Improving Massachusetts Post-Acute Care Transfers

In January 2011, Massachusetts was awarded two HIE Challenge Grants, Improving Massachusetts Post-Acute Care Transfers (IMPACT) and Massachusetts Department of Public Health Net (MDPHNet).

The major themes of IMPACT are:
*Reducing barriers to adoption of Clinical Document Architecture (CDA) Templates in Electronic Health Records (EHRs)
*Enabling facilities that lack EHRs to take advantage of Health Information Exchanges (HIEs)
*Facilitating communication with consumers.

As we journey toward accountable care nirvana, it's increasingly important that information follows the patient at all transfers of care.   Nationally, the S&I Framework Transition of Care Use Case Workgroup is harmonizing the standards needed to support transitions.  In Massachusetts, we're creating the necessary HIE capabilities.

During a recent IMPACT planning call, we discussed the need to incorporate transfer of care HIE into  clinician workflows.   A major barrier to HIE adoption to date has been the use of portals that are separate from the EHRs clinicians use at the point of care.   It is true that Meaningful Use Stage 1 requires EHRs to produce care summaries (CCR or CCD), but it does not require them to be sent through a consistent regional or national transport infrastructure that is tightly coupled to existing care processes.

Here's a possible integrated workflow.

Doctors and nurses use EHRs to enter the necessary data to support transfers of care.    All this data will be assembled in an enhanced CCD.  That CCD will be sent to a skilled nursing facility (SNF) which may or may not have an EHR.    The CCD will be incorporated into the SNF's EHR if one exists.  If no EHR exists, the CCD will be viewable via a portal, renderable as fax, or transmitted by secure email.

The data elements in the ideal transfer of care summary are a superset of the typical CCD.  CDA Templates should provide us the flexibility we need.   For example, a complete transfer document should include patient risks (falls, restraints, elopement), personal belongings (glasses, hearing aids, dental appliances), and whether a healthcare proxy has been invoked .  Keith Boone nicely summarized the gaps between the CCD and the transfer of care summary form developed in Massachusetts.

Of course, the workflow might be more complicated.    Nurses and doctors may complete their portions in EHRs, but there may be additional data provided outside the EHR by case managers.   There may be a need to send preliminary summary information to multiple SNFs to match the patient to the right level of care.    The clinicians filling out the summary may not know which facility the patient will be discharged to.  A case manager may finalize the patient placement, add additional summary information, then route the finished transfer of care document to the right facility.

Once the patient is at the facility, new care will be rendered.   The SNF will need to document a summary of that care and a plan for additional care once the patient is discharged home.    The SNF could use its EHR for such documentation, but since many SNFs are still using paper, they will need a portal which supports structured documentation and routing of summaries electronically to PCPs, homecare agencies, and families.   Ideally, this portal would incorporate data sent from the original transferring hospital, so that the summary could be updated instead of starting from scratch.

Of course, all of these electronic transfers must be protected with appropriate security, auditing, and data integrity checking.

Once we document the workflow, we'll finalize the technical solution.  It could involve secure transmission from hospitals to an intermediary health information services provider (HISP) that hosts a web-based application enabling case managers to monitor queues of soon to be discharged patients and supporting access by appropriate candidate SNF facilities.    The portal will track what has been completed and what still needs to be completed based on the ultimate type of destination for the document (e.g. SNF vs. home health vs. PCP vs. patient, etc.).  Once the patient is matched with a SNF, the final step - transfer to the SNF's EHR could occur securely.   The portal would also send confirmation of the final transmission along with a copy of the complete transfer document back to the original transferring hospital's EHR.

As we drill down on the workflow, we'll find interesting questions.   If transfer data are missing, someone will need to be notified that completion is necessary before it can be sent.  How and to whom does this notification take place?  Different deficiencies require action by different personnel.  Missing treatment or follow-up plans may be the responsibility of the Attending Physician (or Resident), while identifying the actual Home Health Agency or SNF may be the responsibility of a case manager.  How can this be integrated seamlessly into EHR-based workflows without requiring customization of the EHRs?  Should the CCD contain a listing of the entire care team (including case managers and temporary float nurses) from the sending institution?  If state (or national) Provider Directories are created, will they include nurses and case managers?  How will registration and authentication of all of these users take place?  How will users be restricted to just seeing their patients and not anyone else's? Who will proactively manage the audit trails?  Will it pass the "Boston Globe" test to have CCDs from across the state or region stored in a central portal location?

The project will answer many workflow and policy questions.   It's clear that having certified EHRs with the ability to send and receive CDA templates and eventually reducing dependency on stand alone web portals will greatly simplify the workflow.