C-CDA Direct Messaging: Are We There Yet?

Baylor Scott and White Health

PresentersCherie Price, RN, CTT+, IQCIBaylor Scott & White Healthcare at GrapevineRN Care Manager and Care Management Informatics

Cindy Sunderman Neese, MSN, RN-BC, CPHIMSBaylor Scott & White HealthcareNurse Informaticist, Manager — eQuality MeasuresStrategy and Operations, STEEEP Analytics

Oscar Glorioso, RN, MSNBaylor Scott & White Healthcare Clinical Application Specialist IIAllscripts EHR — Clinical Documentation Team

Abeezar Shipchandler, MD, FACPInternal Medicine/HospitalistBaylor Regional Medical Center at PlanoClinical Assistant Professor Texas A&M HSC COM, Dept. of Internal MedicinePhysician Clinical Informatics Leader, Baylor Scott & White Health

Special Thanks

Joseph H. Schneider, MD, MBA, FAAP

David Nickel, PMO

Linda Hodges, PMO

Introduction

Learning Objectives

• Identify pre-implementation considerations and potential challenges to implementing inbound/outbound direct messaging of C-CDA visit summaries

• Discover methods of C-CDA data exchange for outbound direct messaging of C-CDA documents

• Learn about the benefits of implementing inbound/outbound direct messaging of C-CDA documents

The Road Ahead

Baylor Scott & White decided to implement C-CDA not only to avoid steep penalties from Medicare, but also as part of our goal to achieve strong transitions from the inpatient setting to the next level of care.

The Journey

• Resource planning

• Development

– Technical configuration

• C-CDA document data mapping and configuration

• HISP configuration

• MU2 dashboard development

– Workflow development

• Implementation

• Monitoring and Meaningful Use attestation

Resource Planning

C-CDA Document Configuration

• Patient Information• Reason for Referral• Reason for Visit• Functional Status• Treatment Plans• Instructions• Discharge Diet• Hospital Discharge

Instructions

C-CDA Document Configuration

• Vital Signs• Medications• Problems• Hospital Admission

Diagnosis• Hospital Discharge

Diagnosis• Allergies• Results• Procedures• Immunization• Social History

C-CDA Document Configuration

• Encounters• Health Care Provider• Patient Contacts

Data MappingCXD_Functional_Status

Extremity Movement

298331001^Normal motor response to command (finding)^SNOMED CT

MAE on command, no obvious deficits noted

225606002^Abnormal movement (finding)^SNOMED CT

MAE on command, no obvious deficits noted except

225606002^Abnormal movement (finding)^SNOMED CT RUE

225606002^Abnormal movement (finding)^SNOMED CT LUE

225606002^Abnormal movement (finding)^SNOMED CT Bilateral UE

225606002^Abnormal movement (finding)^SNOMED CT RLE

225606002^Abnormal movement (finding)^SNOMED CT LLE

3915700^Flaccid paralysis (finding)^SNOMED CT

Flaccid

26544005^Muscle weakness (finding)^SNOMED CT Weakness

163605002^On examination - quadriplegia (disorder)^SNOMED CT Quadriplegic

163604003^On examination - paraplegia (disorder)^SNOMED CT Paraplegic

163660009^On examination - flexion contracture

(disorder)^SNOMED CTContractures

6077001^Foot-drop (finding)^SNOMED CT Foot drop

298222004^Active range of joint movement reduced

(finding)^SNOMED CT Limited ROM

• Allergies = UNI code• Problems= CPT, ICD 10 and

SNOMED CT• Functional status= SNOMED

CT• Social History = SNOMED

CT

HISP Configuration

• Primarily done by vendor engineer– URL– Direct address

• Smoke testing in non-production environment

Workflow DevelopmentOutbound

Care Coordination use report to

identify patient

Disclosure Note saved on account and

triggers C-CDA Visit Summary

transmission via Direct Messaging

Vendor Cloud

HISP Receiving EHR

Average 80 outbound transmissions/day

Workflow DevelopmentBSWH

partners and other Referring Practices sends C-

CDA

Sender’sHISP

Receiving HISP

Vendor Cloud

InboxCorporate

HIM matches C-CDA to patient

(Name, DOB, Address)

C-CDA saved to patient’s

chart

Clinicians views C-

CDA under the

documents tab or viewer

Inbound

Average 100 matches/day

Implementation

3-4-14 C-CDA Discharge Summary Document (Inpatient) Go Live

4-29-14 C-CDA Summary of Care Document (Outpatient) Go Live

9-16-14 C-CDA-Visit Summary Document Go Live

1-23-15 Inbound Messaging Go Live

6-2-15Sending C-CDA Visit Summary via

Direct Messaging Go Live (Outbound)

Monitoring and Meaningful Use Attestation

Monitoring and Meaningful Use Attestation

Monitoring and Meaningful Use Attestation

Monitoring and Meaningful Use Attestation

• Galvanized focus workgroup– Identified providers/groups who were high admitters

at each facility– Involved Clinical Informatics at each facility– Pursued addition of post-acute care facilities via

vendor portal– Daily monitoring, weekly update meetings

Monitoring and Meaningful Use Attestation

Monitoring and Meaningful Use Attestation

The Bumps Along The Way• People

– HIPAA Privacy office and/or Health Information Management department was engaged late in the planning

• New requirements were added to align with Legal/ Compliance

• Direct Messaging was added on existing HIM workflow

– Leadership changes slowed decision making and escalation of issues

• Logistics– Several hospitals would not meet the MU threshold with only

sending C-CDAs to the one physician group

– Other primary physician groups maintains a one to one Direct Messaging address versus practice Direct Address

The Bumps (cont.)

The Bumps (cont.)

  Technical: Outbound

Occasional C-CDA transmission failures

• 10MB limit (includes document data as well as message information)

• Cloud and/or network failures

• Misspelled Direct Addresses

Functional Status 80% captured

• Discrete vs free text• More Nursing and Allied Health

data than Physician dataMedication Dictionary • Brand vs Generic1

Problem Management • Discharge Dx• Historic vs Current2

The Bumps (cont.)

Technical: Inbound

Matching C-CDA documentation to patients

• limited demographic

Extra document being sent besides C-CDADifferent C-CDA naming convention for every organization

The Destination

• No direct benefit for inpatient physician, the C-CDA provides outpatient providers a snapshot of key information and assume care without combing through hundreds of pages of records

• Next providers of care were able to quickly identify patients in need of additional intervention to prevent readmissions and other issues

– Decrease in readmission rates since July 2015

Lessons Learned

• Conduct an analysis early on in the project to estimate reach for proposed solutions

• Regular meetings, clear communication and detailed documentation are essential to success

• Teamwork is critical

• Development of a report to quickly identify targeted patients is critical to time management

• HIM needs to be at the table• Automation of the process is ideal, but still requires additional

technical work to avoid release of PHI to inappropriate resources

Looking Forward

• Logistics– Facility/hospital ownership of

outbound Direct Messaging workflow (decentralization)

– Leveraging Direct Messaging to build partnership across the country

– Integrate Direct Messaging with other IT initiative

• NSQIP• Breeze

– Measure Direct Messaging patient care outcome

• Workflow– PAMI data reconciliation

(Meaningful Use Stage 3)– Problem list management

• Meaningful Use– 50% threshold for Stage 3

(2018)• Vendor Enhancement

– Show Brand and Generic Drugs

Contact Information

Cherie Price, RN, CTT+, IQCICherie.Price@BSWHealth.org

Cindy Sunderman Neese, MSN, RN-BC, CPHIMSCynthia.Sunderman@BSWHealth.org

Oscar Glorioso, RN, MSNOscar.Glorioso@bswhealth.org

Abeezar Shipchandler, MD, FACPAbeezar.Shipchandler@BSWHealth.org