Transcript Slide 1

THE ROAD TO
INTEROPERABILITY
CARE TRANSITIONS WITH
OKLAHOMA CHALLENGE
GRANT
ROAD TO INTEROPERABILITY
ONC Challenge Grant
The government’s first attempt to look at care
transitions
HIE SMRTNET
Care Coordination Facilitator
Care Transitions
Light-weight options for care coordination
CHALLENGES
WELL-DOCUMENTED ISSUES
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Medication errors
Errors in transitions of care (i.e.; communication)
Familiarity with the patient
Lab/Pharmacy environment
Advanced Directives coordination
IMPACT OF THE NEAR FUTURE
• Between 2000 and 2040 the number of older adults with
disabilities will more than double, increasing from about 10
million to about 21 million, according to the intermediate
disability scenario.
• “The intermediate disability scenario projects that in 2040 there
will be only about 9 adults ages 25 to 64 to support each
disabled older adult, down from about 15 younger adults in
2000.”
Richard W. Johnson, Desmond Toohey, Joshua M. Wiener. May 2007 “Meeting the Long-Term Care Needs of the Baby
Boomers: How Changing Families Will Affect Paid Helpers and Institutions” The Urban Institute.
http://www.urban.org/url.cfm?ID=311451
LOGIC MODEL
CLINICAL TRANSFORMATION
LTC TO ACUTE INTEGRATION
CHALLENGE GRANT TAXONOMY
June 2012, Baltimore, MD
UNIVERSAL TRANSFER FORM
• Disparate Systems
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Acute Care EHR
LTCF Clinical Documentation Tool
Facility MDS
HIE
Direct
HIE ACUTE STAY
DIRECT NEED TO KNOW MESSAGE
EARLY OUTCOMES
• Installed Clinical Documentation Tool in All
Facilities
• 98% Compliance with Daily Assessments
• Phase II Live with INTERACT II Assessments in
Place
• HIE Interfacing Near Completion
• Governance (Local LTPAC) Critical to the
Success and Buy-In of Facilities
PROJECTED OUTCOMES
• 7% Reduction in Avoidable Hospitalizations
• 10% Reduction in Return to ED Only
• Improved Provider and Patient/Patient Advocate
Satisfaction With Handoff Process
• Best Practices for Interoperability, CDT and
INTERACT II Integration in LTCF
• Clarity for Next Steps Toward Deeper Integration
and Provider Communication
WHAT IS HIE/SMRTNET?
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State-wide HIE
Integration with all major EMR platforms
Clinical Decision Support
Enhanced provider workflow via Native EMR
integration
Innovative Environment focused beyond HIE
Six year old physician/hospital-sustained HIE
Disparate connections to all major EMR
platforms
Statewide HIE
• 26 hospitals
• 96 clinics
2.1 million lives
2500 users
DATA SATURATION
• University of Oklahoma Department of Family
and Preventive Medicine
• Comprehensive, tiered risk engine
(recommendation algorithm)
• Evidence-based United States Preventive
Services Task Force (USPSTF) guidelines, CDC
/ ACIP guidelines, and AAFP guidelines for
preventive services
PROVIDER VIEW OF RECOMMENDATIONS
Community
CCD’s
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Acute Care
CCD
Aggregated
CCD
Preventive
Recommendations
Primary Care
CCD
NEXT STEPS
• Case Management Coordination
– Discharge/Transition Checklists
– Condition Checklists
WORKFLOW (HOSPITALIZED PATIENT)
EHR
ADT feed
(HL7)
Daily Patient
lists
Pdf placed in
patient chart
(HL7)
Checklists
completed
Patient-centered collaboration,
coordination, and communication
CARE COLLABORATION
• CareInSync application
mobile device driven
addresses workflow
issues
• Care team collaborating
within context of the
patient
• Team and roles are clearly
identified
• Case manager often
coordinates/manages the
entire process
• LTC intake coordinator
and providers often not
imbedded in the transition
process early enough
CARE TRANSITIONS
• Multidisciplinary discharge
risk assessment checklist
• Additional evidence
provided by clicking on
checklist item
• Team has collaboratively
identified some risks
CAREINSYNC CONFIDENTIAL
NEXT STEPS
• Case Management Coordination
– Discharge Checklists
– Condition Checklists
ELEMENTS OF THE CARE CONTINUUM
Longitudinal
Order
Sets
LOS Content
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Patient Specific
Last Attending to Activate/Renew
Condition Management Service Assign
Custom LOS by Chronic Condition
Transitions of Care Check List
Condition Specific Check List
Readmission Prevention Check List
Nursing Protocol By Condition
Actionable Orders by RN via LOS
• DI, Lab, Consultations
• Notify Physician Parameters
• Send to ER Parameters
CHF LOS Example
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Ima Always Sickly DOB 2/1/1937
Dr Yeaman (Contact Info)
Norman Condition Mgt Service
CHF LOS Version 1.1
CHF Care Transition Check List
CHF Care Parameters Check List
CHF Readmission Prevention Check
List
CHF Nursing Protocol
CHF Actionable Orders by RN via LOS
• Double Lasix x 3 days if > 5lbs
gained in 3 days
• Double Potassium x 3 days if >
5lbs gained in 3 days
• Compression Stockings
• Wound Care
• BMP, BNP, CXR
CHF Related Notify Physician
Parameters
CHF Related Send to ER Parameters
PROVIDER CARE CONTINUUM TASKS
THANK YOU