Care Coordination (and HIE)

Gilad J. Kuperman, MD, PhDNewYork-Presbyterian Hospital

Columbia University – Biomedical Informatics10/1/2013

Motivation for care coordination

Changes in the payment system– Quality rather than quantity– Non-payment for readmission / hospital

acquired conditions– Differential payments for patient satisfaction

Risks shifting to providersProviders have increased financial incentives for efficiency and effectiveness

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Caveat

• “Care coordination” means different things to different people

• Potential for misunderstanding• Confusion when conceiving IT solutions• As always, IT supports a business goal

– Need to understand the goal– Need to understand non-IT aspects of the

program

Approaches to care coordination

• Improve efficiency within a particular setting of care, e.g., hospital stays– Order sets, care pathways, utilization management, etc.

• Manage a population, by segment– Healthy people – keep them healthy– Routine chronic disease – monitor, health promotion– Exacerbations – treat, get back to routine state– Fragile, high utilizers – specialized programs to manage

aggressivelyConsiderations:

Needed to identify who is in a particular segmentPatients move among the segmentsDifferent tools needed to manage each segmentThe sicker the patient, the more individualized the care

Approaches to care coordination

• Manage transitions to lower acute care settings– To improve efficiency and effectiveness at

new setting– To reduce risk of bounce-back to higher level

of care• Improve the referral process

– Transfer of information– “Closing the loop”

• Mix, match, others, etc.

IT features to support PCMH

• Remote telehealth interactions• Measurement of quality and efficiency• Support for care transitions• Personal health records• Registries• Support for team care• Clinical decision support

Bates, Health Affairs, 2010 6

Note: Few of these in current EHRs

Does the current generation of EHRs support care coordination?

• 60 subjects (52 MDs/staff, 4 EHR vendors, 4 national leaders)

• EHR facilitates in-office coordination– Data access, messaging

• Does not support coordination between settings– Not designed to do so; key data elements not standardized

• Current version of EHRs support billable events, not care coordination

• EHR complicates information management– Create data overload

• Does not support decision-making or future care planning• To support care coordination, EHRs require re-design

O’Malley, JGIM, 2010 7

Construct Sample item1. Coordinated within care team

In the past 6 months, how often did your doctor or staff in your doctor’s office ask you about medicines you were prescribed by other doctors?

2. Coordinated across care teams

In general, do you think the doctors that you communicate with to each other about your care?

3. Coordinated between care teams and community resources

Did your doctor or staff in your doctor’s office talk to you about resources available in your neighborhood to support you in managing your health conditions?

4. Continuous familiarity with patient over time

How often do you think other health care providers at your doctor’s clinic really understood all of your important medical information?

5. Continuous proactive and responsive action between visits

In the past 6 months, has your doctor or staff in your doctor’s office contacted you to ask about your condition?

6. Patient centered  Thinking back about the care you received in the past 6 months, how often do you think your doctor understood the things that really matter to you about your health care?

7. Shared responsibility In the past 6 months, did you ever leave your doctor’s office confused about what to do next to manage your health conditions?

Framework for Measuring Integrated Patient Care

Singer, et al.  Medical Care Research and Review, 20118

Care Transition Measures• Now part of Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS)• 3 questions

– During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left

– When I left the hospital, I clearly understood the purpose for taking each of my medications

– When I left the hospital, I had a good understanding of the things I was responsible for in managing my health

• Affiliations– Two medical

schools / faculty practices

– Community providers

• Owned Ambulatory Care Network– 14 PCMH locations– 50 sub-specialties

• NY State-designated health home– Creates

partnerships with CM, SA, MH, etc., organizations

• Participant in regional health information exchange

NewYork-Presbyterian Hospital (NYP)

RHIO in NYC metro area

NYP HIE framework

• Faculty practices– Dedicated interfaces

• Ambulatory Care Network– Part of core systems

• Affiliated ambulatory providers – Dedicated interfaces – Connectivity via RHIO

• Other (nursing homes, home health, case management agencies, etc.)– RHIO

Tighter business partners

Looserbusiness partners

IT principles for care coordination -- NYP1 Data access, 

across EHRs (HIE)(i) Pull vs. push, (ii) structured or unstructured, (iii) how tightly integrated into users EHR

2 Care plan (explicit game plan; inpatient / outpatient)

Who creates it?  Who has access to it?  Who can update it?  How is it (i) viewed and (ii) updated (i.e., in a separate system or in the EHR)?  (How) are changes to the care plan communicated to other relevant providers?

3 Care team(s) How created?  How updated?  How to deal with non‐NYP providers?

4 Messaging Do business partners already have messaging capabilities as part of their EHRs? How to integrate multiple messaging platforms?  

5 Analytics Need to be able to analyze clinical data, encounters, outcomes, costs; Need to integrate across disparate systems

6 Patient engagement

Patient needs to (i) see data, (ii) receive system‐generated message (“time for your appointment”), (iii) be educated 

7 Specialized workflow tools

Task management, specialized charting, etc., (EHR?)

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Improving care for depressed diabetics

• NYSDOH-funded project at NYP– Pts w/ chronic disease and MH co-morbidities

• Three components– IT (certified EHRs + HIE)– Workflow redesign– Data collection and feedback

• Stakeholders along with NYP– ACN primary providers and psychiatrists– ColumbiaDoctors psychiatrists– Affiliated ambulatory physicians– Nursing homes and home health– Healthix

Key features of NYP model• Builds on PCMH model (team based care, “huddles”, etc.)• Standardized care for depressed diabetics

– Screening for depression– Regular symptom monitoring

• Education of primary providers about depressed diabetics– Context; risk factors, screening, diagnosis; choice of initial

treatment; choice of a drug, including management and side effects; special situations, e.g., geriatrics; working as a team, e.g., with social workers and psychiatrists; use of the IT tools, including a registry, quality reports, etc.

• Involvement of non–NYP providers• Patient engagement

– Education, cultural competency• Use of IT (see next slide)

IT features of the model1. EHR-based tools

– Structured documentation for screening and monitoring– Alerts and reminders for screening and monitoring– Patient summary screens– Daily schedule view

2. Registry – To support patient follow-up

3. Analytics– Population management reports

4. PHR– Patient education (English and Spanish)

5. EHRs for community providers6. Interoperability

– Data to/from RHIO– Support specific workflows, e.g., transitions to SNF,

home health

The PHQ-9 questions will be collapsed until the user chooses to expand them.

Once all the answers are documented, the overall score is calculated automatically.

PHQ-2 and PHQ-9 Documentation: Flowsheets

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Enhancem

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Patient summary screen

Daily schedule view

• Improve workflow prior to patient’s visit by presenting the primary care team with details regarding the patient’s upcoming visit and needs (i.e. scheduled provider, diagnosis, tasks, key results).

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Clinical decision support / workflow• Flowsheets / documents

– Positive PHQ-2: user alerted to enter PHQ-9– PHQ-9 ≥ 20 or (+) question #9 (suicidality screen)

Remind MA to notify provider / provider alerted• Patient summary / schedule view

– PHQ-2 overdue– PHQ-9 / Repeat PHQ-9 overdue

• Inbox– Secure health messaging: Primary Provider notified when

patients are admitted/discharged to/from the ED or Inpatient

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Enhancem

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Registry and PHR

• Registry– Patients who meet certain criteria but have not had

timely follow-up with a care provider• PHR -- myNYP.org

– Culturally competent patient education tools for diabetes and depression

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egistry and PH

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DRAFT population management reports

Ability to access RHIO data for the patient from within EHR

Evaluation framework1. Demographics

– Total clinic population, # diabetics, # depressed, # with both– Age, gender, co-morbidities

2. Inpatient utilization – Admissions, re-admissions, ED visits

3. Ambulatory utilization– # total visits / # mental health visits – # missed appointments

4. Screening effectiveness – # non-depressed diabetics screened in previous 12 months– # screened positive who had follow-up symptom assessement (PHQ-9)

5. Monitoring effectiveness– # depressed patients who have regular PHQ-9s

6. Team-based measures– Who is writing notes

7. Outcome measures – HbA1c measures– depression remission at 6 months?– depression remission at 12 months?

8. IT process measures– # of screening / monitoring alerts– Use of registry– # of patients who create a PHR account and use that account

Status

• Interventions implemented in early 2013• Currently in “late burn-in” period

Observation

• None of the components is exotic• Goal is to assemble the appropriate

suite of capabilities along with the complementary workflow

Care coordination -- Challenges• Agreeing on workflow changes• Agreeing on quality measures• Operationalizing quality measures• Implementing HIE-related workflows

– Transfer to / from SNF and home health• What info, what workflow, what technology

• Creating “work lists” from registries– Integrating work list documentation with EHR documentation– Risk stratification algorithms; who needs follow-up?

• PHR signup and use• Etc.

Summary• Many opportunities to improve the efficiency and

effectiveness of care• Collectively, these are called “care coordination”,

but the term is not used consistently• IT is necessary but not sufficient for care

coordination• Key challenges are knitting together IT capabilities

that exist, integrating them with desired workflow, and creating new IT to support the interstitium

• Certified EHRs are not enough– Will they expand to meet the need or will wraparound

services be developed?