What Information

Technology will be in
YOUR future?

Lois Glanz, RN, BSN, State-wide Clinical Information Specialist,

Iowa Health Home Care, Urbandale IA

Karen Martin,
Martin RN,
RN MSN,
MSN FAAN,
FAAN Health Care Consultant,
Consultant Martin
Associates, Omaha, NE

Karen Utterback, RN, MSN, V.P. Clinical Strategy, McKesson

Extended Care Solution Group

NAHC 31th Annual Meeting and Exposition

October 24, 2012

At

the end of this session you should be

able to:

Describe
b

EHR/IT
/ national
a o a events and
a d trends
d
impacting providers and professionals

Describe

how standardization supports patientcentered care and care-giver communication and

collaboration

Discuss

one organizations EHR journey and

transformation to prepare for the changing
models of care, such as ACOs

Objectives

Connected from Anywhere???

2004

and 2007 - President Bush signed Executive

Orders outlining his goals for an Electronic Health
Record
Incentives for the use of health information technology
Position of National Health Information Technology
Coordinator
Vision for a nationwide interoperable health information
technology infrastructure
Requiring Federal Agencies administering or sponsoring a
Federal Health Program adopt and operationalize the use of
HIT

2009

- President Obama weeks into his term

reinforced that all U.S. residents have electronic
y 2014 through
g another Executive
health records by
Order

ARRA

through the HITECH Act funded the initiatives

Why an EHR and Why Now?

The Office of the National Coordinator

Promote development of a nationwide Health IT

infrastructure that allows for electronic use and exchange
of information

Provide leadership
p in the development,
p
, recognition,
g
, and
implementation of standards and the certification of Health
IT products;

Health IT policy coordination

Strategic planning for Health IT adoption and health

information exchange
g

Establish governance for the Nationwide Health

Information Network.

ONC HIT Mission

2011

2012

2013

2015

2014

2011 2012: Data

capture and sharing

2013 2014:
Demonstrate Health
System Improvement

Accelerated adoption
Data capture and
exchange

Widespread adoption and

data exchange
Process improvement

2015+ Transform
Health Care and
Population Health
through Health IT
Demonstrated
Improvements in care,
efficiency and population
health
Breakthrough examples of
delivery and payment reform

STRATIG
IGIC GOALS

Achieve Adoption and Information Exchange

through Meaningful Use of Health IT
Improve Care, Improve Population Health and Reduce
Health Care Costs through the Use of Health IT

Beyond
2015:
Transformed
Healthcare

Enhanced
ability to study
care delivery
and payment
systems

Empowered
individuals and
increased
transparency

Inspire Confidence and Trust in Health IT

Empower Individuals with Health IT to Improve
their Health and the Health Care System
Achieve Rapid Learning and Technological Advancement

Improved care,
efficiency and
population
health
outcomes

Federal Health IT Strategy Map

Medicare

Programs

and Medicaid EHR Incentive

Standards
Regional

and Certification Efforts

Extension Center Program

State

Health Information Exchange and

Nationwide Health Information Network

Beacon

Communities Program

Initiatives of the ONC HIT

- Community Sharing
- Pt-to-pt networking
- Media interchange

Dynamic
Information
Management

Biosurveillance

Quality Reporting

Quality

Bed Availability Checking

Home Carre Orders

Laboratory Orders & Results

Diag. Imaging Orders & Results

Document Availability Notification

Problem List Mgm

mt.

Allergy List Mgm

mt.

Medication List Mg
gmt.

maries
Patient Created Summ

Scanned Documents/P
PDFs

Lab Results

Radiology/ Imag
ging

Patient
ID Mgmt

aries:
Medical Summa
ASTM - HL7 C
CCD

Document Sharing:

Workflow

Public Health R
Reporting

Dynamic
Information
Access

Persistent
Info
Documents

Clinical Content

Securityy Policies

No
ode Authentication
Audit Trail

Conssumer
Authen
ntication

Security and
Identity

Transaction

Resource Locator Services

Internet

An EHR from 40,000 feet

Electronic

Health Record

The EHR represents the legal patient record created in hospitals and
ambulatory environments that is the data source for the EHR. An EHR
is generated and maintained within an institution, such as a hospital,
integrated delivery network, clinic, physician office, or homecare
agency to give patients, physicians and other health care providers,
employers,
l
and
d payers or iinsurers access to
t a patent's
t t' medical
di l records
d
across facilities and can also be referred to as an EMR CPR, EPR, and if
maintained by the patient, a PHR

Interoperablilty

Ability for diverse systems and organizations to work together,

including the ability to exchange information and use the information
that has been exchanged

CCR/CCD/Consolidated

- CCD

Continuity of Care Record/Document an XLM markup standard

intended to specify the encoding, structure and semantics of patient
summary clinical document for exchange Wikipedia July 2010

Key Terms

2010 2013

2014 2016

Rules,
Regulations &
New Funding

Mandates,
Pilots &
Exchanges

2017+
New Normal

Moving Forward

How EHRs Work

 CPOE

(for
Medications)
Drug to Drug and
Drug to Allergy
interaction checks
Demographics,
gender, race,
ethnicity, DOB,
preliminary cause of
death
Problem List
Medication list
Medications allergy list
Vital Signs

Clinical

Decision
Support
Calculate and transmit
CMS quality measures
Electronic copy of
health records
Electronic copy of
discharge instructions
Clinical Summaries
Exchange key clinical
information
Privacy and Security

Meaningful Use - Defined

Automation of individual
care settings

You

cant share what you dont

have

Incentives to drive
adoption of setting
specific applications

Systems

Connectivity between
stakeholders

Automation of workflow
and processes

Transforming the role of

patients

can only help when

they are used

Interoperability

between
disparate systems is key

What

you do with the available

information is what matters,
meaningful use

Its

about them get them

involved

Why Meaningful Use Matters

 Consolidated

Health Informatics (CHI) Initiative

for federally required Patient Assessment
standards:
Clinical LOINC
Endorsed Vocabulary Content:
International Classification of Functioning, Disability and
Health (ICF) for the functioning and disability domains

SNOMED-CT for exact and usefully related content

matches

HL7 (Health Level Seven), Version 2.4 and higher

messaging and
d Clinical
l
l Document Architecture
h
((CDA))
RxNorm Standardized nomenclature for drugs and
drug delivery devices

HITSC Acknowledged Standards

HITSP BioBio-Surveillance Use Case

Better patient
patient outcomes)

health

(improved

Better care (increased standardization,

use of evidence-based practice, clinician
collaboration)
Lower costs (more efficiency,
quantifiable data for reports)

National Goals The Triple Aim

ONC,
HITSC/HITPC

Professional
Standards/
Accreditation

C tifi ti
Certification

OMAHA
SYSTEM

National
Organizations
g

SNOMED CT

HL7,
LOINC

The Power of the Omaha System

Data Exchange

Manager

Clinician

Standards

Administrator

Networks

EHR Partners

Omaha System International Conference: 2011

10

The Omaha System

Research- and practice-based

Public domain
Standardized, comprehensive terminology
Relatively
y simple
p and easy
y to learn
Quantifies practice
Supports evidence based practice
EHR at point-of-care
Improves inter-professional collaboration
Diverse users
P
Promotes
t iinteroperability,
t
bilit use off standards
t d d

Omaha System Characteristics

11

Omaha System Model of the Problem Solving Process

Copyright: Martin KS. (2005). The Omaha System: A Key to Practice, Documentation, and
Information Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.

Structure
Domains

( )
(4)

Problems (42)

Modifiers (2 sets)

Signs/Symptoms (clusters)
Problem Classification Scheme

12

Skin
lesion/pressure

ulcer

drainage

rash

bruising

excessively

hypertrophy

dry
excessively oily
inflammation
pruritus

of nails
delayed incisional
healing
other

Example: Signs/Symptoms

Problemsmostfrequentlyassociatedwiththeproblem,Skin
0

20

40

60

80

100 120 140

Skin
Nutrition
Communicable/infectiouscondition
Circulation
Pain
Neuromusculoskeletalfunction
Personalcare
Healthcaresupervision

Problem Classification Scheme

Client Assessment

13

Structure
Categories (4)

Targets

(75)

Client Specific Information

Client-Specific

Intervention Scheme

Skin
infection precautions (hand washing,

disposal of dressings, protect lesion/incision,

other)

signs/symptoms-physical (evidence of

disease/infection, change in depth/diameter of

lesion, control pain, other)

skin
ki

care (prevent breakdown/keep dry, check

changed temperature/sensation, other)

Example: Teaching Guidance & Counseling

14

Care Provided: Skin

Number of Interventions

400
350
300
250
200
150
100
50
0
Treatmentsand
Treatments
and
Procedures

Teaching
Teaching,
Guidance,and
Counseling

Surveillance

Case Management
CaseManagement

Intervention Scheme

Structure
Knowledge (Scale of 1-5)
Behavior (Scale of 1-5)
Status
St t (Scale of 1-5)

Problem Rating Scale for Outcomes

15

Skin
1.

Cannot describe cause, severity, or treatment of

lesion

2
2.

Recognizes severity of lesion but neither cause

nor treatment

3.

Recognizes severity and treatment of lesion, but

not cause or stages of healing

4.

Describes cause, severity, and healing stages

with partial accuracy

5.

Accurately describes cause, severity, treatment,

and healing stages of lesion

Example: Knowledge

Iowa Health Home Care

States

health

largest provider of integrated home

Provides

an evidence-based integrated chronic

care disease management education and
certification program for its entire clinical
workforce

Point
Part

of Care documentation since 2004

of Pioneer Accountable Care Organization

Iowa Health Home Care

Care Who We Are

16

AYearintheLifeofaChronicallyIllPatient
AYearintheLifeofaChronicallyIllPatient
5
6

13

Social
Workers

Meds

Hospital
Admissions

Nurses

22

37

6
WeeksSNF
Care

Nursing
Homes

19

ClinicVisits

Monthsof
HomeCare

Physical
Therapists

6
Community
Referrals

4
Occupational
Therapists

16
Physicians

HomeCare
Agencies

Source Archer, B 2011

Electronic Health Record journey

Point

of Care 2004

Increase efficiency
Improve workflow
Increase accuracy
Electronic Scheduling
Improves Care Coordination
Physician Portal
Improves Communication
Improves work flow
Wound Advisor
Extends reach of wound specialists to all wound patients

Transformation Steps

17

Electronic Health Record journey

Telehealth monitoring
Non
Non-video
video and video monitoring
Intake

workflow

Centralize intake across sites

Electronic Supply ordering
Patient supplies ordered electronically, delivered to patients
home

Smartphone
Improves communication
Most recent data on the server

Transformation Steps

Defining Home Cares Value

Collaborate
Expert

with physician offices

care in the comfort of home

Caregiver

support

Medication
Complex

management

case management

Transformation Steps

18

 Avoidable
Reducing

hospitalizations
ED visits

Standardization
End-of-life
Experts
Lowest

of processes
p

care

in care coordination
cost for services

Transformation Steps

Driver for patient outcome improvement

Conducts evidence-based assessments:

-depression, pressure ulcer risk,

rehospitalization risk, fall risk

Address
Add

health
h lth literacy:
lit

-Ask Me 3, Red Flag Instructions, disease

education

Medication reconciliation
Interdisciplinary assessments
Interdisciplinary approach to care

intervention
Ongoing OASIS process & outcome
measures
Care Transitions: Defining Home Cares Value

19

Where do we start?

More than
75% of
health care
costs are
due to
chronic
conditions.

Perpetual
Doing
Well

Episodic

Critical
39
39

Reduce

burden
Identify individuals at risk for high
utilization
Evidence-based practice guidelines
Coordinate care
Self-management support
Timely initiation of services
Patient monitoring and empowerment
Transition to appropriate level of care

Addressing Care Opportunities

20

 Interoperability

Meaningful data exchange

Improve Care Coordination
Improve patient outcomes
Continuity of care plan

Opportunities

Video telehealth

Integrated chronic care disease management

staff certification

Palliative care programs for cost savings

Interventional care in the home

Adaptive design to deliver ideal patient care

Changing clinical practice

Innovation: Prepare for the Future

21

Accountable Care Organizations will need

home health as a valuable partner to
provide
Patient-centered and expert
p
care
Practice evidence-based medicine
Cost-effective
High quality care
Safer alternative
In the comfort of the
patients home

Accountable Care & Home Health

Integrated Services
Personalized
Evidence-based
Care

Prevention

Cost-sensitive
Consumer
Value Based
Purchasing
Outcome/
Performance
Based

Healthcare Tomorrow

22

Embrace

the HIT/EHR movement

and educate your leaders
Monitor activities in your state and get
involved
Evaluate your strategic plan
Assess your resources
Establish and communicate with
partners and potential partners
Consider joint grant opportunities and
experimentation with new models with
key providers in your community

How Should You be Responding?

Evaluate

your software vendors ability to partner

with you to achieve your strategies and goals.
How are they positioned currently?
Do they have a clear vision of where their products are
going?
i ?D
Does their
th i vision
i i
match
t h your vision?
i i ?
Do they have the ability to execute on their plans?
Will they meet the standards and certification
requirements necessary to support interoperability
implementation?
What is their timeline and how does it match up with
yours?

When

should Home Health Agencies be taking

these actions?
NOW the New Normal is on is on its way!

What Steps Should You Be Taking?

23

Executive Order 13335 http://edocket.access.gpo.gov/2004/pdf/0410024.pdf

Executive Order 13410 http://edocket.access.gpo.gov/2006/pdf/067220.pdf
American Recovery and Investment Act 2009
http://frwebgate.access.gpo.gov/cgibin/getdoc cgi?dbname=111 cong bills&docid=f:h1enr pdf
bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.pdf
Office of the National Coordinator of Health Information Technology
http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__ho
me/1204
The Omaha System http://www.omahasystem.org
CBO and Health IT http://www.fiercehealthit.com/story/cbo-says-healthit-only-cost-effective-solution-healthcare-reform/2008-12-22
Health Information and Management System Society (HIMSS)
http://www.himss.org/ASP/index.asp
CDC
http://www.cdc.gov/chronicdisease/resources/publications/AAG/chronic.htm
Archer, B., (2011) Making Health Care More Affordable [Power Point
Presentation]. Retrieved June 20, 2012
http://www.leadingageiowa.org/files/public/health_care_afford.pdf

EHR Information & References

Questions and Answers

24