Transcript Document

Coordination of the Physician
Office and Hospital EHR
Bill French, VP eHealth Strategies
Wisconsin Office of Rural Health HIT
Implementation Workshop
Stevens Point, WI
August 24, 2007
Today’s Objectives
Explore methods for sharing information between
the hospital and physician office electronic health
record
Which is really a small part of the discussion of
Continuity of Care (COC)
Review Wisconsin and National initiatives
addressing COC
MetaStar is:
An independent, not-for-profit organization
Mission: to effect positive change in the
quality, efficiency and effectiveness of health
care
Contract with Centers for Medicare &
Medicaid Services (CMS) as the Medicare
Quality Improvement Organization (QIO)
for Wisconsin
The Doctor’s Office Quality
– Information Technology Project (DOQ-IT)
DOQ-IT project promotes the adoption of
EHRs in physician offices.
Assist physician offices who already have
EHRs with disease/population management
and internal or external reporting
FREE service to office practices
MetaStar does not endorse any specific
vendor or services
Wisconsin DOQ-IT Project
DOQ-IT IPG
MetaStar is currently
working with
approximately 40 clinics
ranging in size from
one to 70 physicians
revised 9/06
DOQ-IT Roadmap
Planning an EHR
Organization
 View Webcasts
#1 --What is an EHR?
#2 --Organizing your Efforts

Host MetaStar Planning Visit
Goal Setting
 View Webcasts
#3 --Process Mapping
#4 --Leadership and
Successful Change

Participate in 1-day workshop:
EHR Planning
Documentation
 Complete a commu nication plan

Selection Criteria
 View Webcasts
#6 – Vendor Selection I
#7 – Vendor Selection II
#8 – Interoperability

Complete process mapping
Request additional MetaStar support, as
needed: Onsite visits, Conference Calls
and/or
- E mails
Move to Selecting
an EHR Module
Participate in 1 -day workshop:
Preparing for Selection
Implement ing an EHR
Implementation Plan
 View Webcast s
#10 -- Hardware
#11 – Implementation
Strategy
#12--Communicating with
Patients

Due Diligence
 Complete an RFP

Complete due diligence on 3 -5
vendors

Host a MetaStar
Selection V isit
Host MetaStar Goal Setting Visit
Requirements Specifications
 View Webcast
#5—Business Case and ROI

Select ing an EHR

Select a vendor of c hoice
Contracting
 View W ebcast
#9 – Contract Coaching

Contact with vendor of choice

Coordinate a conference call
with clinic, vendor and
MetaStar
Request additional MetaStar support,
as needed: Onsite visits, Conference
Calls and/or E -mails
Move to Implementing
an EHR Module
Participate in 1 -day workshop:
Implementation Planning
Functional
 View Webcast s
#13 – Forms and Templates
#14 – Chart Conversion
System Build
 View Webcast s
#15 – Guidelines
#16 – Security
#17 – Test Planning

Host a MetaStar Planning Visit
Install
 View Webcast
#18 –Issues Management &
Change Control

Improving with an EHR
Evaluation
 View Webcast
#19 – Benefits Realization &
Utilization

Quality Measures and Reporting
 View Webcast
#24 – Reporting &
Benchmarking
#25 – Using EHR data for
quality

Move to Impr oving
an EHR Module
Submit data to CMS
Warehouse (optio nal)
Improvement Planning
 View Webcast
#20 – Improvement 101
#21 – Strategies to improve
with an EHR
#22 – ePrescribing in the
physician office
#23 -- Integrating EHR
systems & Patient
Portals

Participate in 1 -day workshop:
Improvement with an EHR

Comp lete an improvement plan

Host a MetaStar Improvement
Planning Visit
Go-live date
Request additional MetaStar support, as
needed: Onsite visits , Conference Calls
and/or E-mails
Complete evaluation plan
Request additional MetaStar support, as
needed: Onsite visits, Conference Calls
and/or E -mails
Hospital IT-Related Projects
Computer Provider Order Entry (CPOE)
Patient Centered Bar Code Technology
Telemedicine/telehealth
Other MetaStar Hospital Projects
Reporting of Quality Measures
Improvement on Appropriate Care
Measures
Surgical Care Improvement Project
Rural Organizational Safety Culture
Hospital Payment Monitoring Program
Other MetaStar EHR-Related Activities
Board position on the Wisconsin Health
Information Exchange
Governor’s eHealth and Patient Safety
Board work groups
Other Projects
Culture in Medicine
Quality improvement project for Medicare
drug benefit
Beneficiary protection
Commercial Services
HEDIS Auditor
Completed an environmental scan of EMRs
in Wisconsin hospitals and physician
practices for the Governor’s eHealth and
Patient Safety Board
MetaStar’s Web Site
DOQ-IT and Hospital EHR tools available .
www.metastar.com
Hospital & Physician Office HER - One Path
to Continuity of Care (COC)
Why are we concerned with COC?
Quality of care - patient safety
Efficiency of care
Patient satisfaction
Market share
COC and Quality of Care
Extrapolation of national estimates to SE
Wisconsin
400 people die for lack of recommended
care
55% of patients fail to receive
recommended evidence-based care
COC and Efficiency of Care
Missed prevention opportunities cost $7M
in hospital bills, $80.5M in lost work days
Wisconsin clinicians and staff in outpatient
clinics spend up to 25% of their time
searching for information needed to care for
patients – estimated to be $668 in SE
Wisconsin
Patient Satisfaction
Patients do not like to repeat information
Patients will change providers that lack the
technology for the patient to communicate
with all of their providers
Market Share
Physicians will not continue to refer
patients to hospitals and providers who do
not keep the referral physician informed
What Does the Hospital EHR Need from the
Physician Office EHR?
Why the patient is being referred to the
hospital
Admission for medical and/or surgical
therapy?
Period of observation?
Diagnostic tests?
What Clinical Information Does the Hospital
EHR Need from the Physician Office EHR?
Test results and findings indicating the need
for hospital services
Admitting orders
Medication status to include drug allergies
Patient and family medical history
What Does the Physician Office EHR Need
from the Hospital EHR?
When the patient needs to be seen next?
What follow-up care is required?
Medication status when discharged?
Lab Results?
How May COC Be Achieved?
Health Systems with integrated EHRs
across all providers
Local initiates to share health information
National initiatives to further
interoperability
Health Systems with Integrated EHRs
Small number of large providers will realize
this level of functionality
Large number of small physician practices,
community and rural hospitals will not be
able to obtain this level of functionality
MetaStar Experience
Integration is often a reason to select a
product
Lab interfacing is much easier
Buy-in can be difficult if the hospital
doesn’t include provider in selecting
Workflow needs to be addressed in both
settings
MetaStar Experience
The flow between settings should be
mapped
Need to have both hospital and clinic
representation on the implementation team
Clinical implementation is typically more
difficult
Functionality vs. integration debate
National Initiatives to Achieve COC
American National Standards Institute
(ANSI)
Health Level 7 (HL7)
American Society for Testing and Materials
(ASTM)
National Initiatives to Achieve CCR (Cont)
CCHIT Ambulatory Interoperability 2007
Final Criteria
Regional Health Information Organizations
(RHIOs)
American National Standards Institute (ANSI)
(ANSI) coordinates the development and
use of voluntary consensus standards in the
United States and represents the needs and
views of U.S. stakeholders in
standardization forums around the globe
Approves many HL 7 standards
Health Level 7
Standards for electronic interchange of
clinical, financial, and administrative
information among health care-oriented
computer systems; e.g. hospital information
systems, clinical laboratory systems
Collaborated with ASTM to develop the
Continuity of Care Document (CCD)
CCD
CCD is a “melding” of HL 7’s Clinical
Document Architecture (CDA) and the
Continuity of Care Record (CCR)
developed by ASTM
The final (CCD) will describe how to
implement the CCR dataset with the
standard architecture for clinical records
developed by HL7
American Society for Testing and Materials
(ASTM) (CCR)
CCR developed jointly by ASTM International,
the Massachusetts Medical Society, the Health
Information Management and Systems Society,
the American Academy of Family Physicians and
the American Academy of Pediatrics to improve
continuity of care, to reduce medical errors, and to
assure a minimum standard of health information
transportability when a patient is referred or
transferred to, or is otherwise seen by another
provider.
CCR Basic Patient Information
Header Information
Patient’s, provider and insurance
information
Patients health status - allergies,
medications, vital signs, diagnoses, recent
procedures
Recent care provided
Reason for referral or transfer
Patient, Provider and Insurance InformationHeader
Header, or Document Identifying
Information , contains required information
about the referring or "from" clinician, as
well as information about the referral or
"to" provider, and document date. It also
addresses the purpose for creating the
document and reason for referral.
Patient, Provider and Insurance Information
(Cont)
Patient Identifying Information : This section includes the
required information to identify and distinguish the patient
throughout the referral process, transitioning to and from
hospital, clinic, physician office, or home environments
(any care setting). (Note: The CCR is not based on a
centralized system or a national patient identifier. Rather, it
is based on a federated or distributed identification system
that links various providers and contains the minimal set of
identifying information that could be used by any record
system [paper or electronic] to assign the individual their
own identifier.) Additional information in this section
includes support contacts and advanced directives.
Patient, Provider and Insurance Information
(cont.)
Patient's Insurance and Financial Information.
The individual's Medicare or commercial
insurance information. Data elements include
Insurance Company Name, Subscriber's Name,
Subscriber's Date of Birth, Subscriber's Member
ID, and Other Insurance Information. These are
the minimal data elements from which eligibility
for insurance coverage may be determined.
Patients Health Status - diagnoses
Health Status of the Patient : Diagnoses,
Problems, and Conditions are preferably ranked
by order of importance or in reverse chronological
order. They are described in plain English and by
code, according to the selected coding system.
Also included are date of onset, date of most
recent resolution, status, patient awareness of
condition, family history, social history, and a
source field.
Patients health status - allergies, medications,
(Cont)
Adverse Reactions/Alerts lists allergies by agent
and symptom with optional fields for source and
date of last reaction, as well as other pertinent
alerts about the patient.
Current Medications are listed by brand name,
generic name (optional), code system, code, start
date, dose, schedule, refills, prescriber, status, and
a comments field.
Patient Health Status - Immunizations
Immunizations documentation includes
information about each disease against
which immunization was given, the date the
immunization was received, and (optional)
dose strength, unit and route of
administration as well as manufacturer and
lot #.
Patient Health Status- Vital Signs
Vital Signs documentation includes height,
weight, blood pressure, temperature,
respiratory rate, date vital signs were
recorded, pulse oximetry, and optional peak
expiratory flow rate (PEFR), as well as head
circumference (for Pediatrics).
Patient Health Status- Laboratory Results
Laboratory Results documentation includes
blood sugar, urine protein, creatinine,
sodium, potassium, hemoglobin, hematocrit,
WBC, and the date the sample was taken.
Patient Health Status- Procedures
Procedures/Assessments documentation
includes descriptions of procedures, code
system, procedure code, procedure date and
time, location, result and performed by
whom. Also included here are assessments,
such as mental health assessment,
functional assessment.
Patient Health Status- Extension
The Health Status section may be amplified
in the optional “extension” for medical
specialty-specific information. For instance,
pediatric providers may want to include a
growth chart in the CCR.
Recent Care Provided
Care Documentation: Includes detail on the
patient-clinician encounter history, such as
the dates and times of recent and pertinent
visits and the purposes of the visits and
names of clinicians or providers. This
documentation section may be significantly
expanded in the optional “extensions .”
Reason for Referral or Transfer
Care Plan Recommendation: The Care Plan
is a free text entry section that includes
planned or scheduled tests, procedures, or
regimens of care
Extensions of the Six Major Sections
Enterprise and Institution-specific Information particularly
regarding discharge or transfer, e.g., hospital to nursing
and rehabilitation facilities or to home care agencies, and
vice versa.
Minimum data sets oriented toward Medical Specialties ,
e.g., Pediatrics, Surgery, OB-GYN, Cardiology,
Orthopedics, etc.
Disease Management will accommodate recording specific
disease management information, measures or guidelines,
e.g., diabetes, congestive heart failure, asthma, etc. This
extension may be utilized by health plans, pharmaceutical
companies, patient advocacy groups, and others interested
in promoting “best practices”
Extensions of the Six Major Sections (Cont)
An extension for Patient-entered, Personal Health
Record use, e.g., for complementary and
alternative medicine care documentation or other
patient considerations such as private or sensitive
health information a patient may be reluctant to
share with certain practitioners or spouses.
An extension for more comprehensive Payerspecific Information and possibly claims
attachments.
CCR Goal
Enable the next provider to easily access the
information at the beginning of a first
encounter and easily update the information
when the patient goes on to another
provider to support the safety, quality and
continuity of care.
CCR Format
XML standard document
Machine and human readable
Displayed or printed through use of web
browser, PDF reader and word processor
Developing the ability to forward and
receive this XML document will be useful
when integration of EHR is not present
CCR is Not an
EHR : Although the CCR is meant to address the need for
continuity of care from one provider or practitioner to any
other practitioner, it is not designed to be a mini EHR. Lab
and x-ray and other testing results are included only to the
extent the provider completing the document finds them
relevant. It does not list symptoms as its primary
function. Rather it lists diagnoses and the “Reason for
Referral” to the next provider or diagnostician. The
“Reason for Referral” may include problems or symptoms
but not in the manner in which a traditional EHR uses them
as the starting point for a documentation of the SOAP-type
note. Nor does it include a chronology of events, in the
fashion expected in an EHR
CCR is Not a
Progress Note : Completion of the CCR should not be
thought of as mandatory after every visit to a primary care
physician (PCP) or specialist or other clinician who is
delivering care to the patient. Thus, it is not replacing a
progress note used in the traditional record. However, if
the clinician is planning to refer the patient to another
provider, then the CCR should be updated and prepared
specifically for the next anticipated provider and
customized to assist at the next “point of care”. Any
relevant information for the next provider should be added
to the CCR, just prior to the referral, if feasible.
CCR is Not a
Discharge Summary : The CCR differs from the Discharge
Summary mainly in that the CCR is much more concise,
involves less narrative or free text, and emphasizes the
brief care plan for the next steps to assist the patient to
recover or be rehabilitated following the most recent
episode of illness/care. The CCR highlights or spells out
the next appointments and follow-up visits and instructions
to assist the Visiting Nurse or other next caregiver
regarding expectations of the follow-up encounter from the
perspective of the clinician completing the form
CCR is Not a
Consultation Note : The CCR is not
intended to replace the initial consultant's
note to the referring physician. There is,
however, a potential for the CCR to be used
in lieu of the consultant's note back to the
referring PCP after the second visit,
provided the lengthier summary of findings
and plan of care were documented after the
first visit and sent to the original provider
Medical Records Institute (MRI)
Supports CCR
The Medical Records Institute Inc invites healthcare practitioners, provider institutions,
payers, managed care organizations, and others to submit their application for MRI ’s
prestigious Continuity of Care Awards 2007.
For the purpose of this Awards program, a Continuity of Care application is the adoption
and utilization by a healthcare entity (e.g., solo practitioner, RHIO, provider institution,
physician practice, employer, payer) of the Continuity of Care Record (CCR) data set
detailed in the ASTM Continuity of Care Record Standard Specification 1 for the direct
purpose of giving clinicians access to relevant current and past patient information in
order that they may make informed healthcare assessments and treatment decisions.
Such applications seek to reduce wasteful duplication, improve patient safety, and
enhance quality of care.
Adoption of the CCR data set may be through implementation of the ASTM E31 CCR
and/or through integration of its data set into HL7 ’s Continuity of Care Document
(CCD). Utilization of the CCR data set must include import and export of the data set
to/from other healthcare entities and/or patients for the purpose of supporting delivery of
healthcare. (Note: Recognizing that not every provider entity may have implemented
everything addressed in the CCR data set, submissions will be accepted for partial
implementations as well.)
MRI awarded the winner a $3000 prize during the 2007 TEPR meeting in Dallas
CCHIT Link
http://www.cchit.org/files/Ambulatory_Domai
n/Ambulatory_INTEROPERABILITY_200
7_Proposed_Final_Criteria_14Feb07.pdf
http://www.cchit.org/files/Inpatient_Domain/I
npatient_Interoperability_2007_Draft_Crite
ria.pdf
CCHIT CCHIT Ambulatory Interoperability
2007 Final Criteria
Implement HL-7 ASTM CCD and ASTM
CCR
IA-3.10 Access and view a medication
history from a PHR
IA-5.09 Send data to PHR
CCHIT Ambulatory Interoperability 2007
Final Criteria (Cont)
IA-5.10 Receive data from PHR and import
to EHR
IA 5.11 Receive registration summary from
patient and import into EHR
Regional Health Information Organizations
(RHIOs)
A RHIO is a group of organizations with a
business stake in improving the quality,
safety and efficiency of healthcare
delivery. RHIOs are the building blocks of
the proposed National Health Information
Network (NHIN). To build a national
network of interoperable health records, the
effort must first develop at the local and
state levels.
A Wisconsin RHIO
The Wisconsin Health Information Exchange
(WHIE) is a project that is the first step in
establishing a multi-purpose health information
exchange system in southeastern Wisconsin to
improve the quality and efficiency of health care
National Institute of Medical Informationics
(NIMI) is registered in Wisconsin as a non-profit
501C3 corporation and serves as the non-profit
organizational entity that is creating WHIE
A Wisconsin RHIO (Cont)
Providers may join the WHIE
Membership will enable access to clinical
information required to achieve COC
Questions?
Contact Information
MetaStar, Inc.
2909 Landmark Place
Madison, WI 53713
Phone number
608 441-8246
www.metastar.com
[email protected]
This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-65