January 7, 2015 Tenet: Transition of Summary Program

2 Agenda Tenet Healthcare Overview Overview Meaningful Use Stage 2 –Summary of Care Measure Challenges 2013 Old State 2014 Current State –Direct Enrollment Program Current Outcomes, Lessons Learned, Challenges

Tenet Healthcare Today A diversified provider of healthcare services Alabama 1 Hospitals 5 Outpatient Ctrs New Mexico 2 Outpatient Ctrs Texas 19 Hospitals 62 Outpatient Ctrs Arizona 6 Hospitals 4 Outpatient Ctrs Florida 10 Hospitals 28 Outpatient Ctrs Georgia 5 Hospitals 15 Outpatient Ctrs S. Carolina 4 Hospitals 10 Outpatient Ctrs N. Carolina 2 Hospitals 4 Outpatient Ctrs Connecticut (LOI) 4 Hospitals Pennsylvania 2 Hospitals 3 Outpatient Ctrs Massachusetts 3 Hospitals 4 Outpatient Ctrs Missouri 2 Hospitals 3 Outpatient Ctrs Illinois 4 Hospitals 4 Outpatient Ctrs Michigan 8 Hospitals 9 Outpatient Ctrs Tennessee 2 Hospitals 6 Outpatient Ctrs 80 Hospitals (a) (b) 193 Outpatient Centers California 12 Hospitals 33 Outpatient Ctrs Mississippi 1 Outpatient Ctr Updated 7/15/2014

4 Tenet Clinical Systems Hospital Clinical System Services portfolio attesting for Stage 2 –Cerner –McKesson –Meditech –Epic Case Management Systems –Esend –Allscripts –Midas Objective: Deploy a standard TOC/SOC workflow across Tenet that is EHR agnostic.

January 7, Current State Analysis

6 Summary of Care Workflow 2013 Case managers usually engaged Hospice and Home Health LTAC, SNF, Assisted Living, Rehab Nursing usually engaged Another Care Facility Home with Specialty Follow-up

Summary of Care for Stage 1 1.Nursing checks a box that a Summary of Care was provided in the Nursing Discharge Instructions as part of the discharge process. 2. Case Managers or Health Information Management department personnel prepare and print the documents which are specific to the type of facility the patient is going to or home health, etc. Adoption for STAGE 1 near 100% with easy button

analysis current state Identify Senders Ability to print from EMR –HIM –Nursing Supervisor –Unit Clerks –OB RNs Ability to send from EMR –HIM –Nursing Supervisor  Nursing survey: Who prepares the medical record for transfers in your facility ?

2013 analysis current state Identify Receivers

analysis of future state Identify Receivers Analyze discharge dispositions and opportunity to adopt Post Acute Care facilities: LTAC, hospice, rehab, home health –21 – 25% of discharges –Case Management systems were not direct HISP enabled Follow up specialty services includes ambulatory office –Too many ambulatory clinics still have paper health records or –If EMR in ambulatory, then did not have direct in production –Timeline to support Direct exchanges did not align Hospital to Hospital transfer –Incidence 2% - 7%, too low to be only pathway –HIE – not enough mature models across all Tenet markets

11 MU Stage 2 planning 2013 Post Acute Care facilities: LTAC, hospice, rehab, home health –LTPAC providers are not eligible for incentive payments under the HITECH Act –LTPAC providers have no knowledge of “Direct” or program intent Secret shopping results: “Just it to Solution: Provide Direct to Post Acute Care Facilities Post acute facilities + hospital transfers = ~ 30%

January 7, Current State

13 Direct Program Tasks Consult Legal 1.Design Terms of Use Agreement 2.Design Welcome Letter 3.Approve round 1 external facilities approach a.Analyze ‘discharge placements’ with a look back of 6 months and calculate % of total placements during that period. b.Identify which post acute facilities would add up to 30% c.Design a workbook creating a list of highest frequency placements first d.Track % opportunity as external agencies are enrolled into Direct program

14 Direct Enrollment Program Director of Case Management Responsibility 1.Identify high volume placement facilities – final placement report from case management system 2.Provide Welcome Letter 3.Obtain Terms of Use Agreement 4.Obtain two users info for each facility: name, , phone per facility Org Name (Vault) (Facility - if different from Org Name) User Name User Phone User Referral %Comments Manteca Care and Rehabilitation Center 22% Healthy Living at HomeSacramento 17% St Jude Care Center 10% 48% Magic number is 30%

15 Direct Enrollment Workflow

January 7, Current State

17 Current Outcomes Relevant patient information such as health summaries, physical therapy reports, lab results, diagnostic reports can be shared to provide optimal continuum of care services by simply attaching documents in an . Direct replaces paper, printing, scanning, refaxing, and provides the most secure and efficient method to exchange personal health information By the end of 2014 –Tenet hospitals connect to 324 post acute care agencies –Tenet Sponsored Direct Inbox count 543 National Post Acute Care organizations that have implemented their own Direct program over the course of 2014 –Kindred –Manor Care –Gentiva –AlaCare “ Hospitals want to enroll all of their referring agencies in the Direct program because this is so much faster, better and easier than what we used to do” -Katrina Cravens, Sr. Specialist Case Management

18 Transition of Care Lessons Learned SuccessFailure IT and clinical operations joined at the hip Greater than 30% of transitions are eligible for Measure B Case Manager ownership Off-shift workflows solid Twice daily report monitoring discharge orders depicting ToC met or not met with a look back of 3 days. Trending MU reports for 7 days compliance identifies if there is lack of weekend adoption “This is an IT project and we need to minimize clinical workflow changes” Less than 30% of transitions are eligible for measure B No weekend or after 5 workflows Harder and more expensive: unreliable placement data in the case management system Manage Risks A hospital that has not been documenting placements per standard will struggle with adoption of a new workflow A hospital that turns their workbook in late or can’t get terms of use agreements back, two users etc. will struggle with adoption Escalate to sponsors and execs early if deadlines are missed

19 Current Challenges Constraint: Vendor certified on only one method for reporting Summary of Care transmissions –Excludes automation techniques for generating and sending a ToC that count for MU Stage 2 such as HIE. Tenet sends more than we can count. –Direct is only direct. 1 sender to 1 intended receiver Physicians: “I have too many Direct addresses”. EMR systems supports only one in their system address book Lack national directory for Direct addresses. Resolution in process but what upgrades and training will it take to use it? Note: Tenet will not disclose direct addresses to non-Tenet hospitals that we have provisioned. We have no process to maintain such communication of end user changes to other hospitals. External agencies may share with other hospitals and share personnel changes as they arise.

20 Health Data Sharing Models Direct Exchange * Payor Portals HIE* Physician Portals Cloud Services* ACOs*HL7 Population Health Management (big data) BMDI* Medical Home Lifetime Personal Health Record

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