Electronic Communication Across Provider Settings:Connecting NH Providers

June 10, 2005

Wendy Angelo, MD

Dan Venecek, PMP

Objectives

• Discuss Existing Systems

• Clinical Workflow Examples

• Gaps in clinical handoffs

• Proposed plan to address clinical information sharing

Concord HospitalLead Partner in AHRQ Grant

• Second busiest acute care hospital in NH• 205 beds• Regional referral area 275,000• 15,500 admissions in 2004

Capital Region HealthCare• More than 2,600 employees

• 300+ physicians on medical staff

• 75+ employed physicians

• Serves 5 counties in central New Hampshire

• Approx. 750,000 patient contacts/visits per year

Located in Central NH

Concord Area Partner Organizations

• Concord Hospital• Concord Hospital Primary Care Practices• Concord Hospital Family Health Center• Dartmouth Hitchcock-Concord Clinic• Concord Regional VNA• Riverbend Mental Health Services

Concord Hospital Technology• Over 10 years experience with

barcoded medication administration

• A decade of EMR experience• PACS Medical Imaging System• Physician Portal• > 25 systems communicating via

Interface Engine technology• Implementing Electronic Patient

Record (Document Imaging)

Concord Regional Visiting Nurse Association

• Horizon Homecare - McKesson• Clinicians maintain coded medication lists• Medications reconciled from patient home• Centralized database updated with clinical

information entered remotely• Shared clinical information

electronically (Physician Portal)• Implementing Telehealth technology

Riverbend CommunityMental Health

• TIER - Sequest technologies• Communication tool for multi-disciplinary team• Document visits• Tracking federal and state required forms

Over 170 providers accessing more than 125,000 electronic patient records

90% Primary Care Breast Care Center

100% Pulmonary Lipid Management

40% Surgery Diabetes Education

50% Gastroenterology Wound Healing Center

66% Dermatology Nutrition Counseling

60% OB/Gyn Sleep Center

75% Pediatrics Family Dental Center

3

8

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55 147HillsboroHillsboro

70LaconiaLaconia

53

EMR in the Concord Area

For a rural community we are fortunate to have a

depth of EMR penetration and a culture of

collaborative practice that enhances our ability to take on quality improvement at

a community level.

Current Electronic Communications

• Communication between hospital services and the practices– HL7 interfaces between lab, radiology, hospital

transcription, and the outpatient EMR– Secure messaging of rehab progress notes to PCP

• Primary care to specialty care– electronic outbound referrals from ambulatory EMR – Secure messaging between providers

• Specialty care consult notes to primary care– interfaced directly into ambulatory EMR

Current Electronic Communications

• Providing the “right” information at the “right” time– ED granted access to EMR– Physician Portal brings together hospital

experience (EKG’s, images)– Clinical data gathered by VNA can be viewed

via Physician Portal

Communication Between Inpatient and Outpatient

• “Wrap-around” EMR• Using tools that directly pull information from the

outpatient to the inpatient environment• Discharge processes that facilitate the maintenance

of the outpatient record• Tools and processes used by hospitalists to smooth

transition points

Clinical Handoff Scenario Hospital Admission Orders

• Hospital admission template in EMR

• Order sheet auto-populates with problems, allergies, and medications

• Decreases transcription errors

• Creating hospital admit orders within EMR

Clinical Handoff Scenario Hospital Discharge

Dictation Placeholder for Hospital Course

Clinical Handoff Scenario

Hospital Discharge

Easy to read patient

discharge instructions

Even with our current technologies and collaborative environment there are many

examples of difficult transitions

The Biggest Risk at Any Transition Point is Medication

Error

Our Current PilotPre-op Medication Reconciliation

• Pt is pre-op for lung surgery• Surgery about to be canceled because of elevated

liver functions of unknown etiology• Going through pre-op process• Clearance nurse realized that he was on two meds

that PCP did not know about• Letter faxed to PCP• PCP had him discontinue meds• Liver functions improved

Barriers to Medication Reconciliation

• Varying Accuracy of Medication Lists• Often does not represent what the patient is actually taking

– OTC, herbs, vitamins, meds stopped or started by patient

• Difficult, if not impossible, to share discrete data electronically

• Information not shared between episodes of care in different settings

• Provider push back on any workflow that increases their workload

How do we overcome these barriers…

It’s NOT about the technologyIt is about getting the right people

at the table

Leadership

• Recognized Challenges– A sense of urgency that this issue needs to be

addressed– Financial Match Commitment and Fair

Distribution of Shared Costs– Support for needed changes at each

organization– Liability concerns among partners– Governance Structure

Collaboration of the Clinical Community

• Clinical and Frontline Staff from each partner to address– How to keep the project patient centered– Patient Privacy & Confidentiality Concerns

(HIPAA Standards)

– Sensitivity to provider workload and Clinical Workflow Changes

Our Vision of Success

• Organizational Success Defined by:– A cultural change has occurred– Actively seeking collaboration between

partners– Workflows re- engineered to be more Patient-

centric

Our Vision of Success

• Technological Success Defined by:– All partner EMRs store medications in a discrete

format– Able to share the same medication list across

provider settings– Use Automated Technology to Broadcast

Updates/Changes to all of a patient’s providers– Measure number of updates/changes broadcast

and number accepted

Our Proposed Technological solution

The creation of a community wide grid

Technology SolutionNovo Innovations, Inc

• Information captured in local EMR

• Continuity of Care (CCR) record updated

• Changes securely broadcast to all nodes on the grid

• Provider notified of change and allowed to update EMR

EHR 2

CCRCCR

CCRCCRCCRCCR

CCRCCR

EHR 3EHR 1

EHR 4

Development Considerations• Events – when is the information acquired and

distributed?• Extraction – how is the data acquired from the

local EMR?• Patient matching – who is the patient, who has

interest in the patient?• Intervention – how do providers receive and

accept data?• Insertion – how is data input into the local EMR?

Why we will succeed

• Collaborative environment established

• Record of successfully implementing clinical info systems

• Focused on quality and patient safety

• Partner clinicians and IT

• Patient safety demands that we succeed