Patient Care Summary Exchange

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Patient Care Summary Exchange

• State HIE TA Program Webinar
• August 6, 2010

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Table of Contents

• Care Summaries in the PIN and Meaningful Use
• Care Summaries in Context
• State Strategies for Implementation
• Issues to Consider Implementing Clinical
  Summaries
• Care Summaries in Practice
• Resources
• Discussion is encouraged throughout todays
  webinar!
• For additional TA, inform your project officer !

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Why Use Clinical Care Summaries?

• Allows physicians to receive critical health data
  at transfer of care
• Improves speed and accuracy of data absorption
  into new providers EHR
• Reduces cost in reproducing and transporting
  paper records
• Reduces hassle to patient in completing new
  provider registration materials
• Improves quality of care through more complete
  and timely information
• Can provide patient with an accurate, readable
  record of a visit or encounter

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Care Summaries the PIN

• States should have a concrete and operationally
  feasible plan to enable patient care summary
  exchange across unaffiliated organizations in the
  next year.
• An understanding of the HIE currently taking
  place in the state
• What is your baseline information, including
  specific measurements related to patient care
  summaries.
• Gaps in HIE as identified in the environmental
  scan
• Identify areas where your baseline information
  does not match requirements for Stage 1 MU
• A strategy and work plan to address the gap
• Identify solution strategies to close the
  identified gaps

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Care Summaries Stage 1 Meaningful Use

• The EP, eligible hospital or CAH who transitions
  or refers their patient to another setting of
  care or provider of care provides a summary of
  care record for more than 50 of transitions of
  care and referrals (Meaningful Use Final Rule)

• Core requirement is to perform at least one test
  of EHRs capacity to electronically exchange
  information
• To fulfill menu set requirement, EHR must enable
  a user to electronically transmit a patient
  summary record to other providers and
  organizations including
• Includes, at a minimum, diagnostic test results,
  problem list, medication list, and medication
  allergy list
• Uses HL7 CCD or ASTM CCR

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Care Summaries Stage 1 Meaningful Use

• MU Objectives that might require sharing of a
  CCD/CCR
• Provide patients with an electronic copy of their
  health information upon request
• Provide a clinical summary for each visit
• Exchange clinical information electronically with
  other providers and patient authorized entities
• Provide summary care record for each transition
  of care and referral
• Provide patients with an electronic copy of their
  discharge instructions and procedures
• Other MU requirements could use clinical
  documents (e.g., lab results, public health
  reporting)

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CLINICAL SUMMARIES IN CONTEXT
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Communicating Information Requires Three Things

• Transportation

• Containers / Packaging

• Content

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Data-centered vs. Document Centered

• Data-centered (e.g., X12 or HL7 messages)
  traditional structures to represent the data
  being transported (a row in a file for a record
  delimited or fixed length fields within the
  record) which goes into a database

• Document-centered (e.g., CCR, CCD) electronic
  document where data is pre-arranged in a
  structured format which is filed

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Initial Set of Standards, Implementation
Specifications, and Certification Criteria for
EHR Technology (Jul. 2010 FR)

• Requires clinical summaries for patients for each
  office visit in human readable format and on
  electronic media
• Clinical summary can either HITSP C32-compliant
  CCD or ASTM CCR
• Why 2 standards?
• CCD growing in popularity
• CCR still in use, especially among early adopters
• In some circumstances the CCR is easier, faster,
  and requires fewer resources to implement than
  the CCD
• Electronic exchange not required in Stage 1, so
  why make anyone migrate now from one format to
  the other?

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Continuity of Care Record (CCR)

• History Outgrowth of Patient Care Referral Form
  (PCRF) from the MA Department of Public Health
• Core data set
• Most relevant administrative, demographic, and
  clinical information facts about a patient's
  healthcare, covering one or more healthcare
  encounters
• Summary of the patients health status (for
  example, problems, medications, allergies) and
  basic information about insurance, advanced
  directives, care documentation, and the patients
  care plan
• Primary use case Snapshot in time containing the
  pertinent clinical, demographic, and
  administrative data for a specific patient
• Technical Specification
• XML coding that is required when the CCR is
  created in a structured electronic format
• Permits users to display the fields of the CCR in
  multiple formats
• Source http//www.astm.org/Standards/E2369.htm

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Sample CCR
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Continuity of Care Document (CCD)

• History Collaborative effort between ASTM and
  HL7 as an alternate to the one specified in ASTM
  ADJE2369 for organizations committed to
  implementation of HL7 CDA
• Core data set
• Most relevant administrative, demographic, and
  clinical information facts about a patient's
  healthcare, covering one or more healthcare
  encounters
• Standard intended to specify the encoding,
  structure and semantics of a patient summary
  clinical document for exchange
• Primary use case Provide a snapshot in time
  containing the pertinent clinical, demographic,
  and administrative data for a specific patient
• Technical Specification
• Constraint on the HL7 Clinical Document
  Architecture (CDA) standard based on the HL7
  Reference Information Model (RIM)
• Basis of many IHE profiles and HITSP constructs
• Source http//www.en.wikipedia.org/wiki/Continuit
  y_of_care_document

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Sample CCD
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NHIN Specifications

• Both NHIN Exchange and NHIN Direct offer means to
  transport clinical summaries
• Both mechanisms support Stage 1 Meaningful Use
• Both rely on standards for effective
  communication
• NHIN Exchange offers the means for transporting
  care summaries relies on more sophisticated
  technology, most suitable when participants do
  not necessarily know each other personally.
• NHIN Direct offers specifications that enable
  transport of care summaries relies on simpler
  technology, most suitable when participants know
  each other personally and have a data exchange
  relationship
• Many states are interested in supporting both
  models for different workflows.

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STATE HIE STRATEGIES FOR IMPLEMENTATION OFCARE
SUMMARY EXCHANGE
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State HIE Strategies

• Can take several forms, just like statewide HIE
  can take several forms
• Requires some elements of policy, some elements
  of infrastructure
• Use data from environmental scan to understand
  current situation, capabilities, pilots,
  including other relevant states
• Work with RECs to develop consistent message and
  appropriate capabilities rely on their services

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State HIE Strategies, cont.

• Insist on common terminology and coding
• Keep EHR system vendors feet to the fire in
  implementing capabilities in the field
• Recognize that many sites are still using HL7 v2
  messages
• Provide HIE services to support care summaries
• Full services, like RLS, MPI, directory, IHE XCA
• Enabling services for NHIN Direct, like provider
  directory
• Consider the impact of the availability of many
  clinical documents when exchange is successful

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ISSUES TO CONSIDER IMPLEMENTING PATIENT CARE
SUMMARIES ACROSS TRANSITIONS OF CARE
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1 Data Aggregation Issues

• Most EHR systems cannot yet integrate data from
  clinical documents into their databases
• Over time, clinical users will have access to a
  growing number of point-in-time clinical
  summaries
• We may see an increasing need to create a
  summary of summaries especially for users
  without an EHR-S using a portal/viewer
• Clinical documents do not easily support data
  aggregation and reporting
• So
• Additional processing, including different data
  stores, may be necessary to aggregate and report
  on clinical data received within documents

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2 Data Content Issues

• Some types of data that might be included may
  have additional privacy/security restrictions
  (e.g., mental health, adolescent health)
• So
• Additional parsing and scrutiny may be
  required before clinical documents are exchanged
  policy development may also be required

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CLINICAL SUMMARIES IN PRACTICE
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NEHEN in Massachusetts

• Historical Highlights of NEHENs Clinical Data
  Exchange Efforts
• 1998 NEHEN administrative exchange launched
• 2004 MedsInfoED pilot launched
• 2005 Connecting for Health Record Locator
  Prototype completed
• 2006 MA-SHARE e-Prescribing exchange launched
  MA-SHARE NHIN Prototype completed
• 2007 MA-SHARE Push Pilot launched with BIDMC,
  Childrens, Northeast (discharge summaries)
• 2008 Push Pilot extended to BIDMC affiliated
  CHCs
• 2009 Push Pilot extended to eCW integration for
  BIDPO (discharge summaries)
• 2009 Scoping, architecture, and planning
  sponsored by EMHI
• 2010 Push Pilot extended to Atrius (admission
  notifications, discharge summaries)
• July 2009, NEHEN/MA-SHARE Merger

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NEHEN Clinical Data Exchange Context

• Provider-to-Provider Clinical Summary Exchange
• Clinical Summary Supporting Multiple Use Cases
  (e.g., Discharge Summary, Visit/Encounter
  Summary, Referral Summary, Admission
  Notification)
• Provider-to-Payer Exchange
• Clinical Summary for Case Management and Other
  Use Cases
• Lab Results for Quality Measurement and Other Use
  Cases
• Public Health Reporting
• Clinical Summary for Health Equities Analysis
• Lab Results
• Immunizations
• Syndromic Surveillance
• Quality Reporting
• Clinical Summary for Quality Analysis
• Community Participant/Provider Directory for
  Message Routing
• NEHEN Express Clinical Summary Viewer
• Secure Messaging
• Audit
• Reportable Event Logging
• NEHEN Express Audit Report Viewer
• Network Management Dashboard

• NEHEN Administrative Exchange

• NEHEN e-Prescribing Exchange

• NEHEN Clinical Data Exchange

• To achieve meaningful use, Providers will need a
  combination of capabilities encompassing both
  internal systems capabilities and health
  information exchange capabilities such as those
  offered by NEHEN

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NEHEN Clinical Exchange Current Status
Clinical Release 1.0 Live Pilot Clinical Release 2.0 2010 Clinical Release 2.0 2010
Hospital and physician organizations Atrius Health Beth Israel Deaconess Childrens Hospital Boston Northeast Health Systems Hospital and physician organizations Atrius Health CareGroupBIDMC, BID Needham, Mt Auburn Hospital, New England Baptist Hospital Childrens Hospital Boston Fallon Clinic/SafeHealth Massachusetts Eye and Ear Infirmary Partners Healthcare Signature Health Tufts Medical Center Winchester Hospital More to come.... Public health agencies Boston Public Health Commission MA Department of Public Health Quality data aggregator Massachusetts eHealth Collaborative
Message types Clinical summaries for admission notification and discharge summaries Message types Clinical summaries Admission notification , discharge summaries, visit summaries, etc. Care transition, quality reporting, health disparities analysis Immunization histories to public health Syndromic surveillance reporting to public health Lab results to public health
EMR integration eClinicalWorks EMR integration eClinicalWorks, MEDITECH, custom EMRs, others EMR integration eClinicalWorks, MEDITECH, custom EMRs, others
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MedVirginia in Virginia

• Average disability determination
• 84 days
• With MedVirginia
• 46 days
• 11 completed in 1-2 days
• Submits CCD to SSA through NHIN
• Algorithms by SSA
• Replication of model

• MedVirginia works with SSA, NIHIN and the State
  Agencies over multiple steps to process patient
  claims to shorten the time it takes to receive a
  disability determination

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MedVirginia, NHIN SSA

• Existing and new data suppliers in the
  MedVirginia chain

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Case Study SSA / MedVirginia Use of MEGAHIT

• Commissioned by SSA
• Conducted by Kay Center for eHealth Research
• Perspectives
• Claimant
• Provider
• SSA
• ROI
• Dissertation by Sue Feldman

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A few lessons learned..

• Standards
• Process
• Anticipate
• Communicate
• Partnership
• Eyes on the prize

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KHIE in Kentucky

• Kentucky Health Information Exchange (KHIE) is a
  Medicaid Transformation Grant funded initiative.
• A CCD is created from Medicaid claims data
  (populated from the states MMIS through a daily
  feed) including prescriptions
• CCD is created real time upon request from
  providers, hospitals, etc.
• Kentuckys state lab data is in final phase of
  testing and will be incorporated into the CCD
• Hospital systems are not ready to consume a
  structured CCD
• Plans are to create a consolidated CCD from
  multiple data sources to provide one
  non-duplicated summary document

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Other State Examples

• Vermont
• Rhode Island NHIN Direct Implementation Pilot
• Massachusetts NHIN Direct Implementation Pilot

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Questions Answered Today

• How do you define a patient care summary?
• What is required in Stage I of MU?
• What does a provider need to do beyond adopting a
  certified electronic health record in order to
  securely send patient summaries to another known
  treating provider with a certified electronic
  health record?  How can state designated entities
  assist?  What barriers have providers
  encountered? 
• Who is responsible for gathering, assembling, and
  updating information in a patient care summary?
• Is it meant to be a document that providers will
  base medical diagnosis and clinical action on or
  is it a tool for consumer/patient education?

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Questions Answered Today, cont.

• Do patients have the ability to view the
  information in the summary? To change the
  information?
• Are all providers who see a patient required to
  use a patient care summary?
• How is it envisioned any changes to a patient
  care summary would be made? At the time of
  appointment, at every health care visit, with
  only select providers, on-line or in person?
• Is a health information exchange project required
  in order to populate the information for a
  patient care summary?
• Do HIE network capabilities that display patient
  information on a web portal meet meaningful use
  objectives for Stage 1?

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Resources

• ASTM http//www.astm.org/Standards/E2369.htm
• IHE http//www.ihe.net/
• HL7 http//www.hl7.org/implement/standards/cda.cf
  m
• HIMSS http//www.himss.org/
• HIMSS EHR Association http//www.himssehra.org/AS
  P/index.asp
• NHIN http//www.healthit.hhs.gov/portal/server.pt
  ?open512objID1142parentnameCommunityPagepare
  ntid1mode2in_hi_userid10741cachedtrue
• NHIN Direct http//www.nhindirect.org/

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Patient Care Summary ExchangeDISCUSSION

• State HIE TA Program Webinar
• August 6, 2010