1. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Amie B. Cowart, RN BSN, MSN Carol George, RN BSN, Tenet Katherine Lusk, MHSM, RHIA, Children’s Health System of Texas

2. Conflict of Interest Disclosure I, Amie Cowart, Carol George, nor Katherine Lusk have no real or apparent conflicts of interest to report. 2

3.  Understanding of transitions of care requirements  Knowledge of key factors for successful implementation  Introduction to care practices 3

4.  Transition of care overview  Continuity of care data  Sample communication plan  Transition of care practices  Challenges  Measuring results 4

5. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Tenet: Transition of Summary Program Carol George RN Director, Clinical Integration 5

6. 6  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

7. 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

8. 8  Hospital Clinical System Services portfolio attesting for Stage 2 − Cerner − McKesson − MEDITECH − Allscripts  Case Management Systems − Esend − Allscripts − Midas Objective: Deploy a standard TOC/SOC workflow across Tenet that is EHR agnostic.

9. Overview of Meaningful Use Stage 2 Transition of Care

11. Transition of Care Content  Patient Name  Referring Provider  Procedures (during stay)  Diagnoses  Immunizations  Lab tests (last 48 hours)  Vital Signs (last filed)  Smoking Status  Results (last 48 hours)  Discharge Summary if inpatient  Functional Status  Demographics  Care plan goals & instructions  Care team  Reason for referral  Problem list  Medication List  Medication Allergies

12. September 25, 2015 2013 Current State Analysis

13. 13 Case managers usually engaged Hospice and Home Health LTAC, SNF, Assisted Living, Rehab Nursing usually engaged Another Care Facility Home with Specialty Follow-up

14. 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%

15. 15

16. 16 Ability to print from EMR –HIM –Nursing Supervisor –Unit Clerks –OB RNs Ability to send email from EMR –HIM –Nursing Supervisor  Nursing survey: Who prepares the medical record for transfers in your facility ?

18. 18 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 email 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

19. 19 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 o Secret shopping results: “Just email it to me*@gmail.com” me*@gmail.com Solution: Provide Direct Email to Post Acute Care Facilities Post acute facilities + hospital transfers = ~ 30%

20. 20 “ 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

21. 21

22. 2014 Current State

23. 23 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 email.  Direct Email 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 o National Post Acute Care organizations that have implemented their own Direct Email program over the course of 2014 - 2015  Kindred  Manor Care  Gentiva  AlaCare  Amedisys  Healthsouth

24. 24 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

25. 25  Lack national directory for Direct email addresses. − Directtrust.org is beta testing and national directory  Lagging EP (office) adoption Note: Tenet will not disclose direct email 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.

26. 26 *Direct Exchange * Payor Portals *HIE * Physician Portals *Cloud Services * ACOs *HL7 *FHIR  Population Health Management (big data) *BMDI* Medical Home  Lifetime Personal Health Record

27. 27  Transition of Care CCD (10% ToC Measure B) o Operations Job that automatically sends a CCDA to follow up physician  Radiology Report Outpatient: Innovation o Operations Job  When radiology report is final and ordering physician has external direct email address then send report results  VA Direct Exchange  eHealth Exchange  Surrounding of HIEs and ACOs

28. The EP, eligible hospital, or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of certified EHR technology Includes 3 measures; must satisfy 2 of the 3  Measure 1: Provide TOCs – Increase threshold from 10% to 50%  Measure 2: Receive TOCs NEW: 40%  Measure 3: Reconcile Clinical Information NEW: 80% ToC

29. 29

30. General Acute Care Process Amie B. Cowart, RN, BSN, MSN Director Clinical Informatics Piedmont Medical Center, Rock Hill, South Carolina 30

31. 31  288-bed full service acute care hospital  More than 380 active physicians, 1400 full and part time employees  Services: − Heart and Vascular, Neurosurgery, Orthopedics, Level II Nursery, Oncology, 60 bed Emergency Department  Awards: − Tenet 2015 Circle of Excellence Award − Named 2010 and 2014 SC Distinguished Hospital of the Year by the SC DHEC − Awarded “A” Grade by Leapfrog 4 times in a row − Certified Zero Harm Award for Surgical Site infection by the SCHA

32. 32 The eligible provider who transitions their patient to another setting of care, provider or refers a patient should provide a summary of care record; 50% must have summary of care document with 10% sent electronically using direct messaging. The summary of care document can be faxed or printed to meet 50% requirements.

33. 33  Defined the scope  Identified local key stakeholders: − Case Management Director − Case Managers − Hospital Clinical Informaticists (HCI) − MU Specialists  Defined responsibilities of local stakeholders

34. 34  Participate in project kickoff and weekly meetings  Identify Super Users within the group  Monitor training compliance  Work with HCI to adopt and localize workflow for the hospital  Partner with HCI to monitor performance and collaboration post go-live

35. 35  Case Manager Super User: − May attend calls with Director and assists with establishing classes. − Acts as a support person during go-live − Collaborates with Case Management Director and HCI  Case Managers: − Uses 3 rd party application for placement process − Completes the final disposition process and TOC summary to the receiving agencies via fax/print/direct email within EHR

36. 36  Works in collaboration with Director of Case Management and CM Super User  Attends weekly meetings  Maintains project timelines  Post go-live: − Reviews reports − Communicates project timelines and success factors to IMPACT sponsor, MU sponsor and CPIC

37. Case Managers and HCI work together to:  Identify high volume post acute care facilities- ones that would total up to 30% of the discharges Provide a Welcome Letter to these facilities Obtain a Terms of Use Agreement Obtain 2 users information for each facility: name, email, phone per facility  Information obtained is shared with the point of contact at the home office to maintain an accurate database.

38.  Electronic methods of transmitting the Transition of Care: 1.Electronic Fax 2.Direct Email  Benefits: − Sending via fax meets MU Stage 1 − Sending via Direct Email meets Meaningful Use Stages 1 & 2

39. 1. Case Managers look up the recipients direct email address via the 2. Attach the Transition of Care Documents 3. Enter a message if necessary 4. Send

40. Local Reporting  Allows Case Managers to review if the Transition of Care was delivered.  Reports are available to support MU Transition of Care measure via PowerInsight and Explorer Menu. Meaningful Use Dashboard  Allows home office to review the metric and ensure the sites are meeting their attestation guidelines.

41.  PowerInsight:  Explorer Menu:

42.  MU Dashboard  MU Trending Report

43.  Case Managers are vested in the process  Continuity of care is achieved between facilities  Meaningful Use measures are being met

44. 44

45. Cracking the Transition of Care Nut Katherine Lusk, MHSM, RHIA Chief Health Information Management & Exchange Officer 45

46. Mission : To make life better for children Vision : To be among the very best medical centers in the nation Background :  Serves fourth largest metropolitan area in U.S.  Highest projected pediatric population growth in the USA, next 20 years  Over 5,000 employees and 1,000 physicians  Over 100K inpatient days, 595K outpatient visits, 172K emergency visits  Academic affiliation with University of Texas Southwestern Medical School  Only Level I pediatric trauma center in North Texas (1 of 22 in U.S.)  18 primary care facilities and 23 community practices Dallas, Texas Plano, Texas Southlake, Texas Three Campuses, 562 Licensed Beds

47.  Cracking the Transitions of care nut  What is this all about?  Who’s ready?  Finding organizations who could send / receive  Uploading directories  Communication

48. The movement of a patient from one setting of care or provider to another. Stage 2 Meaningful Use Objective The eligible provider who transitions their patient to another setting of care, provider or refers a patient should provide a summary of care record; 50% must have summary of care document with 10% sent electronically using direct messaging. The summary of care document can be faxed or printed to meet 50% requirements.

49. Key messages  Provides consistent information in a structured manner  Efficient management electronically; eliminating tie to fax machine and phone  Allows working at your convenience, rather than waiting on a phone call  Meaningful Use is all of nothing and this is a requirement Strategy  Through a comprehensive approach using multiple communication vehicles, target various segmented audiences on the importance Vehicles  Meetings  Face to face  Lunch N Learn  News letters  FAQ sheets  Included with EMR training

50.  Transitions of Care (Continuity of Care Document) − All Inpatient Discharges − ER discharges when the patient is being referred or transferred to an external provider or setting − Ambulatory discharges when the patient is being referred or transferred or transitioned to an external provider or setting  Sending and receiving referrals Live July 1, 2014

51.  Centralized incoming with routing to appropriate clinical area  Sending automated for inpatient & emergency room  Requesting referrals included in the order workflow  Sending to the in-basket with an e-mail the first 9 months.

52. Can be different based on the organization…  Data Integrity, Health Information Management − Maintenance and upkeep of the Direct Mailbox − Ensure appropriate transfer of records in a timely manner − Ensure accurate information is exchanged for the purpose of optimal care.

53.  Complete legal name as reflected on government-issued identification (birth certificate, passport, driver’s license)  Date of birth  Gender  Address (US Postal Service)  Phone Number  Social Security Number  Multiple Birth Designation (Yes or No)  Mother’s maiden name ( NYC Immunization Registry 2015, increased success rate matching 34%) Accurate linking of patients requires data… Underlined – Not everyone may use, but should we?

54. General  Legal name only  If no middle name, leave blank  Enter suffix and prefix  Enter nick names as alternative names or alias  Cultural variations for recording surnames (last name) exist – clarify during registration process. Newborns  If birth name not given: -Last Name = Mother’s last name -First Name = Boy or Girl -First Name if Gender unknown = Baby -Middle Name = Mother’s first name  Multiple births -Depict either alpha or numeric -Record with first name

55. 55 IdentificationMother’s First Name First NameMiddle NameLast Name Newborn Male RodriquezMARTHABOYMARTHARODRIQUEZ Newborn Female First Born Foglia CARLAGIRL 1 or ACARLAFOGLIA Patrick Otis St. Peters PATRICKOTISSAINT PETERS K.D. LangKDLang George 7 JonesGEORGE7JONES Dat NguyenDATNGUYEN Gumasha Said Ahmed Al Tuwaijri GUMASHASAID AHMEDAL TUWAIJRI Maria del Carmen Ramirez-Salinas MARIADEL CARMENRAMIREZ-SALINAS

56. Management  Naming Conventions Policy  On-board training  Quality Assurance Process  Daily reconciliation with feedback  Monthly trending Technical  Required fields  Use of accepted national definitions  Minimize free text  Increase use of data attributes Management & standardization improves data integrity...

57. RolesStep 1Step 2Step 3Step 4Step 5 RequestorReferral request sent HIM1.Received HIM data integrity specialist 2.Triage 3.Links patient 4.If no MR# assigns MR# 5.Routes to specialty PAR / ACR pool PAR / ACR Pool Routes to Provider If referral accepted: 1.Registration completed 2.Patient scheduled If not: Communication to requestor Provider1.Reviews for referral potential 2.Decision to PAR / ACR

58. Action Step 1 Referral Request1.Provider referral order 2.Provider picks from directory in communications management workflow Inpatient and Emergency Room Discharge At discharge auto-sends based on PCP provided by patient at registration Ambulatory Transition of Care Provider picks from a directory to route electronically in communications management workflow

59.  CCDA format different by EMR (content the same)  Information overload with receipt (Example pdf with 1000 + pages)  Providers practice at multiple locations  Patients changing providers  Linking patients

61. Current Status  Mixed manual and electronic process  Inconsistent clinical information for referrals  Excessive manpower required to sustain  Managing paper Future  Electronic exchange  Consistent clinical information  Nationally recognized standards  Decreased administrative burden  Elimination of scanning The Transition of Care Nut is CRACKING!!!!

62. Cracked

63. 63  Carol George, RN, BSN − ACI Director, Clinical Integration − Tenet Healthcare − carolann.george@tenethealth.com  Amie B. Cowart, RN, BSN, MSN − Director Clinical Informatics − Piedmont Medical Center − amie.cowart@tenethealth.com  Katherine Lusk, MHSM, RHIA − Chief Health Information Management & Exchange Officer − Children’s Health System of Texas − katherine.lusk@childrens.com