Enhancing Transitions of Care with Direct Interoperability

By Holly Miller, MD, MBA, FHIMSS, Chief Medical Officer, MedAllies, Inc.; a HIMSS Interoperability Showcase Collaborator

As patients transition across care environments, such as primary care provider to specialist or hospital to home, to receive optimal and efficient care it is essential that their information is interoperable. Direct interoperability, a required communication function in all certified electronic health record technology (CEHRT), allows for critical information to securely flow from one care setting to the next during transitions of care.

Direct interoperability includes the four levels of interoperability:

  1. Foundational: Interconnectivity
  2. Structural: Format syntax and organization of data within the consolidated clinical document architecture (C-CDA)
  3. Semantic: Codified data within the C-CDA that can be readily ingested from the sending EHR into the recipient EHR
  4. Organizational: Governance, policy, social, legal and organizational considerations through DirectTrustTM

The following are four specific use cases of how Direct messaging can be used in transitions of care to move patient information across the healthcare ecosystem. The first three involve provider-to-provider interoperability and the fourth highlights provider-to-patient/caregiver.

In all cases, the use of real-time, pushed Direct interoperability decreases provider burden, transcription errors and cost while enhancing transitional care as well as patient, caregiver, provider and staff satisfaction.

Four Transitions of Care Use Cases

1. Referral Management in Ambulatory Care

Once a primary care provider and patient have agreed that the best next treatment step is a referral to a specialist, the provider sends a Direct message to the selected specialist to perform the consultation. The patient information in the message will include a C-CDA document and additional information relevant to the consultation (e.g., test results, recent encounter notes, etc.). The information in the C-CDA document includes discrete data: patient demographics, the problem list, allergies, medications, and immunizations data. The pushed data is not aggregated; it is the most up-to-date, relevant information from the primary care provider’s EHR.

The specialist’s office staff can then use the discrete data and results included in the C-CDA document to automatically populate a new patient chart in the specialist’s EHR, or to update the patient information if the patient has a record in the specialist’s EHR. The ability of the recipient EHR to ingest this data decreases the documentation burden and eliminates transcription errors.

The patient information can then be verified with the patient at the time of the specialty consultation. The specialist’s receipt of pertinent test results and studies may eliminate duplicate testing, reducing costs as well as the inconvenience and potential pain or dangers to the patient from retesting.

After the specialist has completed an encounter with the patient, the specialty office will push, in real time, a C-CDA document with the results of the consultation to the referring provider. The primary care provider can then update and reconcile any new information into their chart for the patient, thereby keeping the patient’s clinical data and treatment plan current.

This also allows the primary care team to reach out to the patient—particularly in high-risk situations—to ensure the patient participates in defining treatment goals and understands and agrees to their revised care plan. This outreach and engagement with high-risk patients can hopefully prevent adverse events or treatment delays.

2. Acute Discharge Home

After the care team and the patient have established a discharge care plan and the discharging clinician has reconciled the discharge information, the acute care facility will push, via Direct messaging, a C-CDA document. They can also include any additional relevant information for the primary care team. As this action is in real time at discharge, this generally will be prior to the completion of the traditional discharge summary, which, depending on variable state laws, may not be completed for several weeks post discharge. In fact, the Centers for Medicare & Medicaid Services (CMS) mandates communication with the post-acute care service providers at the time of discharge.

The receipt of the C-CDA by the clinicians who will care for the patient next, allows for continuity of care and supports the ability to maintain an accurate transitional care plan during the patient’s most vulnerable time following discharge.

As before, the recipient clinicians can reconcile the patient’s record in their EHR, eliminating the risk of transcription errors while decreasing the burden of entering the data manually.

Receipt and reconciliation of this information also allows the primary care provider’s practice to follow up with high-risk patients within 24 hours of discharge to provide appropriate post-discharge care. Specifically, this follow up helps confirm the patient’s understanding and compliance with the discharge care plan, including their ability to adhere to discharge medications and instructions.

Timely patient follow up can prevent adverse events, particularly adverse drug events which have been shown to occur in approximately 20% of patients discharged from hospital. Such follow up can also avert unnecessary readmissions, a financial incentive that should promote this use case.

3. Acute Discharge and Long-Term Post-Acute Care Exchange Loop

The long-term post-acute care (LTPAC) sector encompasses caring for the most complex patients and requires the most up-to-date digitized information in real time.

Sending and receiving real-time Direct messages saves time and money and enhances patient, caregiver, provider and staff experiences. The most up–to-date discrete data pushed in a C-CDA can be used to create a new patient chart or update information in an existing patient chart, lessening transcription burden while preventing errors. The ability to include additional test and study results avoids the expense of duplicate testing. Several LTPAC EHR market suppliers now encompass these capabilities with user-friendly interfaces.

4. Patient Use

U.S. regulations now mandate patients’ right to access their medical records in the form and format requested by the individual. For patients and their designated caregivers who have Direct accounts, C-CDA documents pushed in real time via Direct interoperability meet this requirement and may help patients follow their care plans.

In all cases, the patient or their designated caregiver must be included in defining the goals and activities of their care plan, and the transitioning provider must ensure that the patient information has been updated and reconciled in the EHR prior to sending the Direct message. Following an interaction, the primary care provider, consulting specialist or discharging physician, updates the patient’s information then sends the information to the patient/caregiver via Direct interoperability.

This provides patients with electronic access to their data, helping to improve patient/provider communication and encouraging patient engagement.

These use cases demonstrate how Direct messaging encourages interoperability, health information exchange and transitional care while decreasing documentation burden, transcription errors and duplicate testing. EHRs that build and enhance their Direct capabilities, configurability, functionality and user interfaces, can make a difference in the lives of patients and providers.

Sponsored content. The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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