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Managing Transitions of Care, with Results: An Experience in Oklahoma

August 5, 2013
by Mark Hagland
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Brian Yeaman, M.D., CMIO at Norman Regional Health System, has been involved in leading a transitions of care initiative that has shown impressive results to date

Brian Yeaman, M.D., CMIO at Norman Regional Health System in Norman, Oklahoma, has been involved in helping to lead a transitions of care initiative in his area. Dr. Yeaman was named principal investigator, and the Norman Regional Health System was awarded a federal grant called an ONC challenge grant, from the Office of the National Coordinator for Health Information Technology (ONC), to help design new solutions to look at long-term post-acute care management, and transitions between acute care and long-term post-acute care.

Oklahoma was one of four states in which the ONC challenge grants were awarded in this area; the others were Colorado, Maryland, and Massachusetts. The Oklahoma grant amount was $1.7 million, to be applied across two years, but, says Yeaman, “In reality, we have about 18 months” to do the work covered by the grant. The grant to the Norman Regional Health System, under the umbrella entity known as the Oklahoma Health Information Exchange Trust, was awarded in April 2011, and expires on October 1, 2013. HCI Editor-in-Chief Mark Hagland spoke recently with Dr. Yeaman regarding the lessons learned so far in this initiative, and their broader implications. Below are excerpts from that interview.

What have been the core goals and strategies of this initiative?

Long-term care does not have a lot of adoption of any electronic health records. So we implemented a lightweight EHR [electronic health record] for documenting real-time vitals and activities of daily living. And since real-time documentation is a game-changer for long-term care, by creating that lightweight EHR, what that facilitated was our ability to drop in clinical decision support, including stop-and-launch tools that notify the aide, the director of nursing, and the physician director of the facility, that the patient may be changing status, in order to avert an ER visit or hospitalization.

Brian Yeaman, M.D.

Those tools alert caregivers that a patient is deteriorating, right?


When did you go live with the solution?

The system went live in December 2012. It’s in five facilities; they’re all independent of Normal Regional. Some are owned by corporate entities, and some are owned locally. We’re using a solution called CareTracker, from Cerner [the Kansas City-based Cerner Corporation]. It’s a kiosk-driven solution.

So the aide, nurse, or physician enters information at a kiosk?

Yes, essentially, the aide enters the information, and the nurse then can review a status for it that will show highlights on a patient who’s potentially changing conditions, and can apply an early intervention to avert a readmission. And with the additional technology put in, we connected that with the health information exchange. That connection went live in February of this year. And we also implemented DIRECT, so the long-term care facility uses it, and the emergency department secretary and the hospital case manager use it.

So the health information exchange captures structured data, but with the DIRECT appliance, we allow the facilitators of that data to have direct communication. And we also facilitate what’s called an SBAR (situation, background, assessment, and report); typically, it is the nurse in the nursing home doing it; or the case manager, when they’re sending a patient back to the nursing home. They do universal transfer form.

What have some of the results been so far?

So far, we’ve had six months of intervention, with two measurement periods of three months each. We looked at our baseline, pre-intervention, and we’ve shown a 70-percent reduction with the intervention in emergency department visits, in that first 30 days post-discharge.

That’s a fabulous result.

Yes, I never dreamed we’d achieve those numbers; I expected 7 percent. And we’ve seen a 40-percent reduction in 30-day readmissions.


Yes, it’s been impressive.

Why do you think you’ve gotten such good results? Is it the communication involved?

I think two things, primarily: the project design and workflows were very thoughtful in terms of not creating duplicative processes on the part of the nurses or the aides, or the case managers.

In other words, it worked within the workflow of all the caregivers and care managers?

That’s right.

One of the reasons for some of the challenges involved in reducing ED visits and avoidable readmissions is simply because of gaps in communications and handoffs, right?

Absolutely; I would say, gaps in processes, and silos—those are the main obstacles. And there’s so much low-hanging fruit; if we just facilitate better handoffs, it can lead to outstanding results. And our model applies equally to home health, rehabilitation facilities, and skilled nursing. And docs are trained to do what they do, and we can achieve some of those gains without heavy-handed solutions. A lightweight, elegant solution can make a difference. And so the two things that made this work were the design, as I’ve said here; and the other is the ease of the CareTracker within the Cerner EHR and the HIE. And with 15 minutes of training, they’re ready to go with this solution.

What kind of internal team did you have to implement this with?

Myself as the principal investigator; I have a project director; and then I have a physician clinical analyst and a nurse clinical analyst.

What would your advice be for fellow clinical informaticists in this year?

I think primarily that we have to be mindful of the clinical workflow and process, and not overly eager to chase the panacea of big data; and we have to target some of the low-hanging fruit to get real, tangible results today.


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