Download Laying a Foundation for Care Coordination

About eHealth Initiative
eHealth Initiative (eHI) is a Washington D.C.-based, independent, non-profit organization whose
mission is to drive improvements in the quality, safety, and efficient of healthcare through
information and information technology. eHI is the only national organization that represents all
of the stakeholders in the healthcare industry. Working with its membership, eHI advocates for
the use of health IT that is practical, sustainable and addresses stakeholder needs, particularly
those of patients.
Care Coordination Council
The Care Coordination Council (Council) is a multi-stakeholder group representative of eHI
membership and focused on assessing the necessary health information technology
infrastructure required to facilitate care coordination, in an effort to improve the quality, safety,
and efficiency of healthcare.
Purpose
The report aims to inform the field of healthcare by identifying select elements of the care
coordination process and making recommendations for how the public and private sectors can
help to build and utilize a robust health information technology (health IT) infrastructure to
support the needs of care coordination.
Formation of the Document
The report was developed through a multi-stakeholder, consensus process. The Council met over
the course of 8 months to discuss key themes in care coordination that can be facilitated
through effective use of health information technology. This document is a summary and
synthesis of the information discussed in these meetings with recommendations for policy and
practice. The report is informed by case studies of care coordination communities, inclusive of
Beacon Community Programs, the JWCH Institute Inc., Montefiore Medical Center, Oregon
Health Plan, and the Louisiana Coordinated System of Care.
Intended Audiences
The document is intended to be used by a diverse group of stakeholders who are improving
healthcare through the use of health IT. This includes, but is not limited to: clinicians, consumer
and patient groups, employers and healthcare purchasers, health plans, health information
technology suppliers, hospitals and other entities, laboratories, pharmaceutical and medical
device manufacturers, pharmacies, public health agencies, quality improvement organizations,
standards groups, and state, regional and community-based organizations.
Acknowledgements
The eHealth Initiative would like to acknowledge and extend thanks to the two Co-Chairs of the
Care Coordination Council: Joe Heyman, MD Chair, National Physician Advisory Board
OptumInsight and Eva Powell, MSW, of the National Partnership for Women and Families for
their invaluable contributions and dedication in the creation of this report. Additionally, the
eHealth Initiative would also like to thank the following individuals for their active participation in
this council and overall contributions to the report.
Brian Ahier
Gorge Health Connect, Inc.
Kurt Andrews
Point-of-Care Partners, LLC
Bob Bailey
RTI International
Lora Baker
NextGen Information Services, Inc.
Jeanette Ball
HEALTHeLINK
Alison Banger
RTI International
Leon Q. Barzin
Massachusetts Medical Society
Jim Bettendorf
Gateway EDI, LLC.
Carol Bickford
American Nurses Association, Inc.
Yvette Bolla
American Nurses Association, Inc.
Nick Bonvino
Health Information Exchange of Southern Illinois
Alice Borrelli
Intel Corporation
Amber Brockington
Accenture
Kelly Broder
Surescripts
Bob Brown
Mosaica Partners, LLC
Camilla Hull Brown
Strategies for Tomorrow, Inc.
Mary Brubaker
Healthcare Strategies, Inc. (HQSI)
Corette Byrd
American College of Physicians
Julie Cantor-Weinberg
American College of Pathologists
Jay Chen
ConfiHealth Solutions
Peter Cizik
BridgeFront
Tom Crawford
InterComponentWare AG (ICW)
Tina Cullins
OptumInsight
Patti Dodgen
Hielix
Ralph Donaldson
PRISM Health Services
Jaime Estrada
Health Information Network of Arizona
Liza Fox-Wylie
Colorado Regional Health Information Exchange
Angela Franklin
American College of Emergency Physicians
Rich French
Covisint
Donald George
PRISM Health Services
Rebecca Goldberg
BluePrint Healthcare IT
Lisa Grabert
American Heart Association, Inc.
Eric Grahm
Availity LLC
Chris Gray
AT&T
Jim Hansen
Dossia Consortium
Robert Haskell
Siemens Corporation
Stephanie Hernandez
Planned Parenthood Federation of America
Brandi Herndon
Greenway Medical Technologies, Inc.
Gloria Hitchcock
Greater Rochester RHIO
Chris Hobson
Orion Health
Rick Holdren
HCA Holdings Inc.
Diane Humerick
Smartronix, Inc.
Joyce Hunter
Vulcan Enterprises, LLC.
Debbie Josephson
Arkansas Foundation for Medical Care
Eric Juhl
National Association of Chain Drug Stores, Inc.
Mike Kappel
McKesson Corporation
Gleen Keet
Axolotl Corporation
Leslie Kelly Hall
Healthwise, Inc.
Hannah King
Michiana Health Information Network
Janhavi Kirtane,
Beacon Community Program Office, within the Office of the National Coordinator for HIT
Eric Klos
Cogon Systems, Inc.
Laura Kolkman
Mosaica Partners, LLC
Madeleine Konig
American Heart Association, Inc.
Christopher Kunney
AT&T
Ken LaBresh
RTI International
Cheri Lattimer
Case Management Society of American and National Transitions of Care Coalition
Len Litchtenfeld
American Cancer Society, Inc.
Sandra Lillie
InterComponentWare AG (ICW)
Swati Lotilkar-Kamath
Healthcare Quality Strategies, Inc.
Peter Loupos
Sanofi Aventis, LLC
Barbara Lund
Massachusetts eHealth Collaborative, Inc.
Chatherine Macpherson
WebMD, LLC
Kat Mahan
TNS, Inc.
Martin Margolies
Healthcare Quality Strategies, Inc.
Beki Marshall
American Academy of Pediatrics
Ginny Meadows
McKesson Corporation
Suzanne Mintz
National Family Caregivers Association
Jill Mulligan
Surescripts
David Nace
Mckesson Corporation
Neal Neuberger
RCHN Community Health
Lori Nichols
HInet
Claudia O’Connell
Planned Parenthood Federation of America
Kim Pemble
Wisconsin Health Information Exchange
Deanna Peters
eHealth Global Technologies, Inc.
Dr. Illeana Pina
Montefiore Medical Center
Dan Porreca
HEALTHeLINK
Anne Marie Priddy
Coastal Connect HIE
Edith Rosato
National Association of Chain Drug Stores, Inc.
Ken Rosenfeld
eHealth Global Technologies, Inc.
Sara Samaha
Partners HealthCare Systems
Liplka Samal
Partners HealthCare Systems
Sandra Schafer
Holon Solutions
Craig Schneider
Massachusetts Health Data Consortium
Elizabeth Schofiled
Siemens Corporation
Ray Scott
OptumInsight
Aaron Seib
Cal eConnect, Inc.
Lisa Smaga
Hielix
Cheryl Stephens
Community Health Information Collaborative
John Tempesco
InterComponentWare, Inc.
William Underwood
American College of Physicians
Roger Van Brussel
InterComponentWare AG (ICW)
Adam Vincent
RTI International, Inc.
Lynn A. Volk
Partners Healthcare Systems
Thomas Waller
InterComponentWare AG (ICW)
Chantal Worzala
American Hospital Association
Mathhew Wynia
American Medical Association
Special thanks go to Danielle J. Brooks, JD, for her leadership role within this Council and for
managing the writing and editing; and to Jonathan Dimsdale, MPH, Diane Jones, JD, Alex
Kontur, Katinka Canning, Katie Reidy, Stephanie Zimmerman, Brian Collins, Alexander
Seabrook, Jr., and Jason Goldwater, MA, MPA for their assistance in editing the final report. The
eHealth Initiative would also like to recognize the efforts of the team at the Beacon Community
Program Office, within the Office of the National Coordinator for HIT and Beacon Community
Grantees, as well as the staff of the Louisiana Coordinated System of Care and Montefiore
Medical Center for their contributions to the document. i
i
"The views expressed in this report do not necessarily reflect the policies of the organizations with which the individuals
listed above are affiliated."
Table of Contents
Executive Summary ...................................................................................................................................................................................... 1
Overview of Care Coordination ............................................................................................................................................................. 4
Section I. Key Principles to Guide the Use of Health IT in Care Coordination ................................................ 7
Section II: Key components and functionality necessary to support care coordination ....................... 12
Information Sharing ............................................................................................................................................................................... 12
Team Based Care: Including Patient-Center Care .......................................................................................................... 16
Care Plans ....................................................................................................................................................................................................... 20
Organization of Information and Services ............................................................................................................................ 24
Recommendations ........................................................................................................................................................................................ 26
Case Studies ...................................................................................................................................................................................................... 30
Glossary ................................................................................................................................................................................................................ 52
Resources ............................................................................................................................................................................................................ 68
Executive Summary:
The United States healthcare system is in the midst of a paradigm shift,
transitioning away from a fragmented system in which services are delivered
through multiple providers with limited collaboration, towards a model that
emphasizes shared accountability and continuity of quality, patient-centered care. A
critical component of this transformation is care coordination, which requires
effective and consistent collaboration among providers and organizations caring for
the individual patient.
Care coordination, a process that ensures that the patient’s needs and preferences
for health services and information sharing across people, functions, and sites are
met over time, is primarily accomplished by people, and is not a technological
function. By definition, care coordination is complex and must respond to the needs
of individual patients. Health Information Technology (health IT) can be a useful
tool to facilitate improved care coordination, as the utilization of electronic health
records (EHRs) and health information exchange (HIE)ii can provide for the
capturing, access to and sharing of real-time patient data among those caring for
the patient.
This document describes a vision for how health IT can and should support care
coordination, as well as the qualities and functions necessary to achieve that vision.
The Council decided to focus on specific key principles and components in order to
limit the scope of this document. To accomplish this goal, the document includes:
•
A set of unified principles that should be considered in the implementation of
health IT to ensure its effectiveness in supporting care coordination.
•
Four key components of effective care coordination requiring the support of
health IT.
o Information Sharing
o Team Based Care: Including Patient-Centered Care
o Care Plans
o Organization of Information and Services
In support of these areas of focus, the document considers the experiences of
several Beacon Community Programs, inclusive of a statement from the Office of
the National Coordinator, and the Greater Cincinnati, Western New York,
Southeastern Michigan, Rhode Island, MyHealth Access, Colorado, and Inland
Northwest Beacon Communities. In addition, the Montefiore Medical Center, JWCH
Institute Inc., the Louisiana Coordinated System of Care, and the Oregon Health
ii
For the purposes of this section, health information exchange (HIE) refers to the process rather than the
entity.
1
Plan are featured as examples of successful care coordination activities and
initiatives. These case studies highlight experiences and lessons learned from those
working to implement health IT supported care coordination.
Overall, the report outlines multiple recommendations for the use of health
information technology to facilitate care coordination.
The Council recognizes that relatively few organizations and individuals involved in
care coordination activities today possess robust health IT systems capable of
carrying out all of the functions recommended in this report. Yet, with rapid
evolution of these systems now taking place, we see tremendous opportunity in
providing timely guidance on key principles and components to incorporate into
health IT systems as they evolve to facilitate and improve care coordination.
Listed below are the critical functions identified by the council as being necessary in
order to facilitate the components of care coordination highlighted in this paper.
•
•
•
•
•
•
•
•
•
•
Capturing, accessing and sharing of real-time patient data among those
caring for the patient.
Enabling verification of the accuracy of patient-entered data.
Allowing for flexibility that accommodates various workflow processes and
environmental factors like workload, staff schedules, and patient load.
Facilitating seamless interoperability with evidence-based care management
strategies that support efficient and effective integration of patient
information, laboratory, imaging, therapy, referrals, medications, social and
community services, and self-management assistance, including patient
registries and population-based data.
Alerting the care team of tests and services coordinated within the healthcare
plan.
Facilitating bi-directional communication among professional care team
members and the patient.
Facilitating linkages consistent with applicable state and federal privacy
standards that are outside the traditional healthcare system and are
necessary to meet a patient’s clinical and psychosocial needs (involving social
services, mental health, school systems, etc.).
Facilitating quality improvement and safety; disease management; utilizing
clinical decision support system (CDSS) tools; provider alerts and patient
reminders.
Providing a continuous information flow and feedback loop between a patient
and his or her care team.
Supporting the creation and execution and updating of a care plan that can
be shared across the continuum of care and with the patient and their family,
caregiver, and/or paid health aide.
2
•
•
•
•
•
•
Facilitating decision-making and planning for transitions of care.
Presenting a master care plan that is longitudinal and comprehensive, with
various sub-plans that provide more specific, targeted information.
Presenting information in the most meaningful and actionable manner for the
end user.
Allowing for use of customized tools to synthesize and analyze information
for specific purposes.
Integrating and using information generated as part of the process of care.
Capturing critical information, tracking patient education and selfmanagement support, and community and non-clinical services necessary to
support the patient and his or her caregiver’s needs and preferences.
Significant evolution in the marketplace is necessary to achieve the widespread
availability of the functionalities described above. The Council identified several
concrete steps that can be taken now or in the near future that will advance the
capability of electronic health information systems to support better coordination of
care. This is not intended as an exhaustive list, but rather as a starting place for
focused effort by policy makers, industry representatives and others.
•
•
•
•
•
Identify a starter set of role-based views for presenting data necessary for
care coordination.
Identify professional groups that are often excluded from EHR/HIE
implementation who will be critical for care coordination and engage
professional societies or other organizations representing these groups in
future discussions about improving care coordination using health IT.
Identify prevention goals from Healthy People 2020 that can especially
benefit from health IT and prioritize their integration into health IT enabled
care coordination.
Identify vocabulary and data transfer standards necessary for the
functionalities above, with particular attention to incorporation of patient
contributed data into the EHR.
Identify and spread best practices for making linkages with community
supports.
3
Overview of Care Coordination
There is widespread agreement that care coordination is essential to improving the
quality and reducing the cost of healthcare in the United States. Yet achieving
coordinated care is extraordinarily difficult, partly because “care coordination” is a
highly complex process, without a standard definition.
Many concepts, models and tools are used to describe
“This document calls out
who is responsible, who
approaches for achieving the outcome of better
needs to know what specific
coordinated care, including: care collaboration,
information, and who is
teamwork, continuity of care, disease management,
acting upon this
information. Accountable
case management, care management, Chronic Care
care organizational models,
Model, and care or patient navigator.1 For the purposes
patient centered medical
homes, and health homes
of this document, care coordination will be defined as
are trying to replicate these
“the deliberate organization of patient care among two
care coordination
principles. People will need
or more participants, inclusive of the patient, to facilitate
to invest in electronic tools
the appropriate delivery of healthcare services. Care
to become active and
coordination involves the organization of people and
effective in using available
information.”
other resources necessary to carry out all required
patient care activities, and is managed by the exchange
- Claudia O’Connell Director
of information among participants responsible for
Affiliate Technology
different aspects of care”.2
Initiatives at Planned
Parenthood Federation of
America
The importance of care coordination was recognized in
the Patient Protection and Affordable Care Act (PPACA)
in multiple ways.3 Most importantly, PPACA charged the Department of Health and
Human Services (HHS) with developing a National Quality Strategy (NQS) to align
and focus public and private efforts to improve the effectiveness, safety, and
affordability of healthcare in our nation. Care coordination is one of six priorities
being advanced as part of the NQS. PPACA also provided for several programs and
initiatives to advance care coordination. These initiatives were developed and
continue to be advanced based on models for improving care coordination,4 such
as:
• The Medicare Community-Based Care Transitions Program
• Incentives to reduce Medicare hospital readmissions
• The Medicare Independence at Home demonstration
• Medical Home models in Medicare and Medicaid
• Federally Qualified Health Center Advanced Primary Care Practice (FQHC
APCP) demonstration project
• The Medicare Shared Savings program.5
In addition to the Federal efforts to advance care coordination, numerous private
sector efforts have focused on this critical issue. Of particular note is the multi-
4
stakeholder, consensus-based work of the National Quality Forum (NQF), which
endorsed a definition and framework for care coordination in May 2006 and a
portfolio of care coordination preferred practices and performance measures in
2010.6 Most recently, under contract with HHS, NQF has convened a Care
Coordination Steering Committee which will develop a pathway toward
implementation of emerging care coordination measures, including electronic
capabilities and feasibility to support care coordination and quality measures. Since
one of the primary expectations of health IT is that it will support a more robust
and less labor intensive quality measurement process, it will not only need to
support specific functions related to care coordination, but also quality metrics
related to those functions and the ultimate outcome of better coordinated care.
The framework endorsed by NQF in 2006 identified five domains in the process of
care coordination: 1) Healthcare home; 2) Proactive plan of care and follow-up; 3)
Communication; 4) Information systems; and 5) Transitions. Health IT clearly has
a tremendous role to play in each of these domains, specifically related to the
availability of information to the right people, in the right format, and at the right
time. Health IT can facilitate bi-directional communication between the healthcare
provider and the patient and could enable a longitudinal view of care that would
otherwise be impossible with a paper record.
While care coordination is fundamentally a “people centric” enterprise, health IT
plays a critical role in this process. Various forms of health IT, such as EHRs,
messaging, alert systems, biometric, and telemonitoring devices can be useful to
deliver and analyze data when and where it is needed to support the care
coordination process.7 However, to ensure that health IT delivers on its promise
with regard to care coordination, much work must be done to identify the specific
ways that health IT can and should support the care coordination process.
Health IT is a valuable tool that has the potential to radically improve the
collaborative efforts of multiple care team actors across the continuum of care.
These actors include, but are not limited to: patients and their caregivers, paid
home aides, primary care physicians, physician assistants (PAs), nurses, ancillary
staff such as physical therapists and social workers, mental health professionals,
pharmacists, case managers, insurers, specialists and diagnosticians among others.
Because patients may have multiple conditions and diverse needs that require them
to seek care at different healthcare organizations and care settings, clinical and
preventive care must be coordinated between care teams across time and care
setting to provide the best long-term outcomes. Patients, caregivers, and paid
home healthcare aides, who have not been traditionally considered integral to
healthcare delivery, require support and assistance to fulfill their roles as members
of the care team. Community-based organizations play a critical role in providing
5
support for many patients and their caregivers, and must become part of the
process of coordinating care as well. The effective use of health IT can help ensure
that each actor across care settings and locations has the patient information that
they need to provide well-coordinated care.
While coordinated care is an outcome that should be pursued for all patients, it is
particularly important for the safety and effectiveness of care during transitions
between care settings and for patients who are
chronically ill. It is estimated that 145 million
"While I am convinced absolutely
people in the United States suffer from at least
that health information technology
one chronic healthcare condition.8 In the course
can improve care coordination -much more is needed -- and it
of a year, a patient with a chronic condition may
could be so simple. More important
visit multiple healthcare providers and healthcare
than any technology is a caring
organizations. Without using modern technology
individual who takes ownership of
the process. An essential
to manage, organize and share information
improvement would be the
during transitions between healthcare locations,
elimination of territoriality, passiveaggressive behavior and
healthcare providers, and/or different levels of
selfishness. I cannot
care, there is a high likelihood that patient needs
overemphasize how important it is
will go unmet and resources will be wasted.
that an individual (rather than a
team of people) cares enough to
Unplanned readmissions are attributed to
take charge. Patients and
inability to have appropriate follow-up care,
caregivers need to know that there
is a caring person they can count
including medical follow-up visits and medication
on when it is Friday evening and
adherence. Likewise, less than desirable
things are going wrong."
outcomes in cost and quality are more likely
- Joe Heyman, MD Chair, National
when modern technological solutions are not
Physician Advisory Board
used to deliver the most appropriate and
OptumInsight
effective care to patients who have chronic – or
multiple chronic – illnesses. By using technology to arrange and schedule services,
facilitate communication among multiple healthcare providers, monitor changes and
help patients and their families’ access and negotiate complex delivery systems, we
can begin to address some of the barriers we face in improving the quality of care
while also slowing cost growth.9
As we begin to pay for the quality of healthcare, instead of quantity of services, the
ability to measure and evaluate quality as part of the process of care will be crucial.
Effective quality outcome and process measures will need to be further researched
and developed to allow for an accurate assessment of care coordination. As health
IT is developed, adopted and implemented, it is critical that systems are designed
to incorporate current quality metrics as well as generate information needed for
the more robust quality metrics of the future.10 While current performance
measures generally target dimensions of care within a system, the development of
6
comprehensive longitudinal measures will be crucial to measure the degree to
which care was coordinated over time as an important dimension of quality.11
Key Principles to Guide the Use of Health IT in Care Coordination
The following set of principles should be incorporated into the implementation of
health IT to ensure its effectiveness in supporting care coordination. These
principles are intended to be used as a unified set, and together they act as a
foundation upon which the key components of functionality necessary to support
care coordination should be built.
1. Information should be accessible.
All people involved in the care of the individual – including the patient, family,
caregivers and paid health aides – must have access to the information essential
to effectively perform their individual roles in coordinating care. Patients and
their caregivers, as members of the care team, need to have access to their own
health information. The information should be presented in a manner that is
easily understood and used. Information presented should be able to be used in
self-management electronic health tools (eTools).
Likewise, clinicians need comprehensive, accurate, and meaningful information
to work with their patients in planning and executing individualized patient care
plans. Defining specific roles and responsibilities for individual care team
members in carrying out the care plan is essential in facilitating this process.
2. Technology should facilitate trust.
Technology should be employed in ways that promote trust in electronic
information by all relevant stakeholders. The principle of trust primarily applies
to two important issues within the context of care coordination: 1) patient trust
that their information is used appropriately and kept confidentially and secure
and 2) care team member trust that the information that they are able to access
is accurate and complete. Survey data shows that lack of trust inhibits the
sharing of information, which is fundamental to the process of care
coordination.12 With regard to patient trust in the confidentiality and security of
their information, role-based access to the minimum necessary information,
consent management, data encryption, and the development of audit logs are all
technological strategies that should be part of a comprehensive approach to
protecting patient’s privacy and security. This functionality enables the sharing
of information among care team members who both require and are authorized
to have specified data. Likewise, these functionalities inhibit the access of data
7
by care team members that are not authorized to receive the information.
Fostering trust in the accuracy and completeness of information will require the
standardization of vocabularies and data transfer, and likely will require
relationship building and negotiation among clinicians and healthcare
organizations on the local level who contribute to the care of common patients.
It is also likely that some method of identifying the source of various pieces of
information is a necessary component of trust from the provider perspective,
especially as patients and their caregivers become more frequently used data
sources through the evolution of patient portals, personal health records
(PHRs), mobile applications and other technology solutions of the future.
Continuous information flow and feedback loops between patients and their care
teams are often lacking, but these are essential elements of effective care
coordination. Currently, patient-generated information is not always trusted by
providers for a variety of reasons, including a historically paternalistic medical
culture and concerns about liability for reliance on patient-entered data.13iii
Implementing standardized approaches and formats to collect this information,
as well as enabling methods of verifying the accuracy of the patient-entered
data into clinical workflows may help with the cultural transformation necessary.
3. Information should be actionable, timely, and capable of being
customized.
Information is not helpful - and can diminish safety and result in inappropriate
care - if it is excessive, incomprehensible, and difficult to manage. Technology
should be used to present information in ways that are easily understood and
synthesized, enabling the user to determine appropriate actions. Decisions in
healthcare are often extremely time-sensitive, thus the timeliness of information
availability is a critical benefit to leverage from technological solutions. While it
is critical to have standard formats for representing pieces of information
electronically, health IT must enable the information to be presented in the most
meaningful and actionable manner for the end user.
One way to make information more actionable is through enabling eTools that
synthesize and analyze information for specific purposes. eTools should be
available to patients and their care team members for purposes of clinical
decision-making, performance assessment and improvement, self-management,
and tracking and follow-up. They should integrate data, inclusive of quality
iii There is a distinction between patient-entered data that flows from a home device, requiring the patient to
affirmatively share the data with the provider, and data manually entered or derived from patient
observation. The former is likely to be more trusted, but actual “patient-entered” data is critical to providing
a more complete and patient-centered picture of the impact various elements of his or her care are having on
overall health and well-being.
8
measurements, into the workflow and use information generated as part of the
process of care, rather than requiring additional collection or manipulation of
data.
4. Technology should support the patient and caregiver relationship.
The relationship between patient and clinician or caregiver is paramount, and
should be supported and strengthened through the use of health IT, not
degraded by it. Health IT will never replace people as being the most important
element of the care process; rather eTools can and should be employed to
support the relationship between patients, caregivers, and care team members.
Health IT should be used to enhance care team members’ knowledge of the
“whole person” by soliciting and integrating critical information that can only be
provided by the patient. Health IT also should be used to facilitate multidirectional communication between patients and their caregivers and other care
team members. Health IT can help to reduce the administrative burden of the
collection of patient generated data, like patient and family history and
insurance information, to reserve time spent in the provider setting for more
effective and care specific communication.
5. A proactive and personalized plan of care is central to effective care
coordination.
Health IT and eTools must support the creation and execution of individualized
care plans that can be shared across the continuum of care, including with
patients, their caregivers and paid home aides. Structured and effective
information technology must be in place to document critical information, track
and initiate follow-up care procedures, provide patient education and selfmanagement support, and enable community and non-clinical services
necessary to support the patient and his or her caregiver’s needs and
preferences.
6. Successful care coordination requires numerous linkages throughout
the healthcare system, as well as to non-health related community
support systems.
In many cases, proactive plans of care will involve numerous care team
members across various settings of care, such as primary care, specialists,
rehabilitation, and other health and wellness facilities. Additionally, many
patients have specific support needs for effective self-management, particularly
once they are no longer actively interacting with the healthcare system.
Resources that meet patient and caregiver self-management needs may or may
not be a part of what is traditionally thought of as the healthcare system (e.g.
social services, nutritional supports, transportation, mental health, school
9
systems, etc.) Health IT should facilitate the linkages necessary to meet a
patient’s clinical and psychosocial needs such that they achieve the best
outcomes and sustain the highest degree of wellness possible for an individual.
These linkages are particularly critical during care transitions, when many needs
fall through the cracks, resulting in gaps in care, safety issues, and ultimately
poorer outcomes and increased costs to the healthcare system. Health
information exchange holds promise for helping to bridge some of these gaps.
Linkages between traditional and nontraditional healthcare organizations must
follow state and federal privacy laws and strive to promote trust in healthcare
(See Principle 2)
7. Technology should create efficiencies in clinical workflow.
One benefit of health IT, when implemented well, is the creation of efficiencies
in the clinical workflow that are not possible in a paper record environment.
Workflows across the continuum of care must connect at key points in time in
order to facilitate more appropriate and better coordinated care, rather than
“less” care. Not all workflows are in support of coordinated care and will often
need to be re-worked or replaced with new and more efficient models. Since
care coordination is largely a team-based effort, the workflow of each care team
member must be considered, and systems should be flexible, allowing for
variations when interacting with other workflow process and accommodating
environmental factors like workload, staff schedules, and patient load.
To improve efficiency, all purposes for which an EHR is used in the process of
care coordination should be informed by the process of care. For example, care
plan development should be informed by evidence-based clinical decision
support systems (CDSS) which should be available to both patients and
healthcare providers throughout the care process, not just at the point of
providing care. Care plans are also likely to provide critical pieces of information
for quality measurement in the future, so health IT systems should be designed
to enable automated collection of information from the care plan for these
purposes so that manual data collection will not be necessary. 14
Developing a framework for health IT enabled care coordination is extraordinarily
difficult for a number of reasons. The care coordination process is not well defined,
and by its very nature is highly variable because care is tailored to meet the specific
needs of individual patients. Because there are many different ways to meet the
specific care coordination needs of a given patient, no singular health IT solution
will meet the needs of every individual or every care team. Additionally, there are
many different care team members that must benefit from health IT that enables
care coordination – but not all have a role in every individual’s care. Effective care
coordination that is supported by health IT will require adherence to the above
10
principles when electronic systems are designed and implemented. In order to
achieve the specific benefits that health IT can bring to the care coordination
process, industry should focus on creating and implementing tools that address the
four concrete components of the process as described below.
11
Key Components
There are a number of key functional capabilities that electronic health systems
must have in order to support care coordination. These capabilities can be built
into systems in a number of different ways. Our expectation is that market
innovation will play an important role in developing systems that actually support
better-coordinated care.
Each of these key components can be partially implemented today. Nevertheless,
the discussion that follows is aspirational, as full implementation of these
components is likely to take several years. Development and enactment of these
key components should be approached with the principles listed above in mind, and
should be informed by emerging best practices from the field as new care delivery
models that emphasize better coordinated care are implemented.
Key Component I: Information Sharing
The sharing of information is the foundation on which care coordination is built.
Within every healthcare setting, the care team,
We should look at care coordination
healthcare organization and patient require
from the perspective of customer
access to specific information to make informed
service management. For example,
and appropriate healthcare decisions.
when we go to an online store, and
you enter your name, the site
already knows who you are and
your “favorites”. I think with the
use of health IT, care coordination
can and should function in a similar
way. Like having a Travelocity®,
Orbitz® or Amazon® for health”
Health IT systems should enable the access of
relevant patient information, and allow for
communication among the patient, family,
caregiver, paid health aides, clinicians and
healthcare organizations.15 Successful health IT
-Joyce Hunter, CEO/Industry
systems should provide seamless interoperability
Consultant at Vulcan Enterprises
among the care team and healthcare
LLC
organizations. These systems should enable the
exchange of information to support evidencebased plans of care management, improving the
quality, coordination, and integration of
healthcare services.16 Health IT also should
support the quality and safety of care and
provide clinical decision support tools, including,
but not limited to; provider alerts, patient reminders, and the integration of patientreported information that is critical for comprehensive, whole person care.17
The role of health IT in Information Sharing:
12
•
Should deliver information to care team members in a manner that enables
their use of the system. This information should also be presented in a
manner that is relevant to their specified role;
•
Should provide clinical decision support systems to enable critical pieces of
information (from all providers/care team members) available at the point of
decision-making and care planning, in a way that is understandable;
•
Should enable the development of evidence-based practices through
information sharing.
In order to successfully support care coordination, information should be
available, accessible and integrated in the care team’s workflow.18 Electronic
healthcare record systems should include specific role-based permissions in order to
ensure that the information is protected and presented in a way that is not
overwhelming to the recipient. Likewise, the system should include functionalities
that track assignments, list responsibilities among care team members, and allow
access for multiple authorized individuals concurrently.1920 All information regarding
a patient’s health status, including additional activities that impact their healthcare
needs, services, and results, should be available wherever possible to those that
need it based on their role.21 The standardization of terminology is necessary for
both interoperability and clear, consistent communication across the spectrum of
care.22 Likewise, electronic tools must be available, gather information generated at
the point of care to provide performance feedback to the provider, report measures
for accountability and transmit data necessary to calculate population health
metrics at the practice, community, and national levels. 23
Relevant information should be shared through seamless interoperability with
an evidence-based strategy of care management that supports efficient and
effective integration of patient information, laboratory, imaging, therapy, referrals,
medications, social and community services, and self-management assistance.
Information from care planning processes must be available to populate new quality
measures, such as care coordination, outcomes and longitudinal measures.24 This
should include patient registries and population-based data, especially those
promoted by local, state and federal public health agencies.25 The health
information technology system should alert the care team of tests and services
coordinated within the healthcare plan, and results should be available, at all points
of decision-making, to all relevant care team members to avoid medical errors or
unnecessary duplication of services.26 Information sharing policies that protect the
privacy and security of sensitive health information should be based on compliance
with applicable laws and regulations. 27 Consent management policies should permit
all who require role-based secure access to essential information to have such
13
access. This is inclusive of the patient, caregiver, primary care providers, and
specialty care providers. 28
JWCH Institute, Inc.
The JWCH Institute Inc. (JWCH) partnered within the Skid Row Homeless Healthcare Initiative
(SRHH) and together developed a community project to create a tuberculosis (TB) registry that
functions as an IT system that allows medical, social service, and housing providers access to shared
TB records in order create a provide a medical home, coordinate services and reduce unnecessary
duplication in health care services. JWCH chose a community-developed, open-source, enterprise
electronic medical record system framework. JWCH funded WebReach, Inc., to develop a customized
version of OpenMRS, which is named OpenMRSLA and included a TB module to help track the status
of the homeless population.
JWCH also created a comprehensive data sharing agreement with the Los Angeles Department of
Social Services and the Department of Housing and gave authorized users access to OpenMRSLA so
that they could identify:
•
•
•
Where an individual was currently living;
What medical program (such as Medi-Cal or HealthyWay LA) individuals were on or eligible
for;
Whether their TB status was current.
This comprehensive agreement allowed for the coordination of medical and housing services for the
homeless in addition to managing a prevalent and costly chronic condition. Although at the time of the
site visit there was limited information on the effectiveness of the program, the information gathered
through the medical directors at JWCH indicated that they felt that over 75% of their patient population
was in OpenMRSLA and that each of them was current on their TB vaccinations.
14
Beacon Community of the Inland Northwest (BCIN)
For the Beacon Community of Inland Northwest, care coordination involves not only facilitating
access to patient information among providers, but also assuring that the patient is receiving the
right care. BCIN is using their health IT infrastructure to support their care coordination goals in
multiple ways: sharing data between all members of the patient’s care team, facilitating access to
evidence-based medical practices, and providing quality measurement reports. The shared data
includes clinical data, procedures, diagnoses, demographic information, and clinical outcomes. To
promote use of evidence-based medical practices, BCIN has integrated advanced care coordination
algorithms into the Orion Technology Solution® that has been implemented as the information
technology foundation for the program. The Orion Technoloy Solution® includes a HIE, a clinical
data repository and the ability to support disease management pathways. Through the functionality
of the Orion tool set, health care providers within BCIN are able to create care plans based on an
individual’s disease status. For instance, when tracking type 2 diabetes, patients who successfully
manage their weight and other symptoms will receive recommended care that differs from patients
with other critical health problems.
15
Key Component II: Facilitation of Team-Based Care that Includes the
Patient and Family as Critical Members of the Care Team
Team-based, patient-centered care involves cooperative efforts amongst all
members of the care team, decisions supported by evidence and patient and family
needs, preferences and values; and the use of a comprehensive and coordinated
plan of care that is executed in a reliable, timely and effective manner. Effective
care coordination is rooted in robust
communication and trust, and is influenced by
“You can compare care coordination, to
an audible football game… It involves
care providers, patients and their families and
an entire plan and a strong team. The
initiated in a collaborative dialogue that shares
ability to communicate and change,
and disseminate information to your
information, explores values, and assists
entire team, in a cohesive way is
patients and their families in the decision
important and paramount to the
process. 29
success of the “play”. It’s about being
able to make changes, not just making
a plan, but reacting quickly when
things occur and there has to be that
primary coach or quarterback, which
can be the primary care physician,
orchestrating these plays”
Health IT systems are essential to a teambased, patient-centered care coordination
process. They enable all care team members –
including the patient and family – to be
empowered as well-informed, active and
- Sandra Schafer, Vice President of
accountable participants in the care process.30
Marketing and Business Development,
Holon Solutions
Health IT can provide support for team-based
care by providing real-time performance
information to team-members and facilitating
clinical workflows, improving patient/provider
satisfaction, providing personalized educational support and enabling more timely
and effective communication.31 In order to promote team-based, patient-centered
care coordination, the health IT system should facilitate patient access to and
sharing of information, and allow for collaboration between care team members,
including facilitation of communication among all care team members.
The role of health IT in team-based care:
•
•
•
Connecting various actors, representing a variety of disciplines – including
the patient and family – who are responsible for implementing the care plan,
communicating and coordinating with one another;
Facilitating individual care team member action based on a holistic
understanding of the needs, preferences, and values of the individual;
Integrating care coordination steps into the workflows of both professional
care team members and the patient and family;
16
•
•
•
Enabling patient and caregiver input of preferences and
observations/experiences whenever they are not physically in the healthcare
system;
Providing patient self-management support;
Enabling linkages between community and healthcare organizations.
While it is duly recognized that the collaborative efforts of multiple parties are
essential to the success of coordinated care efforts, the patient must remain the
central focus of care coordination, and healthcare decisions should be inclusive of
their needs and preferences. While this is an important principle of care
coordination at any point in time, it is particularly true during transitions of care.
Part of making “patient centered-ness” actionable during a transition of care is
ensuring that all care team members on both the sending and receiving end have
real-time access to the data they need. These technologies should allow patient
access to and input of information. The patient and/or family or caregiver should
participate directly in preparing for transitions of care, and appropriate protocols
should be used to ensure timely understanding and endorsement of the plan by all
care team members.
Self-management and self-care tools and techniques are critical to patients’ ability
to take an active role in their care. The health information technology systems that
integrate eTools should enable reminders, contact preferences and educational
information in electronic health records or other software solutions that are capable
of receiving and sending information from the patient in response to prescribed
educational information. This can be implemented in similar ways as results from
ordered tests and procedures are included in the medical record.
Likewise, the patient should be an active participant in defining how their
healthcare record is managed, controlled and shared. The patient will help the
clinician and care team understand what particular pieces of information they prefer
to be kept confidential. Patient education by the clinician about should become a
significant component of care coordination. The clinician should help the patient
understand why particular information is critical to overall care coordination, as well
as potential consequences of not sharing information.
Care team members include a variety of disciplines and individuals, and health IT
should support the work of each of them. Nurses, patients, physical therapists,
occupational therapists, social workers, speech therapists, and many other
professionals working at various points along the care continuum (including longterm care settings excluded from current federal health IT incentives) have a role in
collecting information about patient’s needs and preferences. Social support
systems are critical members of a patient’s extended care team, and effective care
coordination must include the necessary linkages to these supports, which can
17
range from traditional medical services to providing transportation services and
resources to help with food and shelter.
Health IT can support the goals of the care team and clinical decision support
systems can help in meeting those goals. The first step of developing a highfunctioning team is to help team members by defining their assignments and
increasing communication between each member. Specialists and other clinical
professionals should be included as part of an individual’s care team as necessary
and be connected with the patient. For patients with limited long-term chronic
illnesses, such as cancer, there may be a need for the specialist (such as an
oncologist) to become the main hub for coordinating care.
Standardized communication methods and formats can help significantly in
improving care coordination, especially during transitions. Such standardization
can include a minimal set of core data elements that are accessible during and after
the transition to both sending and receiving care teams, and including the patient
and caregiver.
Creating methods of continuous feedback loops between the patient and caregiver
and other members of the care team throughout the course of care is essential for
better care coordination. Such feedback loops will facilitate more complete and
accurate information, including any unanticipated problems during or after the
transition or once certain elements of an agreed-upon care plan are implemented.
The monitoring of progress, the effectiveness of the care plan and the ability of
patient/caregiver to adhere to treatment plans should continue once the individual
is at home or in a subsequent care environment. There should be alerts provided
when patients and members of the care team do not adhere to structured care
plans, as well as effective processes for follow-up.
An individual’s care plan should include essential information such as primary
language and information pertaining to family participation, dietary preferences,
and degree of social or community organization participation. Health IT can
facilitate tracking data on the patient and family’s specific communication needs –
whether it be through an interpreter or assistance device - which can facilitate the
process of care and speed up support for patients whose primary language is not
spoken by the healthcare professional. The clinician and care team should be
sensitive to the needs of patients who rely on family members for interpretation
and be notified of situations where independent translation or interpretation
services are necessary.
18
Southeastern Michigan Beacon Community (SEMBC)
SEMBC is using health IT to meet the unique needs of the community it serves through its ongoing
rollout of the Text4Health Initiative for diabetes prevention and care, making it one of only three
Beacons to pilot a mobile texting program. As Terrisca Des Jardins, the Director of SEMBC explains,
“The beauty of the use of the cell-phone, and specifically text messaging, is that it’s ubiquitous in the
community as a communication vehicle and especially among populations that are harder to reach
and underserved.” The Text4Health Initiative targets not only patients diagnosed with diabetes, but
also the family members and other undiagnosed and pre-diabetic individuals. Participants complete
an assessment through text message and then are assigned to a risk category. They set selfmanagement goals and receive targeted reminders for their goals, educational and community
resource text messages throughout a 13-week period.
Western New York Beacon Community (WNYBC)
While WNYBC has only a limited electronic patient education system for the overall population
served, a telemonitoring pilot program for diabetes patients showcases how health IT can be used to
increase patient engagement and communication with the healthcare provider. As a part of the 120
day program, patients answer daily questions online about diabetes treatment in general and their
own self-management practices in order to facilitate patient education. Patients also electronically
submit glucose and weight information to their provider through an online virtual health record. Within
the next 3 months, WNYBC plans to upgrade the system so that self-reported patient information will
be sent directly to the physician’s EHR.
19
Key Component III: Care Plans
A care plan acts as the “roadmap” of clinical and patient-centered goals, actions to
take to reach goals, responsible party for each action, tracking of progress toward
goals, and timeline for completing actions. The care plan should be a living
document that is updated regularly and that can incorporate information gleaned
from secure messaging, patient portals, and subsequent encounters. In essence
there is a need for a master care plan that is longitudinal and comprehensive, with
various sub-plans that provide more specific, targeted information. Care plans
should also include both prevention and wellness information, as well as clinical
treatment information.
The role of health IT in Care Plans:
•
•
•
•
•
•
•
Should provide the ability to view the master plan and click on an area of the
master plan in order to see specific information in a sub-plan; this enables
the availability of comprehensive information while also presenting
information in a manageable format that is not overwhelming;
Allows for the aggregation of patient-contributed data for self-management
support needs; for example, collecting information about a patient’s status as
a caregiver would be important so that need is considered in developing the
care plan; must also be able to include community linkages that need to be
made;
Allows patient and family contributions to the care planning process itself;
Decision support must be available throughout the care planning process, as
well as at the point of care;
Should make available information necessary for incorporating selfmanagement needs into the care plan. For example, Patient Activation
Measure® iv results can be useful in determining the type and degree of
support required by an individual for successful implementation of the care
plan;
Makes advanced directive status and content and risk assessment results
available for inclusion in the care planning process;
Allows notation of when tasks and steps in the care plan are completed.
iv
The Patient Activation Measure® (PAM®) assessment is a reliable and valid measure of the knowledge,
skills and confidence essential to managing one’s own health and healthcare. It was developed by Judy
Hibbard at the University of Oregon. See www.insigniahealth.com for more information.
20
Care planning is a multiple-layered process, requiring a comprehensive longitudinal
view of care and more detailed, disease or discipline-specific sub-plans. Health IT
can be designed to provide a comprehensive picture of a patient’s needs and care
plan, as well as more concise information related
“My hope is that the discussion
to a specific need, thereby avoiding information
about care planning will continually
overload for the end-user. Solutions could be
hit home the point that most
patients spend the vast majority of
built upon the Continuity of Care Record (CCR)
their lives not interacting with the
or Continuity of Care Document (CCD) to include
healthcare system. We really must
updates from each care-team visit and sociouse health IT, to bring the
healthcare system to the patient to
economic needs of the patient. Different views
support them when they are not
of the same data could be developed to meet the
physically within the four walls of a
provider setting. A longitudinal,
needs of various categories of end-users.
shared care plan is vital to ensure
that those helping to care for an
individual have access to the
information they need, regardless of
where they are physically located.
We cannot continue to expect people
always to shoulder the burden of
coordinating care without help from
the professionals working within the
system. More effective care
coordination is essential to
improving care, making care more
affordable, and ultimately to
improving the health of
communities. “
Health IT is a tool that can help facilitate the
development, process, and execution of care
plans by creating linkages, promoting
communication among multiple healthcare
providers, including referrals, authorizations, and
scheduling care appointments32. Additionally,
health IT can assist in linking community
resources in treatment planning and mapping
preventive strategies.33 Health IT is essential to
produce actionable, tailored, information in
useable forms for the patient, family and
Eva Powell, MSW, HIT
healthcare provider –not just raw data. With the
Program Director, the
National Partnership for
support of health IT and health information
Women & Families
exchange, the information needs of the patient,
healthcare provider, and supporting
organizations can be met using data entered once during the process of care.
While health IT is an essential tool for achieving coordinated care, the process itself
relies on human behaviors: specifically the collaborative efforts of the patient,
family, healthcare providers and community supports. Members of the care team
should work together to reach the best possible strategies for meeting the clinical
and personal health goals of the individual. The patient and/or caregiver should be
an active participant in developing the individual care plan. This includes goal
setting and treatment decisions, preferably through a shared decision-making
process. The patient’s life circumstances, current health and health history,
functional status, self-management knowledge and actions and need for supportive
services also are critical factors, and should be considered in developing care plans
and treatment recommendations. The care plan should include community and
nonclinical services that respond to a patient’s needs and preferences and
21
contribute to achieving the patient’s goals, in addition to traditional healthcare
services. Ultimately, team based care should be focused on meeting an individual
patient’s clinical and personal health goals.
Certain information, such as caregiver name and contact information, advance
directive content, pertinent psychosocial information, among others, should be
easily accessible in various views developed for different groups of end-users, even
if it is not among the most commonly used information by that particular group. By
making this information available, but not overwhelming, new interactions can be
fostered between care team members for more effective care coordination.
Data from a variety of sources is required at the point of decision making, the
multi-phased process that ultimately results in a care plan and subsequent revisions
to it. The entry of information into an electronic care plan from various decisionmaking processes should be timely, and time of entry, source of information, and
any necessary explanations about the data should be included. Follow-up processes
for tests, treatments and services should be established and automated to the
degree possible. The healthcare organization and/or clinicians shall develop
protocols for managing care plans that incorporate systems for registering,
tracking, measuring, reporting and improving essential coordinated services. Such
protocols will determine the degree to which and options for using health IT for
these purposes.
As previously stated, care planning should take into account results of risk
assessments and other patient-contributed information that may be stored
elsewhere in the EHR. Since longitudinal care planning will involve multiple points
of decision-making that do not necessarily take place at the point of care, clinical
decision support will need to be available not just at the point of care, but also at
the point of care plan development. Future performance measurement is likely to
require data elements captured in the care plan, therefore making linkages between
the care plan and quality measurement functionalities in an EHR essential, so that
data and measures do not have to be entered by hand into analytical components
of an EHR, but rather can be pulled directly from the care plan.
22
Greater Cincinnati Beacon Community (GCBC)
GCBC is taking several steps to improve the care planning process through the use of health
information technology solutions. The majority of the transitions of care work within the GCBC focus
on preventable emergency room visits and readmissions. One of the greatest challenges for the
program is connecting healthcare providers to critical patient information when the healthcare
organization is outside of the network. The Emergency Department - Inpatient Alert System is another
technology solution that GCBC is initiating to improve the flow of patient information between
hospitals, practices and post-acute providers. As Trudi Matthews, Director of Policy and Public
Relations notes, “Patients are stubborn people. They go where they want to go. Just focusing only on
the ability to share information well within one organization is not sufficient…so as a health
information exchange, HealthBridge is helping to smooth information flows across systems.” Using
targeted groups of children with asthma and adults with diabetes, participating hospitals have agreed
to provide data related to emergency, inpatient, discharge and/or transition of care information.
23
Key Component IV: Organization of Information and Services
EHRs have a distinct advantage over paper in that the technology itself can
organize and present information in ways that are most meaningful to the end user
in a specific circumstance. For example, they can be designed to include linkages to
data analytics software that provide insight based on clinical and other relevant
healthcare encounters. When designed specifically for the purpose of informed
decision-making, EHRs can enable healthcare providers, patients and their family
and caregivers to use data to make better-informed decisions by taking into
account all pertinent information from multiple data sources across time. Effective
care coordination requires a care delivery system to integrate the efforts of care
team members, information generated by these efforts, and other resources
needed to carry out patient care activities.34 The EHR provides a means of recording
both the components of the care plan and the parties responsible and accountable
for specific actions across multiple sites. Although not every healthcare provider is
responsible for capturing every piece of information, information captured by other
care team members should be organized and accessible by others who need it.
Information must be organized and displayed in ways that provide seamless
integration of information without creating data overload.
The role of health IT in the Organization of Information and Services:
•
•
•
Should create customizable information and allow it to be presented in a
manner that is most useful for the end user (which would include any
member of the care team);
Should provide user-centric applications;
Should integrate information from remote monitoring, telehealth, mobile
health, and other relevant eTools.
The health IT infrastructure should enable collaborative decision-making support
among different clinicians and patients.35 Health IT infrastructure should promote
the interoperable exchange of data among the care team and other individuals
participating in the execution of patient-centered care planning.36 EHRs should
include the capacity to enable the care team to receive, record and access
information that clearly outlines the role(s) and responsibilities of participants in a
patient's care for a specific aspect of that care (both within, but also outside of the
primary medical home) and should be clearly delineated and facilitated.37
Specifically, the record should note who is primarily responsible for specified care
and coordination activities, the scope of that responsibility, and when that
responsibility will be transferred to other care participants. 38
Health IT Functionality
24
The health IT infrastructure should incorporate systems for tracking, measuring,
reporting, enhancing communication and improving essential coordinated
services.39 Remote patient monitoring can be a critical component of care
coordination and should be interoperable with or integrated into EHR systems.
Health IT should support the integration of information from these devices into
workflows and care processes.40
Health IT should support meaningful clinician-patient communication and improve
accessibility of the healthcare organization to the patient.41 The infrastructure
should work to facilitate team-based care, and support a multi-disciplinary team
that includes, but is not limited to, other clinical staff, social workers, mental health
workers, health educators, and caregivers, as clinically appropriate. The patient’s
individualized care plan should be shared electronically across the continuum of
care and with the patient.42 The health IT infrastructure should support agreed
upon processes and procedures for clinical notification between hospitals and
outpatient clinicians.
Louisiana Coordinated System of Care (CSoC)
The development of the Coordinated System of Care (CSoC) to serve 2,500 children most at risk or in
out-of-home placement has been a hallmark of development within the overall LBHP system. The CSoC
concept in Louisiana is unique in that it involves a formal collaboration and commitment from the four
critical child-serving agencies: Department of Children and Family Services (DCFS), Office of Juvenile
Justice (OJJ), Department of Education (DOE), and the Office of Behavioral Health (OBH). Each of the
child-serving agencies contributes funding that has been aggregated in order to better leverage federal
Medicaid resources and even more importantly allows for a streamlined and coordinated approach to
managing and directing the care of children with complex behavioral health needs.
To effectively coordinate care in a fractured system, the Louisiana behavioral health providers will use
Magellan’s Clinical Advisor application, built upon the ClaimTrak platform. This application will offer
providers a Web-based, fully customized electronic health record designed specifically for the use by the
behavioral health profession. The new HIT solution will be available to up to 5,000 Louisiana licensed
behavioral health providers who do not currently have an electronic health record (EHR) application, this
will give them the advantages of greater data functionality without additional infrastructure investment for
their practices.
25
Conclusion
Care coordination will continue to grow as an important and vital process that helps
ensure that patient’s needs and preferences for health services and information
sharing across people, functions, and sites are met over time.43
Health IT implementation is an ongoing process, and those doing the difficult work
of implementation are at multiple stages of readiness to incorporate functionality
that supports care coordination. As technology advances, it is important to remain
mindful that the integration of health IT into care coordination will be a
continuously evolving process. The most efficient and effective care coordination
technologies will likely arise from real-world experience with new care delivery
models and redesigned workflows.
There are several key functions that individuals and healthcare organizations will
need to consider in relation to the future application of health IT systems for care
coordination. By enabling the capture and use of data through electronic
technologies, health IT will be instrumental in developing and improving healthcare
practices and preventive services. Health IT should be
used to promote these goals by turning data into
“I think that the health IT
system can eliminate some
actionable steps; however, as technology continues to
of the logistics around
evolve, it is vital that patients remain at the center of
ambiguity in
communication, however, it
all care coordination activities. Successful care
cannot replace the peoplecoordination will depend upon technological solutions
to-people process. Today,
and collaboration between diverse healthcare providers.
you have care coordination
that is neither a good
Before individuals and organizations involved in the
people-to-people process
care coordination process aim to achieve any of the
nor logistics for
communications
recommendations addressed in this report, they should
management. Health IT’s
first engage in a focused dialogue with appropriate
role is to make sure that
stakeholders. Likewise, the healthcare community
the information is at the
right place, at the right
should identify and disseminate best practices for
time, and to the right
making bidirectional linkages with community support
people and with that, the
care team (including the
organizations, healthcare organizations, and individuals
patient) can have
involved in the care coordination process. In order to
meaningful access to
achieve effective care coordination and promote patient
information. “
engagement, greater effort must be made to include
-Leslie Kelly Hall, Senior
professional groups that are traditionally excluded from
Vice President Healthwise
EHR/HIE and Meaningful Use implementation goals.
Examples of important organizations for the long-term
care of a patient include, but are not limited to:
community organizations, such as shelters or educational institutions; mental
health facilities; laboratories; physical therapists and substance rehabilitation
clinics.
26
There is tremendous activity in the area of care coordination, and several best
practices can be applied towards the successful use of technology. Beacon
Community programs, NQF, state health plans, federal initiatives and care
coordination communities exemplify how health IT can improve quality of care while
reducing costs. In addition, the Patient Protection and Affordable Care Act has
encouraged and supported the development of several health IT initiatives that are
focused on improving the care coordination process, specifically medical home
models. Future technological developments should build upon best practices
developed from these initiatives to enable multidirectional linkages with community
organizations and support systems. The systems must be adaptable to the
changing needs of the patient populace.
Health IT is instrumental to support preventive healthcare goals set forth by state
and national organizations. Healthy People 2020 is a national agenda developed by
HHS that communicates a vision for improving health and achieving health equity,
and proposes a comprehensive strategic framework that unites health promotion
and disease prevention. Included in the framework are specific, measurable
objectives in topic areas that target national healthcare goals over the next decade,
such as how health IT functionalities can support preventive healthcare goals.
Healthy People 2020 encourages collaborations across healthcare sectors, guidance
to assist individuals in making informed health decisions, and measuring the impact
of preventive activities. Health IT programs should be developed to support the
achievement of Healthy People 2020 goals, and enable the healthcare community
to track data-driven outcomes, monitor progress, and motivate, guide, and focus
action.
Creative solutions will be required to treat, prevent, and ultimately slow the
epidemic of chronic conditions in the U.S. With promising innovations such as
genomics already on the horizon, health information technology systems must be
able to adapt to future changes in medical practice and procedure. Similarly, care
coordination plans and EHR systems will need to incorporate a host of new
information and data provided by advances in personalized medicine.44
As increasingly more Americans develop one or more chronic conditions, the burden
of care will continue to fall upon the shoulders of patients, families, caregivers,
providers, paid health aides, and the system at large. Healthcare delivery must be
integrated to coordinate care between disparate providers responsible for
chronically ill patients. Health IT and eTools can improve disease monitoring and
management by providing timely and useful data about patients, at both an
individual and population level. Access to electronic tools and data can allow
providers to find and contact patients with specific needs; develop and deliver
team-based care plans; receive feedback on performance; and benefit from
advanced functionalities, such as clinical decision support and automated
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reminders. As the development, implementation and use of health IT become
more ubiquitous, it is expected that new avenues and applications of technology will
continue to be incorporated into the coordination of chronic care.
This document seeks to promote the effective use of health IT to facilitate care
coordination through the articulation of the key principles and components
recommended by the Council. The document is intended not to critique current
practices, but rather to influence the necessary changes to healthcare on the
horizon. While the document is envisioned to be used by multiple care coordination
initiatives, audiences should adapt the recommendations to fit their individual
needs. Healthcare initiatives looking to improve or adapt their care coordination
process through the use of health IT should place particular focus on the
involvement of their respective patient communities, best practices from successful
care coordination initiatives and development of technology solutions that are
flexible enough to meet the needs of a given population.
Listed below are critical functions required of health information technology in order
to facilitate the components of care coordination highlighted in this paper.
•
•
•
•
•
•
•
•
•
Capturing, accessing and sharing of real-time patient data among those
caring for the patient.
Enabling verification of the accuracy of patient-entered data.
Allowing for flexibility that accommodates various workflow processes and
environmental factors like workload, staff schedules, and patient load.
Facilitating seamless interoperability with evidence-based care management
strategies that support efficient and effective integration of patient
information, laboratory, imaging, therapy, referrals, medications, social and
community services, and self-management assistance, including patient
registries and population-based data.
Alerting the care team of tests and services coordinated within the healthcare
plan.
Facilitating bi-directional communication among professional care team
members and the patient.
Facilitating linkages consistent with applicable state and federal privacy
standards that are outside the traditional healthcare system and are
necessary to meet a patient’s clinical and psychosocial needs (involving social
services, mental health, school systems, etc.).
Facilitating quality improvement and safety; disease management; utilizing
CDSS tools; provider alerts and patient reminders.
Providing a continuous information flow and feedback loop between a patient
and his or her care team.
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•
•
•
•
•
Supporting the creation and execution and updating of a care plan that can
be shared across the continuum of care and with the patient and their family,
caregiver, and/or paid health aide.
Facilitating decision-making and planning for transitions of care.
Presenting a master care plan that is longitudinal and comprehensive, with
various sub-plans that provide more specific, targeted information.
Integrating and using information generated as part of the process of care.
Capturing critical information, tracking patient education and selfmanagement support, and community and non-clinical services necessary to
support the patient and his or her caregiver’s needs and preferences.
Significant evolution in the marketplace is necessary to achieve the widespread
availability of the functionalities described above. The Council identified several
concrete steps that can be taken now or in the near future that will advance the
capability of electronic health information systems to support better coordination of
care. This is not intended as an exhaustive list, but rather as a starting place for
focused effort by policy makers, industry representatives and others.
•
•
•
•
Identify a starter set of role-based views for presenting data necessary for
care coordination.
Identify professional groups that are often excluded from EHR/HIE
implementation who will be critical for care coordination and engage
professional societies or other organizations representing these groups in
future discussions about improving care coordination using health IT.
Identify prevention goals from Healthy People 2020 that can especially
benefit from health IT and prioritize their integration into health IT enabled
care coordination.
Identify vocabulary and data transfer standards necessary for the
functionalities above, with particular attention to incorporation of patient
contributed data into the EHR.
Identify and spread best practices for making linkages with community
supports.
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Case Studies:
To illustrate how communities are utilizing health IT to support care coordination,
the document considers the experiences of several Beacon Community programs,
state plans, and community-based organizations. The case studies were developed
through phone interviews, submissions from organizations, and general research.
These studies detail the experiences of the following care coordination
communitiesv:
•
•
•
•
•
•
•
•
•
•
•
•
Statement from the Office of the National Coordinator
Greater Cincinnati Beacon Community, Cincinnati, OH
Western New York Beacon Community, Buffalo, NY Southeastern Michigan
Southeast Michigan Beacon Community, Detroit, MI
Rhode Island Beacon Community, Providence, RI
Greater Tulsa Health Access Network Beacon Community, Tulsa, OK
Colorado Beacon Community, Grand Junction, CO
Beacon Community of the Inland Northwest, Spokane, WA
JWCH Institute Inc., Los, Angeles, CA
Montefiore Medical Center Bronx, New York, New York
Oregon Health Plan
Louisiana Coordinated System of Care
Office of the National Coordinator
The Office of the National Coordinator for Health Information Technology (ONC)
funds the Beacon Communities Program. The Beacon program is one of several new
programs created by the Health Information Technology Economic and Clinical
Health (HITECH) Act as part of the Recovery Act in 2009. Total funding for the
Beacon program initiatives is $250 million plus an additional $15 million for
technical assistance and evaluation, over 3 years. The Beacon Communities are
seventeen communities across the country that had already made significant
inroads in the adoption of health IT prior to the grant award. The Beacon
Community Program goals include building and strengthening a health information
technology infrastructure; improving health outcomes, care quality, and cost
efficiencies; and spearheading innovations to achieve better health and healthcare.
The Beacon Communities are microcosms of the rest of America, and as such, the
lessons that are learned from them will play a key role in healthcare
transformation.
v
For the purposes of this section, health information exchange (HIE) refers to both the process and the
entity.
30
The Beacon Community Cooperative Agreement Program provides funding to 17
selected communities throughout the United States that have already made inroads
in the development of secure, private, and accurate systems of EHR adoption and
health information exchange. The Beacon Program will support these communities
to build and strengthen their health IT) infrastructure and exchange capabilities to
improve care coordination, increase the quality of care, and slow the growth of
healthcare spending.
The 17 Beacon Communities will focus on specific and measurable improvement
goals in the three vital areas for health systems improvement: quality, costefficiency, and population health, to demonstrate the ability of health IT to
transform local healthcare systems. The goals vary according to the needs and
priorities of each community. For instance, some communities will focus in the care
for chronic conditions such as asthma, heart failure, and diabetes to illustrate how
costs can be reduced and patient care improved through the collection, analysis,
and sharing of clinical data.
Greater Cincinnati Beacon Community Program
Through collaborative efforts with several community healthcare programs, the
Greater Cincinnati Beacon Collaboration (GCBC) has become an advanced leader in
the successful use of health IT and HIE.
GCBC was built through the collaborative partnerships of Cincinnati Children’s
Hospital Medical Center, The Health Collaborative of Greater Cincinnati, the Greater
Cincinnati Health Council, GE, the University of Cincinnati and HealthBridge. Unique
to other Beacon Community programs, the GCBC was founded on a strong,
previously established foundation of health IT efforts through HealthBridge, a HIE
serving the Greater Cincinnati tri-state area. Founded in 1997, HealthBridge has
grown to become one of the largest regional health information organizations
(RHIO) in the country, with 50 participating hospitals, more than 7,500
participating healthcare providers, and serving over 2.3 million patients.
HealthBridge is focused on advancing existing health IT and HIE capabilities to
improve coordination of care, the quality, value, and population health and
achieving Meaningful Use within the GCBC.
Building upon existing HIE infrastructure and regional collaboration GCBC led by the
Greater Cincinnati Health Council recently launched the Transitions of Care pilot
program to share discharge summary documents directly between hospitals and
other providers, aimed at removing disruptions and improving the workflow for
receiving these documents. The ultimate goal is to use the Direct Project to send
patient summary records or CCDs between service providers, inclusive of hospitals,
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home health services, long-term care agencies, and primary care providers, in
order to improve transitions of care. However, as many Beacon programs have
experienced, information exchange can only advance as far as participating
providers’ health IT systems allow. As of now, even participating providers with
advanced EHR systems are unable to send CCDs easily. Nevertheless, as Trudi
Matthews, Director of Policy and Public Relations for HealthBridge relates, by using
the Direct Project to send discharge documents GCBC is, “Taking another important
step in the journey toward improving information flow about patients.”
GCBC is taking several steps to improve the care planning process through the use
of health information technology solutions. The majority of the transitions of care
work within the GCBC focus on preventable emergency room visits and
readmissions. One of the greatest challenges for the program is connecting
healthcare providers to critical patient information when the healthcare organization
is outside of the network. The Emergency Department - Inpatient Alert System is
another technology solution that HealthBridge is initiating to improve the flow of
patient information between hospitals, practices and post-acute providers. As
Matthews notes, “Patients are stubborn people. They go where they want to go.
Just focusing only on the ability to share information well within one organization is
not sufficient…so as a health information exchange, HealthBridge is helping to
smooth information flows across systems.” Using targeted groups of children with
asthma and adults with diabetes, participating hospitals have agreed to provide
data related to emergency, inpatient, discharge and/or transition of care
information.
As one of the largest HIEs in the country, HealthBridge is capable of leveraging its
technology infrastructure to not only increase the electronic flow of information but
also ensure that patient information is transferred in the securest method possible.
Using a HIPAA and HITECH compliant system, HealthBridge provides a secure,
private, encrypted connection between healthcare systems. The approach is
“provider-centric”, keeps data off the open internet, and ensures that information is
sent only to authorized healthcare providers. As Matthews stated, “We think secure
electronic connections are far more secure and keep information more private than
the current paper-based system where you have no way of tracking who has seen
your paper record.”
While increasing the secure flow of information is a vital aspect of facilitating care
transitions, the ultimate goal of care coordination is to improve the health of
patients. GCBC is currently engaged in several programs that focus on the use of
technology to improve patient self-management of chronic conditions and provider
communication. The first is a PCMH demonstration led by The Health Collaborative
with 18 participating healthcare practices focusing on improving outreach to patient
populations. Each participating healthcare practice receives training focused on
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PCMH principles, including open access scheduling, team-based care, active
involvement of care, and use of data for improvement. To facilitate these goals,
HealthBridge is working with selected practices to provide a patient registry that is
integrated with their EHR and other community data sources. The registry will also
include the capability for practices to send education materials to patients in a
“simple summary” format and the use of a patient-portal to send patients updates
and monitor treatment.
Additionally, GCBC has partnered in care coordination activities is the Cincinnati
Children’s General Pediatrics Program at Cincinnati Children’s Hospital. Currently,
the General Pediatrics team has 114 high-risk patients enrolled in their care
coordination work. The team is testing a process of identifying high-risk patients in
an effort to prevent emergency room readmissions. To facilitate this, they have
developed a logic model for identifying patients that are at-risk for a preventable
emergency room visit and can benefit the most from care coordination activities.
Another project aimed at patient engagement is the Text4Health initiative, a larger,
mobile technology based public campaign implemented in coordination with
Hamilton County Public Health. The initiative will send targeted text messages
regarding weight management, eating habits, and recommended care to 25,000
pre-diabetic or diabetic patients.
HealthBridge has spent much of the past year designing and building new system
capabilities; therefore, many of their care coordination projects are only now being
tested with a small group of providers. For this reason, it is still too early to show
which of their initiatives are most effective at lowering costs or improving quality of
care. The GCBC evaluation team will begin analyzing results and publishing its
findings in the next 12 months.
In tandem with its Transitions of Care initiatives, HealthBridge is also developing
an advanced HIE system where all data is mapped and exchanged from system to
system as coded, consistent data elements. This advanced HIE capability is being
implemented now under Beacon and will allow greater integration of patient’s
health information and development of a more robust longitudinal patient record
across systems. As Matthews says, “That’s when you’re really going to see
electronic systems fully able to improve care coordination.”
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Western New York Beacon Community
Working within an established HIE system and forming key partnerships with local
physician , payers, and health technology providers, has allowed the Western New
York Beacon Community (WNYBC) to focus on closing gaps in patient services in
order to improve care coordination and health outcomes for diabetic patients.
Established by a grant to HEALTHeLINK™, the regional HIE and RHIO, the Western
New York Beacon Community serves eight counties in western New York, with
communities ranging from the city of Buffalo to rural areas that lack broadband
service. WNYBC’s program goals include expanding the current HIE network to
include long-term care facilities and homecare agencies, as well as greater sharing
of prescription information, emergency room data, and hospital medication
discharge data. Due to a 10.3% diabetic incidence rate in Western New York,
WNYBC is focused on implementing health IT to improve health outcomes for
50,000 diabetic patients within a network of 500 primary healthcare providers.
WNYBC has a unique concentration of healthcare providers utilizing EHRs. The 500
participating healthcare providers were selected based on their prior use of
electronic health record systems that were connected to HEALTHeLINK™. WNYBC
was able to identify six preferred vendors that are qualified to meet Meaningful Use
standards and Certification Commission for Health Information Technology ( CCHIT)
certified, including MEDENT™, eClinicalWorks™, Allscripts Enterprise and
Professional™, STI CHARTMAKER ™, Amazing Charts™, and NextGen Healthcare™.
Through partnerships with Catholic Medical Partners, The P2 Collaborative of
Western New York and local physician associations, WNYBC conducts intensive
assessments of the health IT infrastructure within each practice to improve
workflows and ensure that registries are properly set-up to collect and share deidentified patient data. Currently, a dozen practices have achieved Meaningful Use
Stage 1 and dozens more are able to directly receive laboratory and radiology
results, as well as medication information, within their EHR systems.
Beyond practice care coordination, WNYBC has established several programs to use
health IT to facilitate care transitions, such as an electronic notification system to
send alerts to primary care physicians within the EHR when patients are discharged
from a hospital and the development of an HIE data source for hospital and
rehabilitation clinic discharge medication prescriptions. WNYBC has also developed
a unique telemonitoring pilot project that focuses on transitions of care. Targeting
specifically the co-morbid diabetic populace at-risk for hospitalization and
emergency room visits, WNYBC has implemented telemonitoring devices that
monitor these patients in order to identify issues prior to hospitalization, instead of
post discharge. WNYBC has engaged three different telemonitoring vendors to
assist with this project. Through their engagement, WNYBC is utilizing technology
34
that allows the patients to report their blood pressure, glucose readings and weight
remotely, and lets their doctors receive that information online through the virtual
health record. Technology being used includes on-line patient education and
feedback and unique android based mobile devices for wireless reporting.
While WNYBC has only a limited electronic patient education system for the overall
population served, another telemonitoring pilot program for diabetes patients
showcases how health IT can be used to increase patient engagement and
communication with the healthcare provider. As a part of the 120 day program,
patients answer daily questions online about diabetes treatment in general and
their own self-management practices in order to facilitate patient education.
Patients also electronically submit glucose and weight information to their provider
through an online virtual health record. Within the next three months, WNYBC plans
to upgrade the system so that self-reported patient information will be sent directly
to the physician’s EHR.
WNYBC has established multiple security checks to ensure the privacy of patient
information. In order to become certified for Meaningful Use, practices must
undergo a security assessment. In order to access the individual systems,
healthcare providers sign into the HEALTHeLINK™ HIE web portal. The system
utilizes a two factor authentication process that uses an AnakAM® system and
requires cell phone, direct line phone, or security fob for identity verification in
order to sign-on to the system for a 12-hour period. In addition, WNYBC has a
standing security council that involves the majority partners in the Beacon
Community Program to monitor privacy and security concerns.
In order to show the success of care coordination, WNYBC is tracking 34 cost and
quality measures using claims data from hospitals and insurers and registry data
from each participating practice. From this data, WNYBC hopes to demonstrate
reduced hospital admissions and cost of each admission, as well as specific health
outcomes improvement for diabetic patients.
While it is too early to provide quantitative results of cost and quality improvement,
WNYBC is able to provide numerous anecdotal stories of the effectiveness of their
programs. Virtual health records have allowed provider offices to operate more
efficiently, thus saving precious time. Additionally, by allowing providers to access
patient lab results from other providers, both physicians and patients have been
able to avoid the unnecessary repetition of tests. Nancy Maloney, Sr. Business
Architect and Clinical Transformation Specialist for the WNYBC, shares a story of
how the HIE has helped to save lives by facilitating the verification of donor
information during organ donation. When a donor without any family information
was identified to the local Organ Procurement Agency, the agency staff used the
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HIE to find and contact the family, as well as access the appropriate lab results to
rule out any incompatibility issues for organ donation.
When offering advice to communities looking to implement care coordination,
Nancy Maloney stresses the need to assess how technology fits into each practice
and is incorporated into the practice workflow. WNYBC Project Director Mr. Todd
Norris, PMP states “You can’t just throw technology over the wall and expect it to
stick or work…If it’s not part of their everyday living, they’re just never going to use
it.” Maloney also points out the importance of collecting and reporting data to
practices in order to show that care coordination is making a difference. Maloney
indicates that, “data really can open up eyes.” For example, a doctor may think that
she is giving 100% of patients the flu shot, but after receiving a report may realize
that only 15% of patients have actually been vaccinated.
In the coming year, Nancy Maloney, the Beacon Team and their partners look
forward to creating greater interoperability of data in order to allow increased EHRto-EHR communication between primary caregivers and specialists. In addition,
expanding the notification of patients’ transitions of care will also greatly enhance
the quality and efficiency of the care the patient receives. She believes that the
discrete transfer of data elements across EHRs, rather than the use of direct
messaging systems, is more efficient and effective in the coordination of care.
Southeast Michigan Beacon Community
With a focus on health management at the community level, the Southeast
Michigan Beacon Community (SEMBC) is rapidly becoming a leader in care
coordination within the Beacon Community Programs.
The SEMBC, with the Southeastern Michigan Health Association as its lead agency,
is one of the two most recent Beacon Community Programs to be established,
receiving its award in September 2010. Serving Wayne County with an eye toward
the seven-county region of Southeastern Michigan, which includes the greater
Detroit area, SEMBC is currently conducting work in five major areas to achieve
health delivery and systems improvement: HIE, clinical transformation, leadership
and community accountability, sustainability, and evaluation and measurement. To
date, SEMBC has reached over 14,000 patients with diabetes with a focus on
diabetes prevention and management. It is estimated the clinical transformation
reach through the SEMBC affiliated practices exceeds well over 150,000 patients.
From a health IT perspective, SEMBC considers itself to be unique from other
similar health information exchange efforts by using technology to bring clinical
care decisions for care gaps and alerts from the clinic site level up to the
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community level. Given many residents in the Detroit metropolitan area do not
have a primary physician; a focus on care coordination at the community level is
essential. As Sue Hashisaka, the Director of Clinical Transformation, explains, “If a
patient shows up at one of our 50 partner clinics and then goes to an emergency
department outside of the scope of that clinic, the HIE will enable a prompt to come
up through the HIE so that physicians at the clinic will know that the patient went
elsewhere and be able to look at the clinical data.”
SEMBC is additionally using health IT to meet the unique needs of the community it
serves through its ongoing rollout of the Text4Health Initiative for diabetes
prevention and care, making it one of only three Beacons to pilot a mobile texting
program. As Terrisca Des Jardins, the Director of SEMBC explains, “the beauty of
the use of the cell-phone, and specifically text messaging, is that it’s ubiquitous in
the community as a communication vehicle and especially among populations that
are harder to reach and underserved.” The Text4Health Initiative targets not only
patients diagnosed with diabetes, but also the family members and other
undiagnosed and pre-diabetic individuals. Participants complete an assessment
through text message and then are assigned to a risk category. They set selfmanagement goals and receive targeted reminders for their goals, educational and
community resource text messages throughout a 13-week period.
While SEMBC has a special interest in coordinating care and reaching patients at
the community level, it continues to focus on care planning at the site level because
not all practices have the necessary level of health IT infrastructure to participate in
a community-wide system. Therefore, SEMBC is working to ensure that each
practice has the ability to create patient summaries with specific action plans for
diabetes care from its own registries or EHRs.
As a part of its efforts to improve care coordination within each clinic, SEMBC sends
practice coordinators to train providers in using their own electronic health systems
more efficiently in order to streamline their work. SEMBC has observed providers
have subsequently demonstrated a heightened awareness of the capabilities of their
EHR and registry systems after participating in the training. This change is critical
because many providers previously used their electronic health systems at a
minimal level and exhibited a low adoption rate of technology. Bruce Wiegan,
Director of HIT and HIE, describes the significant value of this change, commenting
that “the more meaningful providers find the use of their own technology, the more
meaningful their participation in the overall HIE system will be.”
Overall, Ms. Des Jardins sites the key to SEMBC’s success is its ability to leverage
existing resources, relationships and initiatives in the community. For example, by
partnering with Michigan’s Quality Improvement Organization (MPRO), the Voices of
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Detroit Initiative (which works with all the Federally Qualified Health Centers in
Wayne County) and other organized health delivery systems, SEMBC is able to
leverage organizations that have been working with providers in the area for years.
She also notes that large physician organizations and health systems, payers, like
Blue Cross Blue Shield of Michigan, and employers such as General Motors
Corporation and Ford Motor Company were also instrumental in supporting the
development of health IT infrastructure in physician organizations and practices.
In the coming months, SEMBC will officially launch their HIE. Ms. Des Jardins
observed “traditionally, HIEs have been about pushing data… but our initiative will
include population-level management tools and the ability to track patients across
the health delivery continuum and over the course of time. The type of clinical
transformation and HIE infrastructure Beacon is pursuing will be an essential
foundational element in healthcare delivery system and payment structures reform
we are all likely to see in the coming years.”
Rhode Island Beacon Community
The state of Rhode Island has a rich tradition of investing in primary care
initiatives, focusing specifically on the PCMH model. The Rhode Island Beacon
Community Program (RI), has built upon this unique foundation, leveraging health
IT to improve the quality, safety, and value of healthcare for patients within its
community.
The RI community includes practices participating in three specific PCMH projects,
spread across 28 practices and 50 sites of care. Included within these projects is
the Chronic Care Sustainability Initiative (a multi-payer demonstration project),
Rhode Island Chronic Care Collaborative (a program sponsored by the state
Department of Health that is focused on Federally Qualified Health Center clinics),
and the PCMH program offered by RI Blue Cross Blue Shield. The goals of the RI
program include supporting RI’s transition to the PCMH model of care through
health IT and improving RI’s ability to see and act on the quality and efficacy of the
healthcare system by providing foundational capabilities in quality and utilization
reporting
The Rhode Island Beacon Community initiatives are led by the Rhode Island Quality
Institute, which also administers currentcare (the statewide health information
exchange) and the state REC. The RI Beacon community strives to demonstrate
that it is possible to achieve interoperability across heterogeneous practices and
EHR platforms through the use of a health information exchange.
The RI program is providing concrete examples of how information technologyenabled PCMH care models can lead to improvements in health outcomes. The RI
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experience has resulted in important quality measurement and reporting lessons in
the following important areas:
•
The role of various forms of leadership
•
The power of community collaboration around shared objectives
•
Ways to motivate and encourage practices and clinics to transform.
The challenges of harmonizing measures and aligning with participants’ pre-existing
measure requirements and achieving Meaningful Use objectives figures prominently
in the RI Beacon Community Program as well as developing Quality Reporting
Measurement Database capabilities. The RI program has deployed services to
aggregate quality measures at the community (Beacon population), practice, and
provider levels. Information is presented using a variety of data visualization
approaches which helps practice and physician leaders to see opportunities for
improvement and motivates them to pursue them.
In summary, the RI Beacon work is showing that health IT investments can be a
potent means of driving practice transformation and that data analytics capabilities
and skills, in particular, are core competencies of a community’s culture of change
and improvement.
Colorado Beacon Consortium
Every Beacon Community values improving the quality of care across communities,
but few have as put as much focus on involving the community in the creation of
care coordination models as the Colorado Beacon Consortium (CBC).
The CBC works with 38 primary care practices across seven counties in western
Colorado to create a community-based model for care coordination with health IT
and HIE at its core. As Julie Schilz, the former Director of Community Collaborative
and Practice Transformation, relates, at the heart of CBC’s mission is the belief,
“That if we deliver on quality, the cost will follow.” With this in mind, CBC is focused
on moving towards a paradigm of care coordination that improves patient care
while reducing costs across multiple independent and provider partner
organizations. With the health information infrastructure building upon community
resources, skills, and involvement, CBC has redesigned primary care practices to
establish a community-based HIE that collects, analyzes, and shares discrete
clinical and administrative data. In doing so, CBC has moved away from the
traditional point-to-point model of data sharing to embrace comprehensive data
aggregation and analytics.
Health information technology facilitates and informs the development of
community-based care coordination in a number ways. One of the core principles of
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a community HIE is data interoperability. As Patrick Gordon, Program Director,
states, “having a central, community-based interoperability service is much more
efficient and will enable us to make much more progress in terms of system
integration across very disparate platforms than we would achieve in a point-topoint model where essentially every large group and hospital is working to recreate
the wheel.” Through the HIE, CBC has access to a secure, standardized method of
communication that creates efficiency for all participating practices and facilitates
coordination of care across multiple, disparate points of care. Recognizing that the
traditional one-size-fits-all approach towards case management does not work, CBC
has expanded care coordination to include shared care planning and innovative
options such as group patient visits to encourage patient activation and increase
access among the community at large.
Health IT is used not only to facilitate coordination of care between providers, but
also within each point of service to transform practices to embrace the chronic care
model and change the dynamics of the patient-provider relationship. Because each
practice has different technology, CBC conducts delivery system redesigns to
establish specialized models and workflows for each practice so that they can best
use their technology for care coordination. CBC trains each practice to use
technology to document shared care plans, show patient progress, and use EHR
functionality to track patients. To improve physician-patient collaboration, CBC is in
the process of implementing and evaluating several pilot studies with software such
as Archimedes IndiGO™, a decision support tool that employs advanced predictive
modeling and health risk assessment to calculate a patient’s risk of adverse events
at a granular level based on diagnostic, behavioral, and biomarker data, and
ultimately suggest appropriate medications and/or interventions that will have the
greatest impact. By using quality metrics, practices are able to identify how well
they’re meeting the needs of the population and can recognize patient outliers who
may need additional support in their care.
CBC has visionary goals for integrating families, consumers, and patients into
multiple levels of the care coordination experience, though Schilz admits that there
is still “a little work to do”. CBC is currently working with practices to design
workflows that incorporate greater patient engagement by having patients serve on
quality improvement teams along with quality improvement advisers and
programmatic members. In the future, CBC plans to create small, structured
community consumer advisory boards to counsel programs and initiatives, such as
the implementation of population health registry tools. As Schilz describes, the goal
of the consumer advisory boards is to “engage the community to think differently
from a cultural standpoint of how to engage consumers, patients, and families” in
their care.
40
CBC also prioritizes how to best serve the patient and community-at-large when
building privacy and security into the health IT framework. While most of the
structure is built at this point, CBC is continuously developing and changing security
measures and protocols to give patients greater control in directing how their
information is shared. Currently, CBC bases privacy of patient information on the
“trust fabric” articulated by ONC to define the types of relationships required for
patient information to be shared within the medical neighborhood community. Both
patients and providers can choose whether to share their information through the
HIE. Even though the system is evolving, Schilz finds that patients are still
comfortable sharing information due to the great level of community involvement
that CBC has fostered. As Schilz describes, “Many of the concerns about privacy
and security are about the ‘what if’ scenarios.” Therefore, the HIE has gone into
many communities and maintained conversations about the purpose and goals of a
community HIE on a regular basis so that people understand how the information
will be shared and the benefits of information sharing for the health and quality of
care .
CBC has made great efforts to include the community in the development and
implementation of care coordination, and it is now able to highlight examples of the
success of its community-based model. For example, hospital readmission rates for
adult Medicaid patients within the area served are approximately 50% lower than
readmission rates for the Medicaid population statewide. However, Gordon
emphasizes the difficulty in drawing correlations between tracked metrics and
changes in the quality and cost of care at the community level, calling it a
“significant intellectual undertaking.”
Additionally, while CBC strives to align data tracking with Meaningful Use
guidelines, many practices are still in the process of upgrading to Meaningful Use
systems. Even when practices have upgraded their EHR systems, the associated
reporting modules often are not. Furthermore, while EHR systems may be certified
in general for Meaningful Use, they often have not been certified for all measures.
Currently, CBC collects information on nine Meaningful Use measures aligned with
previous PQRI initiatives. However, because practices differ in their ability to
provide any or all of the tracked measures, it is difficult to uniformly collect and
analyze data.
When offering advice to other communities looking to establish care coordination,
Schilz underlines that all healthcare is local, recommending to look first to the
existing resources and characteristics of the community and the practices within in
it, before establishing the technical framework. Once the core elements, needs, and
challenges of the community are understood, the technology can then be
implemented in a way that maximizes community support and uses data to engage
the community and show successes. Gordon also adds that care coordination must
41
involve a mix of clinical and non-clinical staff that have the ability and aptitude to
create trusting relationships within the community.
Overall, CBC demonstrates that while the process of modernization needs to be
supported by technology, the patient
Beacon Community of the Inland Northwest
While many Beacon Programs are based in predominantly urban areas, the Beacon
Community of the Inland Northwest (BCIN) has built upon pre-existing health
information technology infrastructure to become a model for establishing care
coordination in rural America.
Serving largely rural communities in eastern Washington and northern Idaho, the
BCIN was formed in May of 2010 with the goal of increasing care coordination for
patients with type 2 diabetes in rural areas. As a rural Beacon Community, BCIN
faces the challenge of establishing care coordination across a large region where
patients often move from small rural practices to specialists in urban centers.
However, unlike many other rural areas, the participating BCIN communities are
uniquely positioned to expand care coordination because of previous investments in
health information technology.
Prior to receiving the Beacon grant, 60% of practices in the BCIN region had
electronic medical systems and the majority of hospitals already used advanced
information systems and participated in some data exchange. With critical
infrastructure already in place, BCIN targeted provider-to-provider communication
to increase care coordination over time. The new system facilitates information
sharing and can send alerts to primary physicians when a patient receives care at
another provider or facility. In the future, BCIN plans to add tools and capabilities
that will improve the downstream flow and sharing of information with patients to
ultimately increase patient engagement.
While the infrastructure being implemented can support any type of care
coordination and health information exchange, due to the large service area and
number of participating organizations BCIN has chosen to focus on tracking
measures for type 2 diabetes to assess the progress in attaining consistent care
across the region. Given its high prevalence in the community and the common
acceptance of best practices for disease management among providers, diabetes
was a natural choice. As Jac Davies, the Director of BCIN, explains, in establishing
care plans and quality measures “We didn’t have to convince people what are the
right things to do; we just needed to make it easier for everyone to do it.”
Care coordination involves not only facilitating access to patient information among
providers, but also assuring that the patient is receiving the right care. BCIN is
42
using their health IT infrastructure to support their care coordination goals in
multiple ways: sharing data among all members of the patient’s care team,
facilitating access to evidence-based medical practices, and providing quality
measurement reports. The shared data includes clinical data, procedures,
diagnoses, demographic information, and clinical outcomes. To promote use of
evidence-based medical practices, BCIN has integrated advanced care coordination
algorithms into the Orion Technology Solution™ that has been implemented as the
information technology foundation for the program. The Orion technical solution
includes a HIE, a clinical data repository and the ability to support disease
management pathways. Through the functionality of the Orion tool set, healthcare
providers within BCIN are able to create care plans based on an individual’s disease
status. For instance, when tracking type 2 diabetes, patients who successfully
manage their weight and other symptoms will receive recommended care that
differs from patients with critical health problems.
In striving to increase communication among providers, BCIN has included
community-based pharmacists in the system because pharmacists often see
patients much more often than physicians do. However, BCIN must first establish
the appropriate level of involvement for pharmacists in care coordination. For
instance, BCIN must decide if it is appropriate for pharmacists to use patient
records to remind patients of overdue health exams when they fill a prescription.
Determining the appropriate level of access is part of the larger process of
protecting patient privacy in health information exchange. The BCIN security
framework includes both role-based and relationship-based limits on access to a
patient’s information. As such, a provider must have a logical clinical relationship to
a patient in order to access medical records and a physician would receive greater
access than a medical assistant. The system continuously audits information access
to ensure the highest level of security.
Over time, BCIN intends to incorporate care coordination for additional disease
states. However, after having spent the last year developing the policy and
technology framework, BCIN will focus for now on implementation and evaluation,
to show improvements in the quality and cost of care for diabetes management.
Davies admits that setting up a community-based care coordination system has
been hard. As she explains, “What’s making it more difficult than it might have
been three years ago are all of the various initiatives to advance the use of
information technology. There are delays in getting clinics in the program because
they’re trying to upgrade their EHRs to meet Meaningful Use. Also after the
introduction of ACO regulations, everyone’s been trying to figure out how they will
realign with everyone else.”
43
Given the many challenges that physician offices face in aligning their health IT
systems with federal and state initiatives, Davies states that successful community
initiatives must help physicians understand the added value of participation in care
coordination and health information exchange programs. Establishing regional care
coordination has been a difficult process, but Davies looks forward to seeing
increased quality and efficiency of care in the rural communities
JWCH Institute
JWCH Institute, Inc. is also a 501(c)(3) community health center that was
established at the Attending Staff Association of the John Wesley County Hospital in
1960 by Los Angeles County physicians. The agency’s current mission is to
improve the health and wellness of under-served groups of the population of Los
Angeles County through the direct provision or coordination of healthcare, health
education services and research. The organization works through a variety of
programs and activities, such as:
•
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•
•
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medical outreach and referrals for medical care
HIV services and drug treatment
health education
psychosocial assessment and intervention
primary medical care
family planning services
research
Homelessness has become a major factor in the resurgence of tuberculosis (TB)
within the United States over the past two decades. This social status is associated
with an increased risk of exposure to Mycobacterium tuberculosis, undetected and
untreated infection, and subsequent progression to TB disease. Homeless persons
with TB are more likely to be hospitalized longer than non-homeless persons, with
the public sector paying most of the costs. In 2010, there were 11,182 (per
100,000 population) cases of TB reported within the US, with 10,541 of those cases
being reported by State health departments as coming from individuals classified as
homeless. The highest concentration of homeless individuals diagnosed with TB
was identified as California.
The Skid Row Homeless Healthcare Initiative (SRHHI) was a partnership of 26
agencies that strove to integrate services, reduce suffering and improve the health
of homeless people in and around the community of Central City East. It is
estimated that 8,000 to 10,000 homeless people reside in a 52-block area of
downtown Los Angeles known as Skid Row. Located less than a mile east of the
center of downtown Los Angeles, the homeless that are assembled in this area have
access to emergency shelters, transitional and permanent housing, social and
medical services, and food provided by a cluster of agencies that serve the largest
44
homeless community in the United States. The vision of the SRHHI was “to reduce
the suffering of homeless people in and around the Skid Row community of
downtown Los Angeles by improving their overall health through increased access
to integrated services” and its mission was “to design and implement a coordinated
system of care for Skid Row.”
The JWCH Institute is a partner within the SRHHI and took on the development of a
community project to create a TB Registry that is an IT system that allows medical,
social service, and housing providers access to shared TB records to provide a
medical home, coordinate services and reduce unnecessary duplication. JWCH
chose OpenMRS, a community-developed, open-source, enterprise electronic
medical record system framework. JWCH funded WebReach, Inc., to develop a
customized version of OpenMRS, which is named OpenMRSLA and included a TB
module to help track the status of the homeless population they serve.
JWCH also created a comprehensive data sharing agreement with the Los Angeles
Department of Social Services and the Department of Housing and gave authorized
users access to OpenMRSLA so that they could identify where an individual was
currently living, what medical program (such as Medi-Cal or HealthyWay LA they
were on or eligible for, and whether their TB status was current. It represented the
most comprehensive agreement at the time and allowed for the coordination of
medical and housing services for the homeless in addition to managing a prevalent
and costly chronic condition. Although at the time of the site visit there was limited
information on the effectiveness of the program, the information gathered through
the medical directors at JWCH indicated that they felt that over 75% of their patient
population was in OpenMRSLA and that each of them was current on their TB
vaccinations.
Montefiore Medical Center
Located in the heart of New York City, the Montefiore Medical Center (Medical
Center) is a shining example of a healthcare provider organization that places a
unique focus on chronic care management, research, and community outreach.
Montefiore Medical Center is a large healthcare organization that includes four
hospitals with a combined 1,491 beds, 21 community-based primary care clinics, 17
school-based clinics offering medical, mental, and dental health services, and a care
management organization responsible for the health of 150,000 at-risk enrollees in
capitated contracts. Montefiore manages a wide range of patient populations,
including Medicare, Medicaid and commercial beneficiaries located throughout the
greater New York City metropolitan area.
To manage this large and diverse population, the Medical Center has a rich history
of care coordination that takes advantage of its elaborate health IT system, which
45
has been in use for more than a decade. This clinical information system includes
an EHR, inpatient, ambulatory, laboratory, imaging and pharmacy functionalities, a
data warehouse and a patient portal.45 The comprehensive system links the entire
medical center through online patient care and business databases. Through the
health IT infrastructure, Montefiore providers can use clinical variables, laboratory
information, medication list summaries, discharge plans, and other clinical data to
identify patients suitable for care management plans and to measure patient
outcomes. Additionally, the Medical Center has an advanced telemonitoring system
for intervention services. Combined, these systems can automatically flag patients
who require special supervision or would benefit from a specialized care plan.
Overall, Montefiore utilizes a patient centered medical home model to direct its care
coordination efforts. Under this model, providers can comprehensively assess
patient populations to determine problem areas and devise targeted care plans to
address them. Various departments throughout the center are integrated into care
coordination activities. For example, the ambulatory department has begun
connecting with inpatient and acute care services through the EHR system.
The efforts of Montefiore’s pharmacy department are strongly representative of the
center’s care coordination activities. The department is composed of a centralized
pharmacy with six satellite pharmacies at other locations. However, this separation
has not prevented the department from taking an active role in the care of patients.
After installing automatic medication dispensers in each nursing unit, pharmacists
have been able to provide more direct patient care, such as counseling patients that
are non-compliant or have particularly complicated medication regimens. The
automatic dispensers have made it possible for many patients to no longer rely on
pharmacists, allowing them to devote time to work within interdisciplinary care
teams. Using wireless laptop technology, pharmacists can also order prescriptions
to provide patients with the appropriate medication at the point of care.
Similarly, the home healthcare agency has worked to successfully coordinate care.
Qualified patients are referred to homecare aides upon discharge from the hospital.
The home healthcare aides help patients reconcile medical information, attend
follow-up procedures, and help coordinate next steps. The aides use a variety of
health IT solutions to help care for patients. Wireless enabled laptops facilitate realtime health information updates, serve as a means for the aides to communicate
with a patient’s care team to ensure patient compliance with their discharge plan,
and can be used to educate the patient about medication reconciliation. Telehealth
technologies play a similar role, and are used primarily within populations with
heart failure or diabetes. Home healthcare aides can use telehealth tools to send
reports to a patient’s doctor on a regular basis, while doctors can use telehealth to
follow-up on a patient’s care.
46
Patient engagement is an important component of the Medical Center’s care
coordination efforts. Patients have access to over 35,000 resources with
information on disorders, disease, wellness, medications, and more. Patient
education tools are available in both Spanish and English to account for diversity in
Montefiore’s patient population. Notably, Montefiore also offers an online patient
portal, called MyMontefiore™. MyMontefiore™ enables patients to schedule
appointments, access educational materials connect with their healthcare providers,
request medication refills, and manage their chronic conditions. Currently, over
50,000 patients use MyMontefiore™.
Likewise, Montefiore performs extensive patient outreach through the Bronx
Regional Health Information Organization (RHIO). The system is connected to a
number of community outreach centers, such as shelter services. When a
Montefiore patient is admitted to a shelter, the provider who last saw the patient
receives an alert, which allows the provider to coordinate care between the shelter,
hospital, and provider and manage the patient’s illness outside of the medical
center. Additionally, the health IT system has functionalities that enable the
emergency department to identify at-risk patients who need special case
management services as soon as they reach the hospital.
The Medical Center’s health IT system has been a necessary component at the
center of all care coordination activities. It is also especially important to the way
Montefiore manages transitions of care. Montefiore’s EHR system prompts providers
with a standard set of questions to help devise a care plan following post-acute
care. These care plans have helped the Medical Center demonstrate significant
reductions in in the readmission rate and have standardized the discharge summary
process for Montefiore’s patient population. Montefiore is partnered with payers and
two other healthcare organizations in its care transitions program. Along with the
care plan and discharge summary, staff are trained in a consistent manner and
have standard data collection tools which allows participants to communicate
effectively across organizations.
Montefiore Medical Center has a rich and bright future, with continued efforts in
care coordination activities. Montefiore is moving ahead to become an accountable
care organization, built upon the relationships developed through the Bronx RHIO
and surrounding community organizations, in order to provide even better care at
affordable costs.
Health Information Technology in the Louisiana Behavioral Health
Partnership
The Louisiana behavioral health service system has historically been characterized
as fractured and heavily dependent on the most restrictive and costly levels of care
such as inpatient hospitalizations and residential levels of care. For adults with
47
serious behavioral health disorders, the service delivery system offered stark
contrasts. Adults could access community-based providers, who offered a limited
array of services or inpatient care at the point of crisis. For children, the behavioral
health service system spanned multiple child-serving departments, which were in
silos and unable to effectively coordinate services. Many of the service system
weaknesses were driven by inflexible funding options in the Medicaid behavioral
health program as well as fractured state general fund and federal grant financing
streams. The limited communications and lack of centralized electronic
coordination compounded problems and often led to duplication and inefficiencies.
To modernize the Louisiana behavioral health system, the State has undertaken a
comprehensive and far reaching reform. Entitled the Louisiana Behavioral Health
Partnership (LBHP), the State’s new behavioral health system includes:
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A statewide managed care entity to authorize and manage hospital and
community-based behavioral health services;
An expanded package of community-based psychiatric rehabilitation services
to those with chronic mental illness;
An array of wraparound services to support children at risk for out-of-home
placement;
An expansion of services under Medicaid to provide for addictive disorders
treatment;
An expansion of coverage of services by independent licensed providers in
the community; and
The establishment of evidence-based practices.
The development of the Coordinated System of Care (CSoC) to serve 2,500 children
most at risk or in out-of-home placement has been a hallmark of development
within the overall LBHP system. The CSoC concept in Louisiana is unique in that it
involves a formal collaboration and commitment from the four critical child-serving
agencies: Department of Children and Family Services (DCFS), Office of Juvenile
Justice (OJJ), Department of Education (DOE), and the Office of Behavioral Health
(OBH). Each of the child-serving agencies contributes funding that has been
aggregated in order to better leverage federal Medicaid resources and even more
importantly allows for a streamlined and coordinated approach to managing and
directing the care of children with complex behavioral health needs.
To effectively coordinate care in a fractured system, the Louisiana behavioral health
providers will use Magellan’s Clinical Advisor application, built upon the ClaimTrak
platform. This application will offer providers a Web-based, fully customized
electronic health record designed specifically for the use by the behavioral health
profession. The new health IT solution will be available to up to 5,000 Louisiana
licensed behavioral health providers who do not currently have an EHR application,
48
this will give them the advantages of greater data functionality without additional
infrastructure investment for their practices.
Magellan has committed to fully certifying its EHR by the Office of the ONC
Accredited Certifying Body within one year of implementation. Providers and the
vendor will continue to improve their Meaningful Use of the system under the
Medicaid and Medicare EHR Incentive programs. Central to Meaningful Use is the
ability for clinical data to be shared between disparate care settings and providers.
Clinical Advisor will interface with the Louisiana Health Information Exchange
(LaHIE) to allow the sharing of a CCD. Through LaHIE, behavioral health providers
will be able to directly download physical health clinical data to their EHR (if they so
choose). The system offers role-based functionality for multiple staff groups
including prescribers, nurses, residents, case managers, behavioral health
specialists, therapists, and administrative and executive level staff.
The Louisiana Department of Health and Hospitals care management program goal
is to support members in achieving their optimal level of wellness and health, and
improve the coordination of care. The EHR and care management teams are the
mechanisms by which this coordination is possible. Every aspect of the patient’s
progress can be reviewed and documented using Clinical Advisor. With easy-tonavigate tabs, categorized elements, and automated on-screen processes the taskfocused process notes offers a convenient way to document clinical services and
patient information. As Louisiana continues to improve health outcomes through
the use of better health information technology, this critical information will be
shared as appropriate across a broad range of healthcare settings giving healthcare
providers the data they specifically need.
Oregon’s Medicaid Transformation
As part of a larger plan to reduce spending and reform state programs in Oregon,
the Health System Transformation Team, composed of a bipartisan group of
legislators and stakeholders, has developed a strategy to transform the Oregon
Health Plan (OHP), Oregon’s Medicaid program. The goal of the reform process is
to deliver better care in a more integrated system while controlling costs.46
The result of the state’s initiative is a new model of care for the Oregon Health
Plan.47 The existing Medicaid Managed Care Organizations (not-for-profit HMOs
that cover OHP members) will be phased out and replaced by new entities, called
Coordinated Care Organizations (CCOs), which will consist of and be governed by,
networks of doctors, hospitals, dentists, community health workers, county mental
health departments and any other providers necessary to deliver physical, mental
and oral health services. The new CCOs will assume responsibility for the care of a
defined population under a global budget that will grow at a fixed rate. This model
is very similar to the Accountable Care Organization model that Medicare has
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implemented as part of the Affordable Care Act, although Medicare will use a
shared savings model rather than a global budgeting system. Nevertheless, the
proposal envisions that each CCO will be held accountable for the health outcomes
of its assigned population and will be expected to effectively coordinate care, with
an emphasis on adoption of patient-centered primary care homes and intensive
care management for dual eligibles.
Oregon will request a federal waiver to combine Medicare payments for the dual
eligible population with Medicaid funds to form the global budgets of the
Coordinated Care Organizations. Once the CCOs has been established and are
demonstrating the ability to integrate care and control costs, there is interest in
opening them to the healthcare plans of public employees and the individual and
small group insurance markets. In the longer term, the hope is that CCOs will be
successful enough that large group and self-insured plans would participate.
The legislature approved the plan with bipartisan support in mid-2011. The set of
criteria that CCOs are required to meet is under development, along with other
features of Oregon’s Medicaid transformation, including quality metrics that CCOs
will be held accountable for meeting, a methodology for establishing global
budgets, and a plan for integrating care for dual eligibles. Workgroups, composed
of stakeholders from throughout the Oregon healthcare system, including providers,
health plans, hospitals, academics, advocates and government officials, are helping
the Oregon Health Authority to specify these details.48 Implementation plans must
be presented to and approved by the legislature during the February 2012 session.
The first CCOs would become operational in mid-2012, pending CMS approval.
The Medicaid reform legislation, HB 3650, mandates that CCOs require their
healthcare providers to communicate with each other and coordinate care with the
primary care home using health IT, although a period of transition is allowed.49
Initially, CCOs are expected to document their health IT and health information
exchange infrastructure, develop a plan to establish the capability to transmit
patient information in real time from the primary care home to the rest of the
healthcare delivery system so care is coordinated, and makes progress toward that
goal. Assessments of each CCO may include the percent of providers with EHR
systems and the percent that have achieved Meaningful Use.50
The stakeholder workgroups charged with developing criteria and outcome
measures for CCOs are considering several provisions on health IT, emphasizing
those CCO participants must have access to electronic information in order to
successfully coordinate care.51 The draft proposes that CCOs be expected to
facilitate EHR adoption and Meaningful Use among providers, and that all CCO
providers must be part of a direct-enabled Health Information Service Provider or
Health Information Organization that allows it to electronically share information
50
with any other provider in the CCO. In the future, minimum rates for EHR and HIE
adoption, including rates for e-prescribing and electronic lab orders, should be
considered by the Oregon Health Authority. Additionally, the CCOs themselves
should have the technical capacity to assess provider performance using patientlevel data, using the analytics to improve care coordination, and report data on care
quality electronically to the Oregon Health Authority. The CCOs will also be
responsible for ensuring that patients have access to information technology that
enables them to participate in coordination of their own care, while identifying and
implementing future tools, such as telemedicine and smart phone apps, to improve
care delivery and coordination.
Ensuring the technical infrastructure necessary to achieve this vision will be
difficult. Carol Robinson, Oregon’s top health IT administrator, testified before the
work groups about the challenges that CCOs will face. 52 While hospitals and large
health systems are implementing EHR systems, they are far less available in
Oregon’s small practices. Federal incentive programs will not help all CCO
participants with the cost of implementing health IT, including behavioral health
and long term care providers. Additionally, Robinson emphasized that health
information exchange is essential for the CCO model, and that progress in
deploying HIE has been slower than expected. Oregon has pursued a federated
model of local HIEs, rather than a central statewide system. This poses the risk
that CCOs in some communities may lack access to a functional HIE. Initially,
these CCOs will need to rely on Direct secure email in order to coordinate care.
The healthcare reform model that Oregon has chosen for its Medicaid program is
dependent on robust health IT systems at the provider and regional HIE levels. A
significant risk to the success of CCOs would be the lack of ability to implement the
necessary health IT infrastructure in order to maximize the ability of providers to
coordinate care. The EHR incentive program will help provide the resources to
develop this infrastructure, but it is unclear how some providers, such as mental
health and long term care, will be able to afford to connect electronically with the
primary care home. Alignment with the Medicare ACO model will enhance the value
proposition for these investments, as health IT will be a critical tool for establishing
a successful Medicare ACO as well.
Glossary
51
Accountable Care Organizational Model (ACOM)
• A group of healthcare providers (e.g. primary care physicians, specialists
and hospitals) that have entered into a formal arrangement to assume
collective responsibility for the cost and quality of care of a specific group of
patients and that receive financial incentives to improve the quality and
efficiency of healthcare. The term accountable care organizational model is
intended to include provider and Center for Medicare and Medicaid
supported entity.
o Source: http://www.rwjf.org/qualityequality/glossary.jsp
Acute care
• Short-term medical treatment, most often in a hospital, for patients who
have a severe illness or injury, or are recovering from surgery
o Source: http://www.rwjf.org/qualityequality/glossary.jsp
Advance healthcare directive or advance directive
• A written instructional healthcare directive and/or appointment of an agent,
or a written refusal to appoint an agent or execute a healthcare directive.
This document is employed to extend patient autonomy into the period in
which the patient has lost the ability to make decisions for him or herself.
o Source: http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm#term
At-risk population
• At risk populations include individuals that have “Diabetes, hypertension,
ischemic vascular disease, heart failure, coronary artery disease, and mental
health or substance abuse disorder, in addition to health disparities affecting
racial and ethnic populations.
o Source: http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/201127461.pdf
Audit Log:
• Computer files containing details of amendments to records, which may be
used in the event of system recovery being required. The majority of commercial
systems feature the creation of an audit log. Enabling this feature incurs some
system overhead, but it does permit subsequent review of all system activity,
and provide details of: which User ID performed which action to which files when
etc. Failing to produce an audit log means that the activities on the system are
'lost'.
o Source:
http://www.seattle.gov/informationsecurity/glossary_A.htm#Audit Log
Beneficiary
52
•
An individual enrolled in a health insurance plan and receives benefits
through those policies.
o http://www.healthinsurance.org/glossary/
Bidirectional Communication
• As a part of care coordination, healthcare practices seek to involve individuals
more directly in managing their own health, and individuals become more
knowledgeable and interact with practices in new ways.
o Source: Kilo, C.M. and Wasson, J.H. (2010). Practice redesign and the
patient-centered home: history, promises, and challenges. Health
Affairs. 29(5): 773-778.
Bundled Payment
• A reimbursement model that links payments for multiple services patients
receive during an episode of care.
o Source: http://innovations.cms.gov/documents/pdf/Fact-SheetBundled-Payment-FINAL82311.pdf
Capitation
• Rate paid to a health plan or provider for services based on a fixed monthly
or yearly amount per person, no matter how few or many services a
consumer uses.
o http://www.ct.gov/oha/cwp/view.asp?a=2277&q=299920
Care
• Services rendered by members of the health professions for the benefit of a
patient. This is inclusive of diagnosis, follow up, and health maintence
treatments.
o Source: http://www.cms.gov/manuals/Downloads/bp102c16.pdf
Care Coordination
• The deliberate organization of patient care among two or more participants,
inclusive of the patient, to facilitate the appropriate delivery of healthcare
services. Care coordination involves the organization of people and other
resources necessary to carry out all required patient care activities, and is
managed by the exchange of information among participants responsible for
different aspects of care.
o Source: http://www.ahrq.gov/qual/careatlas/careatlas2.htm
Care Plan
53
•
Usually a written medical and/or nursing care program designed for an
individual patient.
o Source: http://www.ncbi.nlm.nih.gov/mesh/68010347
Care Site
• Setting in which an individual receives treatment for non-emergency
conditions. The site could be a physician office, retail clinics, urgent care
center, or emergency room.
o Source: Weinick R. M., Burns R. M. and Mehrotra A. (2010). Many
emergency department visits could be managed at urgent care centers
and retail clinics. Health Affairs. 29(9):1630–1636.
Care Team
• Care of patients by a multidisciplinary team, inclusive of pathologist, home
care aids and specialists, usually organized under the leadership of a
physician; each member of the team has specific responsibilities and the
whole team contributes to the care of the patient.
o Source: http://www.ncbi.nlm.nih.gov/mesh/68010348
Care Transitions
• The movement patients make between healthcare practitioners and settings
as their condition and care needs change.
o Source: http://www.caretransitions.org/definitions.asp
Caregiver
• Persons who provide care to those who need supervision or assistance in
illness or disability. They may provide the care in the home, in a hospital, or
in an organization. Caregivers include trained medical, nursing, and other
health personnel, as well as, parents, spouses, or other family members,
friends, members of the clergy, teachers, social workers, and fellow patients.
The definition caregiver also encompasses family caregivers. Family
caregivers are friends and any other unpaid people caring for the patient and
acting as a patient advocate.
o Source: http://www.ncbi.nlm.nih.gov/mesh?term=caregiver
Capitation
• A health insurance payment mechanism in which a fixed amount is paid per
person to cover services; a fixed, per capita (per head) payment.
o Source: http://www.aarc.org/advocacy/resources/glossary.html
Case Manager
• Provides monitoring and coordination of the delivery of health services for
individual patients to enhance care and manage costs. Used for patients with
specific diagnoses or who require high-cost or extensive healthcare services.
o Source: http://www.aarc.org/advocacy/resources/glossary.html
Chronic Care
54
•
The continuum of care required over a prolonged period of time for people
who have lost, or never acquired, functional abilities. Types of care can
include medical care, rehabilitative care, and personal assistance.
o Source:
http://www.rwjf.org/files/publications/other/ChronicCareinAmerica.pdf
Clinician
• A professional directly providing healthcare services.
o Source: http://www.ctri.wisc.edu/Home/Glossary.html
Clinical Decision Support
• A process for enhancing health-related decisions and actions with pertinent,
organized clinical knowledge and patient information.
o Source: http://www.himss.org/ASP/topics_clinicalDecision.asp
Consent Management:
• Giving patients appropriate control over their personal health information and
how it is collected, used, and shared.
o Source:https://www.ccim.on.ca/Documents/CPF/Consent_Managemen
t_Implementation_guide_v1.1_20110602_CPF.pdf
Core Data Elements
• Specific clinical measures that, when viewed together, permit a robust
assessment of the quality of care provided in a given focus area.
o Source: http://www.rwjf.org/qualityequality/glossary.jsp
Community-based Organization
• A public or private nonprofit (including a church or religious entity) that is
representative of a community or a significant segment of a community, and
is engaged in meeting human, educational, environmental, or public safety
community needs.
o Source: http://nnlm.gov/sea/funding/cbodef.html
Continuum of Care:
• The provision of coordinated healthcare services that encompass preventive
care, primary care, acute care, chronic care, rehabilitative care and supportive
care so as to maximize the value of services received by patients.
o Source:http://www.stonybrookmedicalcenter.org/patientcare/healthed
ucation/glossary#C
Dietician
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•
Individuals that plan food and nutrition programs, supervise meal
preparation, and oversee the serving of meals.
o Source: http://www.bls.gov/oco/ocos077.htm
Downside Risk
• Spending that exceeds a target expenditure.
o Source:
http://www.commonwealthfund.org/~/media/Files/Publications/Fund
%20Report/2011/Jul/1530Delbancopromisingpaymentreformrisksharin
g%202.pdf
Electronic Health Record(EHR)
• A computerized medical file that contains the history of a patient's medical
care.
o Source: http://www.rwjf.org/qualityequality/glossary.jsp
Emergency Care
• Evaluation and treatment of an illness, injury, or condition that needs
immediate medical attention in an emergency room.
o http://www.healthcare.gov/glossary/e/emergency-room.html
eTool:
• Health informatics tools that help patients and consumers make decisions
about screening and treatment. These tools provide treatment- and diseasespecific health information to patients, especially when facing choices among
ways to treat and manage their health conditions.
o Source: http://www.ahrq.gov/research/rtisumm.htm
Fee-for-Service (FFS)
• A method of paying healthcare providers for individual medical services
rendered where a provider bills for each patient encounter or service.
o Source: http://www.aarc.org/advocacy/resources/glossary.html
Global Payment
• A single per-member per-month payment is made for all services delivered
to a patient, with payment adjustments based on measured performance and
patient risk.
o Source:
http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/
RAND_TR841.pdf
Health and Human Services (HHS):
56
• The United States government’s principal agency for protecting the health of
all Americans and providing essential human services, especially for those who
are least able to help themselves.
o Source: http://www.hhs.gov/about/
Health Information Exchange (HIE)
• The electronic movement of health-related information among organizations
according to nationally recognized standards
o Source:http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_1
0741_848133_0_0_18/10_2_hit_terms.pdf
Health Information Technology (health IT)
• The use of computers, software programs, electronic devices, and the
Internet to store, retrieve, update, and transmit information about patients'
health.
o Source: http://www.rwjf.org/qualityequality/glossary.jsp
Healthcare Literacy
• The degree to which individuals have the capacity to obtain, process, and
understand basic health information, needed to make appropriate health
decisions
o Source: http://www.health.gov/communication/literacy/
Healthcare Provider
• Provider of medical or health services and any other person or organization
who furnishes, bills, or is paid for healthcare in the normal course of
business.
o Source: http://www.hipaa.com/2009/05/the-definition-of-health-careprovider/
Healthcare Proxy
• A document in which an individual appoints someone else to make healthcare
decisions on his behalf if he becomes physically or mentally incapacitated or
unable to communicate with medical professionals
o Source:
http://www.invesco.com/portal/site/us/menuitem.b69c4947bbe878dc
3e5669
j43acd8fba0/#H
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
57
•
The HIPAA Privacy Rule provides federal protections for personal health
information held by covered entities and gives patients an array of rights
with respect to that information.
o Source:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html
HITECH Act:
• The Health Information Technology for Economic and Clinical Health
(HITECH) Act, enacted as part of the American Recovery and Reinvestment
Act of 2009, was signed into law on February 17, 2009, to promote the
adoption and meaningful use of health information technology.
o Source:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule
/hitechenforcementifr.html
Homecare
• Healthcare services and supplies a doctor decides you may get in your home
under a plan of care established by your doctor.
o Source: http://www.healthcare.gov/glossary/h/homehealthcare.html
Home Health Aide
• Individuals that provide essentially the same care and services as nursing
assistants, but they assist people in their homes or in community settings
under the supervision of a nurse or therapist. They may also perform light
housekeeping tasks such as preparing food or changing linens.
o Source:
http://www.directcareclearinghouse.org/download/NCDCW%20Fact%2
0Sheet-1.pdf
Hospice
• Facilities or services which are especially devoted to providing palliative and
supportive care to the patient with a terminal illness and to the patient's
family.
o Source: http://www.ncbi.nlm.nih.gov/mesh/68006738
Hospital
• Institutions with an organized medical staff which provide medical care to
patients.
o Source: http://www.ncbi.nlm.nih.gov/mesh/68006761
Information System:
58
• A set of interrelated components work together to collect, retrieve, process,
store and disseminate information for the purpose of facilitating planning,
control, analysis, coordination and decision-making in business and other
organizations
o Source: http://www.uotechnology.edu.iq/depcs/english/subjects/1pis.pdf
Interoperability
• The ability of health information systems to work together within and across
organizational boundaries
o Source: http://www.himss.org/ASP/topics_integration.asp
Insurance:
• Financial protection against all or part of the medical care costs to treat
illness or injury. Includes traditional fee-for-service health plans, preferredprovider health plans, health maintenance organizations (HMO's),
commercial Medicare supplements, and other health insurance.
o Source: http://www.health.state.mn.us/clearinghouse/glossary.htm
o Source: http://www.bls.gov/cex/csxgloss.htm
Longitudinal View of Care
• Continuous and comprehensive observation or examination of a patient’s
health and medical treatments over an extended period of time that includes
preventive care and care coordination.
o Source: Saultz, J.W. (2003). Defining and measuring interpersonal
continuity of care. Annals of Family Medicine. 1(3): 134-143.
Long-Term Care
• Services that help people with their medical and non-medical needs over a
period of time
o Source: http://www.medicare.gov/Glossary/l.html
Managed Care
• An approach to health system reform in which health plans compete to
provide health insurance coverage for enrollees. The system relies on market
incentives (namely more subscribers and revenue) to encourage healthcare
plans to restrain the cost of care. Typically, enrollees sign up with a
purchasing entity that buys the services of competing health plans. Enrollees
are provided a choice among the contracting health plans.
o Source: http://www.aarc.org/advocacy/resources/glossary.html
Meaningful Use
59
•
Medicare and Medicaid EHR Incentive Programs for providers requiring proof
of the use of certified EHR technology in ways that can be measured
significantly in quality and in quantity.
o Source:https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_
Use.asp
Medicaid
• A joint federal and state insurance program for eligible individuals with
limited income and resources
o http://www.medicare.gov/Glossary/m.html
Medical Record History:
• The documentation of a patient's past medical conditions and care.
o Source:
http://people.westminstercollege.edu/students/ncb0708/Program%20
Files/FA%20Davis/Fundamentals%20of%20Nursing%20ESG/glossary/
m.htm
Medicare
• The federal health insurance program for people who are age 65 or older,
certain younger people with disabilities, and people with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a transplant,
sometimes called ESRD).
o http://www.medicare.gov/Glossary/m.html
Mental Health Professional
• A licensed individual, including psychiatrists, clinical psychologists, clinical
social workers, psychiatric nurse specialists, and marriage and family therapists,
who provides counseling interventions designed to facilitate individual
achievement of human development goals and remediate mental, emotional, or
behavioral disorders, and associated distresses which interfere with mental
health and development.
o Source:
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealth
hpsaguidelines.html
National Committee for Quality Assurance:
•
An organization that provides information to allow purchasers and consumers
of managed healthcare to compare plans.
o
Source: http://www.ct.gov/oha/cwp/view.asp?a=2277&q=299920
60
National Quality Forum (NQF):
• The National Quality Forum (NQF) is a nonprofit organization that operates
under a three-part mission to improve the quality of American healthcare
by: building consensus on national priorities and goals for performance
improvement and working in partnership to achieve them; endorsing national
consensus standards for measuring and publicly reporting on performance; and
promoting the attainment of national goals through education and outreach
programs.
o Source: http://www.qualityforum.org/About_NQF/About_NQF.aspx
National Quality Strategy (NQS):
• An initiative to increase access to high-quality, affordable healthcare for all
Americans established by the Affordable Care Act and directed by the
Department of Health and Human Services that pursues three broad aims at the
local, state, and national level to provide better care, foster healthy
people/communities, and ensure affordable care.
o Source: http://www.ahrq.gov/workingforquality/nqs/
Nurse Practitioner (NP)
• A registered nurse specially educated and licensed to provide primary and/or
specialty care.
o Source: http://www.health.state.mn.us/clearinghouse/glossary.htm
Palliative Care
• Care provided primarily to relieve symptoms of a disease or condition rather
than for curative purposes
o Source: http://www.va.gov/healtheligibility/Library/Glossary/#p
Patients
• Individuals participating in the healthcare system for the purpose of receiving
therapeutic, diagnostic, or preventive procedures
o Source: http://www.ncbi.nlm.nih.gov/mesh/68010361
Patient-Centered Care
• A healthcare model in which patients become active participants in their own
care and receive services designed to focus on their individual needs and
preferences, in addition to advice and counsel from health professionals
o Source: http://www.ahrq.gov/qual/ptcareria.htm
Patient-Centered Medical Home
61
•
A team-based model of care led by a personal physician who provides
continuous and coordinated care throughout a patient's lifetime to maximize
health outcomes
o Source:
http://www.acponline.org/running_practice/pcmh/understanding/what
.htm
Patient Engagement
• Process through which an individual participates in his or her own healthcare
by harmonizing robust information and professional advice with their own
needs, preferences and abilities in order to prevent, manage, and cure
disease.
o Source: Center for Advancing Health paper entitled, “A new definition
of patient engagement: what is engagement and why is it important”,
http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_2
010.pdf
Patient Protection and Affordable Care Act:
• The Patient Protection and Affordable Care Act (ACA) was signed into law on
March 23, 2010. Essentials of ACA include: 1) a mandate for individuals and
businesses requiring as a matter of law that nearly every American have an
approved level of health insurance or pay a penalty; 2) a system of federal
subsidies to completely or partially pay for the now required health insurance
for about 34 million Americans who are currently uninsured – subsidized
through Medicaid and exchanges; 3) extensive new requirements on the
health insurance industry; and 4) numerous regulations on the practice of
medicine.
o Source: Laxmaiah Manchikanti, David Caraway, Allan T. Parr, Bert
Fellows, and Joshua A. Hirsch. (2011). Patient Protection and
Affordable Care Act of 2010: Reforming the Healthcare Reform for the
New Decade. Pain Physician Journal. 14:35-67.
Pay-for-Performance:
• Health-care payment systems that offer financial rewards to providers who
achieve, improve, or exceed their performance on specified quality, cost, and
other benchmarks. Most approaches adjust aggregate payments to
physicians and hospitals on the basis of performance on a number of
different measures. Payments may be made at the individual, group, or
organizational level. Performance may be measured using benchmarks or
relative comparisons. Generally, there are three types of performance
measures: structure, process, and outcome.
62
o
Source:
http://www.massmed.org/AM/Template.cfm?Section=Home6&TEMPLA
TE=/CM/ContentDisplay.cfm&CONTENTID=30254.
Payer
• A public or private organization that pays for or underwrites coverage for
healthcare expenses
o Source: http://www.ohanet.org/Glossary
Personal Health Record
• An electronic record of health-related information on an individual that
conforms to nationally recognized interoperability standards and that can be
drawn from multiple sources while being managed, shared, and controlled by
the individual.
o Source: The National Alliance for Health Information Technology
Report to the Office of the National Coordinator for Health Information
Technology on Defining Key Health Information Technology Terms,
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_8
48133_0_0_18/10_2_hit_terms.pdf
Pharmacist
• A healthcare professional who is qualified to prepare and dispense medicinal
drugs.
o Source: http://www.diabetes.ca/diabetes-and-you/what/dictionary/
Physician
• Individuals licensed to practice medicine. This is inclusive of primary care and
specialty care.
Source: http://www.ncbi.nlm.nih.gov/mesh/68010820
Physician Assistant (PA)
• Persons academically trained, licensed, or credentialed to provide medical
care under the supervision of a physician. The concept does not include
nurses, but does include orthopedic assistants, surgeon's assistants, and
assistants to other specialists.
o Source:
http://www.ncbi.nlm.nih.gov/mesh?term=physician%20assistant
Point of Care
• The time and place of care being given to the patient, from the healthcare
provider.
63
o
Source:
http://highered.mcgrawhill.com/sites/0073374008/student_view0/glos
sary.html#P
Preventive Care
• Healthcare to prevent illness or detect illness at an early stage, when
treatment is likely to work best.
o Source: http://www.medicare.gov/Glossary/p.html
Primary Care
• Primary care providers include doctors, nurses, nurse practitioners, and
physician assistants. They often maintain long-term relationships with
patients, advising and treating them on a range of health related issues.
They may also coordinate a patient’s care with specialists.
o Source: http://www.healthcare.gov/glossary/p/primary-care.html
Private Insurance
• Coverage of medical expenses by a health plan provided through an
employer or union, or purchased by an individual from a private health
insurance company; includes all forms of health insurance that are not
funded by the government.
o Source:
http://www.census.gov/hhes/www/hlthins/methodology/definitions/cp
s.html
Private Pay
• The ability of a person to pay the cost of services with personal income or
assets
o Source: http://www.loretto-cny.org/index.cfm?PageID=41
Quality Measures:
• Performance measures related to the care of the patient that focus on
patient-level health outcome and experience measures that reflect an ACO's
ability to deliver patient-centered care that is well coordinated across
providers and improves outcomes for patients.
o Source: Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M.
Lieberman, Julie J. Lee, Julie L. Lewis, and Jonathan S. Skinner.
(2009). Fostering Accountable Healthcare: Moving Forward In
Medicare. Health Affairs. 28(2): 219-231.
\
64
Regional Extension Centers
• Organizations that support and serve healthcare providers to become
meaningful users of electronic health records (EHRs).
o Source:
http://healthit.hhs.gov/portal/server.pt/community/hit_extension_pro
gram/1495/home/17174
Regional Health Information Organization (RHIO)
A health information organization that brings together healthcare
stakeholders within a defined geographic area and governs healt h
information exchange among them for the purpose of improving health and
care in that community.
o Source:
http://www.healthit.hhs.gov/portal/server.pt/...0...0.../10_2_hit_term
s.pdf
Rehabilitation
• Treatment used after a serious injury, illness or surgery, that helps the
individual regain strength, relearn skills, or find new ways of doing activities.
Can include any combination of physical therapy, occupational therapy,
speech-language therapy, and treatment of pain.
o Source: http://www.nlm.nih.gov/medlineplus/rehabilitation.html
•
Rehabilitation Hospital
• Facilities which provide programs for rehabilitating the mentally or physically
disablement of individuals.
o Source: http://www.ncbi.nlm.nih.gov/mesh/68012047
Risk-based Model:
• The use of administrative claims data to predict healthcare costs and patient
outcomes with the goal of reducing the cost, while improving the management
and delivery, of care.
o Source: http://www.academyhealth.org/files/awards/RiskBasedPredictiveModeling.pdf
Shared Risk:
• Payment models in which providers share in a portion of the savings they
achieve (upside), but are also at risk for a portion of spending that exceeds a
target (downside).
o Source:
http://www.commonwealthfund.org/~/media/Files/Publications/Fund
65
%20Report/2011/Jul/1530Delbancopromisingpaymentreformrisksharin
g%202.pdf
Skilled Nursing Facility
• Skilled nursing care and rehabilitation services provided on a continuous,
daily basis, in a skilled nursing facility. Examples of skilled nursing facility
care include physical therapy or intravenous injections that can only be given
by a registered nurse or doctor.
o Source: http://www.healthcare.gov/glossary/s/skilled-nursing.html
Social Worker
• A licensed professional who gives families emotional support, help in
adjusting to hospitalization, help planning for hospital discharge, and referral
to community resources
o Source: http://www.ncchildrenshospital.org/parentinfo/glossary#S
Sub-acute Care
• Maintenance care for serious medical conditions that are not urgent or lifethreatening, typically following a stay in a hospital.
o Source: http://www.hr.ucdavis.edu/worklifewellness/Life/eldercare/elder-care-glossary
Telemonitoring:
• Transfer of physiological data such as blood pressure, weight,
electrocardiographic details, and oxygen saturation through telephone or
digital cable from home to healthcare provider.
o Source: Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S.
Telemonitoring or structured telephone support programmes for
patients with chronic heart failure: systematic review and metaanalysis. BMJ. 2007;334:942
Therapist
• A person trained in methods of treatment and rehabilitation other than the
use of drugs or surgery.
o Source: http://www.merriam-webster.com/medical/therapist
Workflow
• The set of clinical and administrative tasks that must be handled by more
than one person in order to oversee the care of a person. For example,
electronic health records are increasingly used to redesign work flows and
improve the quality and value of care.
66
o
Source: Tordal, P., Han, E. S., and Scholle, S. H. (2010). Easing the
adoption and use of electronic health records in small practices. Health
Affairs. 29(4): 668-675.
67
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