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At the Hospital for Special Care, IT-Facilitated Care Management Breakthroughs

December 19, 2018
by Mark Hagland, Editor-in-Chief
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Leaders at the Hospital for Special Care in New Britain, Connecticut, are leveraging HIT to improve care management and clinical workflows

As complex and challenging as it can be to perform care management on mainstream patient populations, the challenges multiply when it comes to caring for patient populations with special and specialized needs. That certainly has been the overall set of challenges facing the Hospital for Special Care in New Britain, Connecticut. The Hospital for Special Care (HSC) is the only long-term acute-care hospital in the nation serving adults and children. HSC is recognized for advanced care and rehabilitation in pulmonary care, acquired brain injury, medically-complex pediatrics, neuromuscular disorders including ALS research, spinal cord injury, comprehensive heart failure and comprehensive inpatient and outpatient treatment for children and adolescents with autism spectrum disorder.

The Hospital for Special Care is addressing the healthcare needs of the growing segments within its community, such as people with autism spectrum disorders, chronic obstructive pulmonary disease, and Parkinson’s disease. Recently, HSC became the only patient care organization in the U.S. to receive level-three Patient Centered Specialty Practice recognition from NCQA, the National Committee for Quality Assurance.

In the past three years, HSC leaders have: created a single integrated clinical information system platform that spans both the acute and ambulatory care sides of the organization; achieved NCQA recognition in the area of autism, for all its medical practices, and in COPD (chronic obstructive pulmonary disease); and succeeded in optimizing workflow management for long-term acute care, specialized for spinal cord injuries, pulmonary rehabilitation, cardiac care, acquired brain injuries, stroke, ventilator management, and geriatrics. In this work, HSC leaders have been collaborating with the team from the Chicago-based Allscripts, for that company’s solutions in all those critical areas.

Recently, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Lynn Ricci, the president and CEO of the Hospital for Special Care, and Stanislaw Jankowski, its vice president and CIO, about the forward evolution of this work. Below are excerpts from that interview.

Can you describe the Hospital for Special Care, and its unique mission?


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Lynn Ricci: Yes, we are a long-term acute-care hospital located in Connecticut, and our hospital serves the Connecticut region, as well as surrounding states. We operate 228-bed facility, and log 50,000 outpatient visits a year. We are a specialty hospital, not acute-care. Our specialty services encompass rehabilitative care; we have a number of areas of specialization, including autism, ALS, muscular dystrophy, spinal cord injury, brain injury, and complex pediatrics, and we have a huge pulmonary population.

How long has the organization been in existence?

Since 1941, so 77 years.

And your physicians and staff?

All of our 30 staff physicians are employed; we also work with consultant physicians. Altogether, we have about 1,200 employees.

Tell me about the ongoing evolution of this current work?

We started with an outpatient platform for an EMR, and we’re rolling that out on the patient side. Specifically, this has been very helpful to our autism program, which started on an outpatient basis. It’s the only patient-centered specialty practice recognized by NCQA. This platform allowed us to provide the data and coordination of care necessary for that designation. We’ve been working with Allscripts for about five years, and in October, we went live on our inpatient side, rolling out their solution in stages.

What elements are live right now?

What are live are with clinical documentation, and with major interfaces to our ancillaries—lab, radiology, and a pulmonary system that sends ventilator settings and information to our electronic health record, so that respiratory therapists don’t have to manually enter data.

Can you tell me a bit about the automation of your autism program?

The autism program started in 2012, and has grown significantly. We see about 7,000 visits in our outpatient center, and in October, we opened an inpatient program, one of only 10 in the country designated to support children and families with significant behavioral issues as a result of autism. We received $10 million in bond funding to expand the program. It’s the Autism Center at Hospital for Special Care. And the inpatient program is our Autism Inpatient Unit, which is our eight-bed unit that will go to 12 beds.

What are some of the specific dimensions of autism care related to healthcare IT concerns?

What we do in this specialty practice is that we’re able to use the data we gather through the Allscripts system to coordinate care with community-based providers at school systems, and with families, and to the clinic itself, which includes a psychiatrist, psychologist, nurse navigator, speech and occupational therapists, family skills care, to make it integrated into the community. We also work with a number of organizations in the community to help coordinate referrals into our outpatient program and now inpatient program. And the ability to gather this information was critical in showing our value to the state of Connecticut in order to obtain that funding.

Is there data complexity in that care management?

Stanislaw Jankowski: Behavior is the most specific metric that we look at that differentiates the center itself. So we’re looking at reducing problematic targeted behaviors, including self-injury, destruction of property, aggression towards family members or in the school setting. We work with behavioral specialists and psychiatrists to reduce those behaviors. So we’re able to use the Allscripts system to gather that data together, so that it’s all in one place, to use, and to be able to track and trend that data, and to show continued reduction in the targeted behavior, or for example, for the psychiatrist to be able to access that data to look at potential changes to medication.

The platform created for autism was able to be used after we had been certified for autism care, and now we’re certified for COPD, and are pursuing a third one as well. And at that point, all of our specialty programs will be certified for specialty practice. We’re looking at Parkinson’s or cognitive health.

What have been the challenges in implementing the system?

Jankowski: We went from being strictly paper-based to being electronic. To give you some context for that, when you walk into a clinic or a unit, there are many paper-based workflows. And so even before we had implemented the system, our opportunity was to identify the different workflows, forms, and documentation, and to customize each form for our particular unit. It took a long time to achieve that. Then we were able to implement a way to implement workflow in all our units using similar forms. Some units did require changes in their documentation.

What have been some of the benefits of these implementations?

Ricci: On the outpatient side, we’ve seen the benefits in our ability to in a very efficient way gather data and be responsive to treatment plans. On the inpatient side, our staff has been very excited to see the implementation. They’re very excited about the opportunity to streamline workflows. This is a highly resourced unit. We need to show our value to payers, so our ability to quickly and succinctly access data and share it with providers and payers.

Jankowski: And whereas previously, it took us days or weeks to collect data to report to outside organizations like payers, state and federal agencies, we can report it now very quickly and efficiently.

What have been some of the biggest learnings from this initiative?

Ricci: I think part of has been, and Stan could tell you—it’s making sure that you have the right stakeholders at the table. We spent a lot of time choosing the product, the platform. We chose the right partner, and Stan, as the project has rolled out, has made sure we had the right people at the table.

Jankowski: What we were looking for from a vendor partner is a long-term relationship. We looked at seven vendors, and ultimately, Allscripts was the vendor of choice for us; one reason was that the culture of Allscripts—they were willing to work with us and were very flexible. The majority of EMR systems are really designed for acute-care hospitals. We needed a partner that would be flexible and would configure a system that would work in our environment. Cost is a big factor. As you know, these types of systems cost millions of dollars.

Do you have any advice to share with CIOs, CMIOs, and other healthcare IT leaders?

Jankowski: It’s important to be mindful of and very conscious about the long-term relationship involved. Do your due diligence. Check your own references.


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DirectTrust Touts 2018 Growth in Data Exchange Volume, Participants

January 23, 2019
by Rajiv Leventhal, Managing Editor
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DirectTrust, a nonprofit organization that supports health information exchange via the Direct message protocols, has announced continued steady growth in the number of healthcare organizations using its interoperability services during 2018.

The organization also noted an upsurge in the number of Direct message transactions, patient use, and addresses. According to year-end 2018 metrics:

  • There were nearly 274 million Direct message transactions between DirectTrust addresses in 2018, a 63-percent increase over the 2017 total of 168 million transactions. There were more than 110 million Direct messages transmitted during the fourth quarter of 2018 alone.
  • The number of patients/consumers involved using Direct increased approximately 35 percent to nearly 248,000.
  • The number of healthcare organizations served by DirectTrust accredited health information service providers (HISPs) increased 30 percent to nearly 139,000, compared with approximately 107,000 at year-end 2017.
  • The number of trusted DirectTrust addresses able to share PHI across the DirectTrust network increased 16 percent to more than 1.8 million since the end of 2017.
  • Eleven healthcare organizations joined DirectTrust during 2018, bringing the organization’s total membership to 115.

Last July, DirectTrust named former Cerner executive Scott Stuewe its new CEO to replace founding CEO Dr. David Kibbe. In a recent interview with Healthcare Informatics, Stuewe spoke about working more closely with EHR vendors and expanded opportunities for his organization’s trust framework.

He told Healthcare Informatics at the time that his organization could make more headway by engaging with the EHR (electronic health record) vendors who so far have not been very engaged with DirectTrust. “There are some gaps in features among the EHRs that frankly are the same gaps we saw in query-based exchange in CommonWell. There are usability problems; the way a given feature surfaces in one EHR is so different than another that you can’t even do the same work flow across the two systems,” Stuewe said.

Stuewe also noted that DirectTrust’s technical trust framework is about “stretching the highest security mechanism across identity-proofed endpoints,” which, he said, “is kind of a unique model.”

A recent data brief from the Office of the National Coordinator for Health IT (ONC) revealed that about four in 10 surveyed hospitals participated in more than one nationwide health information exchange network, such as Surescripts, the e-Health Exchange, DirectTrust, CommonWell, or Carequality. Surescripts was the most commonly network used; 61 percent of hospitals participated. The next highest participation rates were in DirectTrust and the e-Health Exchange; about a quarter of hospitals participated in each.


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Hospitals Outline Agenda to Accelerate Interoperability

January 22, 2019
by Heather Landi. Associate Editor
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Hospitals and health systems are making progress in sharing health information, with 93 percent making records available to patients online, but collaboration across many private and public sector entities, including technology vendors and policymakers, is necessary to achieve comprehensive interoperability, according to a new report from national hospital associations.

The report reviews the current state of interoperability, which show promises but is still a patchwork system, as well as outlines current challenges and provides an agenda for steps to take to improve interoperability among health IT systems. The report was compiled by seven national hospital associations—America’s Essential Hospitals, American Hospital Association (AHA), Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, Federation of American Hospitals and the National Association for Behavioral Healthcare.

“We see interoperability in action all around us. Mobile phones can call each other regardless of make, model, or operating system. The hospital field has made good headway, but it’s time to complete the job. We are united in calling for a truly interoperable system that allows all providers and patients to benefit from shared health records and data, leading to fully informed care decisions,” AHA President and CEO Rick Pollack said in a statement.

“For the best care today, it’s the data stupid. Quality care depends on having the right information at the right time, so our patient’s records need to be available in the hospital or wherever our patients receive care. Hospitals are joining together to support improving interoperability because it is the key to assuring the best for our patients,” Federation of American Hospitals President and CEO Chip Kahn said in a prepared statement.

The report highlights that hospitals and health systems are making progress in sharing health information, with 93 percent making records available to patients online, up from 27 percent in 2012. What’s more, 88 percent of hospitals are sharing records with ambulatory care providers outside their system, up from 37 percent in 2012. And, 87 percent of hospitals enable patients to download information from their health record, up from 16 percent in 2012.

“We are inching closer to, but still short of, the ideal of seamless interoperability. In health care, this refers to the capacity to send and receive a patient’s health information from multiple sources between different systems and locations with its integrity intact,” the report authors wrote. “The information communicated must be useful to the receiving care provider, patients and families, and result in the care decisions that are best for them. Today, interoperability is a partially-achieved aim, working well in some but not all settings.”

The report authors note that the key to leveraging health data’s full potential for improving patient care is the establishment of a framework for compatible technical and linguistic (semantic) standards adopted by all parties that “lead us to a generic, vendor-neutral data exchange platform.” “We currently lack universally agreed upon ways of sharing and using information — “rules-of-the-road” that make possible the uncorrupted transfer of patient data between differing (and often proprietary) health record systems,” the report authors wrote.

Looking at progress made to date, hospitals and health systems have invest hundreds of billions over the past decade in electronic health records (EHRs) and other IT systems that record, store and transfer patient data securely among medical professionals. In 2017 alone, hospitals and health systems invested $62 billion in these IT systems.

According to the Office of the National Coordinator for Health Information Technology (ONC), the vast majority of hospitals use multiple mechanisms to share health information, and more than half must use four or more. Furthermore, most hospitals devote significant resources to manually matching patient records, since we do not have a national patient identifier, the report states.

And, according to 2010 AHA survey data, only 16 percent of hospitals had a basic EHR system in place. By 2017, 97 percent of surveyed hospitals had adopted a certified EHR system.

What’s more, hospitals and health systems have made efforts to link via health information exchanges (HIEs), however, the report notes while HIEs do deliver on some of the promises of interoperability, the exchangeable data is often limited to a regional or statewide scale. “In addition, some HIEs cannot reliably carry out full data exchange within a health system among different source technologies, or data



exchange across health systems including ambulatory or post-acute settings,” the report authors wrote. Also, HIEs may not enable individual patients to access their data.

The report authors also outline the ongoing barriers to comprehensive interoperability. According to an AHA analysis on barriers to health data exchange and interoperability, 63 percent of respondents cited the lack of capable technology as the biggest barrier. That survey also identified difficulties matching or identifying the correct patient between systems also as additional costs to send or receive data with care settings and organizations outside their system as significant interoperability barriers as well.

“Barriers to interoperability must be addressed in order to support the level of electronic sharing of health information needed to provide the best care, engage people in their health, succeed in new models of care, and improve public health. Doing so requires collaboration across many private and public sector entities, including hospitals and health systems, technology companies, payers, consumers, and federal and state governments,” the report authors wrote.

The report also outlines “pathways” to advance interoperability with a particular focus around privacy, security, standards and infrastructure as well as industry stakeholders committing to share best practices and lessons learned.

Among the report’s recommendations, new standards are needed to overcome the significant gaps making communication difficult between systems. “For example, APIs (application programming interfaces), including those based on the FHIR (Fast Healthcare Interoperability Resources) standard, allow for more nimble approaches to accessing needed data. Health care will benefit most from use of standard, secure, non-proprietary APIs that minimize the added costs associated with proprietary solutions and gatekeeping. API access should support both patient access to information from providers and other stakeholders, and the use of trusted third-party tools to support clinical care,” the report authors wrote.

“While we have made much progress, at present, we have the incomplete outline of a national data-sharing system in place, one that lacks the agreed upon rules of the road, conformance, technical standards and standardized implementations to ensure that all HIE platforms can communicate correctly with each other,” the report authors concluded.

The report authors note that true interoperability that advances improved health care and outcomes is within reach with effective federal policies and key stakeholders doing their part. The report calls on health systems to use their procurement power to drive vendors toward compatibility in systems design and lend a voice to the development process.

EHR and IT vendors, in turn, should commit to more field testing and consistent use of standards, the report authors wrote, and avoid pricing models that create a “toll” for information sharing. Vendors also should offer alternatives to expensive, labor-intensive workarounds that drain providers’ time and energy.


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HL7 Model Identifies Clinical Genomics Workflows, Use Cases

January 16, 2019
by David Raths, Contributing Editor
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Domain Analysis Model covers pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics

HL7’s Clinical Genomics Work Group has published an HL7 Domain Analysis Model (DAM) to identify common workflows and use cases to facilitate scalable and interoperable data standards for the breadth of clinical genomics scenarios.

The Domain Analysis Model (DAM), which has underdone a rigorous ISO/ANSI-compatible balloting process, covers a myriad of use cases, including emerging ones such as pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics.

The effort “builds on the DAM Clinical Sequencing work that is already being used to design precision medicine workflows at hospitals across the country,” said Gil Alterovitz, Ph.D., an HL7 Clinical Genomics Work Group co-chair, in a prepared statement. He also serves as a Harvard professor with the Computational Health Informatics Program/Boston Children’s Hospital.

The Clinical Sequencing DAM fueled the design of FHIR Genomics, the subset of HL7’s FHIR standard designed to communicate clinical genomic information. “By extending to broader domains, it can serve as a standard going forward to aid in the design of workflows, exchange formats as well as other areas,” Alterovitz added,

The document presents narrative context and workflow diagrams to guide readers through the stages of each use case and details steps involving the various stakeholders such as patients, health care providers, laboratories and geneticists. This contextual knowledge aids in the development and implementation of software designed to interpret and communicate the relevant results in a clinical computer system, especially a patient's electronic health record.

The HL7 Clinical Genomics Work Group developed several new applications and refinements in the Domain Analysis Model beyond its original scope of clinical sequencing. One notable addition is the analysis of the common workflows for pre-implantation genetic diagnosis (PGD). For those undergoing in-vitro fertilization, advanced pre-implantation genetic screening has become increasingly popular as it avoids the implantation of embryos carrying chromosomal aneuploidies, a common cause of birth defects. Implementers can follow the workflow diagram and see the context for each transfer of information, including the types of tests performed such as blastocyst biopsy and embryo vitrification.

As the clinical utility of proteomics (detecting, quantifying and characterizing proteins) and RNA-sequencing increases, the DAM also outlines clinical and laboratory workflows to capitalize on these emerging technologies.

HL7 notes that future challenges arise from uncertainty about the specific storage location of genomic data, such as a Genomics Archive and Computer/Communication System (GACS), as well as the structure of a patient’s genomic and other omics data for access on demand, both by clinicians and laboratories. Best practices in handling such considerations are being formulated within HL7 and include international input from across the spectrum of stakeholders. In parallel, the HL7 Clinical Genomics Work Group has been preparing an implementation guide for clinical genomics around many of these use cases, to be leveraged alongside the newly published HL7 FHIR Release 4 standard.


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