As hospitals start looking at how to break down the walls between acute and post-acute care, CMIOs would do well to consider the experience of Cleveland Clinic, a pioneer in building health IT bridges across the continuum of care.
When a home health nurse working for Cleveland Clinic sees a patient, he or she can use the wireless card in her laptop computer to retrieve key data on that patient—including lab results, medications, and prior care plans—from the health system’s Epic EHR. And when the nurse enters progress notes in the Allscripts Homecare application, that documentation is pushed into the enterprise EHR via a custom interface so that physicians caring for the patient can view it.
Being able to see home health nursing notes in Epic “opens up the black box,” says family physician and geriatrician Steven Landers, MD, who makes house calls on some of his patients. “Unfortunately, care at home is often totally distanced from care in the office and the hospital. And when we’re not using the same recordkeeping systems, it’s often a black box in terms of what’s going on. So this sheds light on what’s happening in the home, and it’s been really meaningful.”
Opening that black box is increasingly important. The government spends an estimated $12 billion a year on “potentially preventable” readmissions for Medicare patients, according to the Medicare Payment Advisory Commission, an independent congressional agency. And according to the American College of Cardiology (ACC), a substantial portion of the $40 billion a year that Medicare spends on hospitalization for heart failure is spent on readmissions. The group has launched an initiative called Hospital-to-Home, or H2H, to cut the Medicare heart failure readmission rate by 20 percent by December 2012. The H2H initiative focuses on merging and better utilizing data from hospital to home care.
Cleveland Clinic is far ahead of most providers in its ability to connect inpatient, ambulatory-care, and home care systems. For the typical healthcare organization, this has not been a priority up to now. But that is starting to change as hospitals strive to limit readmissions and prepare for impending changes in Medicare reimbursement.
“In the next two or three years, everything will be bundled payments,” predicts Musood Pirzada, director of information technology for the Rehabilitation Institute of Cleveland Clinic. “[Medicare, Medicaid and private insurers will] give so many dollars for the hospital and post-acute care. So there has to be much more integration with the post-acute settings. That’s what we’re trying to prepare for.”
Other healthcare systems are moving in the same direction. St. Vincent Health System in Indianapolis and Partners HealthCare in Boston are both trying to integrate their acute and post-acute systems to varying degrees. Orlando Health in Orlando, Fla., is placing emphasis on feeding vital signs data from home monitoring devices into its Eclipsys EHR. But in the long run, says Rick Schooler, CIO of the system, organizations will need an integrated health record across the continuum of care, so that everyone caring for the patient will know what’s happening at all times.
Fortunately for hospitals that are contemplating this kind of move, the majority of home care documentation is already electronic. According to a survey by the National Association for Home Care & Hospice (NAHC), 65 percent of home care agencies have some kind of electronic health record. A HIMSS survey found that 83 percent of home care agencies that are owned or managed by hospitals use electronic clinical documentation. The agencies have invested in information technology primarily to facilitate the completion of forms required by CMS and to ensure that the acuity of patients is accurately described. These are goals related to reimbursement, but home care EHRs contain a wealth of clinical data that are ready to be transmitted to other care settings.
Another plus for CMIOs who want to link home care systems to their enterprise is that they may be dealing with entities under the same corporate umbrella. According to HIMSS, 44 percent of hospitals own or manage a home health agency, and the NAHC survey shows that 27 percent of agencies are hospital-owned or affiliated. Especially in large metropolitan areas, however, hospitals may be dealing with a number of agencies that they do not own. So whatever online connections they build with their own home health divisions may affect only a fraction of the patients who are referred to home care.
In any case, there is no doubt that home care will become more important to CMIOs in coming years. Here are some facts that may be helpful, along with examples gleaned from healthcare organizations that are plowing this ground.
Delivering patient data to nurses
Some health systems are trying to improve the flow of information to home health nurses by linking discharge planning software with home care applications. The Cleveland Clinic, for instance, has interfaced Allscripts Care Management (formerly ECIN) with the Allscripts Homecare (formerly Misys) application.
Other organizations are using web portals for the same purpose. At Partners, a homegrown “transition of care” program called 4Next allows care managers in the hospital to pull medication lists, lab results, radiology reports, discharge summaries and nursing notes from the enterprise EHR and post them on a web portal for the next care providers, whether they’re in home care or some other post-acute setting. Notably, non-Partners agencies that are hooked up to 4Next can access this information when they accept a referral from a Partners facility. In the near future, when Partners adopts the Cerner home care system, it will be interfaced with 4Next, giving home care nurses in the Partners system direct access to the hospital data.
Where home care nurses have online access to outside data—which is still the exception—it is usually limited to the previous acute-care episode. There is no record of what happened to the patient in ambulatory care, and there is no way for an outpatient physician to send information online to home health nurses along with a referral. At St. Vincent Health System, for instance, the home care nurses are using the Allscripts Homecare EHR, but they cannot access data from St. Vincent’s ambulatory-care clinics, which have Allscripts’ outpatient EHR. They can view some data in the Eclipsys inpatient system, but St. Vincent CMIO Alan Snell, MD, doesn’t believe that the two systems will ever be able to trade data at every level. He looks forward to the day when the home care application will be able to exchange Continuity of Care Documents (CCDs) with the inpatient and outpatient EHRs. But that day may not come soon: neither Allscripts nor McKesson, the home health IT market leaders, has yet added CCD capabilities to their home care systems.
How much data do physicians want?
According to Cleveland Clinic’s Pirzada, both inpatient and outpatient physicians want to follow their patients’ home care progress online. A surgeon who has performed a procedure, for instance, wants to know how quickly the patient is recovering after discharge. Physicians who refer patients to home care from their offices, he says, also are viewing nurses’ progress notes in the enterprise EHR. “They want to be in touch with what’s going on with the patient,” he maintains.
Landers agrees this is important for physicians. “We’re not there at the same time as the other home health clinician, even if we’re doing home visits. And most primary care docs almost never have face-to-face encounters with these home health nurses and therapists. So from both of our perspectives, we benefit from knowing what’s going on and do a better job as a result.”
But many physicians would prefer to keep the home health information they receive to a dull roar, says Cara Babachicos, vice president and CIO for Partners Continuing Care. “Doctors say, ‘Don’t send me every single vital sign on the patient.’ They want to know about significant events. An admission note, a discharge note, and perhaps an important progress note are key events they might want to have information about. So we have a process in place where we’ll have integration with those key events, potentially uploading those documents into the LMR [enterprise EHR], either through an interface or by scanning them in.”
This information will be available in Partner’s LMR, but not in the GE Centricity EHR that many physicians in Partners’ network use or in other applications. Partners could interface the Cerner home care system with Centricity’s Chart Link feature, Babachicos says, “but there’s not a huge business driver for that.” As for putting the data on a web portal, she says, “Some of these things sound great on paper, but physicians say, ‘We’re not going to go to a separate portal to look at two notes on Mrs. Smith when we see 300 patients a month. It’s not realistic. Unless you incorporate that into our practice management system, it’s not happening.’”
Home care nurses, unlike clinicians in hospitals and offices, are unable to message physicians directly within their EHRs. Instead, they pick up the phone or send a computer fax when a patient needs to have their medication adjusted or has a sudden change in condition. Cleveland Clinic could give home care nurses inboxes on the Epic system, says Pirzada. But the nurses themselves don’t think that’s necessary, since the doctors already have access to their progress notes. If a patient needs something stat, nurses call the doctor on their cell phones, he says.
Home monitoring heats up
Another way to keep people out of the hospital and the ED is to monitor their vital signs at home. Cleveland Clinic has been doing a pilot of telemonitoring with patients who have congestive heart failure (CHF), and plans to expand it to conditions like diabetes and COPD. Partners, which also is using home monitoring for CHF, has seen some major improvements in care as a result, says Babachicos.
St. Vincent has gone a step further in testing telemonitoring with diabetic patients. Its parent organization, Ascension Health, has struck a deal with the Best Buy retail chain so that patients can buy digital scales, blood pressure cuffs, and glucometers at a discount. St. Vincent has built a web portal to which the home monitoring data is uploaded. Patients and their designated caregivers can view the data on the portal, and, for a monthly fee, patients can use a nurse contact center to get coaching and evaluation. Physicians view the monitoring data on the portal or receive monthly reports. They are automatically contacted if the vital sign data goes outside the designated parameters. After the pilot, St. Vincent plans to extend the program to CHF and COPD and give home care nurses access to the portal.
At the national level, more money appears to be flowing into telemonitoring than into home care systems. Babachicos points out that there is no “meaningful use” objective directly related to post-acute care, so some healthcare organizations may find it difficult to allocate capital to health IT in that area. In contrast, big companies like Intel, GE and Philips, along with venture capital firms, are pouring funds into the development and implementation of telemonitoring, according to Tom Heatherington, a health management consultant for Accenture.
One reason for this stepped-up activity, he says, is that “the infrastructure is now in place to transmit telemonitoring data wirelessly at megabit speed.” But, even though hospitals can use home monitoring to reduce readmissions, Heatherington doesn’t expect them to lead the charge in this field. Instead, he sees independent firms developing new applications like a disposable vital signs device that straps onto a patient’s arm. The data will most likely be transmitted to a patient health record (PHR) that might be hosted on a web platform such as Microsoft HealthVault or Google Health, he says.
Breaking down digital silos
Snell also sees PHRs playing a key role in telemonitoring. St. Vincent is already using the Medem iHealthRecord and is now transferring the 800 patients who have that PHR to MedFusion, which has acquired iHealthRecord. Later this year, he says, St. Vincent will start to connect monitoring devices to MedFusion and, through that, to the Allscripts outpatient EHR. That would be an advance over the current system, in which telemonitoring alerts are faxed to physicians.
“You want the information flow to be bidirectional,” Snell says. “When a primary care physician orders a test, he or she should be able to push those results into the PHR, and the patient could self-enter data into the PHR, which is pushed to the EHR, so the doctor or nurse could accept that. Home monitoring devices could be generating data that goes into the PHR, which could be shared with physician practices.”
With the Indiana Health Information Exchange and other HIEs in his back yard, Snell also sees the potential for communitywide data exchanges to help break down the walls between home care and other care settings. Perhaps they could be a hub for information that would be delivered securely to providers who have permission to view it, he says. That would be a boon in a world where only some home health agencies and some referring physicians belong to healthcare organizations.
Cleveland Clinic is taking a different approach to this problem. It has already built an order module into Epic that allows any Cleveland Clinic physician to refer a patient to home care within the EHR; the order flows through the discharge planning application into Allscripts Homecare. Soon, Pirzada says, physicians with other EHRs will be able to order home care the same way, he says, using an Epic feature called “My Practice Community.” In the next phase, he adds, Cleveland Clinic will create a two-way communication link between home care and non-Epic EHRs.
The ‘low-hanging fruit’ of connectivity
Independent home health agencies would love to connect online with healthcare systems, says Keith Myers, CEO of LHC Group, a Louisiana agency that has more than 50 joint ventures with hospitals, including the Ochsner Health System. Today, he says, only a handful of hospitals have online links with LHC’s Allscripts Homecare system. “There are so many efficiencies to be gained from that, but it’s not being done on a large scale today,” he notes, adding that Ochsner plans to set up a connection with LHC this year. “If we did nothing more than pull over all the basic patient information—the medications and so forth—it would save us hours of time in the field. It’s the low-hanging fruit, without question.”
Myers believes that more hospitals will invest in these interfaces because of the new government incentives. Snell agrees. “We know we’re in store for different reimbursement models. Whether you’re an independent stand-alone nursing agency or you’re associated with a large system, I predict you’re going to see more bundling of services.” As a result, he says, healthcare organizations will invest in connectivity with home care to help prevention readmissions and ED visits “and conserve their reimbursement. So you’re going to see more utilization of this technology.”