Last week the Office of the National Coordinator for Health Information Technology issued an important briefing document on health IT in Long-term and Post Acute Care (LTPAC). It details a host of interesting experiments being undertaken around the country to try to make health information available across sites of care in a timely way.
The goal is to improve the health outcomes of Americans and decrease wasteful health care utilization.
For example, in one area, they are trying to create a method for turning the nursing home Minimum Data Set assessment information into an exchangeable data record that can inform the work of providers outside the nursing home. Others are trying to ensure that discharge summaries and late-breaking test results get to providers outside the hospital in time to inform patient care.
This is a big deal because almost half of Medicare beneficiaries are discharged from a hospital transition to another kind of care: home health (in the person's home), skilled care in a nursing home/rehab facility, or hospice.
Moreover, for most people receiving care from those short-term providers, as well as for those released without continuing services, there is a need to share information with family, outpatient physicians, and other service providers who are already involved in their care—especially if the patient is already using home-based or institutional supportive services. These are the people with the highest rates of rehospitalization, for whom better coordination, including health information coordination, must be a top priority.
So while I was interested in the experiments being nurtured by the ONC, I was very sobered by the realization of how incredibly far these Long-Term and Post Acute Care entities have to go. We are all amazed by the fact that outpatient physician and hospital rates of electronic health records are up to the 40 percent range. LTPAC providers are far, far behind (although no one knows exactly because there are no data available) and even more critically, the means of sharing information across providers is virtually non-existent.
Another report based on convening a roundtable of stakeholders last July framed up the health IT issues in the LTPAC sector. The summary of findings included this observation:
LTPAC provider health IT needs should be framed around care teams, including patients, families, and caregivers. When considering health IT for LTPAC care settings, roundtable participants advised ONC to move away from provider-centered models of EHR capabilities and needs assessments. One participant proposed adopting a patient-centered view of health IT: start with LTPAC patients and their goals, then consider the care team needed to support and achieve those goals (i.e., to provide optimal patient care), followed by the data and information needed to support service delivery to the individual by the care team, and finally determine which technologies best meet these information needs. Care teams would include families and other support systems. This approach, participants noted, is flexible and extendable, and helps identify gaps in information needs within and across care settings and providers.
I think this patient-centered approach is the only one that can work. The value of information is only fully realized when it can be shared across time and place and support the work of a team of people caring for frail older adults. This team needs information on all the different services a patient needs—from complex medication plans to direct services such as feeding and bathing and everything in-between.
But the health IT work is very complicated. I've only had time to scratch the surface of what is being considered, but interesting resources can be found on the IHE USA website and on the Longitudinal Coordination of Care site. And while I am personally a technophile, experience has taught me to be a professional techno-skeptic in a world of massive hype, overblown claims, and vaporware. So to cut through all the fancy talk and exciting "entrepreneurial energy," I'd like to suggest some simple bottom-line tests for all the fancy technologies:
1. We will have coordination when all involved providers (medical and supportive services) and designees of patients receive contemporaneous notice when the person goes to the emergency room or hospital. I don't want to hear another primary care provider tell me that he or she only heard about a hospitalization months later when the patient mentioned it in conversation.
2. We will have coordination when the receiving provider (home health, skilled nursing facility, hospice) and the regular physician and regular supportive service agencies receive same-day discharge information when a patient is released from the hospital. Thirty days to receive a discharge summary that may or may not have all the needed information and be legible is just wrong. It may have worked in a simpler era of hospital rounding by community-based physicians and longer hospital stays, but in today's environment it is clearly unacceptable.
3. We will have effective coordination when all agencies, providers, and family members who are part of a care plan have access to that plan of care and efficient communication access to each other. These providers and agencies may not always realize it, but they are on the same team—the person’s team—and part of doing their best for that person is working with their teammates.
Additions? Deletions? A different take? Let us know.