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Progress in Cross-Setting Health Information Exchange in Minnesota

Medicare innovation project advances HIE for post-acute care, identifies issues

HIE graphic

A common misconception among consumers is that their medical information already is being shared between health care providers to support their care, said Coral Lindahl, RN-BC PointClickCare coordinator at Ebenezer Ridges Care Center, Burnsville. Recently, two communities moved Minnesota a little closer to that reality, as they tested how to exchange health information by transferring data between electronic health records (EHR), not merely sharing view-only files.

Live exchanges of patient health data in March between two skilled nursing facilities (SNF)—Ecumen North Branch and Ecumen Parmly LifePointes—and Thrifty White Pharmacy were among the first Minnesota exchanges of health information across care settings and across different EHR platforms, to focus on improving transitions of care and medication management.

“It felt like I participated in making a small step to safer health care and better decisions for everybody,” said Lindahl.

This work was part of an 18-month special innovation project, developed and implemented by Stratis Health on behalf of the Centers for Medicare & Medicaid Services (CMS), to improve transitions of care and medication management through health information exchange (HIE).

The two communities—one rural and one urban—with three hospitals and 10 SNFs successfully exchanged health information in test exchanges between care settings: 42 SNF to hospital, 12 hospital to SNF, and two hospital to pharmacy. The project advanced knowledge about what’s needed to support cross-setting HIE.

EHR system design to support care transitions

Every care setting gathers and organizes patient information in EHR systems designed to best support care for their patients in that care setting. These systems have not been designed to support patients as individuals who move across multiple settings in their need for care.

Independent EHR systems can be inefficient and may result in less than optimal care. For example, skilled nursing facilities often share 40 to 65 pages of paper with hospital emergency departments in an effort to provide information believed to be needed in a transition of care. Conversely, skilled nursing facilities and others must print out forms and re-enter information shared by fax or view-only access to a hospital EHR, creating potential transcribing errors.

“EHR systems and workflows were built to support individual organizations and lost track of the patient’s needs,” said Paul Kleeberg, Stratis Health chief medical informatics officer. “Now, the challenge is getting the right people to the table and figuring out workflows across care settings.”

To design systems that work for all care settings, we need to understand what information is needed by all settings, how information will be received on the other end, and how to add information within an EHR so it can be shared effectively. We need to be aware how individual systems interact across settings.

“Actions often cause unintended consequences,” said Joe Litsey, PharmD, director of consulting services, Thrifty White Pharmacy. “Changes on the pharmacy end might require a change in workflow for the nursing home or hospital.”

True interoperability not understood

Health care organizations mistakenly believe that EHRs are interoperable if they are sharing information electronically—which is not so if the information can only be viewed. True interoperability is sharing information seamlessly, moving discrete data that can be inserted into another system’s database and pulled into its EHR fields.

While faxing, sharing PDF files, and other view-only access allows providers to meet the Transfer of Care Summary criteria and attest to Stage 1 meaningful use to receive financial incentives, it treats transitions of care as handoffs of patients and their information from one setting to the next.

Providers need to move to using a continuity of a care document (CCD) that offers all of the information needed to support continuation of care. The CCD specifications outline the encoding, structure, and semantics of a patient summary clinical document in a concise, standard format for exchange between care settings.

EHR software for long term care settings has only recently added the ability to produce and use the CCD. Early use of CCD is being seen both in hospitals and some skilled nursing facilities, although its use to facilitate transitions of care is still rare.

Technology hurdles

According to CMS, over 35 percent of Medicare transfers of care are to post-acute care settings. Until their EHRs are seamlessly connected with other care settings, care transitions will be less than ideal.

Although 2011 data from the Minnesota Department of Health shows EHR adoption rates for nursing homes (69%) slightly lagging clinics (72%), the majority of nursing homes are using their EHRs primarily for Minimum Data Set (MDS) submission, demographics, and billing—not for resident care. Incentive programs, similar to those made available to hospitals and clinics to adopt and optimize EHRs, could significantly advance EHR progress and interoperability in long term post-acute care to successfully support care transitions.

Improving Medication Management

CMS special innovation project findings

Medication management and medication reconciliation are most effective when viewed as a shared responsibility across all care transitions.

Stratis Health made the following recommendations to CMS for hospitals and long term post-acute care organizations based on the findings of a CMS health information technology special innovation project:

  • Require indication/diagnosis for all prescribed medications to be documented in the EHR
  • Increase pharmacy’s role in medication reconciliation
  • Implement prospective medication review (PMR) prior to exchanging health information

A health data intermediary/health information service provider (HISP) which provides the technical mechanism to perform the actual secure HIE, such using the Direct encryption standard, must be available in a geographic area. And, providers need to understand whether their HISPs are connected together to allow for information transfer.

Changing how we communicate in health care

While hospitals, nursing homes, and pharmacies have made great strides in testing and successfully transferring patient data in support of care transitions, much work is needed to achieve the exchange of information that consumers already assume is happening.

Litsey noted, “Health information exchange will change the health care industry by changing the way health care professionals communicate with each other.”

We need bold and courageous leaders within health care to step outside of current models and practices to encourage and support true health information exchange.

Stratis Health serves as the Medicare Quality Improvement Organization for Minnesota.