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Hassle-Free HIE With t he ED. LCC Pilots Subworkgroup S&I Longitudinal Coordination of Care Workgroup March 10 th , 2014. Larry Garber, MD Medical Director for Informatics Reliant Medical Group. Reliant Medical Group (formerly known as Fallon Clinic). - PowerPoint PPT Presentation
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ReliantMedical GroupAtrius Health
LCC Pilots SubworkgroupS&I Longitudinal Coordination of Care Workgroup
March 10th, 2014
Larry Garber, MDMedical Director for InformaticsReliant Medical Group
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•300+ provider multi-specialty group practice •23 sites in central Massachusetts •Not affiliated with any hospitals•Not-for-profit•At financial risk for 70% of our patients•Member of Atrius Health/Pioneer ACO
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St. VincentHospital
Reliant MedicalGroup’s Epic EHR
Outside Record Icon in MedHost Bedboard
CCD with SVH MRN
ADT for Reliant
Patients
CCD with SVH MRN
30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR
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ER and Hospital encounters automatically created in EHR from ADT
ER and hospital Discharge Notes file into EHR as well as InBasket of PCP, PCP’s RN, and Care Manager
ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge (based on ADT) which also go to physician InBasket
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Hospital ADT monitored for hospital discharges
3 Days later, EHR checks to see if follow-up appointment took place or is scheduled
If none, an InBasket message is automatically sent to PCP’s appointment secretary
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3 Days after hospital discharge, medication claims data are reviewed along with past and future labs
Alerts sent to PCP’s InBasket suggesting dose checking, monitoring or discontinuation
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IMPACT
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Sites with EHR or electronic assessment tool use LAND (“Local” Adaptor for Network Distribution) as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR
Non-EHR users receive, edit and send documents using a web browser to access their “Surrogate EHR Environment” (SEE)
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LAND
Hospital
PCP
SEE CCD+
MDS
Billing Program MDS
KeyHIE TransformCCD+
CCD+
CCD+ = Transfer Summary
Nursing Facility
LTPAC Communication using LAND & SEE
Home Health
CCD+
CCD+
LAND
LAND