Care Coordination Through HIE
Dan Paoletti, CEO Ohio Health Information Partnership CliniSync Health Information Exchange
Session’s Purpose
Utilization of the Health Information Exchange Network To Improve Care Coordination Outcomes
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Objectives 1.To understand how the CliniSync Health Information Exchange network can improve communication and care coordination among disparate health entities, clinicians and other organizations that care for patients 2.To learn about use cases and best practices from hospitals, practices and other facilities that have shown improved care coordination through the use of the HIE.
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Healthcare Collaborative “The future of health care isn’t just individual providers doing amazing work for their patients-it’s connectivity among all providers, payers and social services using relevant data to ensure that patients’ whole health is achieved in a coordinated and consistent way.” CARRIE BAKER, President and CEO Healthcare Collaborative of Greater Columbus
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Care Coordination is really HARD!
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The CliniSync Community
Health
No one is left behind.
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OHIO’S Interoperability Environment • Total Contracted Hospitals: 155 • CliniSync Live Hospitals: 144 • Hospitals still in implementation: 11 • Approx. 97% of hospitals in Ohio have committed to an HIE, 95% of 11.5M Ohioans are served. • Over 5,200 independent/affiliated and approximately 8000 health system employed clinicians part of CliniSync. • 500+ long-term and post-acute care facilities participating • 4 Health Plans • Chain and Independent Pharmacies • Home Health and EMS • Behavioral Health • Social Services 7
Hospital Implementation Certificatio n Process Production Data Collect ion
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Data Analysis
Testing
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Affinity Medical Center OhioHealth O’Bleness Hospital Wheeling and Belmont Hospitals (2)
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144
Firelands Regional Medical Center Holzer Health System (2) Ohio State (5) The Medical Center at Elizabeth Place
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Total Active Hospitals As of 10/11/2017
*Adena Health System (3) *Akron Children’s (2) *Akron General (3) *Alliance Community *Aultman (3) *Avita (3) *Barnesville *Bellevue *Berger Hospital *Blanchard Valley (2) *Cleveland Clinic (13) *Coshocton County *Community Health and Wellness (3) *Community Memorial Hicksville *Dayton Children’s *East Liverpool *Fairfield Medical Center *Fayette County *Fisher Titus *Fulton County *Grand Lake/Joint Twp *Genesis *Harrison Community *Henry County *Hocking Valley *Humility of Mary (3) *Pomerene Hospital *Kettering (7)
*Signed off on results delivery
*King’s Daughters (2) – No TRANS for Ashland *Knox Community Hospital *Lake Health (2) *Licking Memorial *Lima Memorial *Madison Health *Magruder Hospital *Marietta Memorial (2) *Mary Rutan *MedCentral/Ohio Health Mansfield(2) *Mercer County *Mercy Canton *Mercy Lorain (2) *Memorial Hospital Union County *Mercy Toledo (7) *METROHealth *Morrow County *Mount Carmel Health System (6) *Nationwide Children’s Ohio Health (9) – NO LAB *Premier Health Partners (4) *Salem Community *SEORMC *Saint Rita’s (2) *St. Vincent Charity *Southern Ohio Med Ctr *Southwest General
*Trinity Health (2) *Summa Health (4) *Union Hospital *University Hospitals (15) *University of Toledo Med Ctr *Van Wert *Wayne Community *Western Reserve *Wilson Health *Wooster Community *Wyandot Hospital
Check Hospital Status http://www.clinisync.org/member-resources/Hospital%20List.pdf
Services Overview
Connec t
Integrat e
Notify
Contribu te
Consu lt
DIRECTor y
AA Community Health Record Clinical Results Inbox DIRECT Messaging Health Plan Services
Clinical Results & Reports Delivery Electronic Orders Integrated DIRECT Messaging
Admission & Discharge Notifications
Public Health Reporting Summary of Care Document (CCD) HL7 Interfaces
CliniSync Community Liaisons Meaningful Use & More
DIRECT email addresses of providers
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Specific Solutions Results Delivery
• Allows you to receive discrete results and reports in real time
Referrals
• Lets you send and receive referrals that you manage and track
Community Health Record
• Permits you to view a patient’s visits to different hospitals and practices in one place
Notify
• Alerts you when a patient is admitted or discharged from a hospital or Emergency Department
Direct Messages
• Lets you send a secure email with attachments
Contribute
• Provides opportunity for you to contribute Continuity of Care Documents (care summaries) to the Community Health Record
Care Coordination and Quality
• Provides a platform to bring data together to manage quality metrics and care coordination
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Clinical Results Delivery #1 – Hospital System
#2 – CliniSync
#3 – Physician Office
Registration - Admission Notice - Discharge Notice - Transfer Notice
PDF File Delivery
Lab - General Chemistry - Microbology - Pathology - Blood Bank Radiology - Reports Transcription -Clinical/Textual - Discharge Summaries -Cardiology Reports
Inbo x
-Normalize -Patient Matching -Build MPI
EH R
Practice EHR
Hospital Patient Information Flow 12
Clinical Results Delivery General chemistry Pathology Microbiology Care summaries History & Physicals
• Integrate patients’lab results, radiology/imaging and transcribed (keyed and dictated) reports into medical practice and skilled nursing facility EHR systems • Improves efficiencies lost with today’s methods of delivering results (fax, VPN login, snail mail)
Operative & Consultive notes 13
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Referrals Closed Loop Referral
ring r e f Re #1 – ovider Pr Physician’s diagnosis leads to a referral Using CliniSync, staff members enter appropriate info, ask questions, add documents.
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#2 – CliniSync Portal
CliniSync automatically tracks activity so original physician knows the outcome of the referral/visit. 14
#3 – R Org eferre aniz d To atio n Staff members receive referral, schedule appointment. CliniSync sends information back to the original provider about visit.
Medical Neighborhood Referral Project: Advancing accountable care coordination across clinical and social service organizations
Organizations Exchanging Referrals • Alliance Healthcare Partners
• La Clinica Latina
• Central Ohio Area Agency on Aging
• LifeCare Alliance
• Central Ohio Diabetes Association
• Lower Lights Christian Health Center
• Central Ohio Primary Care
• Metropolitan Family Care
• Charitable Pharmacy of Central Ohio
• Physicians CareConnection
• Clintonville-Beechwold Community Resource Center • Columbus Free Clinic • Equitas Health (formerly ARC Ohio) www.hcgc.org
• Helping Hands Health and Wellness Center • Kroger Pharmacy
• PrimaryOne Health • Ripple Life Care Planning • Southeast, Inc. • Syntero • The Breathing Association • YMCA of Central Ohio
Healthcare Collaborativ
The Referral Process‌
Search for your patient Add patient if needed Select Create Patient Referral Adjust the Source Select your Destination Enter details on Reason section Answer customized questions Review and click Refer Referral goes to Destination Monitor activity from Sent referrals 16
Creating a Referral
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Community Health Record View patient encounters from different facilities Access to treatment history, hospital encounters, problem list, allergies, results and reports exchanged through CliniSync. Check patient demographic and insurance information captured by other providers.
View, print or download encounter-specific or full continuity of care summaries for your records.
NoQuery Ohio’s Automated Rx Reporting System (OARRS) as required by law.
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Notify Receive alerts from hospitals across the state
Timely notification and intervention to prevent 30-day readmissions for high-risk patients
Diversion from ED dependency to more appropriate community services
Reimbursement for CPT Transitional Care Management Services codes (99495 and 99496) and Chronic Care Management
Improved quality and patient satisfaction scores required for value-based program participation
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Contribute Publish to the Community Health Record
Contribute Continuity of Care Documents (CCDs) to the Community Health Record
Allows other treating providers who care for your patient to view health information from your office or organization
These CCDs contain a wealth of information, including diagnoses, results and reports, treatment plans, medications, demographic and insurance information
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Direct Messages It’s a web-based solution. Allows you to connect with other providers using our HISP (Health Information Service Provider) by sending and receiving secure messages. CliniSync is a DirectTrust member where providers follow standards and can send each other encrypted emails. Direct is also known as Secure Messaging or WebDirect.
Care Coordination and Quality Data Data for Care Coordination and Quality Access to clinical data for those lives you are accountable for. Begin to use near real-time clinical data and supplement with claims.
Access to data in a cost effective efficient manner.
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Demonstrations Referrals Community Health Record
Referral Demonstration: https://youtu.be/4RatJANICVs
Notify Community Health Record Demonstration: https://youtu.be/Yi3eP_tWSzs
Notify Demonstration: https://youtu.be/YSK4vtcTrdo
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Best Practices
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Helping Hands Health & Wellness Center
• Member of Medical Neighborhood Infrastructure Project • Free clinic four times a month • Staffed with volunteer physicians and nurses, pharmacy students • Serves 1,200 patients annually who are at poverty level Consultation at Clinic • Provides medical exams, lab work, pharmacy, consulting • Uses Referral tool • Uses Community Health Record "Helping Hands free clinic treats the whole patient - not just their • Refers patients to Charitable Pharmacy Steve Thompson Administrator
medical needs - from spiritual guidance to social services and counseling,” says Steve Thompson, administrator. "We strive to understand the needs of the patient and help them get a better quality of life.” Read the full story here or go to www.clinisync.org and search for Helping Hands.
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Lower Lights Christian Health Center
Dr. Dana Vallangeon
• Member of Medical Neighborhood Infrastructure Project • Dr. Vallangeon serves on CliniSync Advisory Council • Clinic is Patient-Centered Medical Home, FQHC • Serves 11,000 lower-income patients • Uses the Referral tool • Uses the Community Health Record • Plans to Publish Continuity of Care Documents “By sending and receiving records, we can prevent the duplication of (CCDs)
labs, ensure our patients medication lists stay up-to-date and current as well as collaborate with other entities the patient might have seen for care other than us,” Dr. Vallangeon says. “It allows us to see the whole picture instead of just a few pieces of the puzzle which results in better, more comprehensive care for our patient that is also cost effective.” Read the full story here or go to www.clinisync.org and search for Lower Lights.
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Central Ohio Primary Care Physicians
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Central Ohio Primary Care Largest independent practice group in U.S. 348 providers and 68 practices CliniSync members Care coordinators directly meet and work with Medicare patients after hospital discharge • Uses the Referral tool • Refers them to Central Ohio Area Agency on Aging for in-home services • This is coordinated care management
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Physician Care Connections
• Member of Medical Neighborhood Infrastructure Project • Volunteer physicians and medical personnel • Offers a free clinic • Uses the referral tool • Vulnerable population without primary care physicians • Refers directly to Primary One Health for a PCP • Patient Centered Medical Home model • Goal is to improve health status of families – financial, social and cultural barriers to healthcare
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Cardiovascular Medicine Associates • Cardiovascular practice in Cleveland suburbs • 20,000 patients with 40-50 in hospital every day • Receives test results from Southwest General Health Center and University Hospitals Parma Medical Center • Chooses “structured data” so cardiologists only see pertinent information • Allows them to trend patient health outcomes, especially for those with chronic conditions
“The time savings and efficiencies gained are immeasurable,” says Cindy Volk, RN, practice administrator. “What’s mostly gone is hunting for charts, tracking down where those lab results or documents are.” Read the full story here or go to www.clinisync.org and search for Cardiovascular Medicine.
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Dublin Family Care
Patti Rolan Practice Manager
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Primary Care practice CliniSync member since 2012 In Transitions of Care Management program Uses Community Health Record Uses Notify Publishes Continuity of Care Documents Correct coding increases reimbursement Follow-up from hospitalization or ER visit reassures patients
“It’s amazing because we’re billing for services correctly and providing great continuity of care for the patient,” Patti says. “First and foremost is the patient. TCM provides good continuity of patient care, and it makes the patient feel better.” Read the full story here or go to www.clinisync.org and search for Dublin Family Care.
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Bloomington Medical Services • Multi-specialty group practice with 23 providers in Wooster • Serves 19,000 patients annually • Publishes Continuity of Care Documents (CCDs) to Wooster Hospital Angela Steiner Ambulatory Practice Manager
• Any time a record is changed, it automatically updates in the EHR system
“CCD publishing is just happening; we don’t even know that it’s happening – it’s very smooth,” says Angela Steiner. “We can help the medical record follow the entire patient care episode to provide the best quality of care possible.” Read the full story here or go to www.clinisync.org and search for Bloomington
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