Kuperman Health Information Exchange & Care Coordination


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Kuperman Health Information Exchange & Care Coordination

  1. 1. Care Coordination (and HIE) Gilad J. Kuperman, MD, PhD NewYork-Presbyterian Hospital Columbia University – Biomedical Informatics 10/1/2013
  2. 2. Motivation for care coordination Changes in the payment system – Quality rather than quantity – Non-payment for readmission / hospital acquired conditions – Differential payments for patient satisfaction Risks shifting to providers Providers have increased financial incentives for efficiency and effectiveness 2
  3. 3. Caveat • “Care coordination” means different things to different people • Potential for misunderstanding • Confusion when conceiving IT solutions • As always, IT supports a business goal – Need to understand the goal – Need to understand non-IT aspects of the program
  4. 4. Approaches to care coordination • Improve efficiency within a particular setting of care, e.g., hospital stays – Order sets, care pathways, utilization management, etc. • Manage a population, by segment – Healthy people – keep them healthy – Routine chronic disease – monitor, health promotion – Exacerbations – treat, get back to routine state – Fragile, high utilizers – specialized programs to manage aggressively Considerations: Needed to identify who is in a particular segment Patients move among the segments Different tools needed to manage each segment The sicker the patient, the more individualized the care
  5. 5. Approaches to care coordination • Manage transitions to lower acute care settings – To improve efficiency and effectiveness at new setting – To reduce risk of bounce-back to higher level of care • Improve the referral process – Transfer of information – “Closing the loop” • Mix, match, others, etc.
  6. 6. IT features to support PCMH • Remote telehealth interactions • Measurement of quality and efficiency • Support for care transitions • Personal health records • Registries • Support for team care • Clinical decision support Bates, Health Affairs, 2010 6 Note: Few of these in current EHRs
  7. 7. Does the current generation of EHRs support care coordination? • 60 subjects (52 MDs/staff, 4 EHR vendors, 4 national leaders) • EHR facilitates in-office coordination – Data access, messaging • Does not support coordination between settings – Not designed to do so; key data elements not standardized • Current version of EHRs support billable events, not care coordination • EHR complicates information management – Create data overload • Does not support decision-making or future care planning • To support care coordination, EHRs require re-design O’Malley, JGIM, 2010 7
  8. 8. Construct Sample item 1. Coordinated within  care team In the past 6 months, how often did your doctor or staff in your  doctor’s office ask you about medicines you were prescribed by  other doctors? 2. Coordinated across  care teams In general, do you think the doctors that you communicate with to  each other about your care? 3. Coordinated between  care teams and  community resources Did your doctor or staff in your doctor’s office talk to you about  resources available in your neighborhood to support you in  managing your health conditions? 4. Continuous familiarity  with patient over time How often do you think other health care providers at your  doctor’s clinic really understood all of your important medical  information? 5. Continuous proactive  and responsive action  between visits In the past 6 months, has your doctor or staff in your doctor’s  office contacted you to ask about your condition? 6. Patient centered  Thinking back about the care you received in the past 6 months,  how often do you think your doctor understood the things that  really matter to you about your health care? 7. Shared responsibility In the past 6 months, did you ever leave your doctor’s office  confused about what to do next to manage your health  conditions? Framework for Measuring Integrated Patient Care Singer, et al.  Medical Care Research and Review, 2011 8
  9. 9. Care Transition Measures • Now part of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) • 3 questions – During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left – When I left the hospital, I clearly understood the purpose for taking each of my medications – When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
  10. 10. • Affiliations – Two medical schools / faculty practices – Community providers • Owned Ambulatory Care Network – 14 PCMH locations – 50 sub-specialties • NY State-designated health home – Creates partnerships with CM, SA, MH, etc., organizations • Participant in regional health information exchange NewYork-Presbyterian Hospital (NYP)
  11. 11. RHIO in NYC metro area
  12. 12. NYP HIE framework • Faculty practices – Dedicated interfaces • Ambulatory Care Network – Part of core systems • Affiliated ambulatory providers – Dedicated interfaces – Connectivity via RHIO • Other (nursing homes, home health, case management agencies, etc.) – RHIO Tighter business partners Looser business partners
  13. 13. IT principles for care coordination -- NYP 1 Data access,  across EHRs (HIE) (i) Pull vs. push, (ii) structured or unstructured, (iii) how tightly  integrated into users EHR 2 Care plan  (explicit game  plan; inpatient /  outpatient) Who creates it?  Who has access to it?  Who can update it?  How is it  (i) viewed and (ii) updated (i.e., in a separate system or in the EHR)?   (How) are changes to the care plan communicated to other relevant  providers? 3 Care team(s) How created?  How updated?  How to deal with non‐NYP providers? 4 Messaging Do business partners already have messaging capabilities as part of  their EHRs? How to integrate multiple messaging platforms?   5 Analytics Need to be able to analyze clinical data, encounters, outcomes, costs;  Need to integrate across disparate systems 6 Patient  engagement Patient needs to (i) see data, (ii) receive system‐generated message  (“time for your appointment”), (iii) be educated  7 Specialized  workflow tools Task management, specialized charting, etc., (EHR?) 13
  14. 14. Improving care for depressed diabetics • NYSDOH-funded project at NYP – Pts w/ chronic disease and MH co-morbidities • Three components – IT (certified EHRs + HIE) – Workflow redesign – Data collection and feedback • Stakeholders along with NYP – ACN primary providers and psychiatrists – ColumbiaDoctors psychiatrists – Affiliated ambulatory physicians – Nursing homes and home health – Healthix
  15. 15. Key features of NYP model • Builds on PCMH model (team based care, “huddles”, etc.) • Standardized care for depressed diabetics – Screening for depression – Regular symptom monitoring • Education of primary providers about depressed diabetics – Context; risk factors, screening, diagnosis; choice of initial treatment; choice of a drug, including management and side effects; special situations, e.g., geriatrics; working as a team, e.g., with social workers and psychiatrists; use of the IT tools, including a registry, quality reports, etc. • Involvement of non–NYP providers • Patient engagement – Education, cultural competency • Use of IT (see next slide)
  16. 16. IT features of the model 1. EHR-based tools – Structured documentation for screening and monitoring – Alerts and reminders for screening and monitoring – Patient summary screens – Daily schedule view 2. Registry – To support patient follow-up 3. Analytics – Population management reports 4. PHR – Patient education (English and Spanish) 5. EHRs for community providers 6. Interoperability – Data to/from RHIO – Support specific workflows, e.g., transitions to SNF, home health
  17. 17. The PHQ-9 questions will be collapsed until the user chooses to expand them. Once all the answers are documented, the overall score is calculated automatically. PHQ-2 and PHQ-9 Documentation: Flowsheets •EHREnhancements-NYP
  18. 18. EHREnhancements-NYP Patient summary screen
  19. 19. Daily schedule view • Improve workflow prior to patient’s visit by presenting the primary care team with details regarding the patient’s upcoming visit and needs (i.e. scheduled provider, diagnosis, tasks, key results). EHREnhancements-NYP
  20. 20. Clinical decision support / workflow • Flowsheets / documents – Positive PHQ-2: user alerted to enter PHQ-9 – PHQ-9 ≥ 20 or (+) question #9 (suicidality screen)  Remind MA to notify provider / provider alerted • Patient summary / schedule view – PHQ-2 overdue – PHQ-9 / Repeat PHQ-9 overdue • Inbox – Secure health messaging: Primary Provider notified when patients are admitted/discharged to/from the ED or Inpatient EHREnhancements-NYP
  21. 21. Registry and PHR • Registry – Patients who meet certain criteria but have not had timely follow-up with a care provider • PHR -- myNYP.org – Culturally competent patient education tools for diabetes and depression RegistryandPHRenhancements
  22. 22. DRAFT population management reports
  23. 23. Ability to access RHIO data for the patient from within EHR
  24. 24. Evaluation framework 1. Demographics – Total clinic population, # diabetics, # depressed, # with both – Age, gender, co-morbidities 2. Inpatient utilization – Admissions, re-admissions, ED visits 3. Ambulatory utilization – # total visits / # mental health visits – # missed appointments 4. Screening effectiveness – # non-depressed diabetics screened in previous 12 months – # screened positive who had follow-up symptom assessement (PHQ-9) 5. Monitoring effectiveness – # depressed patients who have regular PHQ-9s 6. Team-based measures – Who is writing notes 7. Outcome measures – HbA1c measures – depression remission at 6 months? – depression remission at 12 months? 8. IT process measures – # of screening / monitoring alerts – Use of registry – # of patients who create a PHR account and use that account
  25. 25. Status • Interventions implemented in early 2013 • Currently in “late burn-in” period
  26. 26. Observation • None of the components is exotic • Goal is to assemble the appropriate suite of capabilities along with the complementary workflow
  27. 27. Care coordination -- Challenges • Agreeing on workflow changes • Agreeing on quality measures • Operationalizing quality measures • Implementing HIE-related workflows – Transfer to / from SNF and home health • What info, what workflow, what technology • Creating “work lists” from registries – Integrating work list documentation with EHR documentation – Risk stratification algorithms; who needs follow-up? • PHR signup and use • Etc.
  28. 28. Summary • Many opportunities to improve the efficiency and effectiveness of care • Collectively, these are called “care coordination”, but the term is not used consistently • IT is necessary but not sufficient for care coordination • Key challenges are knitting together IT capabilities that exist, integrating them with desired workflow, and creating new IT to support the interstitium • Certified EHRs are not enough – Will they expand to meet the need or will wraparound services be developed?