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Health information exchange benefits paper-bound nursing homes

Health information exchange benefits nursing homes. Many remain paper-bound, yet hold up-to-date advance directives for their patients.

Two health information exchanges -- The Great Lakes HIE in Michigan and the Keystone HIE in Pennsylvania -- are throwing technology at a major meaningful use policy paradox that affects vulnerable, elderly patients at the worst possible times. By doing so, they could be demonstrating the type of health information exchange benefits that privately and publicly funded HIEs have been seeking in order to prove their economic viability as federal grants are due to expire.

Nursing homes were left out of federal EHR incentives, but they're the parties who typically hold their patients' up-to-date advance directives. When these patients -- some of them incapable of making their own health care decisions -- get ambulanced to hospitals or go to doctors' offices for treatments, their caregivers are required to collect advance directives from 50% of patients, per the stage 2 meaningful use criteria.

When the advance directive idea worked for the Lansing patients, GLHIE rolled it out to the rest of the HIE, knowing that providers would appreciate the help with meaningful use compliance.

"People are often asked to do more than one [advance directive] because everybody doesn't have access to the one they've done," said Carol Parker, Great Lakes HIE (GLHIE) executive director. "Sometimes they have conflicting information that gets put in there." That might include naming different relatives as being authorized to make care decisions on behalf of the patient -- which makes sense, because different children might take an elderly patient to different providers or be available different days of the week to drive him to appointments.

"It's hard to reconcile the patient's ultimate desire," Parker said. "By making [the advance directives] available, we're hoping that we can work with the providers -- who will work with the patient -- to make sure the advance directive they want is available ... so they're not constantly asked to do an update. Or if they are, at least they can see what they've done before."

The GLHIE, which serves 10 hospitals and 4,500 providers (participating or committed to doing so) in southern and central Michigan, is tackling this issue by taking in faxed advanced directives from nursing homes and EHR-connected providers by piping them into its longitudinal patient record. While it's a simple concept, it cuts down on confusion over a patient's care in potentially tense times when care providers must make informed decisions quickly.

Idea could inject life into ailing HIEs

Of course, the nursing home HIE problem isn't limited to advance directives, information exchange is merely top-of-mind because it's hardwired into the initiative for the meaningful use of EHRs. Nursing homes need to keep up with updated information from physician visits at the nursing home site and their offices. And those doctors need updates as well. Long-term care and home health agencies are stuck in a similar situation, as well as behavioral health providers.

While most nursing homes aren't running EHRs, they must electronically collect and submit in XML format what CMS calls a minimum data set (MDS) on each patient, from which the federal payer determines Medicare and Medicaid reimbursements. The MDS includes such information as nursing notes, dietary data, social services reports, rehab history when appropriate, and other information that determines how much and what kind of care a patient requires.

"It [represents] all departments, and it gives a general, overall assessment of the patient's condition," said Steve Warriner, network systems manager for Maria Joseph Continuing Care Community, a Danville, Pa., nursing home. Facilities typically collect an MDS on a quarterly basis, and update more frequently when there's a major change in a patient's condition.

The MDS isn't regulatory busywork; it contains important information, said Tom Conlin, chief operating officer for the Maria Joseph nursing home, adding that a patient's care plan is devised from the MDS. It needs to be up-to-date and accurate, too, because CMS inspectors periodically show up and compare current MDS submissions to the nursing home's written medical records to verify that reimbursements are correct.

So, MDSes are useful data physicians outside a nursing home could use to inform their care decisions when those patients come in for appointments or are hospitalized. But at the nursing home point of care, the MDSes are just XML files submitted for reimbursement purposes, not assembled into an EHR system.

The Keystone Beacon Community, which is led by Geisinger Health System but includes other providers and works with KeyHIE, decided to integrate MDS data into its data network, so physicians seeing patients who live in nursing homes could see what was new on the home front. The project involved collecting those roughly 30-page nursing home MDSes, aggregating them and making them available to providers in continuity of care document (CCD) format.

KeyHIE, Geisinger make it work for patients, business

Some HIEs are struggling to find sustainable business models as federal grants run out -- if they got grants in the first place, that is. This particular health information exchange benefit -- connecting the health IT haves and have-nots -- could be one path to profitability.

Both advance directives and making data available when a patient's care moves from a provider with an EHR to one without, are needed services. That's true especially for accountable care organizations and other quality-minded providers looking to share as much data as possible with clinicians so they can make better, more well-informed decisions and avoid hospital readmissions -- and reduce the amount of paper handed off at transitions of care.

Jim Younkin, Geisinger IT program director and Keystone Beacon Community administrator, said home health agencies make CMS filings similar to MDS filings through a system called the Outcome and Assessment Information Set (OASIS), and KeyHIE plans to integrate that data into its network.

"We have an OASIS transformation project under way that will offer the same capabilities [as its MDS project]," Younkin said. Both ideas have been so popular among health data policymakers that they've grown bigger than KeyHIE. "Also, because we've been approached by so many organizations about access to this tool, we've taken steps to have it adopted at a national level through HL7 [Health Level 7 International]."

That, Younkin said, could lead to more income, in the form of a KeyHIE-hosted service for any nursing home or home health agency, whether in Pennsylvania or elsewhere, to park its MDS and OASIS sets on its servers.

The GLHIE's advance directive implementation began as a service it provided for a group in Michigan's capital for patients in the Lansing Area Chronic Disease Management Collaborative. GLHIE hosts a longitudinal medical record website for this group of hospitals, long-term care institutions, home health and hospice agencies, and area agencies on aging. They sought to aggregate clinical data to improve transitions of care for local patients who use a combination of those services.

When the advance directive idea worked for the Lansing patients, GLHIE rolled it out to the rest of the HIE, knowing that providers would appreciate the help with meaningful use compliance.

"Really, the impetus for all this was the patients -- to make life better for them," Parker said, "but meaningful use helps incentivize the provider [to participate in the HIE] because they have to have their staff backfill the directive if there's no way to send it to them electronically."

The longitudinal records service also helps GLHIE bring in the "have-nots" as partners, too, Parker said. They willingly sign up to participate because the Web portal quickly gives them access to information they'd have to wait to have delivered on paper.

Let us know what you think about the story; email Don Fluckinger, Features Writer or contact @DonFluckinger on Twitter.

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