Wednesday, December 26, 2012

Game Changing Healthcare Information Exchange

Evolving HIE Beyond just replacing the fax machine

 
HIE can be more of a game changer for healthcare than just being a replacement for the fax machine. The route to being a game changer is to be an enabler of care management. That care management can come from a health plan (managed care organization), an Accountable Care Organization (ACO) like a Patient Centered Medical Home or Medicaid Health Home, or from the patient/consumer as care manager for themselves or as the caretaker of another.
 
To do this, I think the HIE needs to serve the following customers and their use cases. These are the healthcare providers for care coordination, the care manager in the role of managing care, the care management at a program management or quality improvement level, and the care management at a financial management level.
 
 

HIE must Support Provider-Patient Coordination Use Cases

 

Send patient data between providers

This is the primary purpose of the HIE PUSH functionality. This is great for planned transitions in care. It is the basic delivery of information from one provider to another. It can be as basic as sending results from a test or study back to the physician who ordered it. It can be a more advanced communication for a care transition between providers such as a hospital transfer or discharge.
 
This is the basic replacement of the fax machine that most HIEs start with. This is the HIE the verb it is accomplished by either peer to peer or centralized HIE services.

More advanced versions of this support active monitoring of the patient. For example, I defined and had my team implement a "Subscribe with Consent" functionality that is the cornerstone of our offerings for care managers. It is essentially, publish/subscribe that complies with the NYS consent policy. This allows the care manager to subscribe to the patient events and get a PUSH notification or document to trigger care coordination. For example, we can send discharge summaries to care managers for the patients from whom they have collected affirmative consent. That monitoring is a value of HIE the noun over pure peer to peer (P2P) solutions.
 

Review Patient Clinical History

This is the primary purpose of the HIE PULL functionality. The PULL has mistakenly been described by some as the naked and unconscious in the ED use case. However, that is not the case. This functionality covers any unplanned or uncoordinated transition in care. Showing up at the emergency department is one of these, but naked and unconscious has nothing to do with it. In fact, if that were the case, I don't think it would work if the treating team could not identify you. It is more likely that the patient is dressed and conscious and has granted consent to access their records. This is also valuable for other ambulatory visits to review recent activity with other providers that your family physician or specialist may have been unaware of otherwise. It saves time and money tracking down records with other providers.

This is the slightly more advanced HIE query/response that replaces phone calls and fax machines and does in seconds what would have taken hours and probably not even been attempted. This is what more advanced clinical HIEs do today. This is HIE the noun as most people see it.
 

Schedule Patient Visits

The clinical HIE is the ideal place to exchange (both PULL and PUSH) schedule data. It gives the provider a view of upcoming appointments and missed appointments. Being able to request appointments and get one scheduled via HIE enables collaboration between the patient, care coordinator (if not the patient), and the care team (all providers).
 

HIE must Support Care Manager Use Cases

Manage Care Transitions

  • Notify Care manager when patient meets criteria for transition assurance.
    • This is the use of functionality such as the "Subscribe with Consent" mentioned above.
  • Track patients enrolled in various management programs
    • This is basically an additional demographic of the patient. What programs are they enrolled in?
  • Schedule Appointments with Practices. 
 

Manage Patient Adherence to Quality Standards and Physician Orders

  • Support direct contact with patient for Follow-up scheduling. The HIE should be able to connect the consumers system (a PHR or similar) for communicating with their care team.
  • Notify Care Manager when patient falls out of adherence or is about to. This can be adherence for quality measures, attending appointments, or filling orders for medications, lab work, image studies, or other referrals.
 

HIE must Support ACO Program Development and Evaluation Use Cases

 
The product of the ACO is lower cost, higher quality care through evidence based management of the patient care lifecycle. Analytics/Reporting against the HIE activities is a mean to close the loop in that lifecycle for continuous quality improvement (CQI).
 

Analyze Current Operation

The HIE needs to support reporting on clinical and financial outcomes with ability to segment and aggregate based on patient care lifecycle (how the patient flowed from point a to point b with or without intervention along the way)
 

Develop New Programs

The HIE needs to support an ability to define a program and enroll patients into that program. This is covered above in program enrollments as well.
 

Implement Change

The HIE needs to support an ability to assign patients to care managers. The care managers are the implementation of the care management program.

This is all about getting the right data sent to the right person. For example, "subscribe with consent for whom?" The answer is for care manager X and ACO Y or for the PCP, etc.
 

Measure effectiveness

The HIE needs to support the reporting need as “Analyze Current Operation” but with ability to compare with and without ACO program and cost savings versus the cost of the ACO program itself (Value of the ACO program).

This closes the loop on the question: "Did the program work as we expected it to?"
 

HIE must Support ACO Revenue Cycle Use Cases

 

Track patients enrolled in various management programs

This is simply reporting against the HIE by patient demographics (program registrations are essentially just a slowly changing dimension of the patient demographics).
 

Report Quality for Pay for Performance (P4P) measures.

Ease reporting submission to CMS’s Physician Quality Reporting System as it moves to accepting QRDA XML submissions.
 
Theoretically, quality will be how ACOs and other may be paid in the near future. The HIE is a great vehicle not just to submit these documents but to find exceptions in them and to share them with other providers.
 
By finding exceptions in the quality reports, providers can benefit from increased compensation. The HIE can find where the patient is actually in compliance with a measure and send the information back to the ACO or PCP to recalculate their measures.
 
By sharing the quality reports as sections of the on-demand CDA document produced by the HIE for consumption by providers (The CCD or portal view that providers look at), they can get a quick view of patient non-compliance and have an opportunity to bring them into compliance. This opportunity can occur anywhere in the community, not just at the PCP office. The patient will then get the same message on compliance everywhere they go. They can be bought into compliance during an urgent care visit as well as at their PCP so long as compensation models support/reward it.

 

Summary

 
I think the evolution beyond displacing the fax machine above is what will make HIE a game changer for healthcare. We won't be supporting just a better mousetrap for moving information. We will support better management from better information.
 
 

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