Five States, Seven Hundred Physicians and Four Best Practices for HISP/HIE Success

Jenni Peterson, RN BSN, Clinical Integration Analyst, Avera

Kevin DeWald, Executive Director, SDHL

Conflict of Interest Jenni Peterson, RN BSN Kevin DeWald Have no real or apparent conflicts of interest to report.

Agenda • How benefits were realized for the value of Health IT (STEPS) • Creating a multi-state Health Information Exchange (HIE)

– Planning and Development – Innovative Use Cases

• Connecting a large Integrated Delivery Network using one HIE – Planning – Implementation – Post Implementation – Successes – Lessons Learned

Learning Objectives • Recognize the importance of planning and designing HISP/HIE systems to

work with existing workflows to avoid costly and delayed rework

• Identify referral patterns up-front and build them into the design as well; Finding errors of omission and resolving them real-time once the HISP/HIE goes live is extremely challenging

• Plan for efforts to operationalize the functionality once the HISP/HIE goes live, examining ways to address any unexpected errors that occur

An Introduction of How Benefits Were Realized for the Value of Health IT

http://www.himss.org/ValueSuite

Satisfaction • Created >357,000 CCD’s (In 2016 predicted 200% increase)

• Eliminating paper-based practices (Kill the Fax!)

Treatment/Clinical • Improves timeline and treatment plan – eLTC

• Reduces administrative manual calls for data retrieval

Electronic Secure Data • Exchanged messages with 34 HISPs

• 97% of eligible physicians successfully attested for MU2

Patient Engagement & Population Management • >25,000 attributed MN Medicaid Patients

• Avoid ED admissions through timely clinical event notifications

Savings • No cost study savings yet

• Anticipate reduction in administrative costs

Background: South Dakota Health Link • Origins date back to 2006 • Two groups worked to develop a statewide health information

exchange network and meet MU requirements for public health • By 2009, came together to integrate public health and provider

network into ONE platform. Go live 2010! • Today, one’s of the nations most successful HIE’s

– 150 organizations representing 2,200 providers using Direct services

– 95% of hospitals and 75% of primary care clinics use Point of Care Exchange (query-based services)

– First state in the nation to link with a local Veterans Affairs facility

By the numbers 150

Member Organizations Across

6 States

63 Hospitals

300+ Primary Care Clinics

With Member Organizations in

5 States

Direct services

Point of Care Exchange

Correctional Health Care Use Case Stakeholders

• South Dakota Correctional Health (Facilities include Springfield, Sioux Falls, Rapid City, Pierre, and Custer, their Juvenile facility)

• Avera

• Health Department clinicians

Overview

SD Correctional Health is currently rolling out Correcktec (correctional EHR). This EHR is utilized by clinicians that the health department provides to correctional facilities to allow for inmates to receive care at the correctional facility. In collaboration, Avera is providing telehealth (via the eCare program). They will be contributors of data to SDHL.

Correctional Care Use Case This is important as there are often huge gaps in clinical information available to providers, as they have been incarcerated and care has been provided in the correctional facility. In addition, correctional facility providers will be able to query for incarcerated patients in Point of Care (Community Health Record).

Outcomes

Avera EPs are now connected to the health facilities of six SD correctional facilities. In the last 12 months, this otherwise unfeasible level of care coordination helped avoid 322 ER visits (approx 53% avoidance rate).

VA Use Case Stakeholders

• Sioux Falls VA

• Black Hills VA

• First VA’s in the nation to use services from a State HIE!

Overview The VA is using Direct Secure Messaging for outsourced services. They have estimated that they outsource 25M dollars in services annually (e.g. The VA does not do mammograms, using direct, they send the request for services. Direct is also used for VA providers to receive the associated interpretation (report) from the testing. This model allows veterans to utilize local services versus traveling to another VA outside of their geography for services.

VA Use Case - Results

Outcomes In the past 12 months, local VA providers sent nearly 1000 outsourced referrals via Direct Exchange and received more than 800 messages with results from those outsourced visits, eliminating the need to fax or mail referrals or receive results/reports back via fax or mail.

HIE to HIE Use Case Stakeholders

• Avera (Note has hospitals in 5 states)

• Southern Prairie Community Collaborative (SPCC) – cover 15 counties in Southwest MN

Overview

Avera is receiving funding from MN Medicaid for this project. SDHL on their behalf is currently exchanging CCDs for Avera MN residents that are Medicaid patients. This is part of a Medicaid ACO/Home Health Project. The MN Medicaid file is received as HL7 in the network to identify MN Medicaid patients.

HIE to HIE Use Case Once a MN patient is discharged from an Avera facility, it is cross – referenced to the file in the vendor network. If there is a match, the ADT (discharge message) is routed to SPPC (who is utilizing Sandlot). Once SPPC, receives the discharge, Sandlot conducts an automated query to obtain the CCD.

Outcomes/Goals

• Scheduled to go live Q1 2016.

• Goal is to make sure patients are receiving the right care at the right time.

• Avoid ER admissions.

• Follow up on inpatient stay and discharges.

Future Use Cases for SDHL • Connecting payers, public health agencies and additional

correctional health facilities

• Home health, hospice, pharmacies, standalone labs and radiology

• Ultimate goal: Patient information exchange, wherever and however it’s needed

• As an HIE, can serve clients that have locations in multiple states.

• Coming next….nationwide LTPAC integration

Avera Health System • Integrated Delivery Network • 35 Hospitals

• 160 Provider Practices

• 700 Employed Physicians

• 18 Long Term Care Facilities

• 20 Home Health and Hospice Agencies

• eCARE (Telehealth)

• Across 5 States

Alaska Hawaii

Health Information Exchange Large-Scale, Five-State HISP/HIE

HISP/HIE Implementation Timeline

Planning Implementation Post Implementation

Go Live

Eligible Hospital Stage 2 — Year 1 Reporting Period Eligible Provider Stage 2 — Year 1 Reporting Period

Aug 2013

Sept 2013

Oct 2013

Nov 2013

Dec 2013

Jan 2014

Feb 2014

Mar 2014

May 2014

April 2014

June 2014

July 2014

Aug 2014

Sept 2014

Oct 2014

Nov 2014

Dec 2014

Planning: Five-State HISP/HIE

• As part of DirectTrust, a non-profit trade alliance that supports Direct exchange of health information, Medicity enables the transmission of transition of care and other documents to any Direct address on the same HISP.

• eHealth Exchange enables all eHealth-certified entities to communicate HIE-to-HIE.

• One HISP/HIE minimizes risk with capital investment, implementation costs, and maintenance.

• A single Direct address extension supports branding across the entire network.

• Avera collaborated and partnered with South Dakota Health Link and Medicity to establish a single HISP/HIE for a five-state area.

Planning: Define a Strategy • Interpretation of The Office of the National Coordinator for

Health IT and Center for Medicare and Medicaid Services rules and regulations

• Survey the Health Information Exchange (HIE) landscape – Pull/Query – HIE

• eHealth Exchange – Push – Direct transport – Gather Health Care Organizations level of HIE

participation – DirectTrust – Strategy: Direct Transport

Planning: Select HISP(s) • 5 states = 5 HIPSs? • Identify and Interview the 5 state exchanges

– Minnesota with upwards of 13 State-Certified HIEs • All but Nebraska DirectTrust certified • Learn from our EMR vendor’s, MEDITECH, experience • No silver bullet, pick the HISP that is committed to a partnership • South Dakota Health Link powered by Medicity

Implementation: Establish EMR to HISP Connectivity • MEDITECH is HISP agnostic

– Certified for SMIME/SMTP transactions – Certified for XDR/SOAP transactions

• Not plug and play despite governing standards • 3-4 months to establish EMR to HISP connectivity • Numerous working meetings between Avera, Medicity,

and MEDITECH

Implementation: Establish Connectivity with other Organizations • Define address schema – 1 address/hospital, 1 address/clinic

provider, 1 address/clinic • Identify referral patterns • South Dakota Health link brokered conversations to:

– Identify Direct addresses outside Avera – Establish Direct addresses outside Avera – Establish connectivity with other HISPs

• Avera launched marketing campaign

Continuity of Care

Marketing Material

Transition of Care Communication SharePoint Site

Transition of Care Communication SharePoint Site

Transition of Care Communication SharePoint Site

Implementation: What about Workflow? • Technology works but not engineered around optimal

workflow • Avera and MEDITECH worked together

– Hardwired Direct messaging into the Discharge, Departure and Check Out routines

– Referral field mandatory – Now automated and seamless to the provider

Streamlining Care Coordination Across Networks

• A HISP/HIE must go beyond exchanging CCDs. Avera tailored the technology to support existing workflows and avoid costly and inefficient rework.

• Avera worked closely with its EMR vendor to modify and enhance the functionality of discharge and checkout routines for all care settings. This collaboration with the EMR vendor resulted in an automatic generation of a CCD upon entering a referral order.

Emergency Department Depart Routine

Acute Discharge Routine

Ambulatory Check Out Routine

Indicating Health Information Exchange to the End User

Post Implementation Success Metrics

1,100 Providers

189 Facilities have

sent or received Direct messages

356,900 Direct message

transactions

• 186,900 Direct messages sent • 170,000 Direct messages received

34 HISPs

Exchanged messages with

May 2014 – September 2015

• All Stage 2 Eligible Hospitals successfully attested • 97% of Stage 2 Eligible Professionals successfully attested

Post Implementation: Benefits realized

• Reconciliation and consumption of discreet data elements; problems, medications, allergies

• Real time exchange – eliminated waste being on telephone or standing by fax machines

• Decrease in redundant tests (Lab, CT) and reduction in healthcare spend

• Receiving providers cite their appreciation for most recent med list to improve care coordination

• Patient engagement with a sense of security.

Post Implementation: Lessons Learned • Operationalizing Transitions of Care

– Who manages the receipt and consumption of the CCD to maintain EMR integrity?

– Who is responsible for maintaining Direct addresses? – What do you do if the CCD is tied to the incorrect patient? – How do you ensure you are not erroneously accepting

CCDs for the wrong patient? – How do you keep referrals working as providers come and

go? – How do you handle a provider name change?

• Medicity unexpected downtime • Interfaces go down, how does the end user know? • Worked with MEDITECH to send fail-send and read-receipt alerts

to end users

Expanded Benefits of a five-state HISP/HIE

Using Direct exchange to South Dakota QuitLine for smoking cessation referrals

Working to support a State Medicaid Health Home project that will alert providers when patients present in an organization outside their home network.

Transmitting CCDs for virtual office visits (AveraNow) to the EMR to ensure the patient’s EMR is complete.

Planning to implement Point of Care Exchange when SDHL becomes eHealth Exchange certified.

Engaging the web based Point of Care Exchange to support e-Long Term Care

Working to coordinate long-term care with patient discharge instructions, medication lists, and referral/follow up care.

Considering capabilities for sending discharge summaries to retail pharmacies, giving the pharmacist the patient’s clinical picture for greater participation in the patient-centered care team.

Keep Avera’s existing MEDITECH C/S platform in sync with MEDITECH 6.1 on our journey to 6.1.

An unexpected benefit has been Avera’s ability to participate in additional programs of value to patients and providers. By working closely with

SDHL and Medicity, Avera is now:

How Benefits Were Realized for the Value of Health IT

http://www.himss.org/ValueSuite

Satisfaction • Created >357,000 CCD’s (In 2016 predicted 200% increase)

• Eliminating paper-based practices (Kill the Fax!)

Treatment/Clinical • Improves timeline and treatment plan – eLTC

• Reduces administrative manual calls for data retrieval

Electronic Secure Data • Exchanged messages with 34 HISPs

• 97% of eligible physicians successfully attested for MU2

Patient Engagement & Population Management • >25,000 attributed MN Medicaid Patients

• Avoid ED admissions through timely clinical event notifications

Savings • No cost study savings yet

• Anticipate reduction in administrative costs

Questions

Jenni Peterson, RN BSN jenni.peterson@avera.org

Kevin DeWald, Executive Director Kevin.DeWald@state.sd.us