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Top Ten Tech Trends: Closing the Gaps in Transitions of Care

January 23, 2015
by Rajiv Leventhal
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Federal mandates are pushing providers to follow patients along the care continuum, but it will take more than just meeting measures to keep patients out of the hospital

The movement of a patient from one setting of care to another—and the electronic documentation of that movement—is vital in accurately being able to tell the patient’s entire story, but has also become an area that providers have struggled with in terms of meeting the transitions of care (TOC) mandate for Stage 2 of meaningful use. 

 A study published last year in Health Affairs that looked at the adoption of electronic health record (EHR) systems in hospitals since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act found this measure to be a major pain point for healthcare organizations trying to attest to Stage 2. Researchers came to the conclusion that “Functions related to electronic data exchange, both with other providers and with patients (in particular, providing summaries of care during transitions and giving patients the ability to view online, download, and transmit their health information) are critical gaps.”

While the transitions of care objective in Stage 1 is optional, the Stage 2 requirement includes three measures, two of which rely solely on the use of Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care and referrals. These TOC summaries are provided each time the patient moves along the care continuum.

There certainly are health systems that have met this measure with varying degrees of ease. In Columbus, Ohio, for example, Mount Carmel Health System became one of the first 30 eligible hospitals to attest to Stage 2 last July. Mount Carmel met the TOC requirement of the program by using CliniSync—the health information exchange (HIE) in Ohio—to assist the health system with the ability to send and receive transitions of care documents with other treating providers, says Jay Wallin, M.D., chief clinical information officer of Mount Carmel. Historically, this kind of health information may not have been sent, and if it were, in many cases would have been faxed or placed in a paper file that would be transported to the doctor on the other end in a much less timely manner. But today, through a national Direct Trust framework, the information is exchanged information electronically through secure, encrypted emails, says Wallin.

Closing the Gaps

For many other health systems, the transition of care challenge has been much greater, and both vendors and policymakers have been work to close the gaps mentioned in the Health Affairs study. To this end, Naomi Levinthal, consultant, research and insights at The Advisory Board Company (Washington, D.C.), points out that since two of the three TOC Stage 2 measures require CEHRT, the Centers for Medicare & Medicaid Services (CMS) has provided some recent relief as of September 2014. “CMS said that as it was gauging folks’ readiness for Stage 2, it was finding that people were unable to get their hands on the certified upgrade that everyone needed to be up and running on in 2014,” says Levinthal, who spends all nearly all of her time in the meaningful use arena. “For some providers, their vendors weren’t certified in the first place for this new criteria that they needed to satisfy; others couldn’t get the technology fully implemented,” she explains. As such, CMS has said that if you find yourself in one of those buckets, it will let you roll back the clock and report on earlier versions of meaningful use measures and objectives from Stage 1 even if you’re supposed to be in Stage 2 in 2014.

Naomi Levinthal

Regarding vendors, Levinthal says that what is required to be built into these systems is pretty rudimentary, but as the industry moves towards Stage 3, that could change. “For example, I don’t have to prove that you looked at the summary of care record if I’m the hospital sending it out to the specialist,” she says. “But I think we will see some evolution as we move towards Stage 3, how we will have to encourage the market to be more actionable with information that is ported from one source to the next.” Levinthal thinks that, based on the Health IT Policy Committee’s recommendations,  some sense of this actionability will be required in Stage 3, including alerts, notifications, and proof that one provider looked at what another provider sent him or her.

More Than Just a Measure

While the policymakers in D.C. and vendors across the country work to help close these gaps, for many patient care organizations, transitions of care has become about more than just checking something off a list, but instead about trying to create a fuller picture of the patient.  To this end, Michael Elley, vice president and CIO of the 477-bed Owensboro Health in Owensboro, Ky., says that continuity of care documents (CCDs) help physicians—even ones not on Owensboro’s Epic system—receive information from other physicians that will inform them if a patient had has a lab test done, for example, which in turn avoids repeat exams, lowering the cost of healthcare. “And if there are levels of care that we can’t provide, but we can send them to Nashville or Louisville, we will do that, and it’s to our benefit,” Elley says.

What’s more, in a broader context, transitions of care ties into readmissions, an area that most hospitals need to improve on (a recent Kaiser Health News report found that, based on a study of Medicare data, 2,610 U.S. hospitals, or fully three-quarters of those subject to the program are being penalized for having too many patients return within a month for additional care). Traditionally, efforts to reduce avoidable readmissions have focused on hospitals, but it is becoming clear that many factors along the care continuum influence readmissions, as statistics find that 42 percent of patients in the acute care setting end up in some sort of a post-acute care setting.

Three years ago, at the University of Rochester Medical Center (URMC) in Rochester, N.Y., leaders at the healthcare organization realized that medical groups were working in silos when it came to readmissions strategies, says Marc Berliant, M.D., associate chair for clinical affairs in the department of medicine at URMC. Eventually, all of the groups were put together, and a program called “Safe Transitions” was formed, designed to reduce hospital readmissions and foster improved communication among care teams, patients and primary care physicians.

Marc Berliant, M.D.

The program was based on three essential principles, Berliant explains: medication reconciliation at the time of admission, time of discharge, and at time of arrival at primary care provider’s office; refined discharge summaries; and following up post-discharge. Berliant admits that it’s difficult to see if these specific elements have moved the needle on readmissions, however. “Our number of patients seen within two days post-discharge is 45 percent, but there reasons why that number will never be 100 percent, nor should it be.  But it’s better than it was, which was probably zero,” Berliant says.

The idea is that following the patient along the care continuum will lead to lowered readmissions, and thus healthier patients and lower costs. This is why, according to Levinthal, it’s important to not let meaningful use become too “checklisty,” which it is for too many organizations right now.  “I think that people are still trying to think about that end game,” she says. “We don’t know when [this program] will sunset, but nobody wins in meaningful use if you don’t figure out ways to make it more meaningful to you and the patient.”


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