San Diego is an advanced healthcare market where leaders of patient care organizations are moving forward rapidly on risk-based contracting, population health and care management initiatives, and advanced development of health information exchange, as noted in a recent series of articles by Healthcare Informatics Editor-in-Chief Mark Hagland.
Within this regional market, UC San Diego Health, the academic health system of the University of California San Diego in La Jolla, is advancing forward on a number of fronts to improve health information exchange, health information management and revenue integrity. In a recent interview, Cassi Birnbaum, system-wide director of health information management and revenue integrity at UC San Diego Health, outlined the health system’s roadmap for health information exchange initiatives and shared the progress made, to date, on several grant-funded health IT pilot projects.
UC San Diego Health executive leaders are focused on leveraging technology to ensure providers have the right information at the right time, Birnbaum says. The health system participates in San Diego Health Connect (SDHC), the metro area’s health information exchange (HIE). Birnbaum, who serves as secretary on SDHC’s board of directors, says, “I’ve been involved (with SDHC) in many capacities, from when it was a Beacon community to where we’re at right now, where we are an independently viable, regional HIE.”
Birnbaum also views the success of SDHC as indicative of the collaborative spirit among healthcare provider organizations in San Diego. “Even though we are fiercely competitive, as many of us are vying for the same patients, I think we do come together as it relates to IT initiatives. I think for the greater good, we do come together, probably much more than other regions, and I think that San Diego Health Connect is a great example.”
SDHC is seeing particular success with its EMS Hub project, which aims to improve coordination between emergency medical services and hospital emergency departments (EDs). As the ability for EMS providers to have access to relevant health data is critical, the State of California Emergency Medical Services Authority (EMSA) developed a model to advance bidirectional data exchange—from an HIE organization to the on-scene EMS provider and from the EMS provider back to the receiving facility and the HIE.
To this end, EMSA developed the Search, Alert, File and Reconcile (SAFR) model to serve as an HIE framework for EMS by defining the minimum functionality necessary to achieve HIE. The California EMSA was awarded a grant from the Office of the National Coordinator for Health IT (ONC) to pilot the SAFR model as a new EMS HIE workflow. In July 2016, California began two pilot SAFR implementations with SDHC named as one of two HIEs to serve as information hubs, with the Orange County Partnership Regional Health Information Organization (OCPRHIO) serving as the second hub.
UC San Diego Health is a pilot site for the SAFR project, which has been live since April 2017 in the city of San Diego, according to Birnbaum. The pilot involves American Medical Response (AMR), the agency that supports EMS services in the City of San Diego, and both main hospitals of UCSD Health—UC San Diego Medical Center in Hillcrest and the La Jolla campus.
The project focuses on four functionalities: the Search functionality enables paramedics to search individuals’ health information for past medical history, medications and allergies; the Alert functionality enables the receiving hospital to receive real-time data about an individual’s status directly onto a dashboard in the ED; the File functionality enables the structured data of the EMS electronic patient care report (ePCR) to be filed directly into the receiving hospital’s EHR system; and the Reconcile functionality enables the EHR information to be reconciled back into the EMS ePCR for use in clinical quality measures and population health.
“The ER or trauma center is able to see the EMS run sheet, all the documentation, any EKGs that are done in the field, and any other pertinent information that needs to be transmitted to us,” Birnbaum says. “So, once we identify the patient within our enterprise-wide master person index, and our electronic health record (EHR) is Epic, we are able to pull in all the information and assimilate that just within our EHR. And that information is available not only for the emergency room and trauma providers, but also if the patient is transferred to another unit in our organization.”
Drilling down into the progress of the project, for the Search functionality, paramedics are finding HIE data on 42 percent of the patients they query from the scene or in-route, according to Birnbaum. What’s more, the receiving hospital ED sees real-time data in their EHR from the paramedics in 87 percent of the runs, she says. An electronic PCR is sent from the paramedics to the ED’s EHR, and with more than half of cases (55 percent), the ePCR is sent within 24 hours of the patient arriving at the ED. And, 37 percent of the time, an updated report from the hospital is sent back to the paramedics. And, these numbers are considered highly successful by the California EMSA, she says.
Due to the success of the project, SDHC is planning to expand to more ED and agencies, and others EDs are likely to implement SAFR in the next six months, according to Birnbaum.
“At UC San Diego Health, we also reap a financial benefit because we’re able to verify trauma activation and we are able to provide the right level of care confirmation from a charge capture and coding perspective,” she says.
UC San Diego Health also is a pilot site for California’s POLST (Physician Order for Life Sustaining Treatment) eRegisry pilot project. Funded by the California Health Care Foundation, in joint effort with EMS Authority and the Coalition for Compassionate Care of CA, San Diego Health Connect was selected to be one of two pilot communities to launch a POLST electronic registry in its region.
POLST is a standardized form that clearly states what level of medical treatment a patient wants during serious illness or toward the end of life. Unlike an advance directive, POLST is signed by the patient and a physician and becomes a medical order that moves with the patient across care settings. In most states, including California, most POLST information is maintained only as a pink piece of paper that stays with the patient or the medical record.
“POLST gives seriously ill patients more control over their end of life as far as medical treatment. For us, it’s very important to get it into a registry beyond our own integrated delivery system, so we are now scanning in all of our POLST forms. And, one of the things that we’re working on as well is an outbound interface from our document management information system so we can send the information directly without any manual steps associated with it,” Birnbaum says.
To date, SDHC has launched the registry tool and started to receive POLST forms from UC San Diego Health, as well as Sharp HealthCare and Integrated Health Alliance, and HIE users can now retrieve POLST forms.
For Birnbaum and her team at UC San Diego Health, there is an ongoing strategic focus on leveraging technology for identity management, which is critical to exchanging information and treating patients, not only across the organization's continuum of care, but even outside the walls of its facilities. "That’s why we use San Diego Health Connect. We’re constantly looking at better technology to help make sure we have the right information at the right time in order to advance all of our healthcare initiatives," she says.
Health Information Management Across a Vast Network
UC San Diego Health operates three acute care hospitals, the two mentioned above as well as Sulpizio Cardiovascular Center. In addition, the health system operates the Moores Cancer Center, the Shiley Eye Institute and also provides ambulatory services across three counties. Health system leaders also developed the UC San Diego Health Care Network, a collective of regional health care providers, community hospitals, medical groups and physicians based in San Diego, Riverside and Imperial Counties. The network is a clinical integration network that collaborates on developing shared systems, infrastructure, care pathways and quality initiatives.
UC San Diego Health also recently went live on a shared EHR platform with UC Irvine, the first time two U.S. academic medical centers have linked up on one instance of Epic. “UC Riverside provides ambulatory services in the Riverside area, and they are also on our instance of Epic. We also have four large ambulatory specialty organizations that are on our instance of Epic,” Birnbaum says.
Birnbaum notes that sharing a single EHR platform with UC Irvine allows for greater efficiencies and benefits for UC San Diego Health as well. "From a scope and scale perspective, there are certainly a number of advantages to coming together. Obviously, there are some cultural challenges and technical challenges.”
As system-wide director for revenue integrity at UC San Diego Health, Birnbaum is leading efforts to utilize leading-edge technology for coding and reimbursement as well. “We’re doing some really cool things right now with NLP (natural language processing) and working on a coding and reimbursement solutions, not only for the professional fee side, because that is a market that has been largely ignored, but also looking at coding to meet all of our different requirements, whether it is professional fees, facility, coding and charge capture, as well as risk adjustment, and meeting the needs and requirements for some of the population health initiatives,” she says.
However, there are a number of challenges in this work as well. “I think there is always a competition for resources. So, at times, my team and I would like to move a little faster, but we are limited by resources. And, even with the vendor community, because we’re leading the pack, it’s about getting the right vendor support and willingness to partner with us and build a better mouse trap or to create something new and look at innovative approaches.”