1. Reliant Medical Group Atrius Health LCC Pilots Subworkgroup S&I Longitudinal Coordination of Care Workgroup March 10 th, 2014 Larry Garber, MD Medical Director for Informatics Reliant Medical Group

2. 2 300+ provider multi-specialty group practice 23 sites in central Massachusetts Not affiliated with any hospitals Not-for-profit At financial risk for 70% of our patients Member of Atrius Health/Pioneer ACO

3. 3 St. Vincent Hospital Reliant Medical Group’s Epic EHR Outside Record Icon in MedHost Bedboard CCD with SVH MRN ADT for Reliant Patients CCD with SVH MRN 30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR

4. 4  ER and Hospital encounters automatically created in EHR from ADT  ER and hospital Discharge Notes file into EHR as well as InBasket of PCP, PCP’s RN, and Care Manager  ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge (based on ADT) which also go to physician InBasket

5. 5  Hospital ADT monitored for hospital discharges  3 Days later, EHR checks to see if follow-up appointment took place or is scheduled  If none, an InBasket message is automatically sent to PCP’s appointment secretary

6. 6  3 Days after hospital discharge, medication claims data are reviewed along with past and future labs  Alerts sent to PCP’s InBasket suggesting dose checking, monitoring or discontinuation

7. 7 IMPACT

8. 8  Sites with EHR or electronic assessment tool use LAND (“ L ocal” A daptor for N etwork D istribution) as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR  Non-EHR users receive, edit and send documents using a web browser to access their “ S urrogate E HR E nvironment” ( SEE )

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11. 11 LAND Hospital PCP SEE CCD+ MDS Billing Program MDS Billing Program MDS KeyHIE Transform CCD+ CCD+ = Transfer Summary Nursing Facility LTPAC Communication using LAND & SEE Home Health CCD+ LAND

12. 12 Lawrence.Garber@ReliantMedicalGroup.org