The Clinical and Business Case for Interoperability Direct Trust Mini Conference, Sunday, March 22, 2015 Holly Miller, MD, MBA, FHIMSS CMO MedAllies Copyright,

The Clinical and Business Case for Interoperability

Direct Trust Mini Conference, Sunday, March 22, 2015

Holly Miller, MD, MBA, FHIMSSCMO MedAllies

Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission

Agenda

• Transitions of Care (TOC) Current State• Financial Incentives Offered for TOC

Improvements• Developing a Patient Centered Medical

Neighborhood to Enhance Patient Care Transitions and Healthcare Value

• Patient Centered Medical Neighborhood In Action


Transitions of Care:


• Current State

Adverse Events (AE)

1. Forster AJMurff HJPeterson JFGandhi TKBates DW The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med2003;138161- 167

2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates D (2005) Adverse drug events occurring following hospital discharge. Journal of General Internal Medicine 20: 317–323

3. Coleman EASmith JDRaha DMin S Post-hospital medication discrepancies: prevalence, types, and contributing system-level and patient-level factors. Arch Intern Med2005;1651842- 1847

4. Kanaan AQ, Donovan JL, Duchin NP, Field TS, Tjia J, Cutrona SL, Gagne L, Preusse P, Harrold LR, Gurwitz JH. Adverse Drug Events After Hospital Discharge in Older AdultsJ Am Geriatr Soc. 2013;61(11):1894-1899.

5. Gandhi, TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger SL, Shu K, Federico F, Leape LL, Bates DW. Adverse Drug Events in Ambulatory Care. N Engl J Med 2003;348:1556-64.

6. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellie K, Seeger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289(9):1107-16.

• ~ 20% of patients discharged from hospital experience an adverse drug event (ADE) *1,2,3,4

• Similar rates of ADEs in ambulatory patients, particularly among the elderly* 5,6


1/5

• Hospital Discharge1

– 1st Post discharge PCP visit ~ 75% no information about the hospitalization

– 4 weeks post discharge 51-77% discharge summary not available

1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41.

• PCPs and Specialists2, 3

– PCPs report sending information 70% of time; specialists report receiving the information 35% of the time

– Specialists report sending a report 81% of the time; PCPs report receiving it 62% of the time

2 O’Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med, 171 (1), 56-65.3. Mehrotra, A., Forrest, C.B., Lin, C.Y. (2011). Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly, 89 (1), 39-68.

Communication Deficits

5Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission

Adverse Events (AE)

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Root Cause Analysis of Serious Adverse Events (AEs) Most frequent attributable cause is ineffective

communication Most vulnerable parts the TOC process are the “hand-

offs” Most frequent AEs are ADEs due to medication errors

*Greenes, R. (2007). Clinical Decision Support: The Road Ahead. New York, NY: Elsevier, Inc.




• Financial Incentives

• Patient Protection and Affordable Care Act– Transitions of Care• CPT codes for Transitional Care Management

Services–Discharge from Hospital, SNF, Community

Mental Health Center, Outpatient Observation, Partial Hospitalization

Care CoordinationIncentives


• Patient Protection and Affordable Care Act– Transitions of Care• CPT codes for Transitional Care Management Services



Code Medical Decision Making

Communication F2F Visit Reimbursement

99495 Moderate complexity

Within 2 business days of discharge

Within 14 calendar days of discharge

$163.99

99496 High complexity Within 2 business days of discharge

Within 7 calendar days of discharge

$231.26



• Chronic Care Management Fee – Medicare patients

• 2 or more chronic or episodic health conditions

– CPT code 99490 under Part B fee for service• $ 41.92 per patient per month• Only billed once per month per patient and by one physician• > 20 mins clinical staff time directed by a physician spent in

CCM services• Patient consent required: Medicare pays 80%, patient liable for

20% co-insurance• Comprehensive care plan is established, implemented, revised

and monitored

– Requirements

CCM Scope of Service Element Billing Requirement

Certified EHR or Other Electronic Technology Requirement

Structured recording of demographics, problem list, medications, medication allergies and the creation of a structured clinical summary record must inform the care plan, care coordination and ongoing clinical care

Structured recording of demographics, problem list, medications, medication allergies and the creation of a structured clinical summary record using CCM certified technology

24/7 Access to care management servicesContinuity of care Care management for chronic conditionsCreation of a comprehensive care plan for all health and health related issues. Share the care plan as appropriate with other providers

Electronic capture of the care plan available 24/7 within the practice and share care plan electronically (not fax) with other providers

Provide patient with a written or eCopy of the care plan Document provision in the EHR using CCM certified technology

Management of care transitions between and among providers and settings

Format and exchange clinical summaries electronically

Enhanced patient and provider communication including asynchronous communication

Beneficiary consent - for CCM services Document the beneficiary’s written consent and authorization in the EHR using CCM certified technology

Beneficiary consent – right to stop the servicesBeneficiary Consent – only one provider paid during a calendar month

• Patient Protection and Affordable Care Act, Transitions of Care (Cont.)– Value Based Purchasing• Accountable Care Organizations: 1/1/2012• Community-based Care Transitions Program

(CBCT): 1/1/2011• Comprehensive Primary Care Initiative (CPC): 2013

– Expanding Authority to Bundle Payments• Hospital penalties for preventable 30 day readmissions



• American Recovery and Reinvestment Act (ARRA)– Health Information Technology for Economic

and Clinical Health Act (HITECH)• Meaningful Use Stage 2 Core– More than 10% of patients transitioning or

being referred have electronic transmission using CEHRT to recipient





• Developing a Patient CenteredMedical Neighborhood

Practice


Developing a Patient Centered Medical Neighborhood


Practice



Practice


Hospital

HospitalHospital Behavioral

Health

Practice Practice

SNF

HISPHISP


Home Health



• Clinical Leadership• Clinical Trading Partners• EHR Configuration• Establish Role Based Workflows• Training Materials


Identifying Clinical Trading Partners• Acute care facilities analyze most frequent:– Discharge destination points– Transfer destination points

• Ambulatory facilities analyze most frequent:– Referrals or referral sources– Planned admissions to hospitalists

• Readiness assessment of clinical trading partners– 2014 CEHRT upgrade complete– HISP strategy identified


It Has To Be Easy

Direct implementation shouldENHANCE existing clinical workflow

20Copyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission


• Patient Centered Medical Neighborhood in Action


Patient Centered Neighborhood in Action: Example Acute Care Patient Discharged from Hospital to Home

Direct HISP

Hospital Primary Care

Discharge C-CDA to PCP


Primary Care


Patient Centered Medical Home

Care Manager



Direct HISP

Hospital

Home

Primary Care



Patient at Home




Care ManagerPatient at Home

Medication VerificationMedication VerificationMedication Verification




Primary Care

Patient at Home


Care Manager

Discharge Diet and Exercise InstructionsDischarge Diet and

Exercise Instructions


Patient at HomeCopyright, 2015 MedAllies Not for DistributionSource: Holly Miller, MD, not to be used without express permission

The Patient Centered Medical Neighborhood

Hospital HomeHealth

Specialist(s)

LTPAC Settings (SNF, Other

Professionals etc.)

Patient


Integrated Workflow Across the Community

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Patient Centered Medical Neighborhood


Thank You

30

[email protected]


Documents

The Clinical and Business Case for Interoperability Direct Trust Mini Conference, Sunday, March 22, 2015 Holly Miller, MD, MBA, FHIMSS CMO MedAllies Copyright,