1. Improving Transitions of Care
through Intelligent HIE
April 15, 2015
Erick F. Maddox, HealthInsight Nevada
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Michael Lundie, Cognosante LLC.

2. Conflict of Interest Statement
Erick F. Maddox, Health Information Exchange Director, HealthInsight Nevada
has no real or apparent conflicts of interest to report.
Michael Lundie, HIE Practice Director, Cognosante LLC., has no real or
apparent conflicts of interest to report.
© HIMSS 2015

3. Learning Objectives
 Share experiences in implementation and findings from a pilot using an
intelligent alerting system for transitions of care.
 Discuss the items that must be considered in implementing a closed-loop
notification system.
 Demonstrate the use of innovative closed-loop, real time, intelligent alerting
and work flow capability to support transitions of care.
 Describe the metrics available through dashboards to evaluate alert status,
responses, and progress
 Evaluate how lessons learned from the pilot study will translate for a full
scale statewide HIE deployment

4. An Introduction to the Benefits Realized for
the Value of Health IT
The Transitions of Care management pilot study touched on all STEPS™
categories:
 Satisfaction: Evaluated provider perceptions of the alert value
 Treatment/Clinical: Alerts designed to aid physicians in coordinating care
post hospitalization and meeting Medicare reimbursement guidelines
 Electronic Information/Data: Electronic alerts delivered in real time,
prompting physicians to acknowledge with an appointment
scheduled/completed date
 Prevention and Patient Education: Alerts designed to ensure post-
discharge appointments were made to help prevent readmissions
 Savings: Test whether physicians receiving electronic alerts billed more
for Medicare TOC than those who did not get alerts. Since TOC cannot be
billed unless no 30 day readmission occurs, cost savings accrue from
avoiding rehospitalizations

5. Engaging Providers to Further Reduce
30-day Hospital Readmissions
 Nevada - One of the highest hospital readmission rates in the U.S.
 21% reductions achieved through quality improvements in hospitals from
2010 - 2013
 Current post-discharge practices effective but resource intensive
 Automated notifications as a tactic to engage providers in further reducing
readmissions and improve operational efficiency
 Secondary objective - drive value and adoption of HIE

6. Automated Notifications Helped
Transitions of Care
 Automated notifications alerted providers to follow-up on hospital and ER
discharges
 37% increase in billings for CMS Transitions of Care reimbursement codes
observed
 Increased billings an indicator of improvement in care coordination
 Notifications enabled providers to reengage with inactive patients who named
them as primary care providers (PCP) upon hospital admission
 Metrics available throughout the workflow to monitor compliance

7. Pilot Objectives
 Timely notification of a patient’s discharge to the PCP
 Timely scheduling of post-discharge appointments
 Greater compliance in completing patient discharge appointment
 Evaluate features of a health information delivery system with closed – loop
alerting capabilities
 Evaluate workflow design

8. Pilot Design
 Five hospital system in Las Vegas area participating in HIE
 Three month pilot from February 1 – April 30, 2014
 HL7 Admit, Discharge, Transfer (ADT) messages sent via HealtHIE Nevada
from the hospital’s EHR
 Study group (seven practices with 19 physicians) received notifications
 Control group (four practices with 11 physicians) did not receive notifications
 PCPs identified from ADT feed
 Secure notification sent via DIRECT; option to receive notification through
email and/or text message

9. Use of an Intelligent Health Information
Delivery System
 Data stream mining of real time feeds triggered by significant events
 Collects and analyzes data; applies business rules to pinpoint relevant
information
 Generates and delivers appropriate notifications via multiple methods
 Ability to capture responses to notifications; meta-data used to design specific
workflow for transitions of care
 Dashboard provides metrics at each step of workflow; drill-down capabilities
to evaluate efficacy of notification system

10. Intelligent Health Information System
Dashboard

11. Three Scenarios Tested
 Scenario 1: Initial alert sent to PCP upon discharge for all patients from
hospital or ER
 Scenario 2: Subsequent alerts sent to PCP for up to 48 hours after discharge
or until PCP acknowledges the alert
 Scenario 3: Follow-up reminders are sent to the PCP at 7 and 14 days after
the discharge alerts as a reminder to update patient appointment status

12. Alert Workflow

13. Pilot Implementation
 Design, Development and Implementation completed in 120 days
 Collaborative design effort with clinical team, HIE team, quality analysts and
vendor
 Current interoperability standards leveraged
 Other features explored but not pursued: auto-acknowledgement of
messages and secure mobile messaging
 Train-the-Trainer approach
 Quality Improvement Planning (QIP) aligned with implementation

14. Pilot Implementation
Implementation leveraged current interoperability standards and versions of:
HL7 v 2.5.1 for ADT
DIRECT
VPN-MLLP
SMTP
SMS
Data extracted from HL7 ADT A03 messages:
Patient Demographics
Encounter Information
Originating Facility
Provider Identifier

15. Pilot Implementation
Provider contact information to send alerts
DIRECT message address (required)
SMS contact (optional)
Email (SMTP) contact (optional)
 QIP implementation
Current state
Future state
Plan development

16. Challenges
 Initial DIRECT service provider fell through and became unavailable part way
thought the implementation phase of the project
 HIE was not configured to address ADT update messages which caused
issues with duplicate messages sent to the Rules Sub-System
 Tracking of patient compliance for appointment follow-up over such a short
measurement period
 Effective implementation of Quality Improvement Plan with Pilot Sites over
such a short period
 Support by hospital system to adjust workflow and data capture to facilitate
effective alerting

17. Measuring TOC Results Before & After
 Post-discharge follow-up appointments scheduled increased 35%
 Revenue for TOC codes increased 37%
 HIE usage expected to increase but could not be consistently measured
 Providers rated system as somewhat to very effective
 Indicators that 30 day readmissions trended downward over the pilot
 Unexpected benefits – providers appreciated knowing when patients were
discharged from the ER and appreciated re-engaging with inactive patients
who named provider as PCP

18. Pilot Findings—Study Group Before vs.
After
Measure Results—Study Group
Measure Baseline Pilot Period % Change
TOC
Completed
Appointments
Average 45
claims/month in
2013
Average 61
claims/month
+35%
TOC Revenues Estimated
$88,935 in 2013
annual revenue
Estimated
$121,440 in 2014
annual revenue
+37%
30 Day
Readmissions
~22% of total
discharges (pilot
start)
~15% of total
discharges (pilot
end + 1 month)
-7%

19. Pilot Findings--Study vs. Control
Measure Results—Study vs. Control Group
Measure Control
Baseline
Control Pilot
Period
Study Pilot % Differ
TOC
Completed
Appointments
Average 0
claims/month
in 2013
Average 2.7
claims/month
Average 61
claims/month
+2,259%
TOC
Revenues
Estimated $0
in 2013
annual
revenue
Estimated
$5,346 in 2014
annual revenue
Estimated
$121,440 in
2014 annual
revenue
+2,272%
30 Day
Readmissions
Data not
available
Data not
available
~15% of total
discharges
(pilot end + 1
month)
NA

20. Lessons Learned
 Communication Method
Feedback from providers indicated preference for secure mobile messaging
over DIRECT, desire for notifications for patient admits to hospital or ER
 Training
More training to providers and more collaboration with vendor to prepare
training materials
 Testing
More robust testing of the implemented solution
 Workflow
Current state vs. future state

21. A Review of Benefits Realized for the Value
of Health IT
The Transitions of Care management pilot study impacted all STEPS™
categories:
 Satisfaction: Positive provider perceptions of the alert value led to
discussions to implement capability statewide
 Treatment/Clinical: Alerts engaged physicians to coordinate care post
hospitalization and meet Medicare reimbursement guidelines
 Electronic Information/Data: Electronic alerts delivered in real time
prompted to physicians to acknowledge with an appointment
scheduled/completed date
 Prevention and Patient Education: Alerts ensured post-discharge
appointments were made, helping prevent readmissions
 Savings: Physicians receiving electronic alerts billed more for Medicare
TOC than those who did not get the alerts. Since TOC cannot be billed
unless no 30 day readmission occurs, cost savings accrue from avoiding
rehospitalizations

22. Questions
Erick F. Maddox, HIE Director
HealthInsight
emaddox@healthinsight.org
Twitter - @efmaddox
Michael Lundie, HIE Practice Director
Cognosante, LLC.
Michael.Lundie@Cognosante.com