1. Care Coordination (and HIE)
Gilad J. Kuperman, MD, PhD
NewYork-Presbyterian Hospital
Columbia University – Biomedical Informatics
10/1/2013

2. Motivation for care
coordination
Changes in the payment system
– Quality rather than quantity
– Non-payment for readmission / hospital
acquired conditions
– Differential payments for patient satisfaction
Risks shifting to providers
Providers have increased financial
incentives for efficiency and effectiveness
2

3. Caveat
• “Care coordination” means different
things to different people
• Potential for misunderstanding
• Confusion when conceiving IT solutions
• As always, IT supports a business goal
– Need to understand the goal
– Need to understand non-IT aspects of the
program

4. Approaches to care coordination
• Improve efficiency within a particular setting of care, e.g.,
hospital stays
– Order sets, care pathways, utilization management, etc.
• Manage a population, by segment
– Healthy people – keep them healthy
– Routine chronic disease – monitor, health promotion
– Exacerbations – treat, get back to routine state
– Fragile, high utilizers – specialized programs to manage
aggressively
Considerations:
Needed to identify who is in a particular segment
Patients move among the segments
Different tools needed to manage each segment
The sicker the patient, the more individualized the care

5. Approaches to care coordination
• Manage transitions to lower acute care
settings
– To improve efficiency and effectiveness at
new setting
– To reduce risk of bounce-back to higher level
of care
• Improve the referral process
– Transfer of information
– “Closing the loop”
• Mix, match, others, etc.

6. IT features to support PCMH
• Remote telehealth interactions
• Measurement of quality and efficiency
• Support for care transitions
• Personal health records
• Registries
• Support for team care
• Clinical decision support
Bates, Health Affairs, 2010 6
Note: Few of these in current EHRs

7. Does the current generation of EHRs
support care coordination?
• 60 subjects (52 MDs/staff, 4 EHR vendors, 4 national
leaders)
• EHR facilitates in-office coordination
– Data access, messaging
• Does not support coordination between settings
– Not designed to do so; key data elements not standardized
• Current version of EHRs support billable events, not care
coordination
• EHR complicates information management
– Create data overload
• Does not support decision-making or future care planning
• To support care coordination, EHRs require re-design
O’Malley, JGIM, 2010 7

8. Construct Sample item
1. Coordinated within
care team
In the past 6 months, how often did your doctor or staff in your
doctor’s office ask you about medicines you were prescribed by
other doctors?
2. Coordinated across
care teams
In general, do you think the doctors that you communicate with to
each other about your care?
3. Coordinated between
care teams and
community resources
Did your doctor or staff in your doctor’s office talk to you about
resources available in your neighborhood to support you in
managing your health conditions?
4. Continuous familiarity
with patient over time
How often do you think other health care providers at your
doctor’s clinic really understood all of your important medical
information?
5. Continuous proactive
and responsive action
between visits
In the past 6 months, has your doctor or staff in your doctor’s
office contacted you to ask about your condition?
6. Patient centered Thinking back about the care you received in the past 6 months,
how often do you think your doctor understood the things that
really matter to you about your health care?
7. Shared responsibility In the past 6 months, did you ever leave your doctor’s office
confused about what to do next to manage your health
conditions?
Framework for Measuring Integrated Patient Care
Singer, et al. Medical Care Research and Review, 2011
8

9. Care Transition Measures
• Now part of Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS)
• 3 questions
– During this hospital stay, staff took my preferences
and those of my family or caregiver into account in
deciding what my healthcare needs would be
when I left
– When I left the hospital, I clearly understood the
purpose for taking each of my medications
– When I left the hospital, I had a good
understanding of the things I was responsible for
in managing my health

10. • Affiliations
– Two medical
schools / faculty
practices
– Community
providers
• Owned Ambulatory
Care Network
– 14 PCMH locations
– 50 sub-specialties
• NY State-designated
health home
– Creates
partnerships with
CM, SA, MH, etc.,
organizations
• Participant in
regional health
information
exchange
NewYork-Presbyterian Hospital (NYP)

11. RHIO in NYC metro area

12. NYP HIE framework
• Faculty practices
– Dedicated interfaces
• Ambulatory Care Network
– Part of core systems
• Affiliated ambulatory providers
– Dedicated interfaces
– Connectivity via RHIO
• Other (nursing homes, home health, case
management agencies, etc.)
– RHIO
Tighter
business
partners
Looser
business
partners

13. IT principles for care coordination -- NYP
1 Data access,
across EHRs (HIE)
(i) Pull vs. push, (ii) structured or unstructured, (iii) how tightly
integrated into users EHR
2 Care plan
(explicit game
plan; inpatient /
outpatient)
Who creates it? Who has access to it? Who can update it? How is it
(i) viewed and (ii) updated (i.e., in a separate system or in the EHR)?
(How) are changes to the care plan communicated to other relevant
providers?
3 Care team(s) How created? How updated? How to deal with non‐NYP providers?
4 Messaging Do business partners already have messaging capabilities as part of
their EHRs? How to integrate multiple messaging platforms?
5 Analytics Need to be able to analyze clinical data, encounters, outcomes, costs;
Need to integrate across disparate systems
6 Patient
engagement
Patient needs to (i) see data, (ii) receive system‐generated message
(“time for your appointment”), (iii) be educated
7 Specialized
workflow tools
Task management, specialized charting, etc., (EHR?)
13

14. Improving care for depressed diabetics
• NYSDOH-funded project at NYP
– Pts w/ chronic disease and MH co-morbidities
• Three components
– IT (certified EHRs + HIE)
– Workflow redesign
– Data collection and feedback
• Stakeholders along with NYP
– ACN primary providers and psychiatrists
– ColumbiaDoctors psychiatrists
– Affiliated ambulatory physicians
– Nursing homes and home health
– Healthix

15. Key features of NYP model
• Builds on PCMH model (team based care, “huddles”, etc.)
• Standardized care for depressed diabetics
– Screening for depression
– Regular symptom monitoring
• Education of primary providers about depressed diabetics
– Context; risk factors, screening, diagnosis; choice of initial
treatment; choice of a drug, including management and side
effects; special situations, e.g., geriatrics; working as a team,
e.g., with social workers and psychiatrists; use of the IT
tools, including a registry, quality reports, etc.
• Involvement of non–NYP providers
• Patient engagement
– Education, cultural competency
• Use of IT (see next slide)

16. IT features of the model
1. EHR-based tools
– Structured documentation for screening and monitoring
– Alerts and reminders for screening and monitoring
– Patient summary screens
– Daily schedule view
2. Registry
– To support patient follow-up
3. Analytics
– Population management reports
4. PHR
– Patient education (English and Spanish)
5. EHRs for community providers
6. Interoperability
– Data to/from RHIO
– Support specific workflows, e.g., transitions to SNF,
home health

17. The PHQ-9 questions will be collapsed until the user chooses to expand them.
Once all the answers are
documented, the overall
score is calculated
automatically.
PHQ-2 and PHQ-9 Documentation: Flowsheets
•EHREnhancements-NYP

18. EHREnhancements-NYP
Patient summary screen

19. Daily schedule view
• Improve workflow prior to patient’s visit by presenting
the primary care team with details regarding the
patient’s upcoming visit and needs (i.e. scheduled
provider, diagnosis, tasks, key results).
EHREnhancements-NYP

20. Clinical decision support / workflow
• Flowsheets / documents
– Positive PHQ-2: user alerted to enter PHQ-9
– PHQ-9 ≥ 20 or (+) question #9 (suicidality screen)
 Remind MA to notify provider / provider alerted
• Patient summary / schedule view
– PHQ-2 overdue
– PHQ-9 / Repeat PHQ-9 overdue
• Inbox
– Secure health messaging: Primary Provider notified when
patients are admitted/discharged to/from the ED or Inpatient
EHREnhancements-NYP

21. Registry and PHR
• Registry
– Patients who meet certain criteria but have not had
timely follow-up with a care provider
• PHR -- myNYP.org
– Culturally competent patient education tools for
diabetes and depression
RegistryandPHRenhancements

22. DRAFT population management reports

23. Ability to access RHIO data for the patient
from within EHR

24. Evaluation framework
1. Demographics
– Total clinic population, # diabetics, # depressed, # with both
– Age, gender, co-morbidities
2. Inpatient utilization
– Admissions, re-admissions, ED visits
3. Ambulatory utilization
– # total visits / # mental health visits
– # missed appointments
4. Screening effectiveness
– # non-depressed diabetics screened in previous 12 months
– # screened positive who had follow-up symptom assessement (PHQ-9)
5. Monitoring effectiveness
– # depressed patients who have regular PHQ-9s
6. Team-based measures
– Who is writing notes
7. Outcome measures
– HbA1c measures
– depression remission at 6 months?
– depression remission at 12 months?
8. IT process measures
– # of screening / monitoring alerts
– Use of registry
– # of patients who create a PHR account and use that account

25. Status
• Interventions implemented in early 2013
• Currently in “late burn-in” period

26. Observation
• None of the components is exotic
• Goal is to assemble the appropriate
suite of capabilities along with the
complementary workflow

27. Care coordination -- Challenges
• Agreeing on workflow changes
• Agreeing on quality measures
• Operationalizing quality measures
• Implementing HIE-related workflows
– Transfer to / from SNF and home health
• What info, what workflow, what technology
• Creating “work lists” from registries
– Integrating work list documentation with EHR documentation
– Risk stratification algorithms; who needs follow-up?
• PHR signup and use
• Etc.

28. Summary
• Many opportunities to improve the efficiency and
effectiveness of care
• Collectively, these are called “care coordination”,
but the term is not used consistently
• IT is necessary but not sufficient for care
coordination
• Key challenges are knitting together IT capabilities
that exist, integrating them with desired workflow,
and creating new IT to support the interstitium
• Certified EHRs are not enough
– Will they expand to meet the need or will wraparound
services be developed?