Patient Care Summary Exchange

1. Patient Care Summary Exchange State HIE TA Program Webinar August 6, 2010

2. 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 today’s webinar! For additional TA, inform your project officer !

3. 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 provider’s 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

4. 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

5. 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 EHR’s 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

6. 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)

7. CLINICAL SUMMARIES IN CONTEXT

8. Communicating Information Requires Three Things Content Transportation Containers / Packaging

9. 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”

10. 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?

11. 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 patient’s health status (for example, problems, medications, allergies) and basic information about insurance, advanced directives, care documentation, and the patient’s 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

12. Sample CCR

13. 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/Continuity_of_care_document

14. Sample CCD

15. 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.

16. STATE HIE STRATEGIES FOR IMPLEMENTATION OFCARE SUMMARY EXCHANGE

17. 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

18. 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

19. ISSUES TO CONSIDER IMPLEMENTING PATIENT CARE SUMMARIES ACROSS TRANSITIONS OF CARE

20. #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

21. #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

22. CLINICAL SUMMARIES IN PRACTICE

23. NEHEN in Massachusetts Historical Highlights of NEHEN’s 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, Children’s, Northeast (discharge summaries) • 2008 – Push Pilot extended to BIDMC affiliated CHC’s • 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

24. NEHEN Clinical Data Exchange Context NEHEN Clinical Data Exchange NEHEN Administrative 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 NEHEN e-Prescribing Exchange 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 System Administration Tools

25. NEHEN Clinical Exchange Current Status

26. 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

27. MedVirginia, NHIN & SSA Existing and new data suppliers in the MedVirginia chain

28. 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

29. A few lessons learned….. • Standards • Process • Anticipate • Communicate • Partnership • “Eyes on the prize”

30. 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 state’s MMIS through a daily feed) including prescriptions • CCD is created real time upon request from providers, hospitals, etc. • Kentucky’s 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

31. Other State Examples • Vermont • Rhode Island NHIN Direct Implementation Pilot • Massachusetts NHIN Direct Implementation Pilot

32. Resources • ASTM:http://www.astm.org/Standards/E2369.htm • IHE:http://www.ihe.net/ • HL7:http://www.hl7.org/implement/standards/cda.cfm • HIMSS: http://www.himss.org/ • HIMSS EHR Association:http://www.himssehra.org/ASP/index.asp • NHIN: http://www.healthit.hhs.gov/portal/server.pt?open=512&objID=1142&parentname=CommunityPage&parentid=1&mode=2&in_hi_userid=10741&cached=true • NHIN Direct:http://www.nhindirect.org/

33. Patient Care Summary ExchangeDISCUSSION State HIE TA Program Webinar August 6, 2010