The Dimock Center
In the past, when Dimock’s primary care patients received inpatient or Emergency Department acute care services at local hospitals, the health center did not receive electronic discharge summaries automatically from local hospitals. This hindered Dimock’s ability to deliver optimal care as these patients transitioned from the hospital to the ambulatory setting
South Cove Community Health Center
South Cove Community Center, founded in 1972 in Boston’s Chinatown neighborhood, provides medical and behavioral health services, as well as youth and family programs, for nearly 30,000 non-English speaking patients downtown and in nearby Quincy. The center’s mission is to improve the health and well-being of all medically underserved state residents, with a special focus on Boston’s Asian-American population.
South Cove Community Health Center Uses Electronic Health Records to Increase Patient Follow Ups
Leads to Increased Cancer Screening and Better Diabetes Management
The nation’s 62 Regional Extension Centers (RECs) have helped hundreds of thousands of health care providers, doctors, health clinics, and small rural hospitals across the nation learn the best practices for implementing and using electronic health records, or EHRs. Working closely with partners in their cities and towns, RECs are helping drive innovation by assisting healthcare providers to spur practice transformation and provide better health care to their patients.
The REC at the Massachusetts eHealth Institute at MassTech (MeHI) helps eligible providers in Massachusetts implement EHR systems and achieve meaningful use. MeHI has partnered with 3,051 primary care providers to adopt, optimize and transform their practices using health IT tools.
One example is the South Cove Community Health Center, a Federally Qualified Health Center (FQHC), which implemented an EHR interface with their lab vendor at Beth Israel Deaconess Medical Center (BIDMC), with the guidance of the Massachusetts League of Community Health Centers, and through funding provided by MeHI and ONC. South Cove’s work is a great example of what can be accomplished to improve health, health care and control costs when an EHR is used. In 2009, South Cove successfully transitioned entirely from a paper system to an exclusive electronic system using their EHR. South Cove uses its EHR to better track patient care by identifying those patients that are due for follow-up and wellness visits. It also closely tracks high-risk patients, which is often an arduous and time-consuming task.
From 2012-2013, South Cove saw a dramatic increase in the number of colorectal cancer screenings, thanks in part to a new reference lab interface to their EHR. The new interface helped drive increased screenings for patients between the ages of 51 to 75, from 58 to 73 percent. While the initial goal was to broadly improve their internal Quality Assurance and Quality Improvement program, these results were a welcomed byproduct of their newfound ability to keep tabs on patients through the EHR interface and drive outcome improvements. Their reporting requirements changed in 2012 to include three new measures, including colorectal screenings.
Due to this new EHR interface, South Cove staff is able to receive real time numeric and text based results directly into the patient’s progress note. For example, if a pap smear or an in-house colorectal screening comes back positive or abnormal, the staff can see this information flagged as ‘Abnormal‘ in the lab section of the EHR. The provider can then proceed with the appropriate treatment and ensure that the patient returns for follow up visits. Having an interface that submits results directly into the EHR makes it easier for South Cove’s quality improvement team to accurately track what follow up was ordered, when it was ordered, if the result came back, or if an issue exists with the lab sample or in scheduling.
South Cove also increased diabetic control in 2,900 of their diabetic patients from 73 to 79 percent over the same timeframe through the use of the new electronic interface. This technology brings several benefits for the tracking of diabetes care, including:
- All numerical results are now part of the patient note, with abnormal or large A1C difference results flagged in the EHR;
- The interface breaks up the last category of 9.0%+/no test and allows for a report to run for patients with no test A1C; and
- South Cove can keep track of patients who are ‘high-risk’ diabetics in real time, because they can sort and analyze the data and spend more time on those diabetic patients with A1C > 9.0%.
In short, the electronic lists generated by the system are much more accurate and actionable with numerical data than they were in the past.
Through ONC’s and MeHI’s efforts, health care providers and FQHC’s like South Cove are provided with the financial resources and support services which help them move them from paper-based medical record systems to a certified EHR. By adopting an EHR, these providers have been able to improve workflow efficiencies and care coordination, deliver higher quality care to patients, and reduce health-care costs.
To further achieve these goals, South Cove’s next step is to become a full participant in the Massachusetts Health Information Exchange (HIE), called the Mass HIway, which will allow them to share electronic information among health care partners statewide. “Participating in the HIE should make it much easier to collaborate with other agencies in terms of electronically receiving results, imaging, screenings, and progress notes into our EHR. This will really complete the journey of going paperless and allow our providers to have access to important information that might change the way they treat the patient,” stated Brook Hailu, South Cove’s quality improvement program manager.
Massachusetts’s REC will continue to offer a variety of programs and services designed to help clinical providers transition into a practice that meaningfully uses EHRs and facilitates practice transformation.
Reliant Medical Group Pushes EHR to New Frontiers for Diabetes Care
When Reliant Medical Group began employing effective uses for its electronic health record (EHR) system, a program to monitor and manage diabetes within its patient population quickly emerged.
The numbers help to tell the story. Diabetes is among the leading chronic diseases in the United States, affecting nearly 28 million adults and children, according to recent most recent figures from the American Diabetes Association. That equates to more than eight percent of the U.S. population.
The cost of diabetes care is staggering. In 2012, the U.S. health care system spent $176 billion on direct medical costs; another $69 billion is attributed to reduced productivity as a result of the disease.
“It’s a disease that’s very expensive in our country, and it’s getting more expensive as we’ve been having more problems with obesity,” said Larry Garber, M.D., Medical Director for Informatics at Reliant. “It’s also a disease that’s very treatable. There are good standard formulas for how to treat diabetics and improve their health.”
Dr. Garber and his team at Reliant, a non-profit multi-specialty group of community-based medical practices located throughout central Massachusetts and part of the Atrius Health family, have worked to push EHR adoption to the limit since first implementing an Epic EHR system seven years ago. He largely attributes the program’s success to the depth and breadth of the “buy in” from physicians and staff across the practices that use the system. Special attention is given to learning all the processes involved, agreeing on the best course of action, and developing a workflow that maximizes the EHR’s potential, the efficiency of its users, and the care given to their patients.
This is where the EHR intersects with diabetes management. Garber and his colleagues have taken an initiative that incorporates several redundancies in the patient notification, treatment and follow-up process that is designed to ensure diabetics are adhering to their care programs and that the care team has the most relevant information.
“We have a really comprehensive program focused on diabetic care, and it really has shown dramatic improvements in the quality of care as well as the cost of care per diabetic,” said Garber, who is also a fellow with the Office of the National Coordinator for Health Information Technology (ONC).
A significant starting point with the patient interaction arrives one week prior to the scheduled office visit. Diabetic education nurses who help manage the patients receive an EHR alert that informs them on how the patient is doing with their diabetes education program. There are about 10 different topics a patient is educated on, including what to do if their blood sugar gets low or what steps to take if they become ill. The nurses cycles through the series of education lectures with the patient, each of which are triggered by an upcoming appointment.
“So when I see (the patients) for the visit, I know what education they’ve received, I know what problems have been identified by the nurses, and I can reinforce that education during my visit,” said Garber.
The process continues once patients are placed on medication and need to be monitored with blood tests.
“You want to find out how their sugar is doing, how their cholesterol is doing, how their kidneys or eyes are doing,” said Garber. “So we have strategies about making sure all that testing is done that’s necessary to monitor the treatments that we do or to monitor their diabetes.”
The first step is to make sure that the tests get ordered. Prior to when patients are scheduled for follow-up visits, the EHR alerts the appointment staff of what tests need to be ordered based on whether the patient has diabetes, is on medication, is of a certain age or gender, the last time the tests were done, and whether the necessary tests have already been ordered.
The patients are then reminded to go to the lab to get the tests done by the appointment staff, the diabetic education nurses, and an automated reminder phone call triggered by the EHR.
If the patient shows up for the doctor’s visit without getting the tests done, the EHR alerts the doctor to remind the patient to go for the tests; a new order does not have to be put in. If the patient still misses the appointment, the system automatically sends them a letter informing them of the missed appointment and stresses the importance of getting the test completed.
And if the patient still doesn’t go to the lab and get the testing done, Reliant has a registry of its diabetics that searches for patients who are falling through the cracks. Some patients may have missed tests, appointments, eye exams and other procedures that are deemed integral to their care. Medical Assistant “Health Coaches” managing the registry will call them, and if they cannot be reached by phone, a certified letter is sent.
The outreach doesn’t stop there - each patient automatically receives a letter on his or her birthday with all the tests and related items they are due that have not been competed.
“Happy 50th birthday! Please call my office to schedule a colonoscopy,” said Garber with a smile.
“We hit them multiple times to make sure the patients are not slipping through the cracks and making sure they’re being followed up appropriately,” said Garber. “It makes a difference. When you put all of these systems into place it really makes a difference in the outcomes that our patients see.”
To help diabetics who also have high blood pressure, Reliant has distributed 200 blood pressure monitors that can be taken home and plugged into home computers. The blood pressure readings are automatically loaded into their computer and sent to Reliant’s EHR. The readings go to the management nurses who can then determine if changes in medication or other treatments are needed.
Tracking diabetic patients through the EHR did not yield an immediately noticeable result. In fact, it wasn’t until the alert and reminder systems were implemented that a marked improvement in outcomes and costs began to materialize.
“Reliant is at or above the 90th percentile for all of its diabetes care measures compared to the rest of the country,” said Garber. “It’s largely due to the fact that we have this powerful tool: the electronic health record.”
Reliant also receives reports from Medicare informing them of how their cost for diabetes care compares to other group practices around the country. Its average cost for treating a Medicare diabetic patient is less than 96 percent of other group practices across the country.
“So here we are. We’re doing more testing, they’re getting more visits and it’s costing less. So that means giving good quality care actually costs less,” said Garber.
As Reliant pushes forward with its successful diabetes management program, one certainty is that the EHR will continue to play an integral role.
“The fact is that the electronic health record can allow you to search for information, filter the information, sort the information, and present it in a more meaningful way,” said Garber.” That just makes it so much easier to manage these large amounts of information. The data was often there in the paper world. You just couldn’t find it or put it into context. What’s the trend in my patient’s blood sugar? On paper it would take several minutes to find after getting the chart. With my EHR, I do it with one click!”
From Humble Roots, Brockton Neighborhood Health Center Embraces EHR Built for Bold Future
For Ben Lightfoot, M.D., medical director at Brockton Neighborhood Health Center (BNHC), it's hard to pick one electronic health record (EHR) success story that trumps all others.
"At the health center, pretty much every day has a success story with our EHR. There are a million little successes," he said during a recent Regional Health IT Meeting in Taunton, an event organized for area health care executives and providers by the Massachusetts eHealth Institute at MassTech (MeHI).
Since BNHC's EHR went live seven years ago, it has helped the center improve efficiency, patient safety, care coordination, and reporting requirements. It has also led to thousands of dollars in federal Meaningful Use incentive payments.
The non-profit, independent federally qualified health center (FQHC) is well onboard with health IT, and the EHR is just a part of the effort. This summer, BNHC was among the Bay State healthcare outfits to receive funding from MeHI to connect to the state's health information exchange (HIE), the Mass Hlway. The funds will allow BNHC to better collaborate with its trading partner, Network Health, enabling the electronic exchange of care plans for high-risk patients. The goal is to improve care team effectiveness and reduce the rate of emergency department visits by 'low-acuity' patients - those not requiring emergency care.
The Hlway Implementation Grant is the first step in a collaboration that Lightfoot and his team plan to grow into a broader initiative which includes developing integrated care plans within the EHR that can be shared with Network Health.
BNHC has come a long way since starting 20 years ago as a fledgling health care provider with one physician working in a mobile unit parked outside a church. Since those humble origins, the center constructed a $17 million facility that serves roughly 26,000 patients a year, many of whom are low-income. The facility handled about 150,000 patient visits in 2012 alone.
At about the same time BNHC was opening the doors to its sparkling new home, it went live with its first EHR. The experience has brought both rewards and challenges.
It has been an interesting trip down the paperless path," said Lightfoot.
That trip began in 2004 when Brockton was among three Massachusetts communities to share a $50 million grant from Blue Cross Blue Shield to adopt EHRs.
For its EHR system, BNHC chose NextGen Healthcare, which works with several community health centers. The implementation included a considerable learning curve, as BNHC adjusted to an environment that moved away from paper charts in favor of electronic data. Adjusting workflow procedures was key to the implementation.
We did a lot of training," Lightfoot said. "You can't under train.
Another key to the implementation was assembling a comprehensive group of staff from the center to discuss what lay ahead when the system went live. Lightfoot brought in staff from all relevant departments to foster communication and gather input.
One of the big things was to pick an EHR champion, and I was it," he said. "You really need someone who's enthusiastic about the system going live, who is tech savvy, and can communicate well with the other providers.
Some of the challenges BNHC faced included ensuring that providers are properly and consistently entering data into the EHR, so that records and measures across the system are complete. BNHC also has a backup paper system and protocols in place should the EHR go offline or experience other technical problems.
Lightfoot encourages other organizations to keep EHR modifications to a minimum. While it can be tempting to tweak a system to meet personal needs and preferences, it will likely make it difficult to upgrade the system when the time comes, he said.
Meeting Meaningful Use standards has accounted for much of the center's EHR activity.
Stage 1 has been a little challenging, basically getting all the reports to work properly, but it has resulted in some really impressive things for patients," he said.
For example, as part of BNHC's Stage 1 accomplishments, each patient receives a patient plan. Additionally, the center has improved its focus on quality measures.
Lightfoot said the center is in the midst of preparing for Stage 2 and could begin to attest early next year. This next stage includes connecting to a health information exchange (HIE).
As part of the patient-focused measures in Stage 2, BNHC's plans call for implementing a patient portal, which will allow patients to access their health information via the Internet. Since many of the center 's patients lack access to a computer, Lightfoot and his team are exploring whether the patient portal can be accessed through smartphones, which many of the center's patients own.
Plenty of other health IT initiatives are brewing at BNHC, including its participation in Medicare's Electronic Prescribing (eRX) Program, which offers an additional 0.5 percent payment on total Medicare billing to providers using an eRX system. There is a 2 percent penalty for providers who do not e-prescribe. The health center has also gone live with an electronic dental record system which is tied to the NextGen EHR. The connection allows for sharing important data, including a patient's medication. An impending upgrade to the NextGen system will help BNHC improve the OB/GYN and pediatric templates with the EHR.
Twenty years after its founding and nearly a decade since its EHR journey began, BNHC continues to push forward with new technologies that offer the reward of smoother operational efficiencies, improved patient care and lower costs. Its collaboration with Network Health on the Mass Hlway is a first step toward a broader commitment to HIE.
Lightfoot said the health IT path is not without its challenges. Bringing the EHR system and other IT technologies to their current capacity requires a steady diet of education, training and communication between multiple departments in a fast-moving environment.
"The systems are powerful and can do a lot of amazing things, but you have to be careful," he said.
"At the health center, pretty much every day has a success story with our EHR. There are a million little successes" -Ben Lightfoot, M.D., Medical Director, BNHC
Copyright © 2013. Massachusetts eHealth Institute | mehi.masstech.org
MACIPA Powers Transformation with Innovative Health IT Strategies
When the Center for Medicare & Medicaid Innovation (CMMI) selected the Mount Auburn Cambridge Independent Physician Association (MACIPA) and Mount Auburn Hospital as a Pioneer Accountable Care Organization (ACO) in 2012, MACIPA Chief Information Officer Paul Sawyer and his team knew a bold, multi-faceted health IT strategy would be a key factor to becoming an ACO.
The Pioneer ACO project at the Boston-area physician membership organization is driving forward with impressive results. In addition, MACIPA is maximizing the potential of its EMR and coordinating care through its community health information exchange (HIE), two advanced health IT strategies which are well underway. Plus, the organization is eyeing a future connection to the state HIE, the Mass HIway, which will further the organization’s ability to network and exchange information across the Commonwealth.
MACIPA, a physician membership organization, was founded in 1985 and serves roughly 530 physicians affiliated with Cambridge’s Mount Auburn Hospital and Cambridge Health Alliance, providing a wide range of services, including support for physicians as they engage with electronic health records.
Pioneering an ACO through an Optimized EMR
The Pioneer ACO accounts for MACIPA’s widest-ranging health IT initiative. The CMMI project seeks to determine whether highly coordinated care between physicians and hospitals improves seniors’ health. MACIPA and Mount Auburn Hospital are one of five Bay State health care organizations – and 32 nationally – selected as Pioneer ACOs.
“The project has been a big change for us,” said Sawyer in an interview with MeHI. “There are a lot more data analytics needed than we’ve been used to doing. It has also been quite a resource adjustment for us. We’ve got quite a few people who are here specifically related to the ACO initiative.”
MACIPA has had to dig deep into its EMR system to satisfy CMMI’s reporting requirements for ACO status. After meeting the requirements for year-one of the three-year project, MACIPA is steaming ahead with year two. Sawyer and the MACIPA team have worked tirelessly to assist its physician community in using EMRs as optimally as possible to extract data needed to achieve the robust reporting requirements.
But, the benefits of MACIPA’s EMR optimization go beyond simply meeting data reporting requirements.
“We also use the data to help our providers use the EMR system to the best of their ability, ” said Sawyer. “One way we demonstrate this is to choose a particular measure, such as diabetes.”
If a diabetes measure is applied to all patients in the EMR that fit the criteria of being a diabetic, and the percentage of compliance with the measure is known, MACIPA can see which providers are meeting the measure and where numbers are lower than expected, according to Sawyer. The analysis can then be used as a provider educational tool to identify the cause of the lower compliance and address it. Potential causes include how the EMR is configured, a lack of understanding from the person entering the data, or the need for an improved practice workflow.
“So we’re using the data from an educational perspective as well as for reporting back to the contract organizations with our actual results,” Sawyer said.
While the EMRs used by physicians affiliated with the MACIPA community vary, about 220 use eClinicalWorks® (eCW), which is also the records system MACIPA hosts and manages. A small number of physicians still use paper charts, and MACIPA has special protocols in place to collect data from those physicians and integrate it with the electronic systems.
“In the health care market today, to be successful in any kind of managed care contract, you have to have the ability to do population management, and you can’t do population management well with paper,” said Sawyer. “It’s virtually impossible.”
MACIPA takes on Health Information Exchange
While the Pioneer ACO project proceeds, MACIPA continues work with its internal health information exchange (HIE), which connects the roughly 220 physicians using eCW. The exchange allows the practices to share patient information, such as medications, allergies, family medical histories and other useful background information.
In Massachusetts, patients voluntarily “opt in” to the system. Sawyer reports about 92 percent of MACIPA’s patients have opted in and many patients take advantage of the organization’s patient portal system to access their test results and other health information.
“I think most patients are used to having information exchanged,” he said. “A lot of patients are used to patient portals, so in most cases they like the idea of being able to log onto a website and get information that ordinarily they would have to wait a week to get it in the mail.”
Physicians are noting the patients’ acceptance of the technology as well.
“If you already have good background on a patient before you’ve seen them, the patient has an increased level of comfort that they’re in the right place and they’re going to receive good care,” said Sawyer.
Onto the Mass HIway...
With an internal HIE already in place, MACIPA is setting its sights on joining the statewide HIE, the Mass HIway, which will allow the exchange of health information between non-affiliated organizations.
“I think the Massachusetts health information exchange is the most logical place for us to go next,” said Sawyer.
The Mass HIway facilitates the secure exchange of patient data between providers across the Commonwealth. Local HIEs across Massachusetts are connecting their systems to the HIway to generate a far-reaching flow of information to improve the patient experience, quickly produce a complete medical profile and reduce wasted time and resources.
“Providers and patients see the value in being able to exchange information in a common way,” said Sawyer. “Massachusetts has five of the Pioneer ACOs. We all know patients from each of the ACOs often end up at other organizations, so the ability to exchange information is a plus for everybody.”
Achieving Stage 1 Meaningful Use
In 2011, MACIPA needed to upgrade its EMR, eClinicalWorks®, to support Stage 1 Meaningful Use attestation. Funding from the Massachusetts Regional Extension Center (REC) allowed MACIPA to employ a REC-designated Implementation Optimization Organization (IOO) to provide technical services and support for the upgrade. That same year, MACIPA-affiliated eligible providers using eClinicalWorks, totaling 62 individual practitioners, achieved Stage 1 Meaningful Use (MU). In 2012, that number increased to over 130, and MACIPA expects more for MU year 2013. This accounts for over $1.8 million in MU EHR incentive program payments for the organization.
Copyright © 2013. Massachusetts eHealth Institute | mehi.masstech.org
Merrimack Valley Providers Use Health IT to Improve Patient Care Coordination after Emergency Room Visits
Four unaffiliated healthcare providers in the Merrimack Valley region of Massachusetts came together in a collaborative effort to solve a care coordination challenge through the use of Health Information Exchange (HIE) technology for their Community of Care. Their health IT strategic vision was to enhance care coordination by securely sharing of electronic patient data. This particular Community of Care consists of four providers, including the Home Health VNA, Lawrence General Hospital, Pentucket Medical Associates, and the Greater Lawrence Family Health Center, who started working together to address a clear long-standing logistical challenge: the ambulatory care providers did not receive notification when one of their patients visited Lawrence General’s Emergency Center.
This issue was of particular concern to the leaders at Home Health VNA, which often did not learn of emergency room visits until one of its nurses visited a patient at their home, long after the hospital visit.
“Emergency room notification has been an ongoing, insurmountable problem,” said Peg Doherty, RN, the Vice President of Operations at Home Health VNA. “Our patients would go to the ER [Emergency Room], and we wouldn’t know they went. Furthermore, we wouldn’t know what happened or if anything changed when they came back into our care.”
Home Health VNA and its partners also wanted to eliminate data “siloing”, an issue which hinders the sharing of patient health information between unaffiliated organizations.
“Even though we live in the same community, and we have the same strategic goals, visions, and objectives around patient care, we’re still all managing to our separate service lines and business models,” said Jeffrey Brown, Chief Information Officer at Lawrence General.
To achieve their goal, the organizations decided to connect their Electronic Health Record (EHR) systems to the Mass HIway, the statewide Health Information Exchange created by the Commonwealth of Massachusetts, which provided the electronic pathway that allowed them to easily and securely share patient data. But the digital connection was only the initial step. In addition to needed technology upgrades, each of the organizations also underwent workflow changes on both the clinical and operational sides.
The group applied for and received financial support for their project from the Massachusetts eHealth Institute (MeHI) via a Mass HIway Implementation Grant. MeHI’s program supported collaborative projects between two or more healthcare organizations located in regions across Massachusetts, with the goal of improving patient care coordination and reducing costs through connections made via the Mass HIway.
In the spring of 2014, the electronic sharing of patient data among the group of Merrimack Valley providers went live, when Sanin Rahman, Director of Integration & Strategy at Lawrence General Hospital, successfully sent the first electronic notification of a patient’s emergency department visit to Home Health VNA via the Mass HIway. Over time, the group of providers envisions implementing further automated processes to update its partners, processes which will improve efficiency across all the organizations involved, saving staff time and providing critical updates to a patient’s electronic health record.
As collaborating partners implement health IT strategies, communication improves among clinicians which benefits patients in regards to their care. These partners have a shared interest in effectively using technology and electronic patient data. With electronic exchange of patient information through the Mass HIway, the Merrimack Valley clinicians will gain added knowledge and insight into a patient’s path through the continuum of care. Expected improvements from this increased information include:
- Avoiding redundant testing, x-rays, and imaging, saving time, money, and impacts to potentially fragile patients;
- Better adherence to prescription and treatment plans, helping avoid over-prescribing of medication or potential adverse drug interactions;
- Improving patient health outcomes by streamlining care delivery and coordination across all settings, including the emergency department, the primary care physician’s office, and at home.
Ruth Pothier, Chief Information Officer at Pentucket Medical Associates, notes that HIE provides an opportunity to align multiple organizations and eliminate the factors that hinder effective and well-coordinated care.
“We’re trying to affect the beginning of a ‘non-silo’ treatment of patients so that everybody isn’t doing their own thing,” she said. “HIE gets important information into the clinician’s hands before or at the point of care. “
Pothier added that timely notifications of visits to the emergency room will create more opportunities to educate patients about the appropriate use of the emergency room and alternative avenues to receive help, all with the goal of preventing unnecessary visits.
As in Merrimack Valley, providers across the Commonwealth are teaming up to improve patient care within their respective Communities of Care while reducing healthcare costs by connecting with each other via Health Information Exchange technologies, such as the Mass HIway. Peg Doherty of Home Health VNA said this type of collaboration demonstrates that healthcare organizations working together and connecting electronically is the best approach to achieve effective coordination.
“I think what’s extraordinary about what happened here is we brought together four large organizations. There is something terrific about watching everyone say ‘we need to do this,’ and keep that vision in sight while we work out the differences,” Doherty said. “It’s exciting to show people you can solve problems when using technology to share information.”
Holyoke Medical Center Builds Bold New Vision Around Health Information Exchange
These are certainly busy times for Carl Cameron, Chief Information and Analytics Officer at Holyoke Medical Center, and much of this work is focused on the creation of a health information exchange (HIE) between the western Massachusetts hospital and the array of providers with whom it works on a daily basis.
Not only has the 198-bed healthcare facility spearheaded a local community health exchange that is bridging the information void within the hospital’s service area, but it is also connecting to the Commonwealth’s statewide HIE, called the Massachusetts Health Information Highway, or Mass HIway.
These efforts are less than a year old but are already paying dividends and opening doors to a spectrum of possibilities to improve care, while also allowing for the implementation of real-world health information technology applications for HIEs, such as electronic health records (EHRs).
The strategy began to materialize within the past few years when the Centers for Medicare and Medicaid Services (CMS) Meaningful Use program began and started providing financial incentives for strategic EHR adoption. “I approached our physician hospital organization about how we can help the community reach its goals in terms of meeting Meaningful Use and bringing in electronic health records,” said Cameron.
He beefed up his health information technology division at Holyoke Medical Center (HMC) to provide the hosting and support for any of the providers in the community who wanted a contract with HMC and eClinical Works, an EHR system.
Additionally, a community health information exchange, HMC HealthConnect, was established to share patient data across providers in different locations. Initially, HMC delivered laboratory results, radiology results and departmental results in real-time, directly to the EHRs within the physicians’ practices.
“So they’re getting the results faster than they used to get them in the paper world,” said Cameron. “They don’t have to come in and weed through faxes.”
To date, there are 47 providers in the community, in addition to HMC’s emergency and in-patient services department connected to the HMC HealthConnect. HMC created a unified patient consent process, where if a practice decides to participate with the hospital and signs a participation agreement, anytime it makes a notation in its EMR, it automatically goes to the health exchange. The same happens on the HMC side. If a patient is discharged from the emergency department or from in-patient services, the notice automatically goes to the health exchange, thus creating a repository for continuity of care documents (CCD) on HMC HealthConnect.
“That’s basically what we started with, the simple CCD required under (Meaningful Use Stage 1) so that we could work with doctors on changing the flow in their offices, how they truly do continuity of care across the continuum, and getting them to understand that with their EMR, they can now see documents out in health exchange,” said Cameron. If a patient consents that the doctor can exchange his or her information via the HIE, the doctor will then be able to view it and exchange it with other providers.
The same can be done with specialists or referral providers the patient visits, whether at the hospital or externally. Additionally, if the patient visits a specific healthcare professional but does not want that provider to see and exchange information, he or she can opt out.
“So it really gives the patient the flexibility of who can see the data,” explained Cameron. “From the standpoint of privacy and data protection, that’s all built in. We’re running about a 96 percent opt-in rate, so we have high involvement from our patients.”
To make it easier for providers using different EHRs to participate in the system, it is not necessary for them to leave their EHR to access information. Holyoke has built a function into its EHR which allows a provider using a separate EHR system to see there are patient-specific documents on the health exchange, click a button, and then view those documents without leaving their own electronic records system.
“Our goal was ease of use: How can we make it so providers don’t have to leave the EMR that they’re in and go to another Web portal to search the exchange,” said Cameron.
Taking on Diseases Through HIE
In an early project related to HMC HealthConnect, the system is being used to improve patient care around two specific diseases: Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). When patients with either disease are treated at Holyoke and then released, the discharge instructions can be sent electronically to providers within Western Massachusetts Physicians Associates, a physician practice group, which falls under the Valley Health System umbrella, of which HMC is an affiliate.
The goal is to ensure a COPD or CHF patient receives a follow-up visit within seven days of hospital discharge so that the primary care physician responsible for the patient is treating the diseases more actively and aggressively. And the early results are promising.
“When we started and were not doing any electronic exchange, we found that roughly 20 percent of these patients were able to get a visit within seven days after being discharged,” explained Cameron. “Since we went electronic and started working through the health exchange, we’re reaching 43 percent.” For the patient this creates solid linkages across the care continuum, allowing the primary care provider to view discharge instructions electronically, helping to eliminate the confusion that occurs when a patient shows up without papers and is uncertain about the instructions received from the hospital. For the hospital, it creates a system which increases patient engagement, helping it identify potential problems post-discharge, and in an efficient and cost-effective manner.
Onto the Mass HIway
HMC has also connected its community health exchange to the Mass HIway, serving as an example of how the HIway operates as a statewide “network of networks.” The external connection is designed to allow providers within the community exchange to share information throughout the state.
The HIway is a collaborative effort between the Massachusetts eHealth Institute (MeHI) and the Massachusetts Executive Office of Health and Human Services (EOHHS). EOHHS leads infrastructure development and operation of the Mass HIway, which will demonstrate measurable improvements in care quality, population health and reduce health care costs. Mass HIway funding is provided by the Office for the National Coordinator for Health Information Technology (ONC), the Centers for Medicare & Medicaid Services (CMS), and is sustained through private contributions.
Cameron said efforts are underway to facilitate some behavioral health use cases between Holyoke Medical Center, Holyoke Health Center (a Federally Qualified Community Health Center) and River Valley Counseling Center, the primary behavioral health component for referrals.
Cameron said the HIE adoption rate will also rely on the EHR vendors expanding their offerings and additional providers joining. For hospitals such as HMC, the mission is also to communicate the day-to-day benefits to their regional healthcare partners. As he noted, doctors are focused on the care of their patients, so the information provided by HIEs – and how it can improve the care of their patients – is the paramount goal.
“It’s also about having to change physician patterns, in terms of how they see a patient, which is more episodic in terms of ‘what is affecting the patient today,’ rather than being worried about who’s going to see the documentation down the line when something else happens or there is a referral,” said Cameron.
Safe at Home
Hebrew SeniorLife builds broad health IT program for effective transitions across the senior care continuum
At Hebrew SeniorLife (HSL), a 110-year-old national senior services leader dedicated to rethinking, researching and redefining the possibilities of aging, effective care transitions are key to the health of its senior population. Ensuring that patients’ health information follows them across the care continuum is enabled through a broad health IT program that bridges multiple care settings.
The full care continuum can be complex, sending a patient from the home, to the primary care physicians or Emergency Department (ED), then to an acute care facility, on to post-acute care, and finally back home.
HSL has firmly focused on health IT as a means of improving patient care. Adopting electronic health records (EHR) and implementing a health information exchange (HIE) are two of the major parts of a concerted health IT initiative that got underway nearly a decade ago.
Based in Boston, the non-profit, non-sectarian organization has provided communities and health care for seniors, research into aging, and education for geriatric care providers. One of its largest care settings, Hebrew Rehabilitation Center (HRC), provides long-term and rehabilitative care. Long-term care is emerging as a significant slice of the U.S health care industry. In fact, More than 8 million people in the U.S. used long-term care provider services within the past year, according to a December 2013 report based on data from the National Study of Long-Term Providers.
HSL’s full continuum of health care services for seniors also includes home care, primary and specialty care, outpatient care, and adult day health programs.
The organization’s effort to ensure seniors are able to stay healthy and manage chronic diseases dovetails with a broader health care industry movement that seeks to prevent costly hospital admissions and readmissions. Much of this is achieved through effective and appropriate treatment in post-acute care settings, such as a rehabilitation center.
Fran Hinckley, HSL’s chief information officer, knows the challenges that come with transitioning from paper to electronic systems, particularly in complex senior health care services. His view of EHR implementation comes from years of experience integrating them into his organization, but also through a clear understanding of the benefits.
“It’s about getting people on board, making sure everyone understands where the organization wants to go, aiming for that point, and achieving our milestones,” Hinckley notes.
At HRC, the MEDITECH electronic health record (EHR) system is helping providers more efficiently manage a complex array of patient data, lab results, and medication information. The Boston site includes an acute care unit, a major factor in why HRC closely resembles a hospital, even though it does not offer an emergency department or perform surgery. Hinckley said the platform from the Westwood–based MEDITECH best suits the Center’s electronic patient data needs.
When patients transition out of HRC they move toward the less intensive end of the spectrum to HSL’s outpatient physician practices, located within Hebrew SeniorLife’s residential communities. These practices will soon implement a records system from eClinicalWorks (eCW), another Massachusetts-based EHR provider.
Ensuring the care continuum circle begins and ends at home
When HSL started its current health IT progression in 2006, they implemented a Computerized Physician Order Entry (CPOE) system for doctors and nurses. The CPOE was effective for data sharing inside HRC, but HSL wanted to share data with care providers in the acute care hospitals and in the community.
“People can move in and out of our settings of care, from the community to primary care, to acute care, into rehab and home again,” said Hinckley. “Our job is to try and coordinate care across that complicated group of settings.”
The varying residential and care settings produce a complex environment, both for the communication necessary between providers, but also as they involve numerous IT systems. Hinckley recalled one particular physician who needed to access up to eight different systems for the care of a single patient.
“It’s a very common set of problems across the industry, and this is what we’re all trying to solve. Integrated health IT is vital for achieving and accelerating care coordination improvements,” said Hinckley.
Onto the Mass HIway
Hinckley and HSL view health information exchange (HIE) as a key piece of the organization’s future efforts to improve care quality and the patient experience, including in the long-term care setting. With this is mind, HSL is using HRC – post-acute care – for a special grant program that is creating electronic connections between providers via the Mass HIway, the state’s HIE. Launched in 2013, the Implementation Grant Program is helping some 80 organizations across the state connect to the HIway, which is overseen by the Massachusetts eHealth Institute (MeHI) and the state Executive Office of Health and Human Services (EOHHS).
Hinckley said the goal is to get patients headed from its partner hospital Beth Israel Deaconess Medical Center (BIDMC) to HRC by 1 p.m. daily. That means pushing up the discharge time at BIDMC from 3 p.m. to noon. The goal is higher patient satisfaction, lower wait times when patients are moved from one environment to another, and better care utilization rates.
A change in discharge and transfer time might appear to be a small matter, but altering the timeline just a few hours involves intense coordination and procedural changes between the two healthcare organizations.
“Our application of the MeHI/HIway grant is based on a full-cycle use case,” said Hinckley. “ This is where a patient who started at home may consult with a primary care specialist or go to an ER, and then goes to an acute care hospital, then to post-acute care rehab, and finally back to home or a home-like setting.”
Numerous factors have influenced HSL’s desire for an earlier patient transfer time from BIDMC to HSL, but the main reason is the later slot can be inconvenient for both patients and staff. The aging population HSL cares for often tires by late afternoon, and both HSL and BIDMC are in the midst of staff shift changes during that timeframe. HSL must ensure it has a bed to offer the patient, and that the bed is actually offered and accepted. Patient liaisons in the field need to finalize their work and transportation must be coordinated between the two facilities.
The HIway’s benefits become most evident once the patient enters the HSL system. BIDMC creates an electronic continuity of care document (CCD), containing several pieces of vital patient information including medical history, treatments and medication, is available and ready for use by HSL. The data is parsed out and entered into a document that is fed into HRC’s EMR system.
“Ideally, this will get the information in the EMR before the patient arrives on the floor, giving the clinician a chance to look at it,” said Hinckley. “You can use the information in more meaningful ways to help transition that data into the right components of the EMR, which helps the clinicians make better decisions around the care of that patient.”
The other side of HSL’s HIway use case occurs when the patient is discharged from HSL and heads home or to long-term care. The rehab center creates a CCD and pushes it out electronically to physicians at Boston-area Atrius Health, where the patient’s primary care physicians can view the most-recent information in an efficient format.
“This whole cycle is our HIway use case study,” said Hinckley. “It’s driven by changing people’s behaviors, changing the process, laying down the technology, and then taking advantage of the standards in that technology. Everything is related to keeping people on the continuum of aging well, and aging in the best place for their needs.”
While HRC employs physicians and functions similar to a hospital, it is not eligible for Meaningful Use incentive payments. Hinckley and HSL assumed its three physician practices weren’t eligible either, but worked with MeHI, which serves as the Regional Extension Center (REC) for Massachusetts, and determined they were eligible for funding. MeHI also assisted HSL in acquiring an Implementation Optimization Organization (IOO) to guide the physicians toward Meaningful Use. So far, nearly a dozen HSL doctors have achieved Stage 1 status.
Copyright © 2013. Massachusetts eHealth Institute | mehi.masstech.org
East Boston Neighborhood Health Center Eyes Improved Care Transitions, Outcomes with Health IT
With more than 250,000 annual patient visits, 100 physicians, an emergency department, and a wide array of primary and specialty care services, East Boston Neighborhood Health Center (EBNHC) is among the nation’s largest Federally Qualified Health Centers (FQHCs). It’s also a study in how effective health IT can streamline transitions between care settings, advance care delivery, and improve outcomes for a culturally diverse population.
Headquartered in Boston’s most geographically isolated neighborhood - it is almost completely surrounded by water and wedged next to the Logan International Airport - the center has managed to turn its location into an asset, drawing a heavy patient market share from “Eastie” and the nearby communities of Chelsea, Revere Winthrop, and Everett. The center boasts a pediatric department that cares for virtually every East Boston child.
The robust outfit, which includes a senior care program that keeps elders at home, is an early adopter of health IT and a staunch champion for technology, as it helps monitor and organize patients shuffling among the center’s numerous departments.
“The transition of care between primary care and the emergency department was always difficult when it came to paper [charts],” said Laura Rogers, VP and CIO at EBNHC. “Staff could quickly see the benefit of having information readily available to them no matter what department the patient was in.”
Rogers has been there for every step of EBNHC’s Health IT journey, guiding the center through the implementation of new systems, including Epic’s EpiCare EHR. In fact, the center uses Epic for all health IT, including managed care for the senior program and a Radiology Information System (RIS) for the digital radiology suite that opened in 2009. Rogers said using Epic as an enterprise system prevents the center from creating multiple interfaces that connect divergent systems.
In the emergency department (ED), which serves as a common entry point for patients who become steady users of EBNHC’s services, an electronic tracking program implemented nearly a decade ago improves patient flow and care delivery. The center can map each patient’s experience and metrics regarding their treatment, including arrival time, reason for seeking care, wait time, and the department the patient received care from after the ED. The system effectively follows patients across the care continuum.
Similar to other FQHCs in Massachusetts, ENBHC caters to a culturally diverse population including many patients who are non-English speaking. The center provides interpreter services for 24 languages and most doctors and staff are fluent in Spanish, the language of a high percentage of ENBHC patients.
“I think we’ve done a great job, but we are always struggling to keep up with not just language, but the cultural barriers as well,” said Rogers.
The center offers Epic’s patient portal MyChart, which allows online communication between patient and provider. The patient portal concept is part of Meaningful Use Stage 2, and Epic offers MyChart in Spanish, which may help the center increase patient engagement with the portal. ENBHC is currently undertaking a marketing campaign to encourage patient Health IT use.
Providing real results in real-time
Since EBNHC went live with its EHR in 2004, the center and its patients have enjoyed numerous benefits. For example, medication orders are immediately available to the center’s pharmacy. Likewise, orders for tests are waiting when the patient arrives at a lab.
“It’s just a huge patient care improvement,” said Rogers. “They’re not waiting around. The lab knows when a patient comes in and what test has been ordered. It’s hard to believe how different things were with paper.”
The center can also tie the EHR to specific quality improvements. For example, it has significantly boosted the percentage of patients contacted by EBNHC within two days of hospital discharge. The increase is accomplished through streamlined communication among care team members, comprehensive collection of data (both internal to EBNHC and external to hospitals), and tracking of outreach to patients. Since implementation of EHR tracking, two-day outreach at EBNHC increased from 51 percent in June 2012 to 70 percent in October 2013.
On the clinical side, the EHR has increased prescribed controller medications for persistent asthmatics. Specifically, the EHR helps EBNHC classify asthmatics more granularly so that individuals with persistent asthma are highlighted. Between May and October 2013, the center achieved 100 percent compliance of persistent asthma patients on controller medications.
For the future, Rogers said EBNCH is trying to determine how to better use its EHR for decision support, such as notifying providers when a patient is due for a mammogram or whether a patient’s medical profile puts him or her at risk for different diseases.
Here comes MU Stage 2
Nearly all of EBNHC’s physicians have attested to Meaningful Use Stage 1 (90 Day) and are in the process of achieving full year attestation. Stage 2 is approaching quickly and the center will be among the first in Massachusetts to reach one of Stage 2’s key components, use of heath information exchange (HIE). Specifically, the center is slated go live on the Mass HIway, the state’s HIE, by year’s end, and will also connect to the Massachusetts Immunization Information System (MIIS), a web-based immunization registry operated by the Commonwealth.
Current plans call for the HIway to connect all Massachusetts health care providers through a secure, uniform electronic system by 2017.
“I see a huge potential benefit of connecting all providers, particularly around behavioral health integration,” said Rogers. “A lot of those services are outsourced to different organizations and facilities that we don’t have an easy way to communicate with.”
Since EBNHC took hold of health IT in the late ‘90s, strong senior leadership support for new technology has served as a driving factor in the center’s success, as has hiring an engaged staff, said Rogers. Similar to other providers who travelled down the paperless path, the transition works best when medical staff and administrators are well trained in the technology, trust that electronic data is secure and reliable, and embrace its capability to improve care.
“Now when you talk to some of the same doctors who are still here they laugh because they can’t do without the system and never want to see paper again,” she said.
With funding support from the Massachusetts eHealth Institute (MeHI), EBNHC worked with Boston Medical Center (BMC) to serve as the Implementation Optimization Organization (IOO) that guided the center through Meaningful Use. Assistance included help with the center’s data security audit, upgrades to its business object reporting system needed to create certified reports for Meaningful Use, and provided guidance on objectives and measures. To date, Ninety-six percent of EBNHC’s providers have attested to Meaningful Use Stage 1 (90 day) and have received $1.6 million in incentive payments through the Massachusetts Medicaid EHR Incentive Payment Program.
Copyright © 2013. Massachusetts eHealth Institute | mehi.masstech.org