.g., a long-term acute care hospital or hospice). Coordination between the UCDHSC Project Director and leaders at each of the four respective sites was crucial for ensuring successful visits.
To ensure that salient information was collected at each site while not constraining the site visit team to a single set of questions, discussion guides were purposely designed to be flexible and solicit open-ended responses. The site visit team used a variety of data collection methods to collect information. A "General Information about your Health Care Setting" form was submitted to all sites prior to the site visit. Using this form, we collected background information such as ownership, number of employees, EHR system used, etc. During the visits, site visit team members used in-person observation and formal and informal conversations, and questions and responses using the discussion guides created for this project. A set of the discussion guides and the general information form noted above can be found in the Case Study Plan in Appendix A.
Common themes and trends emerged as the data were collected and analyzed during the site visits. The site visit team sought to answer certain pre-determined questions at each site, and then observed and collected information on any actual (or potential) data exchange activities. The following narrative in Section III is a synopsis of these themes, which are largely a series of anecdotes. Specific details from each site visit can be found in Appendices B-E.
The four site visits resulted in the findings illustrated in this section. Using all the data collected both prior to the four site visits and during each three-day visit, a compendium of findings for each site was created. Section A reviews the project objectives and background and Section B focuses on the clinical information exchange across the affiliated and non-affiliated PAC and LTC providers. Areas of HIE commonality are explored in Section C, Section D highlights solutions and future plans, and Section E discusses facilitators and barriers to HIE. The organizational and management issues related to HIT adoption are discussed in Section F, and Section G puts forth specific technological issues and observations made during the site visits.
As noted in Section I, in addition to reporting on the current status of the use of HIT, one of the specific objectives of the visits was to identify the information needed at times of transition, determine how these data were (or were not) exchanged across care settings, and to identify barriers/facilitators to the exchange of data. Project objectives also included investigation of the method by which data are exchanged (electronically and not electronically) and the extent that data are exchanged between physician offices, laboratories, and pharmacies and PAC and LTC facilities.
The sites were not randomly selected, but rather were chosen based on criteria noted in Section II. The findings, therefore, are not necessarily representative for all settings, nor are the sites' HIT solutions replicable without taking into account the nuances of each site (e.g., size of the city, other competitors in the area, involvement of one or more "champions").
All four sites are located in medium to large metropolitan areas. Each site visit had a host or "hub" site and then three or more "spoke" sites. Three of the four host sites had an acute care hospital as the hub site, while the fourth (Erickson in Maryland) had a CCRC as the hub site. Three of the four had HIE organizations in various stages of development (Utah, Indiana, and New York). The fourth site (Maryland) had a well established albeit non-automated data exchange relationship with the local hospital. Thus, all four sites had processes in place that support information sharing across settings, including non-affiliated providers.
As suggested, health information can be exchanged across a variety of providers in a variety of ways. In an early attempt to delineate the different levels employed by different entities in sharing electronic health information, Walker and colleagues developed a four-level taxonomy describing the different stages of health care information exchange and interoperability (Walker et al., 2005). These levels are paraphrased below:
Level 1: Non-electronic data--no use of information technology to share information (examples: mail, telephone).
Level 2: Machine transportable data--transmission of non-standardized information using basic technology (e.g., fax or personal computer [PC]-based exchange of scanned documents, pictures, or portable document format [PDF] files). The information being exchanged cannot be electronically manipulated.
Level 3: Machine-organizable data--structured messages are used to transmit non-standardized data. This requires that the receiving computer "translate" data from the sending computer. This often results in imperfect translations and loss of meaning. Walker provides the following examples of this level of health information and interoperability: e-mail of free text, or PC-based exchange of files in incompatible/proprietary file formats, HL7 messages.
Level 4: Machine-interpretable data--exchange of structured messages that contain standardized and coded data.
Similarly, we observed the use of HIE applications and tools across many of these levels, including HIE that was completely paper-based, with the use of phone and fax to convey information to entities outside of the setting, to limited observations of standards-based, computer-readable, e-HIE that occurred using EHRs. Further, we found a wide range of HIE applications being used even within individual health care organizations. For example, during the site visits it was observed that organizations had both paper and e-HIE applications As a result, it was not possible to consistently apply the HIE and interoperability levels described by Walker et al. to describe the levels of HIE and interoperability within a single organization.
The following tables are heuristic guides to frame the site visit team's observations of HIE capabilities found as a result of the four site visits. Table 1 identifies four levels of HIE--where the first level reflects use of less sophisticated, earlier HIE applications (e.g., fax, telephone, mail) and the use of paper-based records, and the fourth level reflects completely interoperable HIE using standards-based EHRs.
| TABLE 1: Levels of Health Information Exchange |
|
Table 2 is illustrative with features described for each level to suggest a progression from less to more sophistication in terms of HIE. This table was constructed based on literature review as well as our observations concerning HIE and use of EHRs across the sites selected for this study. Although none of the settings observed have reached Level 4 (i.e., completely interoperable EHR systems, using standards-based applications to share information with affiliated and non-affiliated providers), it is included as the purported "future goal" for many of these settings. As will be described in more detail throughout this report, in general, we observed that:
Most HDSs (e.g., hospitals and physician offices) included in our site visits were at Levels 1, 2, and/or 3 for purposes of HIE, and were generally at Level 1 for purposes of HIE with PAC/LTC providers; and
Most PAC/LTC providers also were at Levels 1, 2, and/or 3. However, there were few instances in which PAC/LTC providers were observed to electronically exchange health information with hospitals, physicians, and other providers/clinicians, and there were a few instances in which the PAC/LTC providers were completely paper-based (Level 1).
Not unexpectedly, there may be variation within each Level as well so that, for example, a setting may be rather sophisticated in Level 3 for a function such as e-prescribing or laboratory result reporting, but in that same setting they may not have other electronic information sharing. So while they would be categorized as Level 3 using these criteria, they would be at the "low end" of it. Therefore, labeling an entire health setting at a particular level is not yet feasible, and this is why there are four areas of focus that are broken down by level later in the document. This report highlights our observations concerning the levels of HIE for the providers included in the site visits related to four clinical areas:
| TABLE 2: Illustrative Examples of HIE Capabilities by Level | ||||||||
|---|---|---|---|---|---|---|---|---|
| Level 1 Paper-based Record/ No EHR |
Level 2 Combined Paper Record/EHR |
Level 3 EHR Used/Limited Electronic Data Exchange, Some HIT Standards Used |
Level 4 Completely Interoperable EHR System, Use of HIT Standards |
|||||
| HIE Methods |
|
|
|
|
||||
| Features/Attributes of Patient Health Information and Electronic HIE1 | No Electronic HIE (i.e., not electronic data) | No EHR | Some e-HIE | Limited use of EHR | Data exchange limited to certain systems | Access to data limited to user role/ discipline | EHR is primary record | Standards-based EHR system (i.e., EHR content is standardized) |
| May have software for AR/AP, scheduling | No Anytime/ Anywhere Access | May allow for images to be imported | Clinical information collected on paper & entered into EHR | Continued but limited use of paper record | Some use of standards (messaging &/or content) | Interoperable with internal & external systems | Record can be electronically exchanged/ is transportable | |
| Meets minimum regulatory requirements2 | Limited Anytime/ Anywhere Access | Decision support features & alerts used | Anytime/ Anywhere Access | Computer Empowered Interoperable System | Anytime/ Anywhere Access | |||
| Facilitators of HIE | Limited involved in HIE Network (e.g., admin/claims data) | Some clinical content exchanged within HIE Network | Greater amount clinical information exchanged/shared within HIE Network | |||||
|
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1. Introduction
HIE is an integral component of health care workflow and is important in the provision of quality care to patients. When the exchange of health information is performed well, care provision can achieve positive health outcomes. When information exchange is not performed well (e.g., it is untimely, inaccurate, or absent) potentially costly inefficiencies may occur or it may result in adverse events.
HIE across care settings is very complicated, regardless if the mechanism is electronic or manual. Such exchange involves multiple health settings with different information needs and with different levels of HIT adoption and technological sophistication. Ideally, information exchange should be two-way, with an opportunity for the receiving provider to ask clarifying questions or request supplemental information. However, often communication is a one-way transaction. Although information technology will not, nor should it replace face-to-face interactions, HIT can facilitate and augment information exchange. The goal of interoperable HIT has become a national priority in recent years. HIENs/RHIOs have been identified as important mechanisms in this regard and have experienced prolific growth. One of the requisite tasks for HIEN developers is to formalize who are the network partners and determine what information needs to be exchanged. Often, it seems that there has not been an explicit understanding and agreement about the range of partners that need to be involved in these networks, nor has there been a formal consensus building process for determining the content of information to be exchanged and when. A positive consequence of the push for HIT adoption has been the recognized need to formalize HIE relationships among information "trading partners." Therefore all entities that need information should be included as partners.
Understanding how HIT can be used to facilitate HIE requires a concomitant understanding of the influence of HIT on the daily workflow of health care professionals. In some cases, the workflow issues have been identified to be more challenging than technological issues. Discussions between HIE partners are beginning that further explore this interface and are focusing on questions such as: How can HIE be engineered such that it supports rather than detracts from health care professionals' patient care responsibilities? What information should be exchanged and when in the process of a daily routine should this occur? How can HIT facilitate this exchange?
With this recognition of the mutually dependent relationship between HIE and workflow, the following discussion provides a framework upon which the observations and key issues identified in subsequent sections can be interpreted.
2. What Are the Workflow/Communication Issues?
The four site visits reinforced the central roles that workflow and communication play in HIE and the importance of considering and planning for the desired workflow/communication issues to realize some of the efficiency gains that may be achieved though HIT implementation.
a. Workflow. Information technology is a cross-cutting issue, an observation that permeated the site visit discussions at many levels. In general, relatively highly-paid professionals in hospitals and PAC, and LTC settings are expending a significant proportion of their time on clerical tasks rather than attending to patients' clinical needs. Implementation of EHR solutions did not necessarily provide solutions to this inefficiency. It was common for sites to report that nurses and physicians read from a computer screen or print out a patient's health data from one electronic health application only to manually re-enter the information into another electronic health application (such as an EHR).
Physicians, nurses, and other representatives (admission coordinators, information technology professionals, etc.) from the study sites generally had not considered how the recipient of electronic information could re-use the information to streamline and make workflow processes more efficient. In most cases, the clinicians were not consciously aware of the amount of time and effort that was being expended on multiple tasks involving the re-entering of data that was otherwise electronically available. In many instances, representatives seemed to simply insert electronic documents into existing workflow processes and as a result perpetuating (unnecessarily) duplicative administrative tasks.
The lack of standardized HIT/HIE applications also contributed to inefficient practices. Because of the lack of interoperable EHRs, for example, respondents described manually re-entering laboratory results received electronically into their own EHR system, because the laboratory and receiving health care setting's EHR systems did not have the capabilities of exchanging this type of data electronically.
However, further probing revealed that the manual re-entry of data sometimes was considered to be of value. For example, the literature reports that manual re-entry of a medication list from one system or medium to another may add value in terms of quality and safety, while risking the introduction of new errors (e.g., transcribing the wrong dosage, misspelling the medication that is similar to another medication that treats something completely different or is contraindicated) (Brody, 2007). During site visit discussions, clinicians acknowledged that this manual re-entry activity was not simply a clerical process but rather something that provided an opportunity to cognitively assess whether the medications were in fact appropriate, whether any additional diagnostic testing was required, and whether the patient might be at risk for an adverse drug reaction. Occasionally, the notion of trust also would arise--clinicians seemed to place greater trust in information that had gone through the manual re-entry process. Thus it remains to be determined how these vital tasks will be accomplished once more advanced (e.g., interoperable) electronic solutions are forthcoming. The authors speculate that there always will be a need for "the human element" in reconciling information such as the medication list--information technology solutions will merely augment and assist them in these care processes.
In a typical workflow process, keeping track of when a particular task (e.g., obtaining physician's signature, orders) was completed so that the next person could do her/his job was reported as something on many people's "wish list" for what they would like their EHR to do for them. Current practice requires a great deal of time spent manually tracking tasks that could easily be automated in the EHR.
b. Importance of interpersonal relationships. The importance of interpersonal relationships among health care professionals cannot be overstated. The site visit team observed how established interpersonal relationships impacted HIE. Typically, patient information sharing occurred among hospital discharge planners and/or social workers, and NH and home health care agency intake coordinators. Interestingly, the importance of interpersonal communication was no less in care settings that had the capacity to share information electronically versus those that primarily shared information on paper. For example, despite the fact that several hospitals and NHs in New York and Utah have invested in a proprietary software program, Extended Care Information Network (ECIN), to facilitate more efficient referrals (described in further detail below), it is not uncommon for disposition discussions to precede the distribution of the ECIN information. Thus, although this technology was put in place to facilitate hospital referrals to SNFs/HHAs, informal, less technological approaches (e.g., face-to-face discussions, telephone, faxes) often were the primary mechanisms of data exchange, with HIT being a supplement to this data sharing activity. The perceived value of relationships that exists between these professionals was of more importance when compared to the technology. Our site visit team observed that intake coordinators in referred facilities often received the patient's information telephonically from their hospital colleagues in advance and had already accepted the patient by the time the patient's information is distributed in electronic transfer/discharge summaries, such as ECIN.
c. Other issues that impact communication between referring and receiving providers. Communication and information exchange between some of the observed health care settings was not hindered by a lack of technological solutions. For example, in Maryland, Erickson (a CCRC that provides all health care to their residents with the exception of acute care and hospice) and the local hospital (St. Agnes) have a very close working relationship and freely communicate. Erickson physicians are able to treat their patients should they be admitted to St. Agnes, and they have read-only access to the St. Agnes EHR, but still need to print out anything they would like to have in their Erickson health record. St. Agnes also allows an Erickson-employed nurse to work in the hospital to facilitate discharges back to one of the Erickson facilities (e.g., their SNF, Renaissance Gardens).
Clearly communication between these two entities is occurring, as is HIE, of which most at this point is still manual. Technology was not considered a hindrance; in fact, the leaders at St. Agnes commented that technology is a minor issue in solving the problem of e-HIE. Rather, issues such as who is responsible for protecting the privacy of data at the time of e-HIE and who is liable for the accuracy of the data were identified as the barriers to effective information exchange across health care settings, particularly unaffiliated settings. Further, it remains to be determined who should pay to populate the specific data fields that often are idiosyncratic to each referring/receiving provider. Transmitting data requested by the receiving provider likely will create additional costs (including personnel, programming, troubleshooting/maintenance, upgrades, etc.). The multiplicity of formats may be too burdensome and costly for some providers. For example, the development of an interface between St. Agnes and Erickson to facilitate data sharing was reported by Daniel Wilt (Senior Vice President of Erickson Information Technology Department) to initially cost approximately $50,000, which then would require maintenance and upgrades over time. This interface only benefits this one relationship between these two entities. Creating unique interfaces to support all referring and receiving sources may be unnecessarily costly and inefficient.
In fact, concern about the relatively high cost of an almost unlimited number of needed idiosyncratic interfaces gave rise to the emphasis in recent years concerning the need for HIT standards to support interoperable HIE. For example, it is anticipated that the use of: (i) the HL7 CCD implementation guide and the content standards referenced in that guide; and (ii) standards to support e-prescribing will allow the exchange and re-use of this information without the need for these costly interfaces. However, as described below, during out site visits we observed very limited use of HIT standards to support the electronic exchange of patient information.
d. Timeliness of the communication/information exchange. The element of time permeated through nearly every discussion that occurred during the four site visits. In particular, when hospital staff believe that a patient is ready for discharge and will require short-term placement in a NH or a referral for home health care, receiving providers must be in a position to quickly decide whether or not to accept the patient, often based on incomplete or even inaccurate information. NH staff at Jewish Home and Hospital Agency (JHHA) and Schervier (New York) both commented that information received from local hospitals often is incomplete, and varies depending on the person completing the discharge form at the hospital. As a result, the receiving facilities/agencies may make poorly informed, inaccurate decisions and may not be in a position to meet the patient's needs upon admission.
3. Health Information Exchange Across Care Settings: Hospitals, Post-Acute, and Long-Term Care
Older adults with acute and chronic health conditions often receive care in multiple, disparate settings by a number of care providers (e.g., primary care physician, one or more specialists) who may or may not share (complete) information. The transfer of timely and accurate information across settings and providers is critical to the execution of effective care transitions. Practitioners need an understanding of the patient's goals, baseline functional status, active medical and behavioral health problems, medication regimen, family or support resources, durable medical equipment needs, advanced directives, and ability for self-care (Coleman, 2002; Coleman, 2003; HMO Workgroup on Care Management, 2004). Without this information, service duplications may occur, important aspects of the care plan may be overlooked, and conflicting information may be conveyed to the patient and family caregivers. Incomplete information transfer can result in critical errors, such as the patient returning home without life-sustaining equipment (e.g., supplemental oxygen or equipment used to suction respiratory secretions). The absence of information about an older patient's baseline level of cognitive function may result in an acute decline in cognitive status being mistaken for chronic dementia. Furthermore, a lack of understanding of a patient's functional health status, including both physical and cognitive, may result in transfer to a care venue that does not meet her or his needs. Thus, improved HIE (manual or electronic) is a critical step toward reducing medical errors, improving quality, and increasing efficiencies for patients who receive care across settings.
This section focuses on HIE across affiliated and non-affiliated acute care hospitals, PAC, and LTC providers. Specifically, it examines information exchange between hospitals, physician offices, NHs, home health care agencies, and, in one setting, a CCRC. To frame this discussion, it is important to note that while there are similarities between how care is delivered in each of these settings, there also are key differences that potentially influence both the content and process of information exchange. Hospitals, PAC, and LTC settings treat patients with different needs, have different staffing ratios, different clinical information needs, different orientations and approaches to assessment and management, and face different regulatory and reimbursement requirements. These disparate requirements translate into different data needs. Further, providers' HIE often is guided by the need for compliance with existing policies and regulations, including required reporting for patient assessment instruments (PAIs) such as the MDS and OASIS, the Pre-Admission Screening and Annual Resident Review (PASARR),12 the New York State Patient Referral Instrument (PRI),13 and Medicare Conditions of Participation (CoPs).14
This section begins by describing the clinical domains that the literature identifies as needing to be exchanged and then compares these domains with what was observed on the four site visits, including what is not being exchanged. Next, promising new developments that could support improved HIE will be featured. Key aspects of clinical workflow issues then will be described, followed by comparing and contrasting how health information is exchanged among affiliated and unaffiliated providers. This section will conclude with observed facilitators and barriers to HIE, including e-HIE.
a. What is the content of information exchanged. Based on a review of published literature, summaries of large national conferences, and documents produced by professional societies; at present there is no consensus on the content and type of information exchange needed between hospitals, PAC, and LTC settings. Four distinct national efforts that have begun to address this question include:
The CCD (HL7 and ASTM, 2006).
The Uniform Patient Assessment for Post-Acute Care tool (CMS, 2006). The UCDHSC developed a concept paper for CMS that provided recommendations for developing a uniform assessment tool that would cut across all PAC settings. The Deficit Reduction Act of 2005 requires the demonstration of a comprehensive assessment at the time of hospital discharge to determine appropriate placement and the use of a use a standardized PAI across all PAC sites to measure functional status and other factors during the treatment and at discharge from each provider. CMS awarded a contract to RTI International to specify the elements of this tool (which has been named the Continuity Assessment Record and Evaluation (CARE) instrument) and perform a demonstration project.
The HMO Care Management Workgroup (HMO Workgroup on Care Management, 2004).
The Veterans Affairs Geriatrics and Extended Care (GEC) Referral Discharge Planning Tool (Department of Veterans Affairs, 2006).
Each of these efforts evolved separately. A comparison of the individual domains and classifications needed for information exchange from each of these efforts is shown in Table 3. While there are many similarities among the four efforts with respect to the selection and inclusion of key clinical domains, there are also a considerable number of differences observed as well. A detailed description of the first four efforts can be found on the ASPE website15 (Coleman, et al., 2007). One of the important differences between the CCD and the other activities listed above, is the HL7 CCD identifies not only the pertinent health care domains for which patient specific information may need to be exchanged at the end of an episode of care, but the CCD also specifies the HIE content and messaging standards that enable standardized electronic exchange of a CCD-compliant transfer/discharge document.
While there often was overlap in the clinical domains included in these HIE specification, there was considerable variation in the type of data within each of the domains. For example, each of the efforts identified a problem list and advance directives. However, the GEC (VA) tool does not list allergies and medications because the tool is designed to complement core information available in the VA EHR. The GEC (VA) tool and the Uniform Patient Assessment tool both are more strongly oriented toward PAC and LTC and as a result, have more items that reflect the types of care more typically addressed in these settings such as continence and skin integrity. Some care settings, such as EDs, desire a much smaller subset of core data items as they do not have the opportunity to review much data during the brief clinical encounter.
Within Medicare's regulatory framework, the CoPs include requirements concerning information exchange at the time of transfer for hospitals, NHs, and HHAs (CMS, 2001; Coleman et al., 2007; Hughes, 2003). Where explicitly identified in the CoPs, the required clinical domains at the time of transfer are comparable to those clinical domains specified in the four national efforts described in Table 3.
Responses from those interviewed revealed a high level of consistency in the content of information needed to support HIE at the time of transfer. For example, Wishard Hospital (Indiana) considers the discharge summary, insurance information, medication list, allergies, problem list, and advance directives among the core information needed at the time of transfer from an SNF or HHA to the hospital or vice versa. LDS Hospital in Utah assembled a similar list and added physical therapy (PT) notes. Erickson Retirement Community (Maryland CCRC) regards medications, allergies/intolerances, medical problem list, advance directives, clinical notes, radiology reports, laboratory results, and clinical notes as the highest priority clinical domains. When the JHHA, a New York NH, transfers a patient to hospital, an information packet is prepared that includes a medical summary of recent events completed by the physician, a handwritten medication list, immunization list, EKGs (if available), and recent laboratory tests. Staff at Schervier (New York NH) also send this same set of information with patients who are transferred to the ED or hospital and, in addition, complete an internally-developed standard transfer form that describes the reason for transfer.
| TABLE 3: Overlap of Clinical Domains and Clinical Information to be Exchanged Between Acute Care Hospitals, Post-Acute, and Long-Term Care Settings | ||||
|---|---|---|---|---|
| Key Clinical Information to be Exchanged | CCD (HL7, CDA) | Uniform Pt Assessment (CMS) | HMO Care Mgmt Workgroup | GEC (VA) |
| Purpose (i.e., transfer) | X | |||
| Payers | X | |||
| Advance directives | X | X | X | X |
| Support (persons/family)/Caregivers Information | X | X | X | |
| Functional status | X | X | X | |
| Cognitive | X | X | X | |
| Physical | X | X | ||
| ADLs/IADLS, baseline, current | X | X | X | |
| Problems, Prognosis | X | X | X | X |
| Family History | X | |||
| Social History | X | |||
| Allergies, Adverse Reactions, Alerts | X | X | X | |
| Medications | X | X | X | |
| Medical equipment | X | X | X | X |
| Suppliers | X | |||
| Immunizations | X | X | ||
| Vital signs | X | |||
| Results | X | |||
| Procedures | X | |||
| Encounters | X | |||
| Plan of Care | X | X | ||
| Health Care Providers, PCP | X | X | X | X |
| Goals of care | X | X | X | |
| Discharge instructions, disposition | X | X | ||
| Pain | X | |||
| Skin integrity | X | X | ||
| Sensory deficits | X | X | ||
| Dietary needs | X | X | ||
| Continence | X | X | ||
| Falls risk | X | |||
| Current services receiving in home | X | X | ||
| Capacity to perform self care, educational needs | X | X | X | |
| Ethnic/cultural considerations/language | X | X | X | X |
| Self-rated health status | X | |||
| Source of referral | X | |||
| Where does patient live, with whom | X | X | ||
| Homebound status | X | |||
| Additional information (environmental hazards) | X | |||
| Weight bearing | X | |||