The ability to seamlessly exchange data among disparate healthcare information systems has long been recognized as a key outcome in the adoption of health information and technology by healthcare stakeholders.
The benefits of data interoperability across providers, health systems, and care settings include, but are not limited to:
However, the interoperability discussion has historically focused on hospital-to-hospital data exchange. While important, this focus has made it more difficult to gauge the progress of data exchange between other care settings such as long-term and post-acute care, or LTPAC, organizations.
In view of the need to focus on data interoperability between LTPAC organizations and their acute partners, the HIMSS LTPAC Committee endorsed an effort to document the experiences of U.S.-based cohorts with projects related to data sharing. The objective for this study was to call attention to relevant examples in the real world in order to promote expanded integration and coordination among stakeholders. During this process, we documented successes realized, obstacles faced and lessons learned when sharing data during transitions of care between acute to LTPAC settings.
Transitions of care refers to the movement of individuals between provider healthcare settings as their health condition, medical needs and support needs change. As transitions of care occur, coordination of care is vital to prevent gaps in care delivery, which can lead to declines in health and increases in medical and support needs.
Coordination of care necessitates a timely and complete understanding of care received at the previous provider setting. A gap in information detailing previous treatments and procedures requires the receiving provider to perform resource-intensive, and often costly, discovery of the incoming person’s health status in order to deliver the appropriate care. Although the time and cost of the receiving entity is recognized by many, the time and cost to the sending facility is also very real when data interoperability is not present.
Often, the patients and their family or caregivers assume their information is already available when they arrive at a provider’s doorstep to receive care. They have a notion that the care team will immediately know something about them, which will allow their treatment to be targeted, personalized, and focused on their specific needs and health concerns. When this is not the case, patient and family satisfaction with both the sending and receiving provider can be compromised.
The current environment within acute and long-term and post-acute care settings is fraught with silos of data and differing levels of maturity with regard to data exchange capabilities. In addition, there are multiple stakeholders that contribute to the overall exchange limitations and availability of information at the point of transition. Long-term and post-acute care providers are well aware of these difficulties and have become accustomed to receiving paper documents and faxes, or making phone calls to the sending provider in order to gather necessary information about the patient. This information can be incomplete, or instead contain so much extraneous information that the receiving provider must spend extra time reviewing and locating the desired information needed for treatment. A study published in the Journal of the American Medical Association Open Network highlighted these challenges. The study's authors noted that over 80% of the skilled nursing facilities surveyed cited one or more shortcomings across the domains of timeliness, completeness, and usability of shared data associated with acute care transitions.
In an attempt to mitigate the difficulties detailed above, long-term and post-acute care settings are often provided an opportunity to log into one of multiple EHRs or health system portals as part of accessing the information needed. This solution addresses the issue of data access but falls short in terms of addressing the needs of the people being cared for and relieving the resource burden of the receiving provider. In addition, this approach requires administrative resource support from both providers involved in the transition as part of managing the security, credentials, training and volume of care team members that rely on this information from outside systems.
Overall, there is a need to ensure information follows the person across care settings in an interoperable manner, enabling the movement of data from one clinical record to another without excessive resource burden. An efficient and streamlined approach to data accessibility increases the likelihood of meeting the triple aim for both acute and LTPAC providers. We believe a reduction of clinician burnout, improvement in outcomes, and a boost in patient and family satisfaction is demonstrated when a patient’s information is completely accessible during transitions of care. Finally, unnecessary spend due to duplicate testing and assessment, and unnecessary hospitalizations will be reduced when we are able to effectively exchange data between LTPAC and their transition partners.
Three LTPAC cohorts participated in this study. These cohorts documented and shared their experiences and insights. They were:
In total, the three cohorts represent approximately 880 independent living beds, 800+ assisted living and memory care beds, and 980+ skilled nursing beds. They also represent 12 home health agencies that carry an average daily census of 340 with 74,000 home health episodes per year, and one large hospice that represents, in total, approximately 30,000 lives per day. These organizations included examples of both for-profit and not-for-profit entities.
In these examples, the environments in which these data exchanges are taking place reflect the complexity and diversity of the healthcare landscape. Varied technology implementations, differing resource availability (both human and financial), diverse clinical and administrative workflows, and the variety of affiliations between providers inform the conditions under which these organizations are operating. As such, they also play a significant role in the implementation of data exchange strategies each cohort is able to pursue. When harmonized together, the experiences of the three participating long-term and post-acute care groups call attention to several important realities impacting data exchange that affect continuity of services and treatment during transitions of care.
Several challenges and potential solutions regarding data sharing during transitions of care have been widely known and shared anecdotally. The initiatives described by the cohorts in this report document the reality of these dynamics and their impacts. Our findings lead to the following recommendations to industry stakeholders:
Palomar Health began with two community healthcare providers, a nurse and a dietitian. Now, this organization is California’s largest healthcare district. Composed of two acute care hospitals, a skilled nursing facility, home health agency, numerous outpatient service locations, and a comprehensive rehabilitation and behavioral health program, this network of patient care services serves 850 square miles.
The organizations involved in the case study include:
Unfortunately, a single, integrated EHR is not in place, although it is greatly desired. However, finding an EHR that is fully integrated across care settings that meets the patient care and data needs of these three diverse environments has not been identified. The hospitals and skilled nursing facility (SNF) are utilizing Cerner, while the home health agency, wound care, and radiation oncology units each utilize a different EHR.
Since each of these entities are within the same continuum of care, the desire to facilitate information sharing throughout the healthcare network and its partners was one driver to discuss options. Additionally, during this time the Patient Driven Payment Model and Patient Driven Groupings Model were being launched.
Both payment methodologies rely heavily on having complete clinical information in a timely fashion. The opportunity to participate in the HIMSS LTPAC project and learn from others appealed to Palomar Health.
The key senior leadership participants from Palomar Health were Virginia Barragan, FACHE, DPT, MOMT, vice president, continuum of care; Joseph Parker, RN, MSN, CNL, director, home care services and home caregivers care transitions program, and David Pape, vice president, information technology.
Referrals from the hospital’s clinical resource management (case management) team are made through and received from the care coordination application, Ensocare. Although strongly encouraged, not all referrals go through this system. Clinical resource management attaches a defined set of documents for the entity to which the referral is being made, to use. The care coordination application’s quasi-electronic transmission is preferred. Organizations outside of Palomar’s network of facilities, with minimal exceptions, transmit the patient information via fax. Often the fax materials need to be printed, sorted for the documents needed, and scanned into the respective EHR.
Within the network, upon transfer from the Palomar Health hospitals to The Villas or Palomar’s home health agency, the Cerner EHR generates an electronic file containing key documents that are passed to the receiving entity, including:
The timing of the project was ideal as the organization was kicking off its next fiscal year’s budget planning. As part of the early discussions of the HIMSS LTPAC team, Palomar’s post-acute entities shared its wish list with Palomar’s newly appointed chief information officer:
The good timing was short-lived with the public health crisis created by the pandemic. Patient volumes were down, funding was limited, and IT resources were channeled to other priorities.
However, The Villas and Palomar’s home health leaders offered these five points for the EHR provider’s consideration. Their fifth point recognizes that interoperability is not always present in the outpatient programs of an entity or across entities.
In summary, unlike other case studies participating in the LTPAC initiative, this project is still in germination stages. In the words of Chief Information Officer David Pape, "Interoperability is a struggle for all of us. It is difficult for one EHR to be all things to all users. Each system is written differently or at different stages of its lifecycle. Since these systems are not all written the same, getting each to communicate to the others is very challenging. While the federal government says EHRs must share data, the burden is really on the components functions of our healthcare organizations. Even if we adopt HIEs, these are often written to support one ideology and are not agnostic to the process and needs of each organization."
Rolling Green Village is a not-for-profit life plan community located in Greenville, South Carolina. It was established in 1986 with a mission to serve older adults by providing an environment that enriches quality of life and fosters independence in a setting nurtured by and established on Christian ideals.
The community is managed by Life Care Services® (LCS), an LCS Company® of Des Moines, Iowa. Life Care Services manages 143 communities that provide services and care to a little over 34,000 residents across 33 states.
Rolling Green Village offers the following levels of care:
In 2010, Life Care Services made a commitment to embrace technology and subsequently partnered with a single software provider that could accommodate the healthcare and financial needs of the community in all levels of care.
Rolling Green Village started its technology journey in 2011 when it implemented electronic documentation, order management and care planning in its skilled nursing facility using the EHR recommended and supported by Life Care Services. Since 2011, the organization has used the same EHR with varying degrees of adoption.
In 2016, community leadership made a concerted effort to optimize the utilization of their EHR. At that time, they established an interface with their pharmacy and therapy market suppliers, and adopted electronic workflows to support compliance with documentation policies/requirements.
With their EHR projects essentially complete, leadership at Rolling Green Village looked for their next opportunity to embrace technology to decrease resource burden and improve reimbursement. They decided to focus on improving the following workflows:
In conjunction with LCS and their EHR provider, Rolling Green Village assembled a team of super users that included nursing and admissions staff and set the following goals:
With the help of their EHR provider, Rolling Green Village determined that they would integrate their EHR with a large data sharing network and implement direct secure messaging with their hospital referral partners.
Implementing these features would enable the organization to:
Rolling Green Village successfully sent and received resident data to and from their referral partners using secure messaging. Additionally, they successfully performed ad-hoc searches within the data sharing network and pulled resident health records from other providers directly into the resident's medical record. That said, not all of the project goals were achieved.
Automation of the receipt of data, while a driver for entering into this project, was not fully realized. There was nothing automated about sharing or retrieving data. Someone needed to manually create the CCD and other documents within the EHR. Then those documents had to be sent via direct secure messaging to the recipient. Finally, someone at the receiving entity had to go look for and import the documents into the resident's medical record.
Being able to ensure a complete resident record was another driving factor of this project. This too was not fully realized. The format of the data being shared varied. Some referral partners were only able to share the CCD while others were able to share the CCD and other reports specific to the resident’s care. Additionally, the data made available electronically at the time of the referral was not always in final form often requiring Rolling Green Village to receive additional documentation with the resident upon arrival, and sometimes even days after arrival. This caused patient safety concerns and required the organization to institute additional auditing processes.
In addition, the data sharing network contained a large volume of data and Rolling Green Village struggled to know whether the data was current and found that not all providers share data using the network. Furthermore, the limitations of the facility's EHR still required a large amount of manual entry when importing information received from the network.
The final goal of this project was to decrease time spent on referrals to allow limited resources additional time to accept more admissions daily. Rolling Green Village learned using direct secure messaging to streamline the receipt of resident data did not eliminate the need to continue pulling resident information from the referral portal and/or receive documents in a paper format from their referral partners.
They also learned that the new workflow added steps to the referral process. The EHR provider only allowed demographics, allergies and medications to be imported from the CCD provided by the referral partner, even though the CCD contained a significant amount of data. The limitation of only importing discrete data for demographics, allergies and medications did not help the community save time.
These added steps required the admissions and nursing staff to spend more time on data entry than they spent previously.
Other factors not fully considered during the implementation process were also identified.
Rolling Green Village successfully implemented secure messaging and integration with a data sharing network. They were able to pull electronic information from a variety of sources and import that information into their EHR. They were able to push information electronically to hospitals and local providers to aid in the care of the patient when he/she left the community.
These successes were overshadowed by the following:
Until more standards are put in place, electronic data sharing will continue to be supplemented with the more familiar paper processes.
Ohio Living, a post-acute, not-for-profit stakeholder provides home and community services to older adults in 50 of the 88 counties in Ohio—home to 86% of Ohio’s population—more than 10 million Ohioans. In addition, they receive referrals from more than half of the acute care hospitals in Ohio. According to Leading Age Ziegler 150, this organization is one of the nation’s largest not-for profit, multi-site senior living organizations. From this perspective, we have an opportunity to gain great insight into the possibilities of data sharing between acute and post-acute settings.
This stakeholder has 11 life plan communities, meaning these campuses provide care in settings including all of the following: SNF, assisted living facility (ALF), independent living (IL), memory care and outpatient therapy. They have seven home health agencies (HHA) which provide more than 11,000 episodes of care per year. Their hospice has an average daily census of more than 340. They also have several wellness clinics across the state. Finally, in addition to the many alternative payment models their residents are under, they are also part of a large ACO. All of this means they need to share data to and from the acute setting; to caregivers after their discharges; and to the many different payers. Yes, interoperability is an important and often discussed topic for the chief information officer of Ohio Living.
MatrixCare is used as the EHR in Ohio Living’s skilled nursing and assisted living facilities and has been for many years. HomeCare HomeBase is used as the EHR for its home health and hospice agencies. Clinicians and caregivers document electronically, and this information is available for transfer at time of discharge.
In some regional areas, Ohio Living uses Allscripts Referral Management as part of their process to learn of referrals from the hospital. This process allows for data review and tracking to improve care coordination and reduce administrative time.
Patient Ping is used to obtain information during a stay and to track downstream status after discharge. This information and Ohio Living’s telehealth follow up have helped them reduce hospital readmissions to less than half the average in the state of Ohio (they are near 7.5% and the rest of Ohio is nearly double this number). For the Cleveland Clinic, one of Ohio Living’s referral partners, Ohio Living uses CarePort for the referral and tracking process, essentially combining the Allscripts and Patient Ping tracking functionality into one application.
Ohio Living has account access into the several hospital EHR databases. This is how the data sharing process started several years ago and continues at hospital organizations that have not yet completed their own interoperability solutions. On the upside, this provides access to the complete record, which is sometimes necessary for care or billing purposes. On the downside, this requires an entire full time employee from IT to track and manage this inefficient process. Each hospital organization has their EHR set up a little differently, meaning a user in this role needs to learn the look and feel of each in order to find what they are looking for. In addition, when data is retrieved this way, it is stored in PDF format inside a documentation folder in the resident/patient’s chart, instead of being integrated into the EHR. Because of this process, this information could be missed by caregivers. For clarification, this process is still used at most post-acute settings because in most cases this is the only option.
Late last year, Ohio Living joined the State HIE community health record (CHR). This CHR supports an improvement in obtaining accurate clinical data and having this information immediately available inside of MatrixCare. This also reduces the number of provider systems they need to manually log in to obtain patient information. The CHR allows for a CCD for each patient admitted to any of their life plan communities and complies with all HIPAA regulations around accessing information. This also provides a consistent look and feel for clinicians to learn and access the information.
Along with other providers, Ohio Living expanded their telehealth services under the COVID-19 pandemic. However, they had a great deal of experience to build upon since they started their program in 2017 and expanded the service in 2019 by partnering with an ACO to provide chronic care services and remote monitoring after discharge from their HHA. These patients were provided with a 4G tablet and Bluetooth connected peripheral devices for monitoring heart rate, blood pressure, pulse, weight, etc. These devices also provided interactive face to face video conferencing for disease specific education and patient engagement. In order to provide this great care, updated information needs to be available for the nurses and clinicians at the point of service.
Ohio Living has extensive partnerships with their acute care referral sources. This is represented with active involvement in the ACO and Bundled Payment for Care Improvement programs with these referral sources. In addition, with recent changes in the Medicare Value Based Purchasing Program (VBP) the organization looked for even better ways to share data as one way to reduce rehospitalizations by providing even better transitions of care.
At this point, Ohio Living was already using the Allscripts Referral Management process and they had account access into most hospitals EHR systems. However, both of these processes presented their own challenges. For instance, the referral information did not include all of the needed information for an easy transition nor a complete insurance profile. Separately, the account access into the EHR was a very manual process. In addition, each hospital system set up their own account profiles and had set up their database different from other hospital systems. For these reasons, limitations of access might be identified when logged into one hospital vs. another. In addition, the process was time consuming. Finally, data gathered through either of these processes was not easily presentable to the clinician at the point of care because it was in the form of a PDF copy of the document meaning a clinician (at the point of care) would need to actively go searching to learn if the information was or was not present, or to review the information if it was there, versus having the information integrated into the EHR.
Finally, with the VBP changes, Ohio Living realized the value of learning more about the status of their residents after they were discharged from the SNF setting.
For these reasons, Ohio Living began looking for new solutions. The chief information officer (CIO) took the lead and did extensive research to learn of the various solutions, leading to their involvement in the state HIE and their use of the Patient Ping and CarePort applications.
Further, the CIO discussed the various options with her primary referral sources, leading to the use of the CarePort application. She recognized the need for a solution that would be neutral across all hospitals, with the same look and feel to end users and would have the ability to scale across their entire organization. For these reasons, they are now rolling out the CHR at all their locations.
Traditionally, an HIE does not provide a positive ROI for a SNF. The initial setup cost and the ongoing fees are expensive for the low margins of a post-acute provider. Ohio Living’s CIO recognized these challenges and identified them in the proposal. She outlined the current challenges and the value of a single system with a single look and feel. She also outlined the reduced administrative burden for clinicians to learn and access information, especially when they moved to another location, even on a temporary basis.
The CHR allows Ohio Living to access a patient’s treatment history, hospital encounters, problem list, allergies, lab results, radiology and other transcribed reports. They can also check patient demographic and insurance information which has already been captured by other providers. And, they can view, print, or download either the encounter specific or full continuity of care summaries for their records and do their account setup profile, which is maintained by their organization’s IT department and determined by their workflows.
Ohio Living’s goals for joining the HIE were to be able to easily access, view, retrieve, and download all pertinent health records for continuity of care. In addition, they want to be able to share their data if/when the patient/resident returns to the hospital for additional care. In other words, they want to make even better the transitions of care from their organization to and from any of their referral hospital systems.
Ultimately, they want to reduce unnecessary hospital readmissions, and these processes (along with their telehealth program) are definitely making a positive difference.
Ohio Living’s initial goals were met in that administrative burden is decreased, clinicians can more easily access the necessary information, and the rehospitalization rate continues to decrease.
There are two additional areas of noticeable improvement. Both of these findings are based on comments from end users within Ohio Living and from the hospital referral sources. The first is a noticeable improvement in communication with the hospital referral sources and the second is a noticeable improvement in the continuity of care at times of transition.
Early on, there was a concern expressed related to a possible decrease in communication between the organizations. The concern was that the post-acute organization might be forgotten if this happened. However, what was referenced most often was an improvement in the amount and, more importantly, in the type of communication. In essence, when the data is accessible, the communication was much more pertinent and appropriate, leading to even more trust from both organizations.
Even now, as the adoption rate of the CHR continues, Ohio Living continues to find even better success and improved outcomes.
This leads to one of the major learnings through the process of rolling out the CHR. There is a real value in planning and providing the important process of introducing and training of employees on the CHR. This takes education, reinforcement, and more education, including explaining the value of this new access to the information. Once the employees begin to see the value for an individual resident, they begin to appreciate how the significance of the CHR.
Although the process of retrieving information is easier, we still have a long way to go. As explained by Ohio Living’s CIO, “My real desire is to see a true convergence of the information digested by my EHR. This would be the optimal solution vs. a caregiver needing to log in to any other application.” Even better, we need this process of data digestion to happen on a bi-directional basis.
For this digestion to happen, we need further identification of content and transport standards and these standards need to be encouraged across all of healthcare. We also need even better patient identity standards.
There is work happening right now on the content and transport standards. Two examples are the DaVinci Project and the PACIO Project. In addition, some believe the recent Centers for Medicare & Medicaid Services Data Blocking Rule and the Office of the National Coordinator for Health Information Technology Interoperability Rule will help and they may. In addition, Trusted Exchange Framework and Common Agreement may move the interoperability needle forward a bit further. However, we need to recognize the costs to develop and implement each of these at the Provider level, especially now with the COVID-19 pandemic. If we look at the example of advancing EHRs in the acute and ambulatory sectors, we learn that providing stimulus dollars does advance the process. If we now want to advance interoperability from acute to post-acute settings, then maybe it is time to provide funding designed specifically to incentivize this process. This might include funding the initial start-up costs for a SNF provider to join the state HIE. Maybe then we will see the necessary increase in usage and functionality of the HIE as we move toward the trusted exchange framework by including these post-acute and community centers of care.
HIMSS would like to acknowledge the work of the HIMSS LTPAC Committee in the development this document. In particular, from the following members who authored and made significant contributions to this paper:
HIMSS would also like to recognize the efforts of Palomar Health, Life Care Services and Ohio Living for their work on transitions of care data exchange issues and whose contributions and experiences helped form the basis of this document.
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