About eHealth Initiative

eHealth Initiative (eHI) is a Washington D.C.-based, independent, non-profit organization whose mission is to drive improvements in the quality, safety, and efficient of healthcare through information and information technology. eHI is the only national organization that represents all of the stakeholders in the healthcare industry. Working with its membership, eHI advocates for the use of health IT that is practical, sustainable and addresses stakeholder needs, particularly those of patients.

Care Coordination Council The Care Coordination Council (Council) is a multi-stakeholder group representative of eHI membership and focused on assessing the necessary health information technology infrastructure required to facilitate care coordination, in an effort to improve the quality, safety, and efficiency of healthcare.

Purpose

The report aims to inform the field of healthcare by identifying select elements of the care coordination process and making recommendations for how the public and private sectors can help to build and utilize a robust health information technology (health IT) infrastructure to support the needs of care coordination.

Formation of the Document The report was developed through a multi-stakeholder, consensus process. The Council met over the course of 8 months to discuss key themes in care coordination that can be facilitated through effective use of health information technology. This document is a summary and synthesis of the information discussed in these meetings with recommendations for policy and practice. The report is informed by case studies of care coordination communities, inclusive of Beacon Community Programs, the JWCH Institute Inc., Montefiore Medical Center, Oregon Health Plan, and the Louisiana Coordinated System of Care. Intended Audiences

The document is intended to be used by a diverse group of stakeholders who are improving healthcare through the use of health IT. This includes, but is not limited to: clinicians, consumer and patient groups, employers and healthcare purchasers, health plans, health information technology suppliers, hospitals and other entities, laboratories, pharmaceutical and medical device manufacturers, pharmacies, public health agencies, quality improvement organizations, standards groups, and state, regional and community-based organizations.

Acknowledgements

The eHealth Initiative would like to acknowledge and extend thanks to the two Co-Chairs of the Care Coordination Council: Joe Heyman, MD Chair, National Physician Advisory Board OptumInsight and Eva Powell, MSW, of the National Partnership for Women and Families for their invaluable contributions and dedication in the creation of this report. Additionally, the eHealth Initiative would also like to thank the following individuals for their active participation in this council and overall contributions to the report. Brian Ahier Gorge Health Connect, Inc. Kurt Andrews Point-of-Care Partners, LLC Bob Bailey RTI International Lora Baker NextGen Information Services, Inc. Jeanette Ball HEALTHeLINK Alison Banger RTI International Leon Q. Barzin Massachusetts Medical Society Jim Bettendorf Gateway EDI, LLC. Carol Bickford American Nurses Association, Inc. Yvette Bolla American Nurses Association, Inc. Nick Bonvino Health Information Exchange of Southern Illinois Alice Borrelli Intel Corporation Amber Brockington Accenture Kelly Broder Surescripts

Bob Brown Mosaica Partners, LLC Camilla Hull Brown Strategies for Tomorrow, Inc. Mary Brubaker Healthcare Strategies, Inc. (HQSI) Corette Byrd American College of Physicians Julie Cantor-Weinberg American College of Pathologists Jay Chen ConfiHealth Solutions Peter Cizik BridgeFront Tom Crawford InterComponentWare AG (ICW) Tina Cullins OptumInsight Patti Dodgen Hielix Ralph Donaldson PRISM Health Services Jaime Estrada Health Information Network of Arizona Liza Fox-Wylie Colorado Regional Health Information Exchange Angela Franklin American College of Emergency Physicians Rich French Covisint Donald George PRISM Health Services Rebecca Goldberg BluePrint Healthcare IT

Lisa Grabert American Heart Association, Inc. Eric Grahm Availity LLC Chris Gray AT&T Jim Hansen Dossia Consortium Robert Haskell Siemens Corporation Stephanie Hernandez Planned Parenthood Federation of America Brandi Herndon Greenway Medical Technologies, Inc. Gloria Hitchcock Greater Rochester RHIO Chris Hobson Orion Health Rick Holdren HCA Holdings Inc. Diane Humerick Smartronix, Inc. Joyce Hunter Vulcan Enterprises, LLC. Debbie Josephson Arkansas Foundation for Medical Care Eric Juhl National Association of Chain Drug Stores, Inc. Mike Kappel McKesson Corporation Gleen Keet Axolotl Corporation Leslie Kelly Hall Healthwise, Inc.

Hannah King Michiana Health Information Network Janhavi Kirtane, Beacon Community Program Office, within the Office of the National Coordinator for HIT Eric Klos Cogon Systems, Inc. Laura Kolkman Mosaica Partners, LLC Madeleine Konig American Heart Association, Inc. Christopher Kunney AT&T Ken LaBresh RTI International Cheri Lattimer Case Management Society of American and National Transitions of Care Coalition Len Litchtenfeld American Cancer Society, Inc. Sandra Lillie InterComponentWare AG (ICW) Swati Lotilkar-Kamath Healthcare Quality Strategies, Inc. Peter Loupos Sanofi Aventis, LLC Barbara Lund Massachusetts eHealth Collaborative, Inc. Chatherine Macpherson WebMD, LLC Kat Mahan TNS, Inc. Martin Margolies Healthcare Quality Strategies, Inc. Beki Marshall American Academy of Pediatrics

Ginny Meadows McKesson Corporation Suzanne Mintz National Family Caregivers Association Jill Mulligan Surescripts David Nace Mckesson Corporation Neal Neuberger RCHN Community Health Lori Nichols HInet Claudia O’Connell Planned Parenthood Federation of America Kim Pemble Wisconsin Health Information Exchange Deanna Peters eHealth Global Technologies, Inc. Dr. Illeana Pina Montefiore Medical Center Dan Porreca HEALTHeLINK Anne Marie Priddy Coastal Connect HIE Edith Rosato National Association of Chain Drug Stores, Inc. Ken Rosenfeld eHealth Global Technologies, Inc. Sara Samaha Partners HealthCare Systems Liplka Samal Partners HealthCare Systems Sandra Schafer Holon Solutions

Craig Schneider Massachusetts Health Data Consortium Elizabeth Schofiled Siemens Corporation Ray Scott OptumInsight Aaron Seib Cal eConnect, Inc. Lisa Smaga Hielix Cheryl Stephens Community Health Information Collaborative John Tempesco InterComponentWare, Inc. William Underwood American College of Physicians Roger Van Brussel InterComponentWare AG (ICW) Adam Vincent RTI International, Inc. Lynn A. Volk Partners Healthcare Systems Thomas Waller InterComponentWare AG (ICW) Chantal Worzala American Hospital Association Mathhew Wynia American Medical Association Special thanks go to Danielle J. Brooks, JD, for her leadership role within this Council and for managing the writing and editing; and to Jonathan Dimsdale, MPH, Diane Jones, JD, Alex Kontur, Katinka Canning, Katie Reidy, Stephanie Zimmerman, Brian Collins, Alexander Seabrook, Jr., and Jason Goldwater, MA, MPA for their assistance in editing the final report. The eHealth Initiative would also like to recognize the efforts of the team at the Beacon Community Program Office, within the Office of the National Coordinator for HIT and Beacon Community

Grantees, as well as the staff of the Louisiana Coordinated System of Care and Montefiore Medical Center for their contributions to the document. i

i "The views expressed in this report do not necessarily reflect the policies of the organizations with which the individuals

listed above are affiliated."

Table of Contents

Executive Summary ...................................................................................................................................................................................... 1

Overview of Care Coordination ............................................................................................................................................................. 4

Section I. Key Principles to Guide the Use of Health IT in Care Coordination ................................................ 7

Section II: Key components and functionality necessary to support care coordination ....................... 12

Information Sharing ............................................................................................................................................................................... 12

Team Based Care: Including Patient-Center Care .......................................................................................................... 16

Care Plans ....................................................................................................................................................................................................... 20

Organization of Information and Services ............................................................................................................................ 24

Recommendations ........................................................................................................................................................................................ 26

Case Studies ...................................................................................................................................................................................................... 30

Glossary ................................................................................................................................................................................................................ 52

Resources ............................................................................................................................................................................................................ 68

1

Executive Summary:

The United States healthcare system is in the midst of a paradigm shift,

transitioning away from a fragmented system in which services are delivered

through multiple providers with limited collaboration, towards a model that

emphasizes shared accountability and continuity of quality, patient-centered care. A

critical component of this transformation is care coordination, which requires

effective and consistent collaboration among providers and organizations caring for

the individual patient.

Care coordination, a process that ensures that the patient’s needs and preferences

for health services and information sharing across people, functions, and sites are

met over time, is primarily accomplished by people, and is not a technological

function. By definition, care coordination is complex and must respond to the needs

of individual patients. Health Information Technology (health IT) can be a useful

tool to facilitate improved care coordination, as the utilization of electronic health

records (EHRs) and health information exchange (HIE)ii can provide for the

capturing, access to and sharing of real-time patient data among those caring for

the patient.

This document describes a vision for how health IT can and should support care

coordination, as well as the qualities and functions necessary to achieve that vision.

The Council decided to focus on specific key principles and components in order to

limit the scope of this document. To accomplish this goal, the document includes:

• A set of unified principles that should be considered in the implementation of

health IT to ensure its effectiveness in supporting care coordination.

• Four key components of effective care coordination requiring the support of

health IT.

o Information Sharing

o Team Based Care: Including Patient-Centered Care

o Care Plans

o Organization of Information and Services

In support of these areas of focus, the document considers the experiences of

several Beacon Community Programs, inclusive of a statement from the Office of

the National Coordinator, and the Greater Cincinnati, Western New York,

Southeastern Michigan, Rhode Island, MyHealth Access, Colorado, and Inland

Northwest Beacon Communities. In addition, the Montefiore Medical Center, JWCH

Institute Inc., the Louisiana Coordinated System of Care, and the Oregon Health

ii For the purposes of this section, health information exchange (HIE) refers to the process rather than the

entity.

2

Plan are featured as examples of successful care coordination activities and

initiatives. These case studies highlight experiences and lessons learned from those

working to implement health IT supported care coordination.

Overall, the report outlines multiple recommendations for the use of health

information technology to facilitate care coordination.

The Council recognizes that relatively few organizations and individuals involved in

care coordination activities today possess robust health IT systems capable of

carrying out all of the functions recommended in this report. Yet, with rapid

evolution of these systems now taking place, we see tremendous opportunity in

providing timely guidance on key principles and components to incorporate into

health IT systems as they evolve to facilitate and improve care coordination.

Listed below are the critical functions identified by the council as being necessary in

order to facilitate the components of care coordination highlighted in this paper.

• Capturing, accessing and sharing of real-time patient data among those

caring for the patient.

• Enabling verification of the accuracy of patient-entered data.

• Allowing for flexibility that accommodates various workflow processes and

environmental factors like workload, staff schedules, and patient load.

• Facilitating seamless interoperability with evidence-based care management

strategies that support efficient and effective integration of patient

information, laboratory, imaging, therapy, referrals, medications, social and

community services, and self-management assistance, including patient

registries and population-based data.

• Alerting the care team of tests and services coordinated within the healthcare

plan.

• Facilitating bi-directional communication among professional care team

members and the patient.

• Facilitating linkages consistent with applicable state and federal privacy

standards that are outside the traditional healthcare system and are

necessary to meet a patient’s clinical and psychosocial needs (involving social

services, mental health, school systems, etc.).

• Facilitating quality improvement and safety; disease management; utilizing

clinical decision support system (CDSS) tools; provider alerts and patient

reminders.

• Providing a continuous information flow and feedback loop between a patient

and his or her care team.

• Supporting the creation and execution and updating of a care plan that can

be shared across the continuum of care and with the patient and their family,

caregiver, and/or paid health aide.

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• Facilitating decision-making and planning for transitions of care.

• Presenting a master care plan that is longitudinal and comprehensive, with

various sub-plans that provide more specific, targeted information.

• Presenting information in the most meaningful and actionable manner for the

end user.

• Allowing for use of customized tools to synthesize and analyze information

for specific purposes.

• Integrating and using information generated as part of the process of care.

• Capturing critical information, tracking patient education and self-

management support, and community and non-clinical services necessary to

support the patient and his or her caregiver’s needs and preferences.

Significant evolution in the marketplace is necessary to achieve the widespread

availability of the functionalities described above. The Council identified several

concrete steps that can be taken now or in the near future that will advance the

capability of electronic health information systems to support better coordination of

care. This is not intended as an exhaustive list, but rather as a starting place for

focused effort by policy makers, industry representatives and others.

• Identify a starter set of role-based views for presenting data necessary for

care coordination.

• Identify professional groups that are often excluded from EHR/HIE

implementation who will be critical for care coordination and engage

professional societies or other organizations representing these groups in

future discussions about improving care coordination using health IT.

• Identify prevention goals from Healthy People 2020 that can especially

benefit from health IT and prioritize their integration into health IT enabled

care coordination.

• Identify vocabulary and data transfer standards necessary for the

functionalities above, with particular attention to incorporation of patient

contributed data into the EHR.

• Identify and spread best practices for making linkages with community

supports.

4

Overview of Care Coordination

There is widespread agreement that care coordination is essential to improving the

quality and reducing the cost of healthcare in the United States. Yet achieving

coordinated care is extraordinarily difficult, partly because “care coordination” is a

highly complex process, without a standard definition.

Many concepts, models and tools are used to describe

approaches for achieving the outcome of better

coordinated care, including: care collaboration,

teamwork, continuity of care, disease management,

case management, care management, Chronic Care

Model, and care or patient navigator.1 For the purposes

of this document, care coordination will be defined as

“the deliberate organization of patient care among two

or more participants, inclusive of the patient, to facilitate

the appropriate delivery of healthcare services. Care

coordination involves the organization of people and

other resources necessary to carry out all required

patient care activities, and is managed by the exchange

of information among participants responsible for

different aspects of care”.2

The importance of care coordination was recognized in

the Patient Protection and Affordable Care Act (PPACA)

in multiple ways.3 Most importantly, PPACA charged the Department of Health and

Human Services (HHS) with developing a National Quality Strategy (NQS) to align

and focus public and private efforts to improve the effectiveness, safety, and

affordability of healthcare in our nation. Care coordination is one of six priorities

being advanced as part of the NQS. PPACA also provided for several programs and

initiatives to advance care coordination. These initiatives were developed and

continue to be advanced based on models for improving care coordination,4 such

as:

• The Medicare Community-Based Care Transitions Program

• Incentives to reduce Medicare hospital readmissions

• The Medicare Independence at Home demonstration

• Medical Home models in Medicare and Medicaid

• Federally Qualified Health Center Advanced Primary Care Practice (FQHC

APCP) demonstration project

• The Medicare Shared Savings program.5

In addition to the Federal efforts to advance care coordination, numerous private

sector efforts have focused on this critical issue. Of particular note is the multi-

“This document calls out who is responsible, who needs to know what specific information, and who is acting upon this information. Accountable care organizational models,

patient centered medical homes, and health homes are trying to replicate these care coordination principles. People will need to invest in electronic tools

to become active and effective in using available information.”

- Claudia O’Connell Director

Affiliate Technology

Initiatives at Planned

Parenthood Federation of

America

5

stakeholder, consensus-based work of the National Quality Forum (NQF), which

endorsed a definition and framework for care coordination in May 2006 and a

portfolio of care coordination preferred practices and performance measures in

2010.6 Most recently, under contract with HHS, NQF has convened a Care

Coordination Steering Committee which will develop a pathway toward

implementation of emerging care coordination measures, including electronic

capabilities and feasibility to support care coordination and quality measures. Since

one of the primary expectations of health IT is that it will support a more robust

and less labor intensive quality measurement process, it will not only need to

support specific functions related to care coordination, but also quality metrics

related to those functions and the ultimate outcome of better coordinated care.

The framework endorsed by NQF in 2006 identified five domains in the process of

care coordination: 1) Healthcare home; 2) Proactive plan of care and follow-up; 3)

Communication; 4) Information systems; and 5) Transitions. Health IT clearly has

a tremendous role to play in each of these domains, specifically related to the

availability of information to the right people, in the right format, and at the right

time. Health IT can facilitate bi-directional communication between the healthcare

provider and the patient and could enable a longitudinal view of care that would

otherwise be impossible with a paper record.

While care coordination is fundamentally a “people centric” enterprise, health IT

plays a critical role in this process. Various forms of health IT, such as EHRs,

messaging, alert systems, biometric, and telemonitoring devices can be useful to

deliver and analyze data when and where it is needed to support the care

coordination process.7 However, to ensure that health IT delivers on its promise

with regard to care coordination, much work must be done to identify the specific

ways that health IT can and should support the care coordination process.

Health IT is a valuable tool that has the potential to radically improve the

collaborative efforts of multiple care team actors across the continuum of care.

These actors include, but are not limited to: patients and their caregivers, paid

home aides, primary care physicians, physician assistants (PAs), nurses, ancillary

staff such as physical therapists and social workers, mental health professionals,

pharmacists, case managers, insurers, specialists and diagnosticians among others.

Because patients may have multiple conditions and diverse needs that require them

to seek care at different healthcare organizations and care settings, clinical and

preventive care must be coordinated between care teams across time and care

setting to provide the best long-term outcomes. Patients, caregivers, and paid

home healthcare aides, who have not been traditionally considered integral to

healthcare delivery, require support and assistance to fulfill their roles as members

of the care team. Community-based organizations play a critical role in providing

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support for many patients and their caregivers, and must become part of the

process of coordinating care as well. The effective use of health IT can help ensure

that each actor across care settings and locations has the patient information that

they need to provide well-coordinated care.

While coordinated care is an outcome that should be pursued for all patients, it is

particularly important for the safety and effectiveness of care during transitions

between care settings and for patients who are

chronically ill. It is estimated that 145 million

people in the United States suffer from at least

one chronic healthcare condition.8 In the course

of a year, a patient with a chronic condition may

visit multiple healthcare providers and healthcare

organizations. Without using modern technology

to manage, organize and share information

during transitions between healthcare locations,

healthcare providers, and/or different levels of

care, there is a high likelihood that patient needs

will go unmet and resources will be wasted.

Unplanned readmissions are attributed to

inability to have appropriate follow-up care,

including medical follow-up visits and medication

adherence. Likewise, less than desirable

outcomes in cost and quality are more likely

when modern technological solutions are not

used to deliver the most appropriate and

effective care to patients who have chronic – or

multiple chronic – illnesses. By using technology to arrange and schedule services,

facilitate communication among multiple healthcare providers, monitor changes and

help patients and their families’ access and negotiate complex delivery systems, we

can begin to address some of the barriers we face in improving the quality of care

while also slowing cost growth.9

As we begin to pay for the quality of healthcare, instead of quantity of services, the

ability to measure and evaluate quality as part of the process of care will be crucial.

Effective quality outcome and process measures will need to be further researched

and developed to allow for an accurate assessment of care coordination. As health

IT is developed, adopted and implemented, it is critical that systems are designed

to incorporate current quality metrics as well as generate information needed for

the more robust quality metrics of the future.10 While current performance

measures generally target dimensions of care within a system, the development of

"While I am convinced absolutely that health information technology can improve care coordination -- much more is needed -- and it could be so simple. More important than any technology is a caring

individual who takes ownership of the process. An essential improvement would be the elimination of territoriality, passive-aggressive behavior and selfishness. I cannot

overemphasize how important it is that an individual (rather than a team of people) cares enough to take charge. Patients and caregivers need to know that there is a caring person they can count on when it is Friday evening and

things are going wrong."

- Joe Heyman, MD Chair, National

Physician Advisory Board

OptumInsight

7

comprehensive longitudinal measures will be crucial to measure the degree to

which care was coordinated over time as an important dimension of quality.11

Key Principles to Guide the Use of Health IT in Care Coordination

The following set of principles should be incorporated into the implementation of

health IT to ensure its effectiveness in supporting care coordination. These

principles are intended to be used as a unified set, and together they act as a

foundation upon which the key components of functionality necessary to support

care coordination should be built.

1. Information should be accessible.

All people involved in the care of the individual – including the patient, family,

caregivers and paid health aides – must have access to the information essential

to effectively perform their individual roles in coordinating care. Patients and

their caregivers, as members of the care team, need to have access to their own

health information. The information should be presented in a manner that is

easily understood and used. Information presented should be able to be used in

self-management electronic health tools (eTools).

Likewise, clinicians need comprehensive, accurate, and meaningful information

to work with their patients in planning and executing individualized patient care

plans. Defining specific roles and responsibilities for individual care team

members in carrying out the care plan is essential in facilitating this process.

2. Technology should facilitate trust.

Technology should be employed in ways that promote trust in electronic

information by all relevant stakeholders. The principle of trust primarily applies

to two important issues within the context of care coordination: 1) patient trust

that their information is used appropriately and kept confidentially and secure

and 2) care team member trust that the information that they are able to access

is accurate and complete. Survey data shows that lack of trust inhibits the

sharing of information, which is fundamental to the process of care

coordination.12 With regard to patient trust in the confidentiality and security of

their information, role-based access to the minimum necessary information,

consent management, data encryption, and the development of audit logs are all

technological strategies that should be part of a comprehensive approach to

protecting patient’s privacy and security. This functionality enables the sharing

of information among care team members who both require and are authorized

to have specified data. Likewise, these functionalities inhibit the access of data

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by care team members that are not authorized to receive the information.

Fostering trust in the accuracy and completeness of information will require the

standardization of vocabularies and data transfer, and likely will require

relationship building and negotiation among clinicians and healthcare

organizations on the local level who contribute to the care of common patients.

It is also likely that some method of identifying the source of various pieces of

information is a necessary component of trust from the provider perspective,

especially as patients and their caregivers become more frequently used data

sources through the evolution of patient portals, personal health records

(PHRs), mobile applications and other technology solutions of the future.

Continuous information flow and feedback loops between patients and their care

teams are often lacking, but these are essential elements of effective care

coordination. Currently, patient-generated information is not always trusted by

providers for a variety of reasons, including a historically paternalistic medical

culture and concerns about liability for reliance on patient-entered data.13iii

Implementing standardized approaches and formats to collect this information,

as well as enabling methods of verifying the accuracy of the patient-entered

data into clinical workflows may help with the cultural transformation necessary.

3. Information should be actionable, timely, and capable of being

customized.

Information is not helpful - and can diminish safety and result in inappropriate

care - if it is excessive, incomprehensible, and difficult to manage. Technology

should be used to present information in ways that are easily understood and

synthesized, enabling the user to determine appropriate actions. Decisions in

healthcare are often extremely time-sensitive, thus the timeliness of information

availability is a critical benefit to leverage from technological solutions. While it

is critical to have standard formats for representing pieces of information

electronically, health IT must enable the information to be presented in the most

meaningful and actionable manner for the end user.

One way to make information more actionable is through enabling eTools that

synthesize and analyze information for specific purposes. eTools should be

available to patients and their care team members for purposes of clinical

decision-making, performance assessment and improvement, self-management,

and tracking and follow-up. They should integrate data, inclusive of quality

iii There is a distinction between patient-entered data that flows from a home device, requiring the patient to

affirmatively share the data with the provider, and data manually entered or derived from patient

observation. The former is likely to be more trusted, but actual “patient-entered” data is critical to providing

a more complete and patient-centered picture of the impact various elements of his or her care are having on

overall health and well-being.

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measurements, into the workflow and use information generated as part of the

process of care, rather than requiring additional collection or manipulation of

data.

4. Technology should support the patient and caregiver relationship.

The relationship between patient and clinician or caregiver is paramount, and

should be supported and strengthened through the use of health IT, not

degraded by it. Health IT will never replace people as being the most important

element of the care process; rather eTools can and should be employed to

support the relationship between patients, caregivers, and care team members.

Health IT should be used to enhance care team members’ knowledge of the

“whole person” by soliciting and integrating critical information that can only be

provided by the patient. Health IT also should be used to facilitate multi-

directional communication between patients and their caregivers and other care

team members. Health IT can help to reduce the administrative burden of the

collection of patient generated data, like patient and family history and

insurance information, to reserve time spent in the provider setting for more

effective and care specific communication.

5. A proactive and personalized plan of care is central to effective care

coordination.

Health IT and eTools must support the creation and execution of individualized

care plans that can be shared across the continuum of care, including with

patients, their caregivers and paid home aides. Structured and effective

information technology must be in place to document critical information, track

and initiate follow-up care procedures, provide patient education and self-

management support, and enable community and non-clinical services

necessary to support the patient and his or her caregiver’s needs and

preferences.

6. Successful care coordination requires numerous linkages throughout

the healthcare system, as well as to non-health related community

support systems.

In many cases, proactive plans of care will involve numerous care team

members across various settings of care, such as primary care, specialists,

rehabilitation, and other health and wellness facilities. Additionally, many

patients have specific support needs for effective self-management, particularly

once they are no longer actively interacting with the healthcare system.

Resources that meet patient and caregiver self-management needs may or may

not be a part of what is traditionally thought of as the healthcare system (e.g.

social services, nutritional supports, transportation, mental health, school

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systems, etc.) Health IT should facilitate the linkages necessary to meet a

patient’s clinical and psychosocial needs such that they achieve the best

outcomes and sustain the highest degree of wellness possible for an individual.

These linkages are particularly critical during care transitions, when many needs

fall through the cracks, resulting in gaps in care, safety issues, and ultimately

poorer outcomes and increased costs to the healthcare system. Health

information exchange holds promise for helping to bridge some of these gaps.

Linkages between traditional and nontraditional healthcare organizations must

follow state and federal privacy laws and strive to promote trust in healthcare

(See Principle 2)

7. Technology should create efficiencies in clinical workflow.

One benefit of health IT, when implemented well, is the creation of efficiencies

in the clinical workflow that are not possible in a paper record environment.

Workflows across the continuum of care must connect at key points in time in

order to facilitate more appropriate and better coordinated care, rather than

“less” care. Not all workflows are in support of coordinated care and will often

need to be re-worked or replaced with new and more efficient models. Since

care coordination is largely a team-based effort, the workflow of each care team

member must be considered, and systems should be flexible, allowing for

variations when interacting with other workflow process and accommodating

environmental factors like workload, staff schedules, and patient load.

To improve efficiency, all purposes for which an EHR is used in the process of

care coordination should be informed by the process of care. For example, care

plan development should be informed by evidence-based clinical decision

support systems (CDSS) which should be available to both patients and

healthcare providers throughout the care process, not just at the point of

providing care. Care plans are also likely to provide critical pieces of information

for quality measurement in the future, so health IT systems should be designed

to enable automated collection of information from the care plan for these

purposes so that manual data collection will not be necessary. 14

Developing a framework for health IT enabled care coordination is extraordinarily

difficult for a number of reasons. The care coordination process is not well defined,

and by its very nature is highly variable because care is tailored to meet the specific

needs of individual patients. Because there are many different ways to meet the

specific care coordination needs of a given patient, no singular health IT solution

will meet the needs of every individual or every care team. Additionally, there are

many different care team members that must benefit from health IT that enables

care coordination – but not all have a role in every individual’s care. Effective care

coordination that is supported by health IT will require adherence to the above

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principles when electronic systems are designed and implemented. In order to

achieve the specific benefits that health IT can bring to the care coordination

process, industry should focus on creating and implementing tools that address the

four concrete components of the process as described below.

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Key Components

There are a number of key functional capabilities that electronic health systems

must have in order to support care coordination. These capabilities can be built

into systems in a number of different ways. Our expectation is that market

innovation will play an important role in developing systems that actually support

better-coordinated care.

Each of these key components can be partially implemented today. Nevertheless,

the discussion that follows is aspirational, as full implementation of these

components is likely to take several years. Development and enactment of these

key components should be approached with the principles listed above in mind, and

should be informed by emerging best practices from the field as new care delivery

models that emphasize better coordinated care are implemented.

Key Component I: Information Sharing

The sharing of information is the foundation on which care coordination is built.

Within every healthcare setting, the care team,

healthcare organization and patient require

access to specific information to make informed

and appropriate healthcare decisions.

Health IT systems should enable the access of

relevant patient information, and allow for

communication among the patient, family,

caregiver, paid health aides, clinicians and

healthcare organizations.15 Successful health IT

systems should provide seamless interoperability

among the care team and healthcare

organizations. These systems should enable the

exchange of information to support evidence-

based plans of care management, improving the

quality, coordination, and integration of

healthcare services.16 Health IT also should

support the quality and safety of care and

provide clinical decision support tools, including,

but not limited to; provider alerts, patient reminders, and the integration of patient-

reported information that is critical for comprehensive, whole person care.17

The role of health IT in Information Sharing:

We should look at care coordination from the perspective of customer

service management. For example, when we go to an online store, and you enter your name, the site already knows who you are and your “favorites”. I think with the use of health IT, care coordination

can and should function in a similar way. Like having a Travelocity®, Orbitz® or Amazon® for health”

-Joyce Hunter, CEO/Industry

Consultant at Vulcan Enterprises

LLC

13

• Should deliver information to care team members in a manner that enables

their use of the system. This information should also be presented in a

manner that is relevant to their specified role;

• Should provide clinical decision support systems to enable critical pieces of

information (from all providers/care team members) available at the point of

decision-making and care planning, in a way that is understandable;

• Should enable the development of evidence-based practices through

information sharing.

In order to successfully support care coordination, information should be

available, accessible and integrated in the care team’s workflow.18 Electronic

healthcare record systems should include specific role-based permissions in order to

ensure that the information is protected and presented in a way that is not

overwhelming to the recipient. Likewise, the system should include functionalities

that track assignments, list responsibilities among care team members, and allow

access for multiple authorized individuals concurrently.1920 All information regarding

a patient’s health status, including additional activities that impact their healthcare

needs, services, and results, should be available wherever possible to those that

need it based on their role.21 The standardization of terminology is necessary for

both interoperability and clear, consistent communication across the spectrum of

care.22 Likewise, electronic tools must be available, gather information generated at

the point of care to provide performance feedback to the provider, report measures

for accountability and transmit data necessary to calculate population health

metrics at the practice, community, and national levels. 23

Relevant information should be shared through seamless interoperability with

an evidence-based strategy of care management that supports efficient and

effective integration of patient information, laboratory, imaging, therapy, referrals,

medications, social and community services, and self-management assistance.

Information from care planning processes must be available to populate new quality

measures, such as care coordination, outcomes and longitudinal measures.24 This

should include patient registries and population-based data, especially those

promoted by local, state and federal public health agencies.25 The health

information technology system should alert the care team of tests and services

coordinated within the healthcare plan, and results should be available, at all points

of decision-making, to all relevant care team members to avoid medical errors or

unnecessary duplication of services.26 Information sharing policies that protect the

privacy and security of sensitive health information should be based on compliance

with applicable laws and regulations. 27 Consent management policies should permit

all who require role-based secure access to essential information to have such

14

access. This is inclusive of the patient, caregiver, primary care providers, and

specialty care providers. 28

JWCH Institute, Inc.

The JWCH Institute Inc. (JWCH) partnered within the Skid Row Homeless Healthcare Initiative (SRHH) and together developed a community project to create a tuberculosis (TB) registry that functions as an IT system that allows medical, social service, and housing providers access to shared TB records in order create a provide a medical home, coordinate services and reduce unnecessary duplication in health care services. JWCH chose a community-developed, open-source, enterprise electronic medical record system framework. JWCH funded WebReach, Inc., to develop a customized version of OpenMRS, which is named OpenMRSLA and included a TB module to help track the status of the homeless population.

JWCH also created a comprehensive data sharing agreement with the Los Angeles Department of Social Services and the Department of Housing and gave authorized users access to OpenMRSLA so that they could identify:

• Where an individual was currently living;

• What medical program (such as Medi-Cal or HealthyWay LA) individuals were on or eligible for;

• Whether their TB status was current.

This comprehensive agreement allowed for the coordination of medical and housing services for the homeless in addition to managing a prevalent and costly chronic condition. Although at the time of the site visit there was limited information on the effectiveness of the program, the information gathered through the medical directors at JWCH indicated that they felt that over 75% of their patient population was in OpenMRSLA and that each of them was current on their TB vaccinations.

15

Beacon Community of the Inland Northwest (BCIN)

For the Beacon Community of Inland Northwest, care coordination involves not only facilitating access to patient information among providers, but also assuring that the patient is receiving the right care. BCIN is using their health IT infrastructure to support their care coordination goals in multiple ways: sharing data between all members of the patient’s care team, facilitating access to evidence-based medical practices, and providing quality measurement reports. The shared data includes clinical data, procedures, diagnoses, demographic information, and clinical outcomes. To promote use of evidence-based medical practices, BCIN has integrated advanced care coordination algorithms into the Orion Technology Solution® that has been implemented as the information technology foundation for the program. The Orion Technoloy Solution® includes a HIE, a clinical data repository and the ability to support disease management pathways. Through the functionality of the Orion tool set, health care providers within BCIN are able to create care plans based on an individual’s disease status. For instance, when tracking type 2 diabetes, patients who successfully manage their weight and other symptoms will receive recommended care that differs from patients with other critical health problems.

16

Key Component II: Facilitation of Team-Based Care that Includes the

Patient and Family as Critical Members of the Care Team

Team-based, patient-centered care involves cooperative efforts amongst all

members of the care team, decisions supported by evidence and patient and family

needs, preferences and values; and the use of a comprehensive and coordinated

plan of care that is executed in a reliable, timely and effective manner. Effective

care coordination is rooted in robust

communication and trust, and is influenced by

care providers, patients and their families and

initiated in a collaborative dialogue that shares

information, explores values, and assists

patients and their families in the decision

process. 29

Health IT systems are essential to a team-

based, patient-centered care coordination

process. They enable all care team members –

including the patient and family – to be

empowered as well-informed, active and

accountable participants in the care process.30

Health IT can provide support for team-based

care by providing real-time performance

information to team-members and facilitating

clinical workflows, improving patient/provider

satisfaction, providing personalized educational support and enabling more timely

and effective communication.31 In order to promote team-based, patient-centered

care coordination, the health IT system should facilitate patient access to and

sharing of information, and allow for collaboration between care team members,

including facilitation of communication among all care team members.

The role of health IT in team-based care:

• Connecting various actors, representing a variety of disciplines – including

the patient and family – who are responsible for implementing the care plan,

communicating and coordinating with one another;

• Facilitating individual care team member action based on a holistic

understanding of the needs, preferences, and values of the individual;

• Integrating care coordination steps into the workflows of both professional

care team members and the patient and family;

“You can compare care coordination, to an audible football game… It involves an entire plan and a strong team. The ability to communicate and change, and disseminate information to your

entire team, in a cohesive way is important and paramount to the success of the “play”. It’s about being able to make changes, not just making a plan, but reacting quickly when things occur and there has to be that primary coach or quarterback, which

can be the primary care physician, orchestrating these plays”

- Sandra Schafer, Vice President of

Marketing and Business Development,

Holon Solutions

17

• Enabling patient and caregiver input of preferences and

observations/experiences whenever they are not physically in the healthcare

system;

• Providing patient self-management support;

• Enabling linkages between community and healthcare organizations.

While it is duly recognized that the collaborative efforts of multiple parties are

essential to the success of coordinated care efforts, the patient must remain the

central focus of care coordination, and healthcare decisions should be inclusive of

their needs and preferences. While this is an important principle of care

coordination at any point in time, it is particularly true during transitions of care.

Part of making “patient centered-ness” actionable during a transition of care is

ensuring that all care team members on both the sending and receiving end have

real-time access to the data they need. These technologies should allow patient

access to and input of information. The patient and/or family or caregiver should

participate directly in preparing for transitions of care, and appropriate protocols

should be used to ensure timely understanding and endorsement of the plan by all

care team members.

Self-management and self-care tools and techniques are critical to patients’ ability

to take an active role in their care. The health information technology systems that

integrate eTools should enable reminders, contact preferences and educational

information in electronic health records or other software solutions that are capable

of receiving and sending information from the patient in response to prescribed

educational information. This can be implemented in similar ways as results from

ordered tests and procedures are included in the medical record.

Likewise, the patient should be an active participant in defining how their

healthcare record is managed, controlled and shared. The patient will help the

clinician and care team understand what particular pieces of information they prefer

to be kept confidential. Patient education by the clinician about should become a

significant component of care coordination. The clinician should help the patient

understand why particular information is critical to overall care coordination, as well

as potential consequences of not sharing information.

Care team members include a variety of disciplines and individuals, and health IT

should support the work of each of them. Nurses, patients, physical therapists,

occupational therapists, social workers, speech therapists, and many other

professionals working at various points along the care continuum (including long-

term care settings excluded from current federal health IT incentives) have a role in

collecting information about patient’s needs and preferences. Social support

systems are critical members of a patient’s extended care team, and effective care

coordination must include the necessary linkages to these supports, which can

18

range from traditional medical services to providing transportation services and

resources to help with food and shelter.

Health IT can support the goals of the care team and clinical decision support

systems can help in meeting those goals. The first step of developing a high-

functioning team is to help team members by defining their assignments and

increasing communication between each member. Specialists and other clinical

professionals should be included as part of an individual’s care team as necessary

and be connected with the patient. For patients with limited long-term chronic

illnesses, such as cancer, there may be a need for the specialist (such as an

oncologist) to become the main hub for coordinating care.

Standardized communication methods and formats can help significantly in

improving care coordination, especially during transitions. Such standardization

can include a minimal set of core data elements that are accessible during and after

the transition to both sending and receiving care teams, and including the patient

and caregiver.

Creating methods of continuous feedback loops between the patient and caregiver

and other members of the care team throughout the course of care is essential for

better care coordination. Such feedback loops will facilitate more complete and

accurate information, including any unanticipated problems during or after the

transition or once certain elements of an agreed-upon care plan are implemented.

The monitoring of progress, the effectiveness of the care plan and the ability of

patient/caregiver to adhere to treatment plans should continue once the individual

is at home or in a subsequent care environment. There should be alerts provided

when patients and members of the care team do not adhere to structured care

plans, as well as effective processes for follow-up.

An individual’s care plan should include essential information such as primary

language and information pertaining to family participation, dietary preferences,

and degree of social or community organization participation. Health IT can

facilitate tracking data on the patient and family’s specific communication needs –

whether it be through an interpreter or assistance device - which can facilitate the

process of care and speed up support for patients whose primary language is not

spoken by the healthcare professional. The clinician and care team should be

sensitive to the needs of patients who rely on family members for interpretation

and be notified of situations where independent translation or interpretation

services are necessary.

19

Western New York Beacon Community (WNYBC)

While WNYBC has only a limited electronic patient education system for the overall population served, a telemonitoring pilot program for diabetes patients showcases how health IT can be used to increase patient engagement and communication with the healthcare provider. As a part of the 120 day program, patients answer daily questions online about diabetes treatment in general and their own self-management practices in order to facilitate patient education. Patients also electronically submit glucose and weight information to their provider through an online virtual health record. Within the next 3 months, WNYBC plans to upgrade the system so that self-reported patient information will be sent directly to the physician’s EHR.

Southeastern Michigan Beacon Community (SEMBC)

SEMBC is using health IT to meet the unique needs of the community it serves through its ongoing rollout of the Text4Health Initiative for diabetes prevention and care, making it one of only three Beacons to pilot a mobile texting program. As Terrisca Des Jardins, the Director of SEMBC explains, “The beauty of the use of the cell-phone, and specifically text messaging, is that it’s ubiquitous in the community as a communication vehicle and especially among populations that are harder to reach and underserved.” The Text4Health Initiative targets not only patients diagnosed with diabetes, but also the family members and other undiagnosed and pre-diabetic individuals. Participants complete an assessment through text message and then are assigned to a risk category. They set self-management goals and receive targeted reminders for their goals, educational and community resource text messages throughout a 13-week period.

20

Key Component III: Care Plans

A care plan acts as the “roadmap” of clinical and patient-centered goals, actions to

take to reach goals, responsible party for each action, tracking of progress toward

goals, and timeline for completing actions. The care plan should be a living

document that is updated regularly and that can incorporate information gleaned

from secure messaging, patient portals, and subsequent encounters. In essence

there is a need for a master care plan that is longitudinal and comprehensive, with

various sub-plans that provide more specific, targeted information. Care plans

should also include both prevention and wellness information, as well as clinical

treatment information.

The role of health IT in Care Plans:

• Should provide the ability to view the master plan and click on an area of the

master plan in order to see specific information in a sub-plan; this enables

the availability of comprehensive information while also presenting

information in a manageable format that is not overwhelming;

• Allows for the aggregation of patient-contributed data for self-management

support needs; for example, collecting information about a patient’s status as

a caregiver would be important so that need is considered in developing the

care plan; must also be able to include community linkages that need to be

made;

• Allows patient and family contributions to the care planning process itself;

• Decision support must be available throughout the care planning process, as

well as at the point of care;

• Should make available information necessary for incorporating self-

management needs into the care plan. For example, Patient Activation

Measure® iv results can be useful in determining the type and degree of

support required by an individual for successful implementation of the care

plan;

• Makes advanced directive status and content and risk assessment results

available for inclusion in the care planning process;

• Allows notation of when tasks and steps in the care plan are completed.

iv The Patient Activation Measure® (PAM®) assessment is a reliable and valid measure of the knowledge,

skills and confidence essential to managing one’s own health and healthcare. It was developed by Judy

Hibbard at the University of Oregon. See www.insigniahealth.com for more information.

21

“My hope is that the discussion about care planning will continually hit home the point that most

patients spend the vast majority of their lives not interacting with the healthcare system. We really must use health IT, to bring the healthcare system to the patient to support them when they are not

physically within the four walls of a provider setting. A longitudinal, shared care plan is vital to ensure that those helping to care for an individual have access to the information they need, regardless of where they are physically located.

We cannot continue to expect people always to shoulder the burden of coordinating care without help from the professionals working within the system. More effective care coordination is essential to improving care, making care more

affordable, and ultimately to improving the health of communities. “

- Eva Powell, MSW, HIT

Program Director, the

National Partnership for Women & Families

Care planning is a multiple-layered process, requiring a comprehensive longitudinal

view of care and more detailed, disease or discipline-specific sub-plans. Health IT

can be designed to provide a comprehensive picture of a patient’s needs and care

plan, as well as more concise information related

to a specific need, thereby avoiding information

overload for the end-user. Solutions could be

built upon the Continuity of Care Record (CCR)

or Continuity of Care Document (CCD) to include

updates from each care-team visit and socio-

economic needs of the patient. Different views

of the same data could be developed to meet the

needs of various categories of end-users.

Health IT is a tool that can help facilitate the

development, process, and execution of care

plans by creating linkages, promoting

communication among multiple healthcare

providers, including referrals, authorizations, and

scheduling care appointments32. Additionally,

health IT can assist in linking community

resources in treatment planning and mapping

preventive strategies.33 Health IT is essential to

produce actionable, tailored, information in

useable forms for the patient, family and

healthcare provider –not just raw data. With the

support of health IT and health information

exchange, the information needs of the patient,

healthcare provider, and supporting

organizations can be met using data entered once during the process of care.

While health IT is an essential tool for achieving coordinated care, the process itself

relies on human behaviors: specifically the collaborative efforts of the patient,

family, healthcare providers and community supports. Members of the care team

should work together to reach the best possible strategies for meeting the clinical

and personal health goals of the individual. The patient and/or caregiver should be

an active participant in developing the individual care plan. This includes goal

setting and treatment decisions, preferably through a shared decision-making

process. The patient’s life circumstances, current health and health history,

functional status, self-management knowledge and actions and need for supportive

services also are critical factors, and should be considered in developing care plans

and treatment recommendations. The care plan should include community and

nonclinical services that respond to a patient’s needs and preferences and

22

contribute to achieving the patient’s goals, in addition to traditional healthcare

services. Ultimately, team based care should be focused on meeting an individual

patient’s clinical and personal health goals.

Certain information, such as caregiver name and contact information, advance

directive content, pertinent psychosocial information, among others, should be

easily accessible in various views developed for different groups of end-users, even

if it is not among the most commonly used information by that particular group. By

making this information available, but not overwhelming, new interactions can be

fostered between care team members for more effective care coordination.

Data from a variety of sources is required at the point of decision making, the

multi-phased process that ultimately results in a care plan and subsequent revisions

to it. The entry of information into an electronic care plan from various decision-

making processes should be timely, and time of entry, source of information, and

any necessary explanations about the data should be included. Follow-up processes

for tests, treatments and services should be established and automated to the

degree possible. The healthcare organization and/or clinicians shall develop

protocols for managing care plans that incorporate systems for registering,

tracking, measuring, reporting and improving essential coordinated services. Such

protocols will determine the degree to which and options for using health IT for

these purposes.

As previously stated, care planning should take into account results of risk

assessments and other patient-contributed information that may be stored

elsewhere in the EHR. Since longitudinal care planning will involve multiple points

of decision-making that do not necessarily take place at the point of care, clinical

decision support will need to be available not just at the point of care, but also at

the point of care plan development. Future performance measurement is likely to

require data elements captured in the care plan, therefore making linkages between

the care plan and quality measurement functionalities in an EHR essential, so that

data and measures do not have to be entered by hand into analytical components

of an EHR, but rather can be pulled directly from the care plan.

23

Greater Cincinnati Beacon Community (GCBC)

GCBC is taking several steps to improve the care planning process through the use of health information technology solutions. The majority of the transitions of care work within the GCBC focus on preventable emergency room visits and readmissions. One of the greatest challenges for the program is connecting healthcare providers to critical patient information when the healthcare organization is outside of the network. The Emergency Department - Inpatient Alert System is another technology solution that GCBC is initiating to improve the flow of patient information between hospitals, practices and post-acute providers. As Trudi Matthews, Director of Policy and Public Relations notes, “Patients are stubborn people. They go where they want to go. Just focusing only on the ability to share information well within one organization is not sufficient…so as a health information exchange, HealthBridge is helping to smooth information flows across systems.” Using targeted groups of children with asthma and adults with diabetes, participating hospitals have agreed to provide data related to emergency, inpatient, discharge and/or transition of care information.

24

Key Component IV: Organization of Information and Services

EHRs have a distinct advantage over paper in that the technology itself can

organize and present information in ways that are most meaningful to the end user

in a specific circumstance. For example, they can be designed to include linkages to

data analytics software that provide insight based on clinical and other relevant

healthcare encounters. When designed specifically for the purpose of informed

decision-making, EHRs can enable healthcare providers, patients and their family

and caregivers to use data to make better-informed decisions by taking into

account all pertinent information from multiple data sources across time. Effective

care coordination requires a care delivery system to integrate the efforts of care

team members, information generated by these efforts, and other resources

needed to carry out patient care activities.34 The EHR provides a means of recording

both the components of the care plan and the parties responsible and accountable

for specific actions across multiple sites. Although not every healthcare provider is

responsible for capturing every piece of information, information captured by other

care team members should be organized and accessible by others who need it.

Information must be organized and displayed in ways that provide seamless

integration of information without creating data overload.

The role of health IT in the Organization of Information and Services:

• Should create customizable information and allow it to be presented in a

manner that is most useful for the end user (which would include any

member of the care team);

• Should provide user-centric applications;

• Should integrate information from remote monitoring, telehealth, mobile

health, and other relevant eTools.

The health IT infrastructure should enable collaborative decision-making support

among different clinicians and patients.35 Health IT infrastructure should promote

the interoperable exchange of data among the care team and other individuals

participating in the execution of patient-centered care planning.36 EHRs should

include the capacity to enable the care team to receive, record and access

information that clearly outlines the role(s) and responsibilities of participants in a

patient's care for a specific aspect of that care (both within, but also outside of the

primary medical home) and should be clearly delineated and facilitated.37

Specifically, the record should note who is primarily responsible for specified care

and coordination activities, the scope of that responsibility, and when that

responsibility will be transferred to other care participants. 38

Health IT Functionality

25

The health IT infrastructure should incorporate systems for tracking, measuring,

reporting, enhancing communication and improving essential coordinated

services.39 Remote patient monitoring can be a critical component of care

coordination and should be interoperable with or integrated into EHR systems.

Health IT should support the integration of information from these devices into

workflows and care processes.40

Health IT should support meaningful clinician-patient communication and improve

accessibility of the healthcare organization to the patient.41 The infrastructure

should work to facilitate team-based care, and support a multi-disciplinary team

that includes, but is not limited to, other clinical staff, social workers, mental health

workers, health educators, and caregivers, as clinically appropriate. The patient’s

individualized care plan should be shared electronically across the continuum of

care and with the patient.42 The health IT infrastructure should support agreed

upon processes and procedures for clinical notification between hospitals and

outpatient clinicians.

Louisiana Coordinated System of Care (CSoC)

The development of the Coordinated System of Care (CSoC) to serve 2,500 children most at risk or in out-of-home placement has been a hallmark of development within the overall LBHP system. The CSoC concept in Louisiana is unique in that it involves a formal collaboration and commitment from the four critical child-serving agencies: Department of Children and Family Services (DCFS), Office of Juvenile Justice (OJJ), Department of Education (DOE), and the Office of Behavioral Health (OBH). Each of the child-serving agencies contributes funding that has been aggregated in order to better leverage federal Medicaid resources and even more importantly allows for a streamlined and coordinated approach to managing and directing the care of children with complex behavioral health needs.

To effectively coordinate care in a fractured system, the Louisiana behavioral health providers will use Magellan’s Clinical Advisor application, built upon the ClaimTrak platform. This application will offer providers a Web-based, fully customized electronic health record designed specifically for the use by the behavioral health profession. The new HIT solution will be available to up to 5,000 Louisiana licensed behavioral health providers who do not currently have an electronic health record (EHR) application, this will give them the advantages of greater data functionality without additional infrastructure investment for their practices.

26

Conclusion

Care coordination will continue to grow as an important and vital process that helps

ensure that patient’s needs and preferences for health services and information

sharing across people, functions, and sites are met over time.43

Health IT implementation is an ongoing process, and those doing the difficult work

of implementation are at multiple stages of readiness to incorporate functionality

that supports care coordination. As technology advances, it is important to remain

mindful that the integration of health IT into care coordination will be a

continuously evolving process. The most efficient and effective care coordination

technologies will likely arise from real-world experience with new care delivery

models and redesigned workflows.

There are several key functions that individuals and healthcare organizations will

need to consider in relation to the future application of health IT systems for care

coordination. By enabling the capture and use of data through electronic

technologies, health IT will be instrumental in developing and improving healthcare

practices and preventive services. Health IT should be

used to promote these goals by turning data into

actionable steps; however, as technology continues to

evolve, it is vital that patients remain at the center of

all care coordination activities. Successful care

coordination will depend upon technological solutions

and collaboration between diverse healthcare providers.

Before individuals and organizations involved in the

care coordination process aim to achieve any of the

recommendations addressed in this report, they should

first engage in a focused dialogue with appropriate

stakeholders. Likewise, the healthcare community

should identify and disseminate best practices for

making bidirectional linkages with community support

organizations, healthcare organizations, and individuals

involved in the care coordination process. In order to

achieve effective care coordination and promote patient

engagement, greater effort must be made to include

professional groups that are traditionally excluded from

EHR/HIE and Meaningful Use implementation goals.

Examples of important organizations for the long-term

care of a patient include, but are not limited to:

community organizations, such as shelters or educational institutions; mental

health facilities; laboratories; physical therapists and substance rehabilitation

clinics.

“I think that the health IT system can eliminate some of the logistics around ambiguity in communication, however, it cannot replace the people-

to-people process. Today, you have care coordination that is neither a good people-to-people process nor logistics for communications management. Health IT’s

role is to make sure that the information is at the right place, at the right time, and to the right people and with that, the care team (including the

patient) can have meaningful access to information. “

-Leslie Kelly Hall, Senior Vice President Healthwise

27

There is tremendous activity in the area of care coordination, and several best

practices can be applied towards the successful use of technology. Beacon

Community programs, NQF, state health plans, federal initiatives and care

coordination communities exemplify how health IT can improve quality of care while

reducing costs. In addition, the Patient Protection and Affordable Care Act has

encouraged and supported the development of several health IT initiatives that are

focused on improving the care coordination process, specifically medical home

models. Future technological developments should build upon best practices

developed from these initiatives to enable multidirectional linkages with community

organizations and support systems. The systems must be adaptable to the

changing needs of the patient populace.

Health IT is instrumental to support preventive healthcare goals set forth by state

and national organizations. Healthy People 2020 is a national agenda developed by

HHS that communicates a vision for improving health and achieving health equity,

and proposes a comprehensive strategic framework that unites health promotion

and disease prevention. Included in the framework are specific, measurable

objectives in topic areas that target national healthcare goals over the next decade,

such as how health IT functionalities can support preventive healthcare goals.

Healthy People 2020 encourages collaborations across healthcare sectors, guidance

to assist individuals in making informed health decisions, and measuring the impact

of preventive activities. Health IT programs should be developed to support the

achievement of Healthy People 2020 goals, and enable the healthcare community

to track data-driven outcomes, monitor progress, and motivate, guide, and focus

action.

Creative solutions will be required to treat, prevent, and ultimately slow the

epidemic of chronic conditions in the U.S. With promising innovations such as

genomics already on the horizon, health information technology systems must be

able to adapt to future changes in medical practice and procedure. Similarly, care

coordination plans and EHR systems will need to incorporate a host of new

information and data provided by advances in personalized medicine.44

As increasingly more Americans develop one or more chronic conditions, the burden

of care will continue to fall upon the shoulders of patients, families, caregivers,

providers, paid health aides, and the system at large. Healthcare delivery must be

integrated to coordinate care between disparate providers responsible for

chronically ill patients. Health IT and eTools can improve disease monitoring and

management by providing timely and useful data about patients, at both an

individual and population level. Access to electronic tools and data can allow

providers to find and contact patients with specific needs; develop and deliver

team-based care plans; receive feedback on performance; and benefit from

advanced functionalities, such as clinical decision support and automated

28

reminders. As the development, implementation and use of health IT become

more ubiquitous, it is expected that new avenues and applications of technology will

continue to be incorporated into the coordination of chronic care.

This document seeks to promote the effective use of health IT to facilitate care

coordination through the articulation of the key principles and components

recommended by the Council. The document is intended not to critique current

practices, but rather to influence the necessary changes to healthcare on the

horizon. While the document is envisioned to be used by multiple care coordination

initiatives, audiences should adapt the recommendations to fit their individual

needs. Healthcare initiatives looking to improve or adapt their care coordination

process through the use of health IT should place particular focus on the

involvement of their respective patient communities, best practices from successful

care coordination initiatives and development of technology solutions that are

flexible enough to meet the needs of a given population.

Listed below are critical functions required of health information technology in order

to facilitate the components of care coordination highlighted in this paper.

• Capturing, accessing and sharing of real-time patient data among those

caring for the patient.

• Enabling verification of the accuracy of patient-entered data.

• Allowing for flexibility that accommodates various workflow processes and

environmental factors like workload, staff schedules, and patient load.

• Facilitating seamless interoperability with evidence-based care management

strategies that support efficient and effective integration of patient

information, laboratory, imaging, therapy, referrals, medications, social and

community services, and self-management assistance, including patient

registries and population-based data.

• Alerting the care team of tests and services coordinated within the healthcare

plan.

• Facilitating bi-directional communication among professional care team

members and the patient.

• Facilitating linkages consistent with applicable state and federal privacy

standards that are outside the traditional healthcare system and are

necessary to meet a patient’s clinical and psychosocial needs (involving social

services, mental health, school systems, etc.).

• Facilitating quality improvement and safety; disease management; utilizing

CDSS tools; provider alerts and patient reminders.

• Providing a continuous information flow and feedback loop between a patient

and his or her care team.

29

• Supporting the creation and execution and updating of a care plan that can

be shared across the continuum of care and with the patient and their family,

caregiver, and/or paid health aide.

• Facilitating decision-making and planning for transitions of care.

• Presenting a master care plan that is longitudinal and comprehensive, with

various sub-plans that provide more specific, targeted information.

• Integrating and using information generated as part of the process of care.

• Capturing critical information, tracking patient education and self-

management support, and community and non-clinical services necessary to

support the patient and his or her caregiver’s needs and preferences.

Significant evolution in the marketplace is necessary to achieve the widespread

availability of the functionalities described above. The Council identified several

concrete steps that can be taken now or in the near future that will advance the

capability of electronic health information systems to support better coordination of

care. This is not intended as an exhaustive list, but rather as a starting place for

focused effort by policy makers, industry representatives and others.

• Identify a starter set of role-based views for presenting data necessary for

care coordination.

• Identify professional groups that are often excluded from EHR/HIE

implementation who will be critical for care coordination and engage

professional societies or other organizations representing these groups in

future discussions about improving care coordination using health IT.

• Identify prevention goals from Healthy People 2020 that can especially

benefit from health IT and prioritize their integration into health IT enabled

care coordination.

• Identify vocabulary and data transfer standards necessary for the

functionalities above, with particular attention to incorporation of patient

contributed data into the EHR.

Identify and spread best practices for making linkages with community

supports.

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Case Studies:

To illustrate how communities are utilizing health IT to support care coordination,

the document considers the experiences of several Beacon Community programs,

state plans, and community-based organizations. The case studies were developed

through phone interviews, submissions from organizations, and general research.

These studies detail the experiences of the following care coordination

communitiesv:

• Statement from the Office of the National Coordinator

• Greater Cincinnati Beacon Community, Cincinnati, OH

• Western New York Beacon Community, Buffalo, NY Southeastern Michigan

• Southeast Michigan Beacon Community, Detroit, MI

• Rhode Island Beacon Community, Providence, RI

• Greater Tulsa Health Access Network Beacon Community, Tulsa, OK

• Colorado Beacon Community, Grand Junction, CO

• Beacon Community of the Inland Northwest, Spokane, WA

• JWCH Institute Inc., Los, Angeles, CA

• Montefiore Medical Center Bronx, New York, New York

• Oregon Health Plan

• Louisiana Coordinated System of Care

Office of the National Coordinator

The Office of the National Coordinator for Health Information Technology (ONC)

funds the Beacon Communities Program. The Beacon program is one of several new

programs created by the Health Information Technology Economic and Clinical

Health (HITECH) Act as part of the Recovery Act in 2009. Total funding for the

Beacon program initiatives is $250 million plus an additional $15 million for

technical assistance and evaluation, over 3 years. The Beacon Communities are

seventeen communities across the country that had already made significant

inroads in the adoption of health IT prior to the grant award. The Beacon

Community Program goals include building and strengthening a health information

technology infrastructure; improving health outcomes, care quality, and cost

efficiencies; and spearheading innovations to achieve better health and healthcare.

The Beacon Communities are microcosms of the rest of America, and as such, the

lessons that are learned from them will play a key role in healthcare

transformation.

v For the purposes of this section, health information exchange (HIE) refers to both the process and the

entity.

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The Beacon Community Cooperative Agreement Program provides funding to 17

selected communities throughout the United States that have already made inroads

in the development of secure, private, and accurate systems of EHR adoption and

health information exchange. The Beacon Program will support these communities

to build and strengthen their health IT) infrastructure and exchange capabilities to

improve care coordination, increase the quality of care, and slow the growth of

healthcare spending.

The 17 Beacon Communities will focus on specific and measurable improvement

goals in the three vital areas for health systems improvement: quality, cost-

efficiency, and population health, to demonstrate the ability of health IT to

transform local healthcare systems. The goals vary according to the needs and

priorities of each community. For instance, some communities will focus in the care

for chronic conditions such as asthma, heart failure, and diabetes to illustrate how

costs can be reduced and patient care improved through the collection, analysis,

and sharing of clinical data.

Greater Cincinnati Beacon Community Program

Through collaborative efforts with several community healthcare programs, the

Greater Cincinnati Beacon Collaboration (GCBC) has become an advanced leader in

the successful use of health IT and HIE.

GCBC was built through the collaborative partnerships of Cincinnati Children’s

Hospital Medical Center, The Health Collaborative of Greater Cincinnati, the Greater

Cincinnati Health Council, GE, the University of Cincinnati and HealthBridge. Unique

to other Beacon Community programs, the GCBC was founded on a strong,

previously established foundation of health IT efforts through HealthBridge, a HIE

serving the Greater Cincinnati tri-state area. Founded in 1997, HealthBridge has

grown to become one of the largest regional health information organizations

(RHIO) in the country, with 50 participating hospitals, more than 7,500

participating healthcare providers, and serving over 2.3 million patients.

HealthBridge is focused on advancing existing health IT and HIE capabilities to

improve coordination of care, the quality, value, and population health and

achieving Meaningful Use within the GCBC.

Building upon existing HIE infrastructure and regional collaboration GCBC led by the

Greater Cincinnati Health Council recently launched the Transitions of Care pilot

program to share discharge summary documents directly between hospitals and

other providers, aimed at removing disruptions and improving the workflow for

receiving these documents. The ultimate goal is to use the Direct Project to send

patient summary records or CCDs between service providers, inclusive of hospitals,

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home health services, long-term care agencies, and primary care providers, in

order to improve transitions of care. However, as many Beacon programs have

experienced, information exchange can only advance as far as participating

providers’ health IT systems allow. As of now, even participating providers with

advanced EHR systems are unable to send CCDs easily. Nevertheless, as Trudi

Matthews, Director of Policy and Public Relations for HealthBridge relates, by using

the Direct Project to send discharge documents GCBC is, “Taking another important

step in the journey toward improving information flow about patients.”

GCBC is taking several steps to improve the care planning process through the use

of health information technology solutions. The majority of the transitions of care

work within the GCBC focus on preventable emergency room visits and

readmissions. One of the greatest challenges for the program is connecting

healthcare providers to critical patient information when the healthcare organization

is outside of the network. The Emergency Department - Inpatient Alert System is

another technology solution that HealthBridge is initiating to improve the flow of

patient information between hospitals, practices and post-acute providers. As

Matthews notes, “Patients are stubborn people. They go where they want to go.

Just focusing only on the ability to share information well within one organization is

not sufficient…so as a health information exchange, HealthBridge is helping to

smooth information flows across systems.” Using targeted groups of children with

asthma and adults with diabetes, participating hospitals have agreed to provide

data related to emergency, inpatient, discharge and/or transition of care

information.

As one of the largest HIEs in the country, HealthBridge is capable of leveraging its

technology infrastructure to not only increase the electronic flow of information but

also ensure that patient information is transferred in the securest method possible.

Using a HIPAA and HITECH compliant system, HealthBridge provides a secure,

private, encrypted connection between healthcare systems. The approach is

“provider-centric”, keeps data off the open internet, and ensures that information is

sent only to authorized healthcare providers. As Matthews stated, “We think secure

electronic connections are far more secure and keep information more private than

the current paper-based system where you have no way of tracking who has seen

your paper record.”

While increasing the secure flow of information is a vital aspect of facilitating care

transitions, the ultimate goal of care coordination is to improve the health of

patients. GCBC is currently engaged in several programs that focus on the use of

technology to improve patient self-management of chronic conditions and provider

communication. The first is a PCMH demonstration led by The Health Collaborative

with 18 participating healthcare practices focusing on improving outreach to patient

populations. Each participating healthcare practice receives training focused on

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PCMH principles, including open access scheduling, team-based care, active

involvement of care, and use of data for improvement. To facilitate these goals,

HealthBridge is working with selected practices to provide a patient registry that is

integrated with their EHR and other community data sources. The registry will also

include the capability for practices to send education materials to patients in a

“simple summary” format and the use of a patient-portal to send patients updates

and monitor treatment.

Additionally, GCBC has partnered in care coordination activities is the Cincinnati

Children’s General Pediatrics Program at Cincinnati Children’s Hospital. Currently,

the General Pediatrics team has 114 high-risk patients enrolled in their care

coordination work. The team is testing a process of identifying high-risk patients in

an effort to prevent emergency room readmissions. To facilitate this, they have

developed a logic model for identifying patients that are at-risk for a preventable

emergency room visit and can benefit the most from care coordination activities.

Another project aimed at patient engagement is the Text4Health initiative, a larger,

mobile technology based public campaign implemented in coordination with

Hamilton County Public Health. The initiative will send targeted text messages

regarding weight management, eating habits, and recommended care to 25,000

pre-diabetic or diabetic patients.

HealthBridge has spent much of the past year designing and building new system

capabilities; therefore, many of their care coordination projects are only now being

tested with a small group of providers. For this reason, it is still too early to show

which of their initiatives are most effective at lowering costs or improving quality of

care. The GCBC evaluation team will begin analyzing results and publishing its

findings in the next 12 months.

In tandem with its Transitions of Care initiatives, HealthBridge is also developing

an advanced HIE system where all data is mapped and exchanged from system to

system as coded, consistent data elements. This advanced HIE capability is being

implemented now under Beacon and will allow greater integration of patient’s

health information and development of a more robust longitudinal patient record

across systems. As Matthews says, “That’s when you’re really going to see

electronic systems fully able to improve care coordination.”

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Western New York Beacon Community

Working within an established HIE system and forming key partnerships with local

physician , payers, and health technology providers, has allowed the Western New

York Beacon Community (WNYBC) to focus on closing gaps in patient services in

order to improve care coordination and health outcomes for diabetic patients.

Established by a grant to HEALTHeLINK™, the regional HIE and RHIO, the Western

New York Beacon Community serves eight counties in western New York, with

communities ranging from the city of Buffalo to rural areas that lack broadband

service. WNYBC’s program goals include expanding the current HIE network to

include long-term care facilities and homecare agencies, as well as greater sharing

of prescription information, emergency room data, and hospital medication

discharge data. Due to a 10.3% diabetic incidence rate in Western New York,

WNYBC is focused on implementing health IT to improve health outcomes for

50,000 diabetic patients within a network of 500 primary healthcare providers.

WNYBC has a unique concentration of healthcare providers utilizing EHRs. The 500

participating healthcare providers were selected based on their prior use of

electronic health record systems that were connected to HEALTHeLINK™. WNYBC

was able to identify six preferred vendors that are qualified to meet Meaningful Use

standards and Certification Commission for Health Information Technology ( CCHIT)

certified, including MEDENT™, eClinicalWorks™, Allscripts Enterprise and

Professional™, STI CHARTMAKER ™, Amazing Charts™, and NextGen Healthcare™.

Through partnerships with Catholic Medical Partners, The P2 Collaborative of

Western New York and local physician associations, WNYBC conducts intensive

assessments of the health IT infrastructure within each practice to improve

workflows and ensure that registries are properly set-up to collect and share de-

identified patient data. Currently, a dozen practices have achieved Meaningful Use

Stage 1 and dozens more are able to directly receive laboratory and radiology

results, as well as medication information, within their EHR systems.

Beyond practice care coordination, WNYBC has established several programs to use

health IT to facilitate care transitions, such as an electronic notification system to

send alerts to primary care physicians within the EHR when patients are discharged

from a hospital and the development of an HIE data source for hospital and

rehabilitation clinic discharge medication prescriptions. WNYBC has also developed

a unique telemonitoring pilot project that focuses on transitions of care. Targeting

specifically the co-morbid diabetic populace at-risk for hospitalization and

emergency room visits, WNYBC has implemented telemonitoring devices that

monitor these patients in order to identify issues prior to hospitalization, instead of

post discharge. WNYBC has engaged three different telemonitoring vendors to

assist with this project. Through their engagement, WNYBC is utilizing technology

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that allows the patients to report their blood pressure, glucose readings and weight

remotely, and lets their doctors receive that information online through the virtual

health record. Technology being used includes on-line patient education and

feedback and unique android based mobile devices for wireless reporting.

While WNYBC has only a limited electronic patient education system for the overall

population served, another telemonitoring pilot program for diabetes patients

showcases how health IT can be used to increase patient engagement and

communication with the healthcare provider. As a part of the 120 day program,

patients answer daily questions online about diabetes treatment in general and

their own self-management practices in order to facilitate patient education.

Patients also electronically submit glucose and weight information to their provider

through an online virtual health record. Within the next three months, WNYBC plans

to upgrade the system so that self-reported patient information will be sent directly

to the physician’s EHR.

WNYBC has established multiple security checks to ensure the privacy of patient

information. In order to become certified for Meaningful Use, practices must

undergo a security assessment. In order to access the individual systems,

healthcare providers sign into the HEALTHeLINK™ HIE web portal. The system

utilizes a two factor authentication process that uses an AnakAM® system and

requires cell phone, direct line phone, or security fob for identity verification in

order to sign-on to the system for a 12-hour period. In addition, WNYBC has a

standing security council that involves the majority partners in the Beacon

Community Program to monitor privacy and security concerns.

In order to show the success of care coordination, WNYBC is tracking 34 cost and

quality measures using claims data from hospitals and insurers and registry data

from each participating practice. From this data, WNYBC hopes to demonstrate

reduced hospital admissions and cost of each admission, as well as specific health

outcomes improvement for diabetic patients.

While it is too early to provide quantitative results of cost and quality improvement,

WNYBC is able to provide numerous anecdotal stories of the effectiveness of their

programs. Virtual health records have allowed provider offices to operate more

efficiently, thus saving precious time. Additionally, by allowing providers to access

patient lab results from other providers, both physicians and patients have been

able to avoid the unnecessary repetition of tests. Nancy Maloney, Sr. Business

Architect and Clinical Transformation Specialist for the WNYBC, shares a story of

how the HIE has helped to save lives by facilitating the verification of donor

information during organ donation. When a donor without any family information

was identified to the local Organ Procurement Agency, the agency staff used the

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HIE to find and contact the family, as well as access the appropriate lab results to

rule out any incompatibility issues for organ donation.

When offering advice to communities looking to implement care coordination,

Nancy Maloney stresses the need to assess how technology fits into each practice

and is incorporated into the practice workflow. WNYBC Project Director Mr. Todd

Norris, PMP states “You can’t just throw technology over the wall and expect it to

stick or work…If it’s not part of their everyday living, they’re just never going to use

it.” Maloney also points out the importance of collecting and reporting data to

practices in order to show that care coordination is making a difference. Maloney

indicates that, “data really can open up eyes.” For example, a doctor may think that

she is giving 100% of patients the flu shot, but after receiving a report may realize

that only 15% of patients have actually been vaccinated.

In the coming year, Nancy Maloney, the Beacon Team and their partners look

forward to creating greater interoperability of data in order to allow increased EHR-

to-EHR communication between primary caregivers and specialists. In addition,

expanding the notification of patients’ transitions of care will also greatly enhance

the quality and efficiency of the care the patient receives. She believes that the

discrete transfer of data elements across EHRs, rather than the use of direct

messaging systems, is more efficient and effective in the coordination of care.

Southeast Michigan Beacon Community

With a focus on health management at the community level, the Southeast

Michigan Beacon Community (SEMBC) is rapidly becoming a leader in care

coordination within the Beacon Community Programs.

The SEMBC, with the Southeastern Michigan Health Association as its lead agency,

is one of the two most recent Beacon Community Programs to be established,

receiving its award in September 2010. Serving Wayne County with an eye toward

the seven-county region of Southeastern Michigan, which includes the greater

Detroit area, SEMBC is currently conducting work in five major areas to achieve

health delivery and systems improvement: HIE, clinical transformation, leadership

and community accountability, sustainability, and evaluation and measurement. To

date, SEMBC has reached over 14,000 patients with diabetes with a focus on

diabetes prevention and management. It is estimated the clinical transformation

reach through the SEMBC affiliated practices exceeds well over 150,000 patients.

From a health IT perspective, SEMBC considers itself to be unique from other

similar health information exchange efforts by using technology to bring clinical

care decisions for care gaps and alerts from the clinic site level up to the

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community level. Given many residents in the Detroit metropolitan area do not

have a primary physician; a focus on care coordination at the community level is

essential. As Sue Hashisaka, the Director of Clinical Transformation, explains, “If a

patient shows up at one of our 50 partner clinics and then goes to an emergency

department outside of the scope of that clinic, the HIE will enable a prompt to come

up through the HIE so that physicians at the clinic will know that the patient went

elsewhere and be able to look at the clinical data.”

SEMBC is additionally using health IT to meet the unique needs of the community it

serves through its ongoing rollout of the Text4Health Initiative for diabetes

prevention and care, making it one of only three Beacons to pilot a mobile texting

program. As Terrisca Des Jardins, the Director of SEMBC explains, “the beauty of

the use of the cell-phone, and specifically text messaging, is that it’s ubiquitous in

the community as a communication vehicle and especially among populations that

are harder to reach and underserved.” The Text4Health Initiative targets not only

patients diagnosed with diabetes, but also the family members and other

undiagnosed and pre-diabetic individuals. Participants complete an assessment

through text message and then are assigned to a risk category. They set self-

management goals and receive targeted reminders for their goals, educational and

community resource text messages throughout a 13-week period.

While SEMBC has a special interest in coordinating care and reaching patients at

the community level, it continues to focus on care planning at the site level because

not all practices have the necessary level of health IT infrastructure to participate in

a community-wide system. Therefore, SEMBC is working to ensure that each

practice has the ability to create patient summaries with specific action plans for

diabetes care from its own registries or EHRs.

As a part of its efforts to improve care coordination within each clinic, SEMBC sends

practice coordinators to train providers in using their own electronic health systems

more efficiently in order to streamline their work. SEMBC has observed providers

have subsequently demonstrated a heightened awareness of the capabilities of their

EHR and registry systems after participating in the training. This change is critical

because many providers previously used their electronic health systems at a

minimal level and exhibited a low adoption rate of technology. Bruce Wiegan,

Director of HIT and HIE, describes the significant value of this change, commenting

that “the more meaningful providers find the use of their own technology, the more

meaningful their participation in the overall HIE system will be.”

Overall, Ms. Des Jardins sites the key to SEMBC’s success is its ability to leverage

existing resources, relationships and initiatives in the community. For example, by

partnering with Michigan’s Quality Improvement Organization (MPRO), the Voices of

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Detroit Initiative (which works with all the Federally Qualified Health Centers in

Wayne County) and other organized health delivery systems, SEMBC is able to

leverage organizations that have been working with providers in the area for years.

She also notes that large physician organizations and health systems, payers, like

Blue Cross Blue Shield of Michigan, and employers such as General Motors

Corporation and Ford Motor Company were also instrumental in supporting the

development of health IT infrastructure in physician organizations and practices.

In the coming months, SEMBC will officially launch their HIE. Ms. Des Jardins

observed “traditionally, HIEs have been about pushing data… but our initiative will

include population-level management tools and the ability to track patients across

the health delivery continuum and over the course of time. The type of clinical

transformation and HIE infrastructure Beacon is pursuing will be an essential

foundational element in healthcare delivery system and payment structures reform

we are all likely to see in the coming years.”

Rhode Island Beacon Community

The state of Rhode Island has a rich tradition of investing in primary care

initiatives, focusing specifically on the PCMH model. The Rhode Island Beacon

Community Program (RI), has built upon this unique foundation, leveraging health

IT to improve the quality, safety, and value of healthcare for patients within its

community.

The RI community includes practices participating in three specific PCMH projects,

spread across 28 practices and 50 sites of care. Included within these projects is

the Chronic Care Sustainability Initiative (a multi-payer demonstration project),

Rhode Island Chronic Care Collaborative (a program sponsored by the state

Department of Health that is focused on Federally Qualified Health Center clinics),

and the PCMH program offered by RI Blue Cross Blue Shield. The goals of the RI

program include supporting RI’s transition to the PCMH model of care through

health IT and improving RI’s ability to see and act on the quality and efficacy of the

healthcare system by providing foundational capabilities in quality and utilization

reporting

The Rhode Island Beacon Community initiatives are led by the Rhode Island Quality

Institute, which also administers currentcare (the statewide health information

exchange) and the state REC. The RI Beacon community strives to demonstrate

that it is possible to achieve interoperability across heterogeneous practices and

EHR platforms through the use of a health information exchange.

The RI program is providing concrete examples of how information technology-

enabled PCMH care models can lead to improvements in health outcomes. The RI

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experience has resulted in important quality measurement and reporting lessons in

the following important areas:

• The role of various forms of leadership

• The power of community collaboration around shared objectives

• Ways to motivate and encourage practices and clinics to transform.

The challenges of harmonizing measures and aligning with participants’ pre-existing

measure requirements and achieving Meaningful Use objectives figures prominently

in the RI Beacon Community Program as well as developing Quality Reporting

Measurement Database capabilities. The RI program has deployed services to

aggregate quality measures at the community (Beacon population), practice, and

provider levels. Information is presented using a variety of data visualization

approaches which helps practice and physician leaders to see opportunities for

improvement and motivates them to pursue them.

In summary, the RI Beacon work is showing that health IT investments can be a

potent means of driving practice transformation and that data analytics capabilities

and skills, in particular, are core competencies of a community’s culture of change

and improvement.

Colorado Beacon Consortium

Every Beacon Community values improving the quality of care across communities,

but few have as put as much focus on involving the community in the creation of

care coordination models as the Colorado Beacon Consortium (CBC).

The CBC works with 38 primary care practices across seven counties in western

Colorado to create a community-based model for care coordination with health IT

and HIE at its core. As Julie Schilz, the former Director of Community Collaborative

and Practice Transformation, relates, at the heart of CBC’s mission is the belief,

“That if we deliver on quality, the cost will follow.” With this in mind, CBC is focused

on moving towards a paradigm of care coordination that improves patient care

while reducing costs across multiple independent and provider partner

organizations. With the health information infrastructure building upon community

resources, skills, and involvement, CBC has redesigned primary care practices to

establish a community-based HIE that collects, analyzes, and shares discrete

clinical and administrative data. In doing so, CBC has moved away from the

traditional point-to-point model of data sharing to embrace comprehensive data

aggregation and analytics.

Health information technology facilitates and informs the development of

community-based care coordination in a number ways. One of the core principles of

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a community HIE is data interoperability. As Patrick Gordon, Program Director,

states, “having a central, community-based interoperability service is much more

efficient and will enable us to make much more progress in terms of system

integration across very disparate platforms than we would achieve in a point-to-

point model where essentially every large group and hospital is working to recreate

the wheel.” Through the HIE, CBC has access to a secure, standardized method of

communication that creates efficiency for all participating practices and facilitates

coordination of care across multiple, disparate points of care. Recognizing that the

traditional one-size-fits-all approach towards case management does not work, CBC

has expanded care coordination to include shared care planning and innovative

options such as group patient visits to encourage patient activation and increase

access among the community at large.

Health IT is used not only to facilitate coordination of care between providers, but

also within each point of service to transform practices to embrace the chronic care

model and change the dynamics of the patient-provider relationship. Because each

practice has different technology, CBC conducts delivery system redesigns to

establish specialized models and workflows for each practice so that they can best

use their technology for care coordination. CBC trains each practice to use

technology to document shared care plans, show patient progress, and use EHR

functionality to track patients. To improve physician-patient collaboration, CBC is in

the process of implementing and evaluating several pilot studies with software such

as Archimedes IndiGO™, a decision support tool that employs advanced predictive

modeling and health risk assessment to calculate a patient’s risk of adverse events

at a granular level based on diagnostic, behavioral, and biomarker data, and

ultimately suggest appropriate medications and/or interventions that will have the

greatest impact. By using quality metrics, practices are able to identify how well

they’re meeting the needs of the population and can recognize patient outliers who

may need additional support in their care.

CBC has visionary goals for integrating families, consumers, and patients into

multiple levels of the care coordination experience, though Schilz admits that there

is still “a little work to do”. CBC is currently working with practices to design

workflows that incorporate greater patient engagement by having patients serve on

quality improvement teams along with quality improvement advisers and

programmatic members. In the future, CBC plans to create small, structured

community consumer advisory boards to counsel programs and initiatives, such as

the implementation of population health registry tools. As Schilz describes, the goal

of the consumer advisory boards is to “engage the community to think differently

from a cultural standpoint of how to engage consumers, patients, and families” in

their care.

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CBC also prioritizes how to best serve the patient and community-at-large when

building privacy and security into the health IT framework. While most of the

structure is built at this point, CBC is continuously developing and changing security

measures and protocols to give patients greater control in directing how their

information is shared. Currently, CBC bases privacy of patient information on the

“trust fabric” articulated by ONC to define the types of relationships required for

patient information to be shared within the medical neighborhood community. Both

patients and providers can choose whether to share their information through the

HIE. Even though the system is evolving, Schilz finds that patients are still

comfortable sharing information due to the great level of community involvement

that CBC has fostered. As Schilz describes, “Many of the concerns about privacy

and security are about the ‘what if’ scenarios.” Therefore, the HIE has gone into

many communities and maintained conversations about the purpose and goals of a

community HIE on a regular basis so that people understand how the information

will be shared and the benefits of information sharing for the health and quality of

care .

CBC has made great efforts to include the community in the development and

implementation of care coordination, and it is now able to highlight examples of the

success of its community-based model. For example, hospital readmission rates for

adult Medicaid patients within the area served are approximately 50% lower than

readmission rates for the Medicaid population statewide. However, Gordon

emphasizes the difficulty in drawing correlations between tracked metrics and

changes in the quality and cost of care at the community level, calling it a

“significant intellectual undertaking.”

Additionally, while CBC strives to align data tracking with Meaningful Use

guidelines, many practices are still in the process of upgrading to Meaningful Use

systems. Even when practices have upgraded their EHR systems, the associated

reporting modules often are not. Furthermore, while EHR systems may be certified

in general for Meaningful Use, they often have not been certified for all measures.

Currently, CBC collects information on nine Meaningful Use measures aligned with

previous PQRI initiatives. However, because practices differ in their ability to

provide any or all of the tracked measures, it is difficult to uniformly collect and

analyze data.

When offering advice to other communities looking to establish care coordination,

Schilz underlines that all healthcare is local, recommending to look first to the

existing resources and characteristics of the community and the practices within in

it, before establishing the technical framework. Once the core elements, needs, and

challenges of the community are understood, the technology can then be

implemented in a way that maximizes community support and uses data to engage

the community and show successes. Gordon also adds that care coordination must

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involve a mix of clinical and non-clinical staff that have the ability and aptitude to

create trusting relationships within the community.

Overall, CBC demonstrates that while the process of modernization needs to be

supported by technology, the patient

Beacon Community of the Inland Northwest

While many Beacon Programs are based in predominantly urban areas, the Beacon

Community of the Inland Northwest (BCIN) has built upon pre-existing health

information technology infrastructure to become a model for establishing care

coordination in rural America.

Serving largely rural communities in eastern Washington and northern Idaho, the

BCIN was formed in May of 2010 with the goal of increasing care coordination for

patients with type 2 diabetes in rural areas. As a rural Beacon Community, BCIN

faces the challenge of establishing care coordination across a large region where

patients often move from small rural practices to specialists in urban centers.

However, unlike many other rural areas, the participating BCIN communities are

uniquely positioned to expand care coordination because of previous investments in

health information technology.

Prior to receiving the Beacon grant, 60% of practices in the BCIN region had

electronic medical systems and the majority of hospitals already used advanced

information systems and participated in some data exchange. With critical

infrastructure already in place, BCIN targeted provider-to-provider communication

to increase care coordination over time. The new system facilitates information

sharing and can send alerts to primary physicians when a patient receives care at

another provider or facility. In the future, BCIN plans to add tools and capabilities

that will improve the downstream flow and sharing of information with patients to

ultimately increase patient engagement.

While the infrastructure being implemented can support any type of care

coordination and health information exchange, due to the large service area and

number of participating organizations BCIN has chosen to focus on tracking

measures for type 2 diabetes to assess the progress in attaining consistent care

across the region. Given its high prevalence in the community and the common

acceptance of best practices for disease management among providers, diabetes

was a natural choice. As Jac Davies, the Director of BCIN, explains, in establishing

care plans and quality measures “We didn’t have to convince people what are the

right things to do; we just needed to make it easier for everyone to do it.”

Care coordination involves not only facilitating access to patient information among

providers, but also assuring that the patient is receiving the right care. BCIN is

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using their health IT infrastructure to support their care coordination goals in

multiple ways: sharing data among all members of the patient’s care team,

facilitating access to evidence-based medical practices, and providing quality

measurement reports. The shared data includes clinical data, procedures,

diagnoses, demographic information, and clinical outcomes. To promote use of

evidence-based medical practices, BCIN has integrated advanced care coordination

algorithms into the Orion Technology Solution™ that has been implemented as the

information technology foundation for the program. The Orion technical solution

includes a HIE, a clinical data repository and the ability to support disease

management pathways. Through the functionality of the Orion tool set, healthcare

providers within BCIN are able to create care plans based on an individual’s disease

status. For instance, when tracking type 2 diabetes, patients who successfully

manage their weight and other symptoms will receive recommended care that

differs from patients with critical health problems.

In striving to increase communication among providers, BCIN has included

community-based pharmacists in the system because pharmacists often see

patients much more often than physicians do. However, BCIN must first establish

the appropriate level of involvement for pharmacists in care coordination. For

instance, BCIN must decide if it is appropriate for pharmacists to use patient

records to remind patients of overdue health exams when they fill a prescription.

Determining the appropriate level of access is part of the larger process of

protecting patient privacy in health information exchange. The BCIN security

framework includes both role-based and relationship-based limits on access to a

patient’s information. As such, a provider must have a logical clinical relationship to

a patient in order to access medical records and a physician would receive greater

access than a medical assistant. The system continuously audits information access

to ensure the highest level of security.

Over time, BCIN intends to incorporate care coordination for additional disease

states. However, after having spent the last year developing the policy and

technology framework, BCIN will focus for now on implementation and evaluation,

to show improvements in the quality and cost of care for diabetes management.

Davies admits that setting up a community-based care coordination system has

been hard. As she explains, “What’s making it more difficult than it might have

been three years ago are all of the various initiatives to advance the use of

information technology. There are delays in getting clinics in the program because

they’re trying to upgrade their EHRs to meet Meaningful Use. Also after the

introduction of ACO regulations, everyone’s been trying to figure out how they will

realign with everyone else.”

44

Given the many challenges that physician offices face in aligning their health IT

systems with federal and state initiatives, Davies states that successful community

initiatives must help physicians understand the added value of participation in care

coordination and health information exchange programs. Establishing regional care

coordination has been a difficult process, but Davies looks forward to seeing

increased quality and efficiency of care in the rural communities

JWCH Institute

JWCH Institute, Inc. is also a 501(c)(3) community health center that was

established at the Attending Staff Association of the John Wesley County Hospital in

1960 by Los Angeles County physicians. The agency’s current mission is to

improve the health and wellness of under-served groups of the population of Los

Angeles County through the direct provision or coordination of healthcare, health

education services and research. The organization works through a variety of

programs and activities, such as:

• medical outreach and referrals for medical care

• HIV services and drug treatment

• health education

• psychosocial assessment and intervention

• primary medical care

• family planning services

• research

Homelessness has become a major factor in the resurgence of tuberculosis (TB)

within the United States over the past two decades. This social status is associated

with an increased risk of exposure to Mycobacterium tuberculosis, undetected and

untreated infection, and subsequent progression to TB disease. Homeless persons

with TB are more likely to be hospitalized longer than non-homeless persons, with

the public sector paying most of the costs. In 2010, there were 11,182 (per

100,000 population) cases of TB reported within the US, with 10,541 of those cases

being reported by State health departments as coming from individuals classified as

homeless. The highest concentration of homeless individuals diagnosed with TB

was identified as California.

The Skid Row Homeless Healthcare Initiative (SRHHI) was a partnership of 26

agencies that strove to integrate services, reduce suffering and improve the health

of homeless people in and around the community of Central City East. It is

estimated that 8,000 to 10,000 homeless people reside in a 52-block area of

downtown Los Angeles known as Skid Row. Located less than a mile east of the

center of downtown Los Angeles, the homeless that are assembled in this area have

access to emergency shelters, transitional and permanent housing, social and

medical services, and food provided by a cluster of agencies that serve the largest

45

homeless community in the United States. The vision of the SRHHI was “to reduce

the suffering of homeless people in and around the Skid Row community of

downtown Los Angeles by improving their overall health through increased access

to integrated services” and its mission was “to design and implement a coordinated

system of care for Skid Row.”

The JWCH Institute is a partner within the SRHHI and took on the development of a

community project to create a TB Registry that is an IT system that allows medical,

social service, and housing providers access to shared TB records to provide a

medical home, coordinate services and reduce unnecessary duplication. JWCH

chose OpenMRS, a community-developed, open-source, enterprise electronic

medical record system framework. JWCH funded WebReach, Inc., to develop a

customized version of OpenMRS, which is named OpenMRSLA and included a TB

module to help track the status of the homeless population they serve.

JWCH also created a comprehensive data sharing agreement with the Los Angeles

Department of Social Services and the Department of Housing and gave authorized

users access to OpenMRSLA so that they could identify where an individual was

currently living, what medical program (such as Medi-Cal or HealthyWay LA they

were on or eligible for, and whether their TB status was current. It represented the

most comprehensive agreement at the time and allowed for the coordination of

medical and housing services for the homeless in addition to managing a prevalent

and costly chronic condition. Although at the time of the site visit there was limited

information on the effectiveness of the program, the information gathered through

the medical directors at JWCH indicated that they felt that over 75% of their patient

population was in OpenMRSLA and that each of them was current on their TB

vaccinations.

Montefiore Medical Center

Located in the heart of New York City, the Montefiore Medical Center (Medical

Center) is a shining example of a healthcare provider organization that places a

unique focus on chronic care management, research, and community outreach.

Montefiore Medical Center is a large healthcare organization that includes four

hospitals with a combined 1,491 beds, 21 community-based primary care clinics, 17

school-based clinics offering medical, mental, and dental health services, and a care

management organization responsible for the health of 150,000 at-risk enrollees in

capitated contracts. Montefiore manages a wide range of patient populations,

including Medicare, Medicaid and commercial beneficiaries located throughout the

greater New York City metropolitan area.

To manage this large and diverse population, the Medical Center has a rich history

of care coordination that takes advantage of its elaborate health IT system, which

46

has been in use for more than a decade. This clinical information system includes

an EHR, inpatient, ambulatory, laboratory, imaging and pharmacy functionalities, a

data warehouse and a patient portal.45 The comprehensive system links the entire

medical center through online patient care and business databases. Through the

health IT infrastructure, Montefiore providers can use clinical variables, laboratory

information, medication list summaries, discharge plans, and other clinical data to

identify patients suitable for care management plans and to measure patient

outcomes. Additionally, the Medical Center has an advanced telemonitoring system

for intervention services. Combined, these systems can automatically flag patients

who require special supervision or would benefit from a specialized care plan.

Overall, Montefiore utilizes a patient centered medical home model to direct its care

coordination efforts. Under this model, providers can comprehensively assess

patient populations to determine problem areas and devise targeted care plans to

address them. Various departments throughout the center are integrated into care

coordination activities. For example, the ambulatory department has begun

connecting with inpatient and acute care services through the EHR system.

The efforts of Montefiore’s pharmacy department are strongly representative of the

center’s care coordination activities. The department is composed of a centralized

pharmacy with six satellite pharmacies at other locations. However, this separation

has not prevented the department from taking an active role in the care of patients.

After installing automatic medication dispensers in each nursing unit, pharmacists

have been able to provide more direct patient care, such as counseling patients that

are non-compliant or have particularly complicated medication regimens. The

automatic dispensers have made it possible for many patients to no longer rely on

pharmacists, allowing them to devote time to work within interdisciplinary care

teams. Using wireless laptop technology, pharmacists can also order prescriptions

to provide patients with the appropriate medication at the point of care.

Similarly, the home healthcare agency has worked to successfully coordinate care.

Qualified patients are referred to homecare aides upon discharge from the hospital.

The home healthcare aides help patients reconcile medical information, attend

follow-up procedures, and help coordinate next steps. The aides use a variety of

health IT solutions to help care for patients. Wireless enabled laptops facilitate real-

time health information updates, serve as a means for the aides to communicate

with a patient’s care team to ensure patient compliance with their discharge plan,

and can be used to educate the patient about medication reconciliation. Telehealth

technologies play a similar role, and are used primarily within populations with

heart failure or diabetes. Home healthcare aides can use telehealth tools to send

reports to a patient’s doctor on a regular basis, while doctors can use telehealth to

follow-up on a patient’s care.

47

Patient engagement is an important component of the Medical Center’s care

coordination efforts. Patients have access to over 35,000 resources with

information on disorders, disease, wellness, medications, and more. Patient

education tools are available in both Spanish and English to account for diversity in

Montefiore’s patient population. Notably, Montefiore also offers an online patient

portal, called MyMontefiore™. MyMontefiore™ enables patients to schedule

appointments, access educational materials connect with their healthcare providers,

request medication refills, and manage their chronic conditions. Currently, over

50,000 patients use MyMontefiore™.

Likewise, Montefiore performs extensive patient outreach through the Bronx

Regional Health Information Organization (RHIO). The system is connected to a

number of community outreach centers, such as shelter services. When a

Montefiore patient is admitted to a shelter, the provider who last saw the patient

receives an alert, which allows the provider to coordinate care between the shelter,

hospital, and provider and manage the patient’s illness outside of the medical

center. Additionally, the health IT system has functionalities that enable the

emergency department to identify at-risk patients who need special case

management services as soon as they reach the hospital.

The Medical Center’s health IT system has been a necessary component at the

center of all care coordination activities. It is also especially important to the way

Montefiore manages transitions of care. Montefiore’s EHR system prompts providers

with a standard set of questions to help devise a care plan following post-acute

care. These care plans have helped the Medical Center demonstrate significant

reductions in in the readmission rate and have standardized the discharge summary

process for Montefiore’s patient population. Montefiore is partnered with payers and

two other healthcare organizations in its care transitions program. Along with the

care plan and discharge summary, staff are trained in a consistent manner and

have standard data collection tools which allows participants to communicate

effectively across organizations.

Montefiore Medical Center has a rich and bright future, with continued efforts in

care coordination activities. Montefiore is moving ahead to become an accountable

care organization, built upon the relationships developed through the Bronx RHIO

and surrounding community organizations, in order to provide even better care at

affordable costs.

Health Information Technology in the Louisiana Behavioral Health

Partnership

The Louisiana behavioral health service system has historically been characterized

as fractured and heavily dependent on the most restrictive and costly levels of care

such as inpatient hospitalizations and residential levels of care. For adults with

48

serious behavioral health disorders, the service delivery system offered stark

contrasts. Adults could access community-based providers, who offered a limited

array of services or inpatient care at the point of crisis. For children, the behavioral

health service system spanned multiple child-serving departments, which were in

silos and unable to effectively coordinate services. Many of the service system

weaknesses were driven by inflexible funding options in the Medicaid behavioral

health program as well as fractured state general fund and federal grant financing

streams. The limited communications and lack of centralized electronic

coordination compounded problems and often led to duplication and inefficiencies.

To modernize the Louisiana behavioral health system, the State has undertaken a

comprehensive and far reaching reform. Entitled the Louisiana Behavioral Health

Partnership (LBHP), the State’s new behavioral health system includes:

• A statewide managed care entity to authorize and manage hospital and

community-based behavioral health services;

• An expanded package of community-based psychiatric rehabilitation services

to those with chronic mental illness;

• An array of wraparound services to support children at risk for out-of-home

placement;

• An expansion of services under Medicaid to provide for addictive disorders

treatment;

• An expansion of coverage of services by independent licensed providers in

the community; and

• The establishment of evidence-based practices.

The development of the Coordinated System of Care (CSoC) to serve 2,500 children

most at risk or in out-of-home placement has been a hallmark of development

within the overall LBHP system. The CSoC concept in Louisiana is unique in that it

involves a formal collaboration and commitment from the four critical child-serving

agencies: Department of Children and Family Services (DCFS), Office of Juvenile

Justice (OJJ), Department of Education (DOE), and the Office of Behavioral Health

(OBH). Each of the child-serving agencies contributes funding that has been

aggregated in order to better leverage federal Medicaid resources and even more

importantly allows for a streamlined and coordinated approach to managing and

directing the care of children with complex behavioral health needs.

To effectively coordinate care in a fractured system, the Louisiana behavioral health

providers will use Magellan’s Clinical Advisor application, built upon the ClaimTrak

platform. This application will offer providers a Web-based, fully customized

electronic health record designed specifically for the use by the behavioral health

profession. The new health IT solution will be available to up to 5,000 Louisiana

licensed behavioral health providers who do not currently have an EHR application,

49

this will give them the advantages of greater data functionality without additional

infrastructure investment for their practices.

Magellan has committed to fully certifying its EHR by the Office of the ONC

Accredited Certifying Body within one year of implementation. Providers and the

vendor will continue to improve their Meaningful Use of the system under the

Medicaid and Medicare EHR Incentive programs. Central to Meaningful Use is the

ability for clinical data to be shared between disparate care settings and providers.

Clinical Advisor will interface with the Louisiana Health Information Exchange

(LaHIE) to allow the sharing of a CCD. Through LaHIE, behavioral health providers

will be able to directly download physical health clinical data to their EHR (if they so

choose). The system offers role-based functionality for multiple staff groups

including prescribers, nurses, residents, case managers, behavioral health

specialists, therapists, and administrative and executive level staff.

The Louisiana Department of Health and Hospitals care management program goal

is to support members in achieving their optimal level of wellness and health, and

improve the coordination of care. The EHR and care management teams are the

mechanisms by which this coordination is possible. Every aspect of the patient’s

progress can be reviewed and documented using Clinical Advisor. With easy-to-

navigate tabs, categorized elements, and automated on-screen processes the task-

focused process notes offers a convenient way to document clinical services and

patient information. As Louisiana continues to improve health outcomes through

the use of better health information technology, this critical information will be

shared as appropriate across a broad range of healthcare settings giving healthcare

providers the data they specifically need.

Oregon’s Medicaid Transformation

As part of a larger plan to reduce spending and reform state programs in Oregon,

the Health System Transformation Team, composed of a bipartisan group of

legislators and stakeholders, has developed a strategy to transform the Oregon

Health Plan (OHP), Oregon’s Medicaid program. The goal of the reform process is

to deliver better care in a more integrated system while controlling costs.46

The result of the state’s initiative is a new model of care for the Oregon Health

Plan.47 The existing Medicaid Managed Care Organizations (not-for-profit HMOs

that cover OHP members) will be phased out and replaced by new entities, called

Coordinated Care Organizations (CCOs), which will consist of and be governed by,

networks of doctors, hospitals, dentists, community health workers, county mental

health departments and any other providers necessary to deliver physical, mental

and oral health services. The new CCOs will assume responsibility for the care of a

defined population under a global budget that will grow at a fixed rate. This model

is very similar to the Accountable Care Organization model that Medicare has

50

implemented as part of the Affordable Care Act, although Medicare will use a

shared savings model rather than a global budgeting system. Nevertheless, the

proposal envisions that each CCO will be held accountable for the health outcomes

of its assigned population and will be expected to effectively coordinate care, with

an emphasis on adoption of patient-centered primary care homes and intensive

care management for dual eligibles.

Oregon will request a federal waiver to combine Medicare payments for the dual

eligible population with Medicaid funds to form the global budgets of the

Coordinated Care Organizations. Once the CCOs has been established and are

demonstrating the ability to integrate care and control costs, there is interest in

opening them to the healthcare plans of public employees and the individual and

small group insurance markets. In the longer term, the hope is that CCOs will be

successful enough that large group and self-insured plans would participate.

The legislature approved the plan with bipartisan support in mid-2011. The set of

criteria that CCOs are required to meet is under development, along with other

features of Oregon’s Medicaid transformation, including quality metrics that CCOs

will be held accountable for meeting, a methodology for establishing global

budgets, and a plan for integrating care for dual eligibles. Workgroups, composed

of stakeholders from throughout the Oregon healthcare system, including providers,

health plans, hospitals, academics, advocates and government officials, are helping

the Oregon Health Authority to specify these details.48 Implementation plans must

be presented to and approved by the legislature during the February 2012 session.

The first CCOs would become operational in mid-2012, pending CMS approval.

The Medicaid reform legislation, HB 3650, mandates that CCOs require their

healthcare providers to communicate with each other and coordinate care with the

primary care home using health IT, although a period of transition is allowed.49

Initially, CCOs are expected to document their health IT and health information

exchange infrastructure, develop a plan to establish the capability to transmit

patient information in real time from the primary care home to the rest of the

healthcare delivery system so care is coordinated, and makes progress toward that

goal. Assessments of each CCO may include the percent of providers with EHR

systems and the percent that have achieved Meaningful Use.50

The stakeholder workgroups charged with developing criteria and outcome

measures for CCOs are considering several provisions on health IT, emphasizing

those CCO participants must have access to electronic information in order to

successfully coordinate care.51 The draft proposes that CCOs be expected to

facilitate EHR adoption and Meaningful Use among providers, and that all CCO

providers must be part of a direct-enabled Health Information Service Provider or

Health Information Organization that allows it to electronically share information

51

with any other provider in the CCO. In the future, minimum rates for EHR and HIE

adoption, including rates for e-prescribing and electronic lab orders, should be

considered by the Oregon Health Authority. Additionally, the CCOs themselves

should have the technical capacity to assess provider performance using patient-

level data, using the analytics to improve care coordination, and report data on care

quality electronically to the Oregon Health Authority. The CCOs will also be

responsible for ensuring that patients have access to information technology that

enables them to participate in coordination of their own care, while identifying and

implementing future tools, such as telemedicine and smart phone apps, to improve

care delivery and coordination.

Ensuring the technical infrastructure necessary to achieve this vision will be

difficult. Carol Robinson, Oregon’s top health IT administrator, testified before the

work groups about the challenges that CCOs will face. 52 While hospitals and large

health systems are implementing EHR systems, they are far less available in

Oregon’s small practices. Federal incentive programs will not help all CCO

participants with the cost of implementing health IT, including behavioral health

and long term care providers. Additionally, Robinson emphasized that health

information exchange is essential for the CCO model, and that progress in

deploying HIE has been slower than expected. Oregon has pursued a federated

model of local HIEs, rather than a central statewide system. This poses the risk

that CCOs in some communities may lack access to a functional HIE. Initially,

these CCOs will need to rely on Direct secure email in order to coordinate care.

The healthcare reform model that Oregon has chosen for its Medicaid program is

dependent on robust health IT systems at the provider and regional HIE levels. A

significant risk to the success of CCOs would be the lack of ability to implement the

necessary health IT infrastructure in order to maximize the ability of providers to

coordinate care. The EHR incentive program will help provide the resources to

develop this infrastructure, but it is unclear how some providers, such as mental

health and long term care, will be able to afford to connect electronically with the

primary care home. Alignment with the Medicare ACO model will enhance the value

proposition for these investments, as health IT will be a critical tool for establishing

a successful Medicare ACO as well.

Glossary

52

Accountable Care Organizational Model (ACOM)

• A group of healthcare providers (e.g. primary care physicians, specialists

and hospitals) that have entered into a formal arrangement to assume

collective responsibility for the cost and quality of care of a specific group of

patients and that receive financial incentives to improve the quality and

efficiency of healthcare. The term accountable care organizational model is

intended to include provider and Center for Medicare and Medicaid

supported entity.

o Source: http://www.rwjf.org/qualityequality/glossary.jsp

Acute care

• Short-term medical treatment, most often in a hospital, for patients who

have a severe illness or injury, or are recovering from surgery

o Source: http://www.rwjf.org/qualityequality/glossary.jsp

Advance healthcare directive or advance directive

• A written instructional healthcare directive and/or appointment of an agent,

or a written refusal to appoint an agent or execute a healthcare directive.

This document is employed to extend patient autonomy into the period in

which the patient has lost the ability to make decisions for him or herself.

o Source: http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm#term

At-risk population

• At risk populations include individuals that have “Diabetes, hypertension,

ischemic vascular disease, heart failure, coronary artery disease, and mental

health or substance abuse disorder, in addition to health disparities affecting

racial and ethnic populations.

o Source: http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-

27461.pdf

Audit Log:

• Computer files containing details of amendments to records, which may be

used in the event of system recovery being required. The majority of commercial

systems feature the creation of an audit log. Enabling this feature incurs some

system overhead, but it does permit subsequent review of all system activity,

and provide details of: which User ID performed which action to which files when

etc. Failing to produce an audit log means that the activities on the system are

'lost'.

o Source:

http://www.seattle.gov/informationsecurity/glossary_A.htm#Audit Log

Beneficiary

53

• An individual enrolled in a health insurance plan and receives benefits

through those policies.

o http://www.healthinsurance.org/glossary/

Bidirectional Communication

• As a part of care coordination, healthcare practices seek to involve individuals

more directly in managing their own health, and individuals become more

knowledgeable and interact with practices in new ways.

o Source: Kilo, C.M. and Wasson, J.H. (2010). Practice redesign and the

patient-centered home: history, promises, and challenges. Health

Affairs. 29(5): 773-778.

Bundled Payment

• A reimbursement model that links payments for multiple services patients

receive during an episode of care.

o Source: http://innovations.cms.gov/documents/pdf/Fact-Sheet-

Bundled-Payment-FINAL82311.pdf

Capitation

• Rate paid to a health plan or provider for services based on a fixed monthly

or yearly amount per person, no matter how few or many services a

consumer uses.

o http://www.ct.gov/oha/cwp/view.asp?a=2277&q=299920

Care

• Services rendered by members of the health professions for the benefit of a

patient. This is inclusive of diagnosis, follow up, and health maintence

treatments.

o Source: http://www.cms.gov/manuals/Downloads/bp102c16.pdf

Care Coordination

• The deliberate organization of patient care among two or more participants,

inclusive of the patient, to facilitate the appropriate delivery of healthcare

services. Care coordination involves the organization of people and other

resources necessary to carry out all required patient care activities, and is

managed by the exchange of information among participants responsible for

different aspects of care.

o Source: http://www.ahrq.gov/qual/careatlas/careatlas2.htm

Care Plan

54

• Usually a written medical and/or nursing care program designed for an

individual patient.

o Source: http://www.ncbi.nlm.nih.gov/mesh/68010347

Care Site

• Setting in which an individual receives treatment for non-emergency

conditions. The site could be a physician office, retail clinics, urgent care

center, or emergency room.

o Source: Weinick R. M., Burns R. M. and Mehrotra A. (2010). Many

emergency department visits could be managed at urgent care centers

and retail clinics. Health Affairs. 29(9):1630–1636.

Care Team

• Care of patients by a multidisciplinary team, inclusive of pathologist, home

care aids and specialists, usually organized under the leadership of a

physician; each member of the team has specific responsibilities and the

whole team contributes to the care of the patient.

o Source: http://www.ncbi.nlm.nih.gov/mesh/68010348

Care Transitions

• The movement patients make between healthcare practitioners and settings

as their condition and care needs change.

o Source: http://www.caretransitions.org/definitions.asp

Caregiver

• Persons who provide care to those who need supervision or assistance in

illness or disability. They may provide the care in the home, in a hospital, or

in an organization. Caregivers include trained medical, nursing, and other

health personnel, as well as, parents, spouses, or other family members,

friends, members of the clergy, teachers, social workers, and fellow patients.

The definition caregiver also encompasses family caregivers. Family

caregivers are friends and any other unpaid people caring for the patient and

acting as a patient advocate.

o Source: http://www.ncbi.nlm.nih.gov/mesh?term=caregiver

Capitation

• A health insurance payment mechanism in which a fixed amount is paid per

person to cover services; a fixed, per capita (per head) payment.

o Source: http://www.aarc.org/advocacy/resources/glossary.html

Case Manager

• Provides monitoring and coordination of the delivery of health services for

individual patients to enhance care and manage costs. Used for patients with

specific diagnoses or who require high-cost or extensive healthcare services.

o Source: http://www.aarc.org/advocacy/resources/glossary.html

Chronic Care

55

• The continuum of care required over a prolonged period of time for people

who have lost, or never acquired, functional abilities. Types of care can

include medical care, rehabilitative care, and personal assistance.

o Source:

http://www.rwjf.org/files/publications/other/ChronicCareinAmerica.pdf

Clinician

• A professional directly providing healthcare services.

o Source: http://www.ctri.wisc.edu/Home/Glossary.html

Clinical Decision Support

• A process for enhancing health-related decisions and actions with pertinent,

organized clinical knowledge and patient information.

o Source: http://www.himss.org/ASP/topics_clinicalDecision.asp

Consent Management:

• Giving patients appropriate control over their personal health information and

how it is collected, used, and shared.

o Source:https://www.ccim.on.ca/Documents/CPF/Consent_Managemen

t_Implementation_guide_v1.1_20110602_CPF.pdf

Core Data Elements

• Specific clinical measures that, when viewed together, permit a robust

assessment of the quality of care provided in a given focus area.

o Source: http://www.rwjf.org/qualityequality/glossary.jsp

Community-based Organization

• A public or private nonprofit (including a church or religious entity) that is

representative of a community or a significant segment of a community, and

is engaged in meeting human, educational, environmental, or public safety

community needs.

o Source: http://nnlm.gov/sea/funding/cbodef.html

Continuum of Care:

• The provision of coordinated healthcare services that encompass preventive

care, primary care, acute care, chronic care, rehabilitative care and supportive

care so as to maximize the value of services received by patients.

o Source:http://www.stonybrookmedicalcenter.org/patientcare/healthed

ucation/glossary#C

Dietician

56

• Individuals that plan food and nutrition programs, supervise meal

preparation, and oversee the serving of meals.

o Source: http://www.bls.gov/oco/ocos077.htm

Downside Risk

• Spending that exceeds a target expenditure.

o Source:

http://www.commonwealthfund.org/~/media/Files/Publications/Fund

%20Report/2011/Jul/1530Delbancopromisingpaymentreformrisksharin

g%202.pdf

Electronic Health Record(EHR)

• A computerized medical file that contains the history of a patient's medical

care.

o Source: http://www.rwjf.org/qualityequality/glossary.jsp

Emergency Care

• Evaluation and treatment of an illness, injury, or condition that needs

immediate medical attention in an emergency room.

o http://www.healthcare.gov/glossary/e/emergency-room.html

eTool:

• Health informatics tools that help patients and consumers make decisions

about screening and treatment. These tools provide treatment- and disease-

specific health information to patients, especially when facing choices among

ways to treat and manage their health conditions.

o Source: http://www.ahrq.gov/research/rtisumm.htm

Fee-for-Service (FFS)

• A method of paying healthcare providers for individual medical services

rendered where a provider bills for each patient encounter or service.

o Source: http://www.aarc.org/advocacy/resources/glossary.html

Global Payment

• A single per-member per-month payment is made for all services delivered

to a patient, with payment adjustments based on measured performance and

patient risk.

o Source:

http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/

RAND_TR841.pdf

Health and Human Services (HHS):

57

• The United States government’s principal agency for protecting the health of

all Americans and providing essential human services, especially for those who

are least able to help themselves.

o Source: http://www.hhs.gov/about/

Health Information Exchange (HIE)

• The electronic movement of health-related information among organizations

according to nationally recognized standards

o Source:http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_1

0741_848133_0_0_18/10_2_hit_terms.pdf

Health Information Technology (health IT)

• The use of computers, software programs, electronic devices, and the

Internet to store, retrieve, update, and transmit information about patients'

health.

o Source: http://www.rwjf.org/qualityequality/glossary.jsp

Healthcare Literacy

• The degree to which individuals have the capacity to obtain, process, and

understand basic health information, needed to make appropriate health

decisions

o Source: http://www.health.gov/communication/literacy/

Healthcare Provider

• Provider of medical or health services and any other person or organization

who furnishes, bills, or is paid for healthcare in the normal course of

business.

o Source: http://www.hipaa.com/2009/05/the-definition-of-health-care-

provider/

Healthcare Proxy

• A document in which an individual appoints someone else to make healthcare

decisions on his behalf if he becomes physically or mentally incapacitated or

unable to communicate with medical professionals

o Source:

http://www.invesco.com/portal/site/us/menuitem.b69c4947bbe878dc

3e5669 j43acd8fba0/#H

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

58

• The HIPAA Privacy Rule provides federal protections for personal health

information held by covered entities and gives patients an array of rights

with respect to that information.

o Source:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html

HITECH Act:

• The Health Information Technology for Economic and Clinical Health

(HITECH) Act, enacted as part of the American Recovery and Reinvestment

Act of 2009, was signed into law on February 17, 2009, to promote the

adoption and meaningful use of health information technology.

o Source:

http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule

/hitechenforcementifr.html

Homecare

• Healthcare services and supplies a doctor decides you may get in your home

under a plan of care established by your doctor.

o Source: http://www.healthcare.gov/glossary/h/homehealthcare.html

Home Health Aide

• Individuals that provide essentially the same care and services as nursing

assistants, but they assist people in their homes or in community settings

under the supervision of a nurse or therapist. They may also perform light

housekeeping tasks such as preparing food or changing linens.

o Source:

http://www.directcareclearinghouse.org/download/NCDCW%20Fact%2

0Sheet-1.pdf

Hospice

• Facilities or services which are especially devoted to providing palliative and

supportive care to the patient with a terminal illness and to the patient's

family.

o Source: http://www.ncbi.nlm.nih.gov/mesh/68006738

Hospital

• Institutions with an organized medical staff which provide medical care to

patients.

o Source: http://www.ncbi.nlm.nih.gov/mesh/68006761

Information System:

59

• A set of interrelated components work together to collect, retrieve, process,

store and disseminate information for the purpose of facilitating planning,

control, analysis, coordination and decision-making in business and other

organizations

o Source: http://www.uotechnology.edu.iq/dep-

cs/english/subjects/1pis.pdf

Interoperability

• The ability of health information systems to work together within and across

organizational boundaries

o Source: http://www.himss.org/ASP/topics_integration.asp

Insurance:

• Financial protection against all or part of the medical care costs to treat

illness or injury. Includes traditional fee-for-service health plans, preferred-

provider health plans, health maintenance organizations (HMO's),

commercial Medicare supplements, and other health insurance.

o Source: http://www.health.state.mn.us/clearinghouse/glossary.htm

o Source: http://www.bls.gov/cex/csxgloss.htm

Longitudinal View of Care

• Continuous and comprehensive observation or examination of a patient’s

health and medical treatments over an extended period of time that includes

preventive care and care coordination.

o Source: Saultz, J.W. (2003). Defining and measuring interpersonal

continuity of care. Annals of Family Medicine. 1(3): 134-143.

Long-Term Care

• Services that help people with their medical and non-medical needs over a

period of time

o Source: http://www.medicare.gov/Glossary/l.html

Managed Care

• An approach to health system reform in which health plans compete to

provide health insurance coverage for enrollees. The system relies on market

incentives (namely more subscribers and revenue) to encourage healthcare

plans to restrain the cost of care. Typically, enrollees sign up with a

purchasing entity that buys the services of competing health plans. Enrollees

are provided a choice among the contracting health plans.

o Source: http://www.aarc.org/advocacy/resources/glossary.html

Meaningful Use

60

• Medicare and Medicaid EHR Incentive Programs for providers requiring proof

of the use of certified EHR technology in ways that can be measured

significantly in quality and in quantity.

o Source:https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_

Use.asp

Medicaid

• A joint federal and state insurance program for eligible individuals with

limited income and resources

o http://www.medicare.gov/Glossary/m.html

Medical Record History:

• The documentation of a patient's past medical conditions and care.

o Source:

http://people.westminstercollege.edu/students/ncb0708/Program%20

Files/FA%20Davis/Fundamentals%20of%20Nursing%20ESG/glossary/

m.htm

Medicare

• The federal health insurance program for people who are age 65 or older,

certain younger people with disabilities, and people with End-Stage Renal

Disease (permanent kidney failure requiring dialysis or a transplant,

sometimes called ESRD).

o http://www.medicare.gov/Glossary/m.html

Mental Health Professional

• A licensed individual, including psychiatrists, clinical psychologists, clinical

social workers, psychiatric nurse specialists, and marriage and family therapists,

who provides counseling interventions designed to facilitate individual

achievement of human development goals and remediate mental, emotional, or

behavioral disorders, and associated distresses which interfere with mental

health and development.

o Source:

http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealth

hpsaguidelines.html

National Committee for Quality Assurance:

• An organization that provides information to allow purchasers and consumers

of managed healthcare to compare plans.

o Source: http://www.ct.gov/oha/cwp/view.asp?a=2277&q=299920

61

National Quality Forum (NQF):

• The National Quality Forum (NQF) is a nonprofit organization that operates

under a three-part mission to improve the quality of American healthcare

by: building consensus on national priorities and goals for performance

improvement and working in partnership to achieve them; endorsing national

consensus standards for measuring and publicly reporting on performance; and

promoting the attainment of national goals through education and outreach

programs.

o Source: http://www.qualityforum.org/About_NQF/About_NQF.aspx

National Quality Strategy (NQS):

• An initiative to increase access to high-quality, affordable healthcare for all

Americans established by the Affordable Care Act and directed by the

Department of Health and Human Services that pursues three broad aims at the

local, state, and national level to provide better care, foster healthy

people/communities, and ensure affordable care.

o Source: http://www.ahrq.gov/workingforquality/nqs/

Nurse Practitioner (NP)

• A registered nurse specially educated and licensed to provide primary and/or

specialty care.

o Source: http://www.health.state.mn.us/clearinghouse/glossary.htm

Palliative Care

• Care provided primarily to relieve symptoms of a disease or condition rather

than for curative purposes

o Source: http://www.va.gov/healtheligibility/Library/Glossary/#p

Patients

• Individuals participating in the healthcare system for the purpose of receiving

therapeutic, diagnostic, or preventive procedures

o Source: http://www.ncbi.nlm.nih.gov/mesh/68010361

Patient-Centered Care

• A healthcare model in which patients become active participants in their own

care and receive services designed to focus on their individual needs and

preferences, in addition to advice and counsel from health professionals

o Source: http://www.ahrq.gov/qual/ptcareria.htm

Patient-Centered Medical Home

62

• A team-based model of care led by a personal physician who provides

continuous and coordinated care throughout a patient's lifetime to maximize

health outcomes

o Source:

http://www.acponline.org/running_practice/pcmh/understanding/what

.htm

Patient Engagement

• Process through which an individual participates in his or her own healthcare

by harmonizing robust information and professional advice with their own

needs, preferences and abilities in order to prevent, manage, and cure

disease.

o Source: Center for Advancing Health paper entitled, “A new definition

of patient engagement: what is engagement and why is it important”,

http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_2

010.pdf

Patient Protection and Affordable Care Act:

• The Patient Protection and Affordable Care Act (ACA) was signed into law on

March 23, 2010. Essentials of ACA include: 1) a mandate for individuals and

businesses requiring as a matter of law that nearly every American have an

approved level of health insurance or pay a penalty; 2) a system of federal

subsidies to completely or partially pay for the now required health insurance

for about 34 million Americans who are currently uninsured – subsidized

through Medicaid and exchanges; 3) extensive new requirements on the

health insurance industry; and 4) numerous regulations on the practice of

medicine.

o Source: Laxmaiah Manchikanti, David Caraway, Allan T. Parr, Bert

Fellows, and Joshua A. Hirsch. (2011). Patient Protection and

Affordable Care Act of 2010: Reforming the Healthcare Reform for the

New Decade. Pain Physician Journal. 14:35-67.

Pay-for-Performance:

• Health-care payment systems that offer financial rewards to providers who

achieve, improve, or exceed their performance on specified quality, cost, and

other benchmarks. Most approaches adjust aggregate payments to

physicians and hospitals on the basis of performance on a number of

different measures. Payments may be made at the individual, group, or

organizational level. Performance may be measured using benchmarks or

relative comparisons. Generally, there are three types of performance

measures: structure, process, and outcome.

63

o Source:

http://www.massmed.org/AM/Template.cfm?Section=Home6&TEMPLA

TE=/CM/ContentDisplay.cfm&CONTENTID=30254.

Payer

• A public or private organization that pays for or underwrites coverage for

healthcare expenses

o Source: http://www.ohanet.org/Glossary

Personal Health Record

• An electronic record of health-related information on an individual that

conforms to nationally recognized interoperability standards and that can be

drawn from multiple sources while being managed, shared, and controlled by

the individual.

o Source: The National Alliance for Health Information Technology

Report to the Office of the National Coordinator for Health Information

Technology on Defining Key Health Information Technology Terms,

http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_8

48133_0_0_18/10_2_hit_terms.pdf

Pharmacist

• A healthcare professional who is qualified to prepare and dispense medicinal

drugs.

o Source: http://www.diabetes.ca/diabetes-and-you/what/dictionary/

Physician

• Individuals licensed to practice medicine. This is inclusive of primary care and

specialty care.

Source: http://www.ncbi.nlm.nih.gov/mesh/68010820

Physician Assistant (PA)

• Persons academically trained, licensed, or credentialed to provide medical

care under the supervision of a physician. The concept does not include

nurses, but does include orthopedic assistants, surgeon's assistants, and

assistants to other specialists.

o Source:

http://www.ncbi.nlm.nih.gov/mesh?term=physician%20assistant

Point of Care

• The time and place of care being given to the patient, from the healthcare

provider.

64

o Source:

http://highered.mcgrawhill.com/sites/0073374008/student_view0/glos

sary.html#P

Preventive Care

• Healthcare to prevent illness or detect illness at an early stage, when

treatment is likely to work best.

o Source: http://www.medicare.gov/Glossary/p.html

Primary Care

• Primary care providers include doctors, nurses, nurse practitioners, and

physician assistants. They often maintain long-term relationships with

patients, advising and treating them on a range of health related issues.

They may also coordinate a patient’s care with specialists.

o Source: http://www.healthcare.gov/glossary/p/primary-care.html

Private Insurance

• Coverage of medical expenses by a health plan provided through an

employer or union, or purchased by an individual from a private health

insurance company; includes all forms of health insurance that are not

funded by the government.

o Source:

http://www.census.gov/hhes/www/hlthins/methodology/definitions/cp

s.html

Private Pay

• The ability of a person to pay the cost of services with personal income or

assets

o Source: http://www.loretto-cny.org/index.cfm?PageID=41

Quality Measures:

• Performance measures related to the care of the patient that focus on

patient-level health outcome and experience measures that reflect an ACO's

ability to deliver patient-centered care that is well coordinated across

providers and improves outcomes for patients.

o Source: Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M.

Lieberman, Julie J. Lee, Julie L. Lewis, and Jonathan S. Skinner.

(2009). Fostering Accountable Healthcare: Moving Forward In

Medicare. Health Affairs. 28(2): 219-231.

\

65

Regional Extension Centers

• Organizations that support and serve healthcare providers to become

meaningful users of electronic health records (EHRs).

o Source:

http://healthit.hhs.gov/portal/server.pt/community/hit_extension_pro

gram/1495/home/17174

Regional Health Information Organization (RHIO)

• A health information organization that brings together healthcare

stakeholders within a defined geographic area and governs healt h

information exchange among them for the purpose of improving health and

care in that community.

o Source:

http://www.healthit.hhs.gov/portal/server.pt/...0...0.../10_2_hit_term

s.pdf

Rehabilitation

• Treatment used after a serious injury, illness or surgery, that helps the

individual regain strength, relearn skills, or find new ways of doing activities.

Can include any combination of physical therapy, occupational therapy,

speech-language therapy, and treatment of pain.

o Source: http://www.nlm.nih.gov/medlineplus/rehabilitation.html

Rehabilitation Hospital

• Facilities which provide programs for rehabilitating the mentally or physically

disablement of individuals.

o Source: http://www.ncbi.nlm.nih.gov/mesh/68012047

Risk-based Model:

• The use of administrative claims data to predict healthcare costs and patient

outcomes with the goal of reducing the cost, while improving the management

and delivery, of care.

o Source: http://www.academyhealth.org/files/awards/Risk-

BasedPredictiveModeling.pdf

Shared Risk:

• Payment models in which providers share in a portion of the savings they

achieve (upside), but are also at risk for a portion of spending that exceeds a

target (downside).

o Source:

http://www.commonwealthfund.org/~/media/Files/Publications/Fund

66

%20Report/2011/Jul/1530Delbancopromisingpaymentreformrisksharin

g%202.pdf

Skilled Nursing Facility

• Skilled nursing care and rehabilitation services provided on a continuous,

daily basis, in a skilled nursing facility. Examples of skilled nursing facility

care include physical therapy or intravenous injections that can only be given

by a registered nurse or doctor.

o Source: http://www.healthcare.gov/glossary/s/skilled-nursing.html

Social Worker

• A licensed professional who gives families emotional support, help in

adjusting to hospitalization, help planning for hospital discharge, and referral

to community resources

o Source: http://www.ncchildrenshospital.org/parentinfo/glossary#S

Sub-acute Care

• Maintenance care for serious medical conditions that are not urgent or life-

threatening, typically following a stay in a hospital.

o Source: http://www.hr.ucdavis.edu/worklife-

wellness/Life/eldercare/elder-care-glossary

Telemonitoring:

• Transfer of physiological data such as blood pressure, weight,

electrocardiographic details, and oxygen saturation through telephone or

digital cable from home to healthcare provider.

o Source: Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S.

Telemonitoring or structured telephone support programmes for

patients with chronic heart failure: systematic review and meta-

analysis. BMJ. 2007;334:942

Therapist • A person trained in methods of treatment and rehabilitation other than the

use of drugs or surgery. o Source: http://www.merriam-webster.com/medical/therapist

Workflow

• The set of clinical and administrative tasks that must be handled by more than one person in order to oversee the care of a person. For example, electronic health records are increasingly used to redesign work flows and improve the quality and value of care.

67

o Source: Tordal, P., Han, E. S., and Scholle, S. H. (2010). Easing the adoption and use of electronic health records in small practices. Health

Affairs. 29(4): 668-675.

68

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