Hassle-Free HIE With t he ED

1. Hassle-Free HIE With the ED LCC Pilots Subworkgroup S&I Longitudinal Coordination of Care Workgroup March 10th, 2014 Larry Garber, MD Medical Director for Informatics Reliant Medical Group

2. Reliant Medical Group (formerly known as Fallon Clinic) • 300+ provider multi-specialty group practice • 23 sites in central Massachusetts • Not affiliated with any hospitals • Not-for-profit • At financial risk for 70% of our patients • Member of Atrius Health/Pioneer ACO

3. Hassle-Free to ED 30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR ADT for Reliant Patients CCD with SVH MRN Reliant Medical Group’s Epic EHR St. Vincent Hospital CCD with SVH MRN Outside Record Icon in MedHost Bedboard

4. Improving Transitions of Care • ER and Hospital encounters automatically created in EHR from ADT • ER and hospital Discharge Notes file into EHR as well as InBasket of PCP, PCP’s RN, and Care Manager • ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge (based on ADT) which also go to physician InBasket

5. Alerts for follow-up appointments • Hospital ADT monitored for hospital discharges • 3 Days later, EHR checks to see if follow-up appointment took place or is scheduled • If none, an InBasket message is automatically sent to PCP’s appointment secretary

6. Alerts for monitoring of medications • 3 Days after hospital discharge, medication claims data are reviewed along with past and future labs • Alerts sent to PCP’s InBasket suggesting dose checking, monitoring or discontinuation

7. Getting Connected:LAND & SEE, KeyHIE Transform, and IMPACT

8. LAND & SEE • Sites with EHR or electronic assessment tool use LAND(“Local” Adaptor for Network Distribution) as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR • Non-EHR users receive, edit and send documents using a web browser to access their “Surrogate EHR Environment” (SEE)

9. Inbound LAND Transformations

10. Outbound LAND Transformations

11. LTPAC Communication using LAND & SEE CCD+ = Transfer Summary PCP Home Health LAND LAND CCD+ CCD+ CCD+ CCD+ LAND KeyHIE Transform SEE CCD+ MDS Hospital Billing Program MDS Nursing Facility

12. Questions? Lawrence.Garber@ReliantMedicalGroup.org