Session Notes 9

Session 9: Achieving Meaningful Use: Transitions in Care
4/13/11: 12:45 –2:15PM

Session Objectives

• Discuss how Direct can be used to meet meaningful use and State HIE Program requirements to exchange transitions of care documents

Presenters/Panelists

• Gary Christensen, CIO/COO, Rhode Island Quality Institute
• Holly Miller, MD, MBA, FHIMSS, Chief Medical Officer, MedAllies Inc.

Introduction, Brian Ahier

• Meaningful Use Stage 1 Requirements
  • Providing summary of care record and discharge summary
  • You can use Direct protocols to meet requirements
• PIN requirements -
  • Strategy to fill MU gaps is relevant for transitions of care
• Why use Direct for transition of care?
  • MU compliant
  • Standardized
    • Transport is key
  • Simplicity
    • Elegant solution
  • Scalable
    • Can be utilized beyond 2011
• Use case 1: Provider sends patient care summaries to specialist and specialist sends it back
  • • Sending through HISP
    • Context has made determination that it is appropriate to send to specialist
    • If you took HISP out and put in a fax machine, this happens a lot today
• Hospital sends discharge information to referring provider
  • • Time of admission PCP of record is verified with patient, discharge transferred
    • System triggered to send packet to patient’s referring physician

Presentation 1, Gary Christensen, RIQI

• Two objectives in Direct pilot
  • Provider-to-provider exchange via Direct
  • Specialist sends information back to referring provider
• Worked with EHR vendors and practices that were interested in these cases
  • Integrate pieces of reference code into EHR platform
  • Has been an “easy sell” with EHR vendors
  • Three things from vendors:
    • Ability to create C32 v2.5 CCD
    • Pick a trigger point in workflow
      • Where would the vendor want to put the trigger point to notify when data should be sent to HIE
      • What works best for their product
    • Make one “call”
      • Part of reference implementation
      • Through the HISP
      • Allows for program to auto generate message,address it, attach CCD, and send to HIE Direct box
    • Targeted nine vendors
  • Using Direct in order to notify PCMH of a discharge
    • The exchange of EHR information from EHR to HIE
      • Easy as 1 (step)
      • Don’t have universal patient identifiers
      • Steps: Update patient’s record, EHR generates CCD and sends message to HIE Direct mailbox (currentcare), HIE matches patient to MPI and absorbs CCD as data.
  • Provider notification process
    • Simple, simple, simple
    • Start small, start vanilla
    • Take capability that we already have that PCMH needed
    • RI - poor re-admission rates
    • If docs know patients are discharged, readmits would likely go down
    • RI can watch ADT feeds, match patients, go out to provider directory (doc and his or her direct address), get direct address, and then create a Direct message using same single line of code, saying patient got discharged
      • Wouldn’t be easy to add discharge summary? Yes, but then we have to get hospitals involved. With this way, HIE does this independently.
      • Great goal, we’ll go there. For now, we are leveraging what we have
    • This is the only reason why we are talking about a provider directory
    • Don’t need a provider directory to do Direct
  • Beacon program Quality reporting
    • Quality reporting important as we shift to a different payment model
    • Sustainability ideas
    • RI is full of small practices, and smaller practices may not have reporting function capability to do quality reporting
    • On a scheduled basis, RIQI can generate reports and send them out to support quality reporting goals.
    • Direct as work queue. We are thinking about lots of ways to use Direct mailbox to trigger or queue events
      • We know what docs prescribe via a feed from Surescripts. We also know what was prescribed and what was filled.
      • RIQI can compare those and do auto medication adherence. Let prescribers know that prescribed medications are still not filled.
        • This is a value-added service for practices

Presentation 2, Holly Miller, MedAllies

• Direct pilot objectives
  • MedAllies is a HISP. Bundle network connectivity with EHRs. Don’t have anything in the middle.
  • Goal is to have the information flow from physician-to-physician
  • Critically important that physicians feel their systems are useful to their workflow
• Sidebar: EHR adoption and use is an exercise in change management
  • 17% of projects that don’t utilize change management principles don’t meet project objectives and don’t stay on schedule.
• Direct is well-suited to support small practices
  • 80% of care delivered today occurs in practices with 8 or fewer providers.
• Direct truly supports new models of care: PCMH and ACOs
  • Messages can be directed to the appropriate care givers
• Geographic pilot project taking place at multiple healthcare orgs and EHR vendors in NY:
  • Hospitals, primary care and specialists
• Transition of Care Type 1: Hospital Discharge to PCP work flow:
  • Planning overtime to expand the organization to others but nationally
  • Notion of some standard information being shared. Beyond that, we want there to be physician selection.
• Transition of Care Type 2: Closed Loop Referral (means PCP to specialist and back)
• Important for MU:
• Entire process (clinical and technical track) was four months
• B/c systems were EHRs that docs where already using, there was basically no training involved.
• When docs have an upgrade, there is always updates. So there might be this type of ongoing maintenance/training
  • Speed/latency
    • Messages - 5/10 seconds to go from EHR to EHR
  • Clinical adoption
    • Key measure of success
    • Have received positive feedback from physicians on Direct
  • Approach to bundle network with EHRs
• Real work lessons
  • Standards
  • Process
  • Anticipate
  • Communicate
  • Partnership
  • “Eyes on the Prize”

FAQ Session

• Question for Holly Miller: How were you able to get vendors to work together and adopt Direct protocols?
  • When their clients (end users) ask, it’s much more persuasive. ONC truly has aligned the stars and vendors recognize that they must communicate to other products to stay viable in the market.
  • We have strong relationships with providers in Hudson Valley.
• Question for Gary: How are the RECs helping to get vendors to adopt Direct?
  • We have a lot of ready and willing customers. Vendors have products they want to sell . We are in the position to put conditions on vendors to “play” in our marketplace. We will be going out and adding to specification the three things (CCD, trigger, and call) because that is what will generate interoperability across the state. Don’t feel bad, because that is a low bar for vendors.
  • RIQI will have a separate Direct adoption program. PPCP program. this is sep. from the help that providers will get from REC.
  • New users will be exposed to training.
  • REC as retail distribution channel in the state for Direct.
• Question for Gary: How do you know who the PCP is when the system needs to send a discharge alert?
  • currentcare sends a note that the patient has been discharged. PCPs in PCMH will know what to do. It would be better to attach a discharge summary, but it makes the process so much harder. We do have to do a look up of the Direct address.
  • Can collect Direct address during HIE sign-up process and help keep provider directory up-to-date.
  • When it comes to PCMH, we maintain direct relationship so we know who PCP is.
• Question for Gary: What is the provider perspective on level of clinical decision support?
  • In Beacon program, CDS is a big piece. Lever capabilities of EHRs to provide CDS based on things that are agreed workflows.
• Question for Gary: How do physicians access quality reports - do they sign up on a portal?
  • Quality reporting is just getting started. We’ll start with the baseline.
• Question for Holly: Do you know if your organizations have had discussions about beginning PCMHs and ACOs?
  • Yes, many are involved in those types of pilots.
  • Who will receive initial message?
  • Clinics elect nurse care manager to receive first message.
• Gary : There has been controversy around Direct and HIEs. Some of the things that I have been talking about today are things that only the HIE can do. Can’t believe that the concept of HIE is broken by Direct. It’s enhanced by Direct.
• Question for Gary: Regarding RI’s stringent consent policy, how does that work with patient adoption?
  • Do have to have critical mass of patients. If we are successful, than none of the value will happen.
  • 350 sites signed up. Part of the intake, they present what RIQI is and obtains consent.
  • PCMHs want this, so they are very motivated to get patients to sign up
  • When doctors say they should participate in HIE, patient participate in more likely.
• Claudia: Grant program has HIE in it, but it doesn’t mean you always need to enable a particular model or approach.
  • May be that you never have a repository
  • Models that allow for Direct approach AND other types of exchange
  • Goal of program is patient care and meeting MU
• Comment for Gary: Glossing over that PCPs know what to do when they get a discharge notification. A lot goes into how they know.
  • Our PCMH programs are pretty advanced. This is what we are doing this year. This is not where we’ll end up. We can make a big different in readmits if we just let the doctors know.
  • Holly - perfect is the enemy of good. Analysis paralysis. Crawl, then walk, then run.
• Brian - you can use Direct to enable providers to provide the best care. With transitions of care, favorite use cases with Direct. Think in the short-term, it will have the biggest impact.