LeadingAge Magazine · July/August 2014 • Volume 04 • Number 04

Health Information Exchange is a Key to Better Transitions, Better Outcomes and Cost Savings

June 24, 2014 | by Debra Wood, R.N.

These providers are making significant changes to their operations so they can work with regional health information exchanges, in pursuit of better communication of clinical information between themselves and hospitals or physician groups.

In today’s health care environment, the smooth transition of patients between settings has become critical to achieving the triple aim of improved outcomes at lower cost and with better patient experiences. Even so, long-term and post-acute care (LTPAC) providers often lack complete medical information about the people they admit.

Most providers still rely on fax and phone communication, rather than using an electronic health information exchange (HIE), which moves clinical information among providers, using national standards, while maintaining the integrity of the data.

“I’m an advocate that all organizations should make the effort to integrate with a regional health information organization,” says Michael Rosenblut, president and CEO of Parker Jewish Institute for Health Care and Rehabilitation in New Hyde Park, NY, which began sharing information on a regional health information exchange (RHIO) in 2010.

Although few in number, HIE interventions have resulted in reduced hospital admissions, avoided emergency department transfers and improved physician follow-up care after discharge, according to a U.S. Department of Health and Human Services study reported in 2013. Other benefits the researchers found include better assessments of patients’ functional and cognitive status and suitability for services offered by that provider, avoidance of duplicative tests and procedures, and improved care planning before admission.

While the majority may be lagging behind, several forward-thinking LeadingAge members have plunged into participating in HIEs.

Parker Jewish Institute and Beechwood Homes in Getzville, NY, were among the first LTPAC providers to participate in a regional HIE organization. Within seven months of sharing information on the exchange, Parker Jewish began to see its hospital readmission rates start to fall.

Now, Parker’s skilled nursing and home care programs are able to integrate with the Healthix regional HIE, with the managed long-term care AgeWell New York scheduled to start transferring clinical data later this year. Parker also is working on a patient/provider portal that will allow providers in the community to look up information, Rosenblut reports.

Beechwood primarily uses HEALTHeLINK, the RHIO in western New York, to access information the patient has agreed to share once a patient is identified as a candidate for admission. From the two main health systems, it can obtain electronic history and physicals, operation reports, discharge summaries, medication lists, lab results and rehabilitation information.

“I feel that it helps reduce readmissions,” says Barbara Gorenflo, administrator of Blocher Homes, a part of the Beechwood community.

Additionally, nurses and physicians can access pharmacy data to learn about additional medications a person may have been taking before the acute hospital admission. Beechwood also sends data to HEALTHeLINK about emergency department visits, inpatient admissions, discharges and transfers.

“Any physician using HEALTHeLINK will know if one of his patients has been admitted to Beechwood,” Gorenflo explains.

About 134 LTPAC locations are working with the Colorado Regional Health Information Organization (CORHIO) and can access view-only information about their residents’ medical care from past hospitalizations and laboratory test results during a hospital stay. The CORHIO is starting to collect information from physician offices and, eventually, from nursing homes, but it’s a long and complicated process.

“In the long-term care setting, there’s an excitement about getting this information,” says Brian Braun, chief financial and corporate operations officer of the CORHIO. “This saves them time tracking down results.”

Stratis Health in Minnesota received a Centers for Medicare & Medicaid Services grant for the Health Information Technology for Post Acute Care (HITPAC) project, aimed at improving transitions of care and medication management through the use of the electronic health record working towards health information exchange. By the end of the 18-month-long project, 42 nursing-home-to-hospital test exchanges occurred, as did two hospital-to-nursing-home test exchanges and two nursing-home-to-pharmacy exchanges. Some participants achieved actual live health information exchange using patient data.

“Everything we did could be viewed as baby steps toward true interoperability,” says Candy Hansen, program manager for the HITPAC project at Stratis Health. “We need to continue to take incremental steps for a while so we don’t run the risk of missing something and creating unintended problems.”

Cost and limited resources to implement and use electronic records and HIEs present barriers to their use, as do a general lack of awareness among providers about HIE solutions and their value. Additionally, clinical processes and information needs differ in various settings, presenting an obstacle to the sharing of pertinent information, according to the HHS report.

Vendor integration costs occur at the participating facility and at the RHIO and are not uniform, Braun explains. Fees for the interface work may range from $1,500 to $20,000.

Some money is available to help with the transition. The Office of the National Coordinator for Health Information Technology (ONC) provided 17 communities with funding to develop HIEs, and some included LTPAC providers. Beechwood received a grant from the Western New York Beacon Community to fund expenses related to connecting to the RHIO.

In 2013, Ingleside at King Farm, a continuing care retirement community in Rockville, MD, received a $102,000 grant from the Maryland Health Care Commission, in collaboration with the Chesapeake Regional Information System for our Patients (CRISP), the state’s HIE, to promote the use of health information technology for its residents. ONC provided the funding.

“The goal is better care coordination for our residents,” says Dusanka Delovska-Trajkova, chief information officer at Westminster Ingleside. “We wanted to use the existing infrastructure.”

Delovska-Trajkova says that hospitals tend to prefer working with nursing homes with EHRs that synchronize with their EHRs, rather than going through a HIE, but creating each interface requires financial and human resources. CRISP reduces the time and money spent on creating interfaces and in printing documents.

“It frees the staff to better care for people,” Delovska-Trajkova reports.

Rosenblut adds that clinicians should lead HIE implementation projects, explaining that the people using the system must be involved to obtain support.

“Our success has been clinicians taking the lead in the information technology system and having their support for the process,” Rosenblut adds.

Beechwood brought together its physicians and nurses and all of the organizations it works with, including the hospitals, home health care providers, hospices, laboratories and pharmacies to discuss their concerns. The group learned of the need for more pharmaceutical information, as discharge instruction sheets contained medications associated with the recent admission but not medications the patient may have been taking prior to the hospitalization.

“Everyone had an opportunity to relay their part of the story and difficulties,” Gorenflo recalls. “I don’t know if the hospitals realized it was a dire need.”

Stratis Health experienced a similar revelation. Hospitals provide episode-based care and require information about that incident, while nursing homes provide broader, longer-term care. Typically, nursing homes sent hospitals too much information, sometimes as much as 40 to 60 pages in a single care transition, which made it difficult for emergency doctors to find what data was necessary to provide care. This also was true for a care transition back to the nursing home. Hospitals were organizing information in ways that made it difficult for nursing homes.

“Organizations did not understand what the other organizations needed; they just sent what they thought was relevant,” said Deb McKinley, MPH, director of communications for Stratis Health. “The conversations across settings were enlightening to everyone involved in care transitions.”

Many LTPAC providers recognize the need for better information exchange and implementing electronic medical records that can interface with HIEs.

“Health information exchange is not primarily about technology; it’s about workflow redesign,” Hanson says. That includes creating standardized documents.

Hanson, with Stratis Health’s HITPAC project, first met with all providers to assess current status and processes for transitioning patients from one setting to another. Then Stratis Health worked with them to figure out what would be needed for effective transitions and determined protocols.

Participating in CRISP required some workflow changes at Ingleside at King Farm, which does not yet have a fully functioning electronic health record.

Maryland is an HIE “opt-out” state. Residents’ information is included in the HIE unless they request it not be accessible. Ingleside held educational meetings for its residents to fully inform them about the HIE and its benefits for them.

The CRISP encounter notification service sends an email to Ingleside, and staff can access information about admissions, discharges and transfers of any patients who will be admitted to the nursing home. Ingleside has worked to standardize the formats it uses to send and receive data.

Beechwood has found that some staff members tend to revert to reviewing paper transfer forms rather than logging on and accessing the additional information available through the RHIO. Yet using the HIE pays off. Gorenflo offered as an example how the manager of the Beechwood rehabilitation unit reviewed an incoming patient’s laboratory data and noted a low hemoglobin level. Realizing that could adversely affect the person’s rehabilitation due to poor stamina, she contacted the hospital and asked if the patient could be transfused prior to leaving the acute-care setting. That saved a return visit to the hospital and improved the person’s rehabilitation.

Stratis Health recommends communities begin to discuss their needs with providers across settings and learn from each other. Additionally, Hanson says, success will depend on executive leadership support for HIE. Super users of the EHR also will help facilitate adoption of the system and its interoperability. Stratis Health has developed and offers, at no charge, a Health Information Technology Toolkit for Nursing Homes.

“The underlying principle is safer, enhanced patient care,” McKinley says. “A lot of things are pointing to using electronic health records and interoperability successfully.”

From the editor: LeadingAge’s Center for Aging Services Technologies (CAST) has developed a pair of Technology Selection Tools to help aging-services providers learn more about—and choose—electronic health record (EHR) packages or telehealth and remote patient monitoring (RPM) tools.  Each tool is a portfolio that includes: a white paper on planning and choosing products; a selection matrix of systems available; a selection tool to help narrow choices in keeping with an organization’s needs; and a set of case studies.  A similar portfolio of tools on medication management technologies will be released this fall.