Southeast Minnesota Beacon Community...Learning Objectives • Propose the technology infrastructure...
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Session: 28- Community-based Care Coordination by Harnessing Health IT Session Date: Monday, March 04, 2013 - Session Time: 11:00 AM - 12:00 PM Room: 268- Ernest N Morial CC Southeast Minnesota Beacon Community Harnessing Health IT From a Community Perspective DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Transcript of Southeast Minnesota Beacon Community...Learning Objectives • Propose the technology infrastructure...
Session: 28- Community-based Care Coordination by Harnessing Health IT Session Date: Monday, March 04, 2013 - Session Time: 11:00 AM - 12:00 PM
Room: 268- Ernest N Morial CC
Southeast Minnesota Beacon Community Harnessing Health IT From a Community Perspective
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
© 2013 HIMSS
Speaker Bios
Christopher G. Chute, M.D., Dr.P.H.
Mayo Clinic, Health Sciences Research Professor of Medical Informatics
Associate Professor of Epidemiology Principal Investigator, SE MN Beacon & SHARP
Lacey A. Hart, MBA, PMP®
Mayo Clinic, Science of Healthcare Delivery Director, Project Management Office
Program Manager, SE MN Beacon & SHARP
Has no real or apparent conflicts of interest to report.
© 2013 HIMSS
Conflict of Interest Disclosure Christopher G. Chute, M.D., Dr.P.H.
Lacey A. Hart, MBA, PMP®
Learning Objectives • Propose the technology infrastructure required to analyze,
track and measure clinical, financial and patient experience outcomes
• Describe an iterative approach to clinical process improvement and outcomes measurement
• Outline how to organize and build permanent, integrated teams composed of clinicians, technologists, analysts and quality improvement personnel to drive adoption of evidence-based medicine and superior outcomes
• Define the key factors to developing a sustainable and effective partnership between clinical and IT and why a clinically-led approach delivers buy-in and overall organizational value most quickly
© 2013 HIMSS
Taken from: Blumenthal, D. “Launching HITECH,” posted by the NEJM on 12-30-2009.
BEACON
The Beacon Community Program: Where HITECH Comes to Life
Presenter
Presentation Notes
Hawaii County Beacon Community
Hilo, HI
Southeast Michigan Beacon Community
Detroit, MI
Crescent City Beacon Community New Orleans, LA
Delta BLUES Beacon Community
Stoneville, MS
Keystone Beacon Community Danville, PA
Utah Beacon Community
Salt Lake City, UT
Beacon Community of Inland Northwest
Spokane, WA
Great Tulsa Health Access Network Beacon
Community Tulsa, OK
Southeastern Minnesota Beacon Community
Rochester, MN
Rhode Island Beacon Community
Providence, RI
Greater Cincinnati Beacon Community
Cincinnati, OH
Southern Piedmont Beacon Community
Concord, NC San Diego Beacon Community
San Diego, CA
Western New York Beacon Community
Buffalo, NY
Colorado Beacon Community
Grand Junction, CO
Bangor Beacon Community Brewer, ME
Central Indiana Beacon Community
Indianapolis, IN
17 Beacon Communities
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Presentation Notes
Represent communities from Hawaii to Maine, with more advanced E.H.R adoption and HIT infrastructure investments. Diverse communities with very different starting points (very sophisticated delivery systems e.g., Geisinger, Intermountain Mayo, and HIEs e.g., HealthBridge, IHIE, to rural communities in the Mississippi Delta and other very competitive provider markets like San Diego and New Orleans). Award was given to a lead organization (listed here), but the true intent is that accountability for project deliverables extends across each community, including payers, providers, employers, public health departments.
Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.
Improve cost, quality, and population health - translating investments in health IT in the short run to measureable improvements in the 3-part aim.
Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.
Beacon Community Aims 17 grantees each funded ~$12-15M over 3 yrs to:
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Presentation Notes
Our 3 pillars along which we have encouraged our awardees to organize their work are listed here : Build and strengthen health IT infrastructure and exchange capabilities. Here is where we hope that data will be liberated and full, longitudinal pictures of patients’ health status will be made available safely and securely to both traditional and non-traditional partners. Improve. This embodies leveraging health IT to achieve the 3-part aim of improved health, better health care delivery and lower costs. Our quarterly submission data is starting to show movement in the measures that Beacon communities have chosen to pursue. Test innovation. This is the real fun of it all. We have communities testing the limits of mobile health technology as a consumer outreach and wellness strategy. We have communities looking to more substantively empower patients in their care thru patient reported outcomes and shared decision support tools. And we have communities using wireless technologies to break down the traditional barriers of care and enabling emergency medical personnel out in the field to play a more active role in getting the right care to the patient in a more timely manner.
Community of Practice focusing upon delivering
High-value community-based
care delivery model
Communities of Practice
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Ensuring the values and preferences of informed patients are brought into our program through
meaningful conversation.
Guiding Values
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The SE Minnesota Beacon challenges the traditional healthcare models in our nation from provider centric to patient-centric and community driven.
This commitment is woven into the very fabric of each project in our program.
Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.
Improve cost, quality, and population health - translating investments in health IT in the short run to measureable improvements in the 3-part aim.
Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.
Beacon Community Aims
Presenter
Presentation Notes
Our 3 pillars along which we have encouraged our awardees to organize their work are listed here : Build and strengthen health IT infrastructure and exchange capabilities. Here is where we hope that data will be liberated and full, longitudinal pictures of patients’ health status will be made available safely and securely to both traditional and non-traditional partners. Improve. This embodies leveraging health IT to achieve the 3-part aim of improved health, better health care delivery and lower costs. Our quarterly submission data is starting to show movement in the measures that Beacon communities have chosen to pursue. Test innovation. This is the real fun of it all. We have communities testing the limits of mobile health technology as a consumer outreach and wellness strategy. We have communities looking to more substantively empower patients in their care thru patient reported outcomes and shared decision support tools. And we have communities using wireless technologies to break down the traditional barriers of care and enabling emergency medical personnel out in the field to play a more active role in getting the right care to the patient in a more timely manner.
Peer – to – Peer HIE
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Health Information Exchange (HIE) connecting to National Health Information Network (NwHIN) and exchanging Continuity of Care Document (CCD): With 100% EMR/EHR adoption rate in the community, members are making significant strides in a standards-based Health Information Exchange (HIE). The region is deploying the latest national IT standards to leverage data interoperability and timely exchange to enable health care professionals to quickly access valuable information about a patient, such as: allergies, medications and relevant health conditions allowing providers to offer the patient the right care at the right time. This will reduce costs by avoiding test and procedure duplication, unintended consequences such as adverse medication reactions and will improve the quality of the care.
Network Collaboration
“PH-Doc” ( PH EHR) Application
Server
Database Server
File Server
Message Server
Structured Data written to Database
CCD saved as PDF onto File Server
Message to User – CCD ready to view and consume
County PH requests PCP CCD County PH Parses and consumes CCD
Medication Reconciliation
Parsing ,Consumption and Reconciliation of Medication Information into PH-Doc
Medication Reconciliation
Transitions of Care
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Tackling a change to the discharge planning process at admission time by notifying local public health case managers of their clients’ hospitalization at point of admit can allow better client centered discharge planning to occur and reduce readmission risk. Utilizing healthcare technology to identify and facilitate this notification is a practical application of the Beacon infrastructure.
Clinical Data Repository ‘aka Community Data Repository’
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Presentation Notes
With Community Based Care Delivery being the underpinning and guiding principle of SE MN Beacon, a repository of information for all of SE MN Beacon was a natural progression. The advantage of having the CDR in parallel from the HIE is that it can contain all community-driven data beyond what ‘goes over the wire’ in the HIE use-cases. Repository Requirements: Correlate patients, students, and PH cases Identified & anatomized patient access Merge & unmerge patient EMR data to accurately identify patient’s for clinical care. Support complex access authorization matrix to protected patient information Easy access to various authorized data sets for reporting and analytics requirements Secure, audited, scalable, cost efficient …
Community Data Repository
Minnesota Research Authorization (MRA)
Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.
Improve cost, quality, and population health - translating investments in health IT in the short run to measureable improvements in the 3-part aim.
Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.
Beacon Community Aims
Presenter
Presentation Notes
Our 3 pillars along which we have encouraged our awardees to organize their work are listed here : Build and strengthen health IT infrastructure and exchange capabilities. Here is where we hope that data will be liberated and full, longitudinal pictures of patients’ health status will be made available safely and securely to both traditional and non-traditional partners. Improve. This embodies leveraging health IT to achieve the 3-part aim of improved health, better health care delivery and lower costs. Our quarterly submission data is starting to show movement in the measures that Beacon communities have chosen to pursue. Test innovation. This is the real fun of it all. We have communities testing the limits of mobile health technology as a consumer outreach and wellness strategy. We have communities looking to more substantively empower patients in their care thru patient reported outcomes and shared decision support tools. And we have communities using wireless technologies to break down the traditional barriers of care and enabling emergency medical personnel out in the field to play a more active role in getting the right care to the patient in a more timely manner.
IT Enabled & Community based ‘Transitions of Care’
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The program aims to demonstrate best practices in ‘transitions of care’ between traditional and non-traditional ‘providers’ using health information technology as a tool. The focus is on a high-value community-based care delivery model at low-cost. These information technology interventions in ‘transitions of care are expected to have an impact on approximately 2500 providers caring for about 500,000 patients. These initiatives include: •Health Information Exchange (HIE) connecting to National Health Information Network (NwHIN) and exchanging Continuity of Care Document (CCD) ,and Asthma Action Plans ( AAP) •Clinical Data Repository ( CDR) •Attesting to Stage 1 Meaningful Use •Patient engagement through portals, including school portals for Asthma Action Plans. •IT enabled clinical tools in ‘transitions of care’. E.g. AAP, Diabetes Decision Aids, Diabetes Patient Reported Outcome Quality of Life( PRO QOL) tool •Transitions of Care with a goal to reduce hospital re-admissions
In-Reach Social Worker
Public Health Surveillance
School Portal Exchange of Care Plans
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This fall the process will enable the electronic exchange of AAPs as well as a communication loop back directly to providers and parents of incident reports (i.e. number of trips to the office for symptom controls) as well as allowing data exchange of population metrics such as absenteeism. Five schools across Dodge, Mower and Olmsted county have committed and are receiving Beacon funds to ‘going-live’ with the system and are currently undergoing workflow training in preparation: Elton Hills Elementary School (Rochester); Lincoln K-8 Choice School (Rochester); Kellogg Middle School (Rochester); Neveln Elementary School (Austin); Triton School District (Dodge Center) �
Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.
Improve cost, quality, and population health - translating investments in health IT in the short run to measureable improvements in the 3-part aim.
Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.
Beacon Community Aims
Presenter
Presentation Notes
Our 3 pillars along which we have encouraged our awardees to organize their work are listed here : Build and strengthen health IT infrastructure and exchange capabilities. Here is where we hope that data will be liberated and full, longitudinal pictures of patients’ health status will be made available safely and securely to both traditional and non-traditional partners. Improve. This embodies leveraging health IT to achieve the 3-part aim of improved health, better health care delivery and lower costs. Our quarterly submission data is starting to show movement in the measures that Beacon communities have chosen to pursue. Test innovation. This is the real fun of it all. We have communities testing the limits of mobile health technology as a consumer outreach and wellness strategy. We have communities looking to more substantively empower patients in their care thru patient reported outcomes and shared decision support tools. And we have communities using wireless technologies to break down the traditional barriers of care and enabling emergency medical personnel out in the field to play a more active role in getting the right care to the patient in a more timely manner.
Asthma ‘Cocoon of Care’ Care Coordination between parents, providers, public health & schools.
Shared Decision Making
http://webpages.charter.net/vmontori/Wiser_Choices_Program_Aids_Site/Diabetes_Choice_files/diabetes.html
Create a two-way conversation that enables patients to participate in making decisions to the extent they prefer.
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His clinician walks through shared decision making in treatment plan taking into account Pee Wee’s preferences
Filling in Data Gaps – Patient Centric Data PRO QOL WEB TOOL
“It is about time we were asked about these things beyond just glucose & A1C levels.”
(Type I diabetes patient for over 30 years)
Synergistic Community Care
Transitions of Care – Rural Telemed
Nurse
Help Desk Agent
Healthcare Provider
Coordinator or Receptionist
Virtual Appointment
Room
Patient/Nurse
Telephone Bridge
Participants
Patient Guests
Healthcare Provider
Caretaker/ Patient Guests
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Presentation Notes
Winona County expands the program through a regional telemedicine network along with its connectivity provider Hiawatha Broadband Communications (HBC). The Telehealth structure is focused on innovative solutions to three prevalent rural America conditions: an aging demographic, declining physician population, and fewer people available to transport people to health care. The telemedicine network will take health care to the consumer utilizing eVisits to extend physician reach and parlaying the effort into lower health care costs, and improved consumer satisfaction. It is also expected, the initiative will extend independent living through improved care, security, and reduced isolation. Current Telemed Applications under Beacon: Nursing Home Applications Assisted Living Programs Remote Clinic Primary Care HCO Remote Psychiatric Counseling HCO Resident in-Home Health Care HCO Internal Residential Management Winona Home Health Care Winona County Home Health Care Diabetes and Nutrition Education Mayo Remote Cardiology Consults Winona School Programs
Legal Considerations • Business Associate Agreements between
– Between or among Beacon participants – Beacon consortium and data repository
• Privacy Compliance: – Health Insurance Portability and Accountability Act (HIPAA) – Family Educational Rights and Privacy Act (FERPA) – Public Health Agency State Data Practices Act (DPA)
• Consent & Authorization Compliance: – Minnesota Standard Consent Form to Release Health Information – Minnesota Research Authorization statute – Federal protection of human subject research regulations
• Regional Exemption Obtained for State Certificate of Authority: – Health Information Exchange, Health Data Intermediary, Record locator
service
24 JD’s
33
Presenter
Presentation Notes
The Southeast Minnesota Beacon project required the involvement of lawyers in various capacities ranging from the documentation of the governance of the program to regulatory compliance with state and federal requirements relating to operation of information exchanges, research and patient privacy. Each technology intervention requires a legal review to ensure compliance to Federal and State regulations and maintain the privacy and security of Protected Health Information (PHI)
Thank You!
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
http://semnbeacon.org
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