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The road to interoperability

The road to interoperability. Care Transitions with Oklahoma challenge grant. Road to Interoperability. ONC Challenge Grant The government’s first attempt to look at care transitions HIE SMRTNET Care Coordination Facilitator Care Transitions Light-weight options for care coordination.

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The road to interoperability

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  1. The road to interoperability Care Transitions with Oklahoma challenge grant

  2. Road to Interoperability ONC Challenge Grant The government’s first attempt to look at care transitions HIE SMRTNET Care Coordination Facilitator Care Transitions Light-weight options for care coordination

  3. Challenges

  4. Medication errors Errors in transitions of care (i.e.; communication) Familiarity with the patient Lab/Pharmacy environment Advanced Directives coordination Well-documented issues

  5. Between 2000 and 2040 the number of older adults with disabilities will more than double, increasing from about 10 million to about 21 million, according to the intermediate disability scenario. “The intermediate disability scenario projects that in 2040 there will be only about 9 adults ages 25 to 64 to support each disabled older adult, down from about 15 younger adults in 2000.” Richard W. Johnson, Desmond Toohey, Joshua M. Wiener. May 2007 “Meeting the Long-Term Care Needs of the Baby Boomers: How Changing Families Will Affect Paid Helpers and Institutions” The Urban Institute. http://www.urban.org/url.cfm?ID=311451 Impact of the Near Future

  6. Logic Model

  7. Clinical Transformation

  8. LTC to Acute Integration

  9. Challenge Grant Taxonomy

  10. June 2012, Baltimore, MD

  11. Universal Transfer Form • Disparate Systems • Acute Care EHR • LTCF Clinical Documentation Tool • Facility MDS • HIE • Direct

  12. HIE Acute Stay

  13. Direct Need to Know Message

  14. Early Outcomes Installed Clinical Documentation Tool in All Facilities 98% Compliance with Daily Assessments Phase II Live with INTERACT II Assessments in Place HIE Interfacing Near Completion Governance (Local LTPAC) Critical to the Success and Buy-In of Facilities

  15. Projected Outcomes 7% Reduction in Avoidable Hospitalizations 10% Reduction in Return to ED Only Improved Provider and Patient/Patient Advocate Satisfaction With Handoff Process Best Practices for Interoperability, CDT and INTERACT II Integration in LTCF Clarity for Next Steps Toward Deeper Integration and Provider Communication

  16. What is hie/smrtnet? • State-wide HIE • Integration with all major EMR platforms • Clinical Decision Support • Enhanced provider workflow via Native EMR integration • Innovative Environment focused beyond HIE • Six year old physician/hospital-sustained HIE • Disparate connections to all major EMR platforms • Statewide HIE • 26 hospitals • 96 clinics • 2.1 million lives • 2500 users

  17. Data Saturation

  18. University of Oklahoma Department of Family and Preventive Medicine • Comprehensive, tiered risk engine (recommendation algorithm) • Evidence-based United States Preventive Services Task Force (USPSTF) guidelines, CDC / ACIP guidelines, and AAFP guidelines for preventive services

  19. Provider View of Recommendations

  20. Community CCD’s = Aggregated CCD Acute Care CCD Preventive Recommendations Primary Care CCD

  21. Next Steps • Case Management Coordination • Discharge/Transition Checklists • Condition Checklists

  22. Workflow (hospitalized patient) ADT feed (HL7) EHR Daily Patient lists Pdf placed in patient chart (HL7) Patient-centered collaboration, coordination, and communication Checklistscompleted

  23. Care Collaboration • CareInSync application mobile device driven addresses workflow issues • Care team collaborating within context of the patient • Team and roles are clearly identified • Case manager often coordinates/manages the entire process • LTC intake coordinator and providers often not imbedded in the transition process early enough

  24. Care Transitions • Multidisciplinary discharge risk assessment checklist • Additional evidence provided by clicking on checklist item • Team has collaboratively identified some risks CAREINSYNC CONFIDENTIAL

  25. Next Steps • Case Management Coordination • Discharge Checklists • Condition Checklists

  26. Elements of the Care Continuum Longitudinal Order Sets

  27. LOS Content • Patient Specific • Last Attending to Activate/Renew • Condition Management Service Assign • Custom LOS by Chronic Condition • Transitions of Care Check List • Condition Specific Check List • Readmission Prevention Check List • Nursing Protocol By Condition • Actionable Orders by RN via LOS • DI, Lab, Consultations • Notify Physician Parameters • Send to ER Parameters

  28. CHF LOS Example • Ima Always Sickly DOB 2/1/1937 • Dr Yeaman (Contact Info) • Norman Condition Mgt Service • CHF LOS Version 1.1 • CHF Care Transition Check List • CHF Care Parameters Check List • CHF Readmission Prevention Check List • CHF Nursing Protocol • CHF Actionable Orders by RN via LOS • Double Lasix x 3 days if > 5lbs gained in 3 days • Double Potassium x 3 days if > 5lbs gained in 3 days • Compression Stockings • Wound Care • BMP, BNP, CXR • CHF Related Notify Physician Parameters • CHF Related Send to ER Parameters

  29. Provider Care Continuum Tasks

  30. Thank You

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