This document discusses patient care summary exchange through state health information exchanges. It covers how care summaries fit within the Promoting Interoperability program and meaningful use objectives. It also discusses strategies states can take to implement clinical summary exchange, such as insisting on common standards and terminology. Finally, it provides examples of how various state HIEs, like those in Massachusetts, Virginia, and Kentucky, are exchanging care summaries in practice.

1. Patient Care Summary Exchange
State HIE TA Program Webinar
August 6, 2010

2. Table of Contents
• Care Summaries in the PIN and Meaningful Use
• Care Summaries in Context
• State Strategies for Implementation
• Issues to Consider Implementing Clinical Summaries
• Care Summaries in Practice
• Resources
Discussion is encouraged throughout today’s webinar!
For additional TA, inform your project officer !
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3. Why Use Clinical Care Summaries?
• Allows physicians to receive critical health data at
transfer of care
• Improves speed and accuracy of data absorption
into new provider’s EHR
• Reduces cost in reproducing and transporting paper
records
• Reduces hassle to patient in completing new
provider registration materials
• Improves quality of care through more complete and
timely information
• Can provide patient with an accurate, readable
record of a visit or encounter
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4. Care Summaries & the PIN
• States should have a concrete and operationally
feasible plan to enable patient care summary
exchange across unaffiliated organizations in the
next year.
• “An understanding of the HIE currently taking place
in the state”
– What is your baseline information, including specific measurements
related to patient care summaries.
• “Gaps in HIE as identified in the environmental
scan”
– Identify areas where your baseline information does not match
requirements for Stage 1 MU
• “A strategy and work plan to address the gap”
– Identify solution strategies to close the identified gaps
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5. Care Summaries & Stage 1 Meaningful Use
The EP, eligible hospital or CAH who transitions or refers their
patient to another setting of care or provider of care provides a
summary of care record for more than 50% of transitions of care
and referrals (Meaningful Use Final Rule)
• Core requirement is to perform at least one test of
EHR’s capacity to electronically exchange
information
• To fulfill menu set requirement, EHR must enable a
user to electronically transmit a patient summary
record to other providers and organizations
including
– Includes, at a minimum, diagnostic test results, problem list,
medication list, and medication allergy list
– Uses HL7 CCD or ASTM CCR

6. Care Summaries & Stage 1 Meaningful Use
• MU Objectives that might require sharing of a
CCD/CCR:
– Provide patients with an electronic copy of their health
information upon request
– Provide a clinical summary for each visit
– Exchange clinical information electronically with other providers
and patient authorized entities
– Provide summary care record for each transition of care and
referral
– Provide patients with an electronic copy of their discharge
instructions and procedures
– Other MU requirements could use clinical documents (e.g., lab
results, public health reporting)
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7. CLINICAL SUMMARIES IN
CONTEXT
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8. Communicating Information Requires
Three Things
Transportation
Today’s
Focus
Containers /
Packaging
Content
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9. Data-centered vs Document Centered
Extract and
Transform Internet RDBMS
e.g., X12
or HL7
Clinical Message
EHR-S or
messages Provider/Sender Data File HIE/Receiver
• Data-centered: traditional structures to represent the data
being transported (a row in a file for a record; delimited or
fixed length fields within the record) which goes into a
database
Clinical
Document Meta
Database
e.g., CCR, Extract and
Transform Internet
Document
Database
CCD
EHR-S
Provider/Sender HIE/Receiver
• Document-centered: electronic document where data is
pre-arranged in a structured format which is ―filed‖
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10. Initial Set of Standards, Implementation Specifications,
and Certification Criteria for EHR Technology (Jul. 2010 FR)
• Requires clinical summaries for patients for each
office visit in “human readable” format and on
electronic media
• Clinical summary can either HITSP C32-compliant
CCD or ASTM CCR
• Why 2 standards?
– CCD growing in popularity
– CCR still in use, especially among early adopters
– In some circumstances the CCR is easier, faster, and requires
fewer resources to implement than the CCD
– Electronic exchange not required in Stage 1, so why make
anyone migrate now from one format to the other?
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11. Continuity of Care Record (CCR)
• History: Outgrowth of Patient Care Referral Form (PCRF) from the
MA Department of Public Health
• Core data set:
– Most relevant administrative, demographic, and clinical information facts
about a patient's healthcare, covering one or more healthcare
encounters
– Summary of the patient’s health status (for example, problems,
medications, allergies) and basic information about insurance,
advanced directives, care documentation, and the patient’s care plan
• Primary use case: Snapshot in time containing the pertinent
clinical, demographic, and administrative data for a specific patient
• Technical Specification:
– XML coding that is required when the CCR is created in a structured
electronic format
– Permits users to display the fields of the CCR in multiple formats
Source: http://www.astm.org/Standards/E2369.htm
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12. Sample CCR
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13. Continuity of Care Document (CCD)
• History: Collaborative effort between ASTM and HL7 as an
alternate to the one specified in ASTM ADJE2369 for organizations
committed to implementation of HL7 CDA
• Core data set:
– Most relevant administrative, demographic, and clinical information facts
about a patient's healthcare, covering one or more healthcare
encounters
– Standard intended to specify the encoding, structure and semantics of a
patient summary clinical document for exchange
• Primary use case: Provide a snapshot in time containing the
pertinent clinical, demographic, and administrative data for a specific
patient
• Technical Specification:
– Constraint on the HL7 Clinical Document Architecture (CDA) standard
based on the HL7 Reference Information Model (RIM)
– Basis of many IHE profiles and HITSP constructs
Source: http://en.wikipedia.org/wiki/Continuity_of_care_document
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14. Sample CCD
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15. NHIN Specifications
• Both NHIN Exchange and NHIN Direct offer means to
transport clinical summaries
• Both mechanisms support Stage 1 Meaningful Use
• Both rely on standards for effective communication
• NHIN Exchange offers the means for transporting care
summaries; relies on more sophisticated technology,
most suitable when participants do not necessarily know
each other personally.
• NHIN Direct offers specifications that enable transport of
care summaries; relies on simpler technology, most
suitable when participants know each other personally
and have a data exchange relationship
• Many states are interested in supporting both models for
different workflows.
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16. STATE HIE STRATEGIES FOR
IMPLEMENTATION OF
CARE SUMMARY EXCHANGE
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17. State HIE Strategies
• Can take several forms, just like statewide HIE can
take several forms
• Requires some elements of policy, some elements of
infrastructure
• Use data from environmental scan to understand
current situation, capabilities, pilots, including other
relevant states
• Work with RECs to develop consistent message and
appropriate capabilities; rely on their services
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18. State HIE Strategies, cont.
• Insist on common terminology and coding
• Keep EHR system vendors’ feet to the fire in
implementing capabilities “in the field”
• Recognize that many sites are still using HL7 v2
messages
• Provide HIE services to support care summaries
– Full services, like RLS, MPI, directory, IHE XCA
– Enabling services for NHIN Direct, like provider directory
• Consider the impact of the availability of many
clinical documents when exchange is successful
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19. ISSUES TO CONSIDER
IMPLEMENTING PATIENT
CARE SUMMARIES ACROSS
TRANSITIONS OF CARE
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20. #1: Data Aggregation Issues
• Most EHR systems cannot yet integrate data from clinical
documents into their databases
• Over time, clinical users will have access to a growing
number of point-in-time clinical summaries
• We may see an increasing need to create a “summary of
summaries” especially for users without an EHR-S using
a portal/“viewer”
• Clinical documents do not easily support data
aggregation and reporting
----So----
Additional processing, including different data
stores, may be necessary to aggregate and report
on clinical data received within documents
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21. #2: Data Content Issues
• Some types of data that might be included may have
additional privacy/security restrictions (e.g., mental
health, adolescent health)
----So----
Additional parsing – and scrutiny – may be required
before clinical documents are exchanged; policy
development may also be required
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22. CLINICAL SUMMARIES IN
PRACTICE
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23. NEHEN in Massachusetts
Historical Highlights of NEHEN’s Clinical Data Exchange Efforts
• 1998 – NEHEN administrative exchange launched
• 2004 – MedsInfoED pilot launched
• 2005 – Connecting for Health Record Locator Prototype completed
• 2006 – MA-SHARE e-Prescribing exchange launched; MA-SHARE NHIN Prototype
completed
• 2007 – MA-SHARE Push Pilot launched with BIDMC, Children’s, Northeast
(discharge summaries)
• 2008 – Push Pilot extended to BIDMC affiliated CHC’s
• 2009 – Push Pilot extended to eCW integration for BIDPO (discharge summaries)
• 2009 – Scoping, architecture, and planning sponsored by EMHI
• 2010 – Push Pilot extended to Atrius (admission notifications, discharge
summaries)
July 2009, NEHEN/MA-SHARE Merger

24. NEHEN Clinical Data Exchange Context
Provider-to-Provider Clinical Summary Exchange
NEHEN •Clinical Summary Supporting Multiple Use Cases (e.g.,
Administrative Discharge Summary, Visit/Encounter Summary, Referral
Exchange Summary, Admission Notification)
Provider-to-Payer Exchange
NEHEN e- •Clinical Summary for Case Management and Other Use Cases
Prescribing •Lab Results for Quality Measurement and Other Use Cases
Exchange Public Health Reporting
NEHEN Clinical •Clinical Summary for Health Equities Analysis
•Lab Results
Data Exchange •Immunizations
•Syndromic Surveillance
To achieve meaningful Quality Reporting
use, Providers will •Clinical Summary for Quality Analysis
need a combination of Community Participant/Provider Directory for Message Routing
capabilities
NEHEN Express Clinical Summary Viewer
encompassing both
internal systems Secure Messaging
capabilities and health Audit
information exchange •Reportable Event Logging
capabilities such as •NEHEN Express Audit Report Viewer
those offered by
NEHEN Network Management Dashboard
System Administration Tools

25. NEHEN Clinical Exchange Current Status
Clinical Release 1.0
Live Pilot Clinical Release 2.0 2010
Hospital and physician Hospital and physician • Signature Health
organizations: organizations: • Tufts Medical Center
•Atrius Health •Atrius Health • Winchester Hospital
•Beth Israel Deaconess •CareGroup—BIDMC, BID • More to come....
•Children’s Hospital Boston Needham, Mt Auburn Hospital, New Public health agencies:
•Northeast Health Systems England Baptist Hospital • Boston Public Health Commission
•Children’s Hospital Boston • MA Department of Public Health
•Fallon Clinic/SafeHealth Quality data aggregator:
•Massachusetts Eye and Ear • Massachusetts eHealth
Infirmary Collaborative
•Partners Healthcare
Message types: Message types:
•Clinical summaries for •Clinical summaries: • Immunization histories to public
admission notification and •Admission notification , discharge health
discharge summaries summaries, visit summaries, etc. • Syndromic surveillance reporting
•Care transition, quality reporting, to public health
health disparities analysis • Lab results to public health
EMR integration: EMR integration:
• eClinicalWorks • eClinicalWorks, MEDITECH, custom EMRs, others

26. MedVirginia in Virginia
• Average disability
determination:
– 84 days
• With MedVirginia:
– 46 days
• 11% completed in 1-2
days
• Submits CCD to SSA
through NHIN
• Algorithms by SSA
• Replication of model

27. MedVirginia, NHIN & SSA
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28. Case Study: SSA / MedVirginia Use of MEGAHIT
• Commissioned by
SSA
• Conducted by Kay
Center for eHealth
Research
• Perspectives:
– Claimant
– Provider
– SSA
• ROI
• Dissertation by Sue
Feldman

29. A few lessons learned…..
• Standards
• Process
• Anticipate
• Communicate
• Partnership
• “Eyes on the
prize”

30. KHIE in Kentucky
• Kentucky Health Information Exchange (KHIE) is a
Medicaid Transformation Grant funded initiative.
• A CCD is created from Medicaid claims data (populated
from the state’s MMIS through a daily feed) including
prescriptions
• CCD is created real time upon request from providers,
hospitals, etc.
• Kentucky’s state lab data is in final phase of testing and
will be incorporated into the CCD
• Hospital systems are not ready to consume a structured
CCD
• Plans are to create a consolidated CCD from multiple
data sources to provide one non-duplicated summary
document
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31. Other State Examples
• Vermont
• Rhode Island NHIN Direct Implementation Pilot
• Massachusetts NHIN Direct Implementation Pilot
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32. Resources
• ASTM: http://www.astm.org/Standards/E2369.htm
• IHE: http://www.ihe.net/
• HL7:
http://www.hl7.org/implement/standards/cda.cfm
• HIMSS: http://www.himss.org/
• HIMSS EHR Association:
http://www.himssehra.org/ASP/index.asp
• NHIN:
http://healthit.hhs.gov/portal/server.pt?open=512&ob
jID=1142&parentname=CommunityPage&parentid=1
&mode=2&in_hi_userid=10741&cached=true
• NHIN Direct: http://nhindirect.org/
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33. Patient Care Summary Exchange
DISCUSSION
State HIE TA Program Webinar
August 6, 2010