Redwood MedNet Transition of Care (ToC) Messaging Service

Pilot Project Brief - Redwood MedNet : : RWMN Direct Pilot Shared Documents : : Cal eConnect IZ Demonstration
Updated October 1, 2011

Background

The transition of care (“ToC”) use case investigates direct messaging as an option for communication of clinical content during two specific transitions of care: 1) transfer of a skilled nursing facility (SNF) patient to a hospital; and 2) transfer of a patient from a hospital to a SNF. The project identified two sets of trading partners that currently exchange patients with each other and have previously established (i.e., out of band) the business, legal and consent requirements for exchanging clinical data. Both hospitals are Critical Access Hospitals (CAH), and both are independent facilities owned and operated by taxpayers of their districts. Both SNFs are privately owned and operated, and each is located within 2 miles of the corresponding hospitals.
Community
Healdsburg

Fort Bragg
County
Sonoma

Mendocino
Population of Medical Trading Area
400,000

10,000
Hospital
Healdsburg District Hospital

Mendocino Coast District Hospital
Hospital Beds
43

25
SNF
Healdsburg Senior Living

Sherwood Oaks Health Center
SNF Beds
38

79
Distance
1.5 miles

1.8 miles
To determine whether direct messaging is a viable solution for information transfer between these paired trading partners, this project seeks to inventory all standard documents exchanged between the facilities during patient transfer. Each clinical document will be evaluated within its workflow for the potential benefit that may be possible if the facility changes the workflow to use electronic transport via direct messaging. At a high level, the project asks first if either facility is far enough along in electronic health record adoption to move this care transition process from a "print and fax" handoff to an electronic handoff, and second if direct messaging is the correct transport for an electronic handoff.

Project Tasks

  1. Stakeholder interviews to develop an As-Is workflow with an inventory of transfer documents
  2. Evaluation of To-Be workflow candidates which utilize direct messaging for document transport
  3. If selected as an optimum workflow, build a direct messaging transport solution
  4. If built, train users and monitor usability
  5. Report on project

Participants

Abbreviation

Facility
RWMN

Redwood MedNet
HDH

Healdsburg District Hospital
HSL

Healdsburg Senior Living
MCDH

Mendocino Coast District Hospital
SOHC

Sherwood Oaks Health Center

Production Timeline

June 2011 -- Project grant funds received in late June
July 2011 -- Workflow investigation and document inventory
August 2011 -- Workflow investigation and document inventory
September 2011 -- Direct messaging candidate investigation
October 2011 -- Functional requirements for direct messaging solution
November 2011 -- Test Direct Messaging solution
December 2011 -- Publish final report to funder

Findings to Date

The rural setting in Fort Bragg features two health care facilities as trading partners in an isolated community of 10,000 people with no nearby alternatives for patient transfers - - the next closest hospital is a 60 minute drive, and the next closest SNF is a 90 minute drive. This isolation creates a health care market where efficient collaboration is an operational priority for both facilities. Therefore the setting in Fort Bragg is conducive to the direct messaging solution. The suburban setting in Healdsburg features two health care facilities which each have multiple alternate trading partners for patient transfers in a metropolitan area of 400,000 people. This confluence of multiple independent trading partners creates market-based competition for patient placement at SNFs. Therefore the setting in Healdsburg is suboptimal for a bilateral direct messaging service between just two out of many local health market participants. The Sonoma County health market might be conducive to direct messaging as a communications solution if all local trading partners participate; however, the scale of deployment necessary for such a region-wide investigation is beyond the scope of this project.

Workflow Overview
There are two basic care transitions in this direct messaging investigation.
  1. Placement of a hospital patient at a SNF. In this workflow a Case Manager evaluates optional SNF locations for each planned patient discharge. After accumulating sufficient clinical, demographic and financial details, the Case Manager contacts candidate SNFs and typically faxes patient information to the admissions staff at the SNF for evaluation. If the SNF agrees to the patient transfer, then a full set of transfer documents is prepared to accompany the patient, typically as a paper chart. Some content, such as final lab test results or discharge narrative transcription, are sent to the SNF after the patient transfer, typically by fax.
  2. Transfer of a SNF patient to a hospital. In this workflow there are two types of patient transfer: a non-emergent temporary transfer of a resident to the hospital for an acute procedure; and an urgent transport of the patient to the hospital emergency department. Both types essentially gather the same clinical content, which are presented by the SNF to the hospital admissions staff. Some patient information is faxed to the hospital, and some is delivered with the patient as paper reports.

Technology at each Facility
Healdsburg District Hospital:
The hospital is a current participant in Redwood MedNet, with active interfaces to the hospital's laboratory test results, radiology narrative text and ADT messages. Currently funded HIE expansion tasks will add full patient medication history and clinical discharge summaries in 2012. The hospital has plans to adopt CPOE in the future, but provider orders and nursing notes remain hand written, and the patient chart is still managed as a paper folder. The hospital information system is from HMS. Laboratory test results, imaging consult reports and patient demographic and insurance information are currently available as electronic data from HMS or via interfaces with Redwood MedNet. The hospital has enterprise wide scanning tools which enables the electronic capture of handwritten documents, although lacking a formal scanned document archive the common practice is to photocopy handwritten documents for the patient chart, and to fax paper copies rather than scan them for electronic transport.

Healdsburg Senior Living: Patient charts are on paper. Fax machines are the primary communications method for clinical documents sent to or from the hospital. However, during the new resident evaluation phase the local hospitals have divergent communication strategies with local SNFs in the Santa Rosa metropolitan area.

Hospital

City
Miles
Beds

Healdsburg District Hospital

Healdsburg
2
43

Sutter Medical Center

Santa Rosa
16
135

Santa Rosa Memorial Hospital

Santa Rosa
17
278

Palm Drive Hospital

Sebastopol
23
37
The game changer in this environment is the new extranet established by Santa Rosa Memorial Hospital (SRMH). Currently the three smaller facilities fax full patient details on potential transfer candidates to HSL, while SRMH sends an electronic referral message to HSL. SRMH has a full CPOE environment. All patient data on a transfer candidate is available electronically for review by HSL. In this workflow environment, if given the choice between direct messaging from HDH or electronic access to the candidate patient data via a clinical portal, HSL would choose the portal over the secure e-mail. As a current user of online tools that enable investigation of patient referral candidates in real time, a proposal to use a secure email solution feels like a step backwards.

Mendocino Coast District Hospital: The hospital is a current participant in Redwood MedNet, with active interfaces to the hospital's laboratory test results and radiology narrative text. The hospital has a Meditech Hospital Information System (HIS) and is installing a CPOE solution from NextGen in 2012. Currently the hospital uses a paper chart for patient clinical data and also uses the Galactica enterprise document imaging solution so that most paper content is also available as a scanned image. In addition, medical records uses an enterprise transcription service. The hospital Case Managers do not use the Meditech case management module, but rather work out of each patient's paper chart. Moving to an electronic process for document transfer will be a major disruption, but may be desirable pending final study of the planned electronic workflow.

Sherwood Oaks Health Center: Patient charts are on paper. Fax machines are the primary communications method for clinical documents sent to or from the hospital. The SNF uses PointClickCare for patient demographics and some clinical document tracking. Given the tight workflow dependence upon bilateral communication with Mendocino Coast District Hospital, the administration of SOHC is interested in increasing their use electronic documents if it increases efficiency in communicating with the hospital.

ToC Document Inventory

facility
total
electronic
handwritten

Healdsburg District Hospital
21
3
18

Healdsburg Senior Living
2
0
2

Mendocino Coast District Hospital
36
21
15

Sherwood Oaks Health Center
8
3
5

Hospital Transfers Patient to SNF

As Is Flow of Patient Data
rwmn_direct_h2s_asis_v2.jpg

To Be Flow of Patient Date


SNF Transfers Patient to Hospital

As Is Flow of Patient Data
rwmn_direct_s2h_asis_v2.jpg

To Be Flow of Patient Data


Next Steps


Healdsburg
Hospital transfers patient to SNF
  1. final planning at HDH
    • with Gary ( IT)
    • with Diana (Medical Records)
    • with Karen (Case Mgr)
  2. final design for clinical document access by SNF
    • final approval by CNO
    • final approval by HSL
  3. if no direct messaging, then project complete; if direct messaging selected, then build it
    • if build, then service spec
    • if build, then write user facing instructions
    • if build, then test install
    • if build, then train users
    • if build, then release to production
  4. write report

SNF transfers patient to Hospital
  1. direct messaging unlikely due to lack of electronic source documents
    • confirm with ED of HSL that there are not electronic source documents
    • if there are electronic source documents, then review option for direct messaging payloads
    • of direct messaging is an option, then build
  2. write report

Fort Bragg
Hospital transfers patient to SNF
  1. complete messaging specifications
    • final planning with Sylvia (Medical Records)
    • final planning with Phil (Case Mgr)
    • final planning with Jeff & Kris (IT)
  2. final design for content transport
    • final approval by CNO
    • final approval by SOHC
  3. build direct messaging solution
    • Mirth service spec
    • Write user facing instructions
    • Test installation
    • Train users
    • Release to production
  4. write report

SNF transfers patient to Hospital
  1. complete messaging specifications
    • contact pcc software, get specs for pdf export
    • final planning with Juliann (Nursing @ SOHC)
    • final planning with Sylvia (Medical Records @ MCDH)
    • final planning with Admissions @ MCDH
  2. final design for content transport
    • final approval by CNO
    • final approval by SOHC
  3. build direct messaging solution
    • Mirth service spec
    • Write user facing instructions
    • Test installation
    • Train users
    • Release to production
  4. write report