Putting the 'IT' in Care Transitions

Putting the IT in TransITionsSponsored by: The John A. Hartford Foundation, The Gordon and Betty Moore Foundation, and Kaiser Permanente with the Office of the National Coordinator for Health IT and Partnership for Patients

Media Partners: Health Affairs and Health 2.0

Washington DC and Online (#ITrans)October 14, 2011 8am-3pm EST

Welcome, Introductions, and Review of the Meeting

Aaron McKethan, PhD and Janhavi Kirtane, Beacon Communities

Chris Langston, PhD, The John A. Hartford Foundation

George Bo-Linn, MD, The Gordon and Betty Moore Foundation

Scott Young, MD, Kaiser Permanente

Charge to Group and Call to Action

Farzad Mostashari, MD, Office of the National Coordinator for HIT

Todd Park, US Department of Health and Human Services

Putting the IT in TransITions: What are the opportunities today?

Aaron McKethan, PhD and Janhavi Kirtane, Beacon Communities

Donna Cryer, CryerHealth

Joanne Lynn, MD, Altarum Institute

Introduction to Facilitated Sessions

Carol Beasley, Institute for Healthcare Improvement, IHI

Barbara Balik, IHI

Roger Chaufournier, IHI

The Context:

Session Overview (9:15-10:30)

From the point of view of patients and caregivers, identify the most intractable challenges related to care transitions.

“Open Space” workgroups:

• Harvest the best IT enabled solutions available today—those ready for spread and scale-up now.

• Recommend high-priority areas for IT-enabled innovation.

Identify key drivers for spread and uptake of IT-enabled solutions

Break-Out into 5 Facilitated Sessions

* Refer to map in your folder, and number on your name tag

1. Discharge process (Janhavi Kirtane)2. Medication reconciliation (Carol Beasley)3. Information flow and feedback

A. Information flows ambulatory care and medical home (Roger Chaufournier)

B. Information flows across the medical home “neighborhood” (Jason Kunzman)

4. Patient and care-giver activation (Barbara Balik)

Intended Outputs

Topic-specific recommendations:

• Near-term actions

• Longer term innovation

Rapid input to consolidated priorities

• SurveyMonkey accessible via wireless devices, or paper version

Set-up for action/commitment session 2:00-2:45

Break-Out into 5 Facilitated Sessions

* Refer to map in your folder, and number on your name tag

1. Discharge process2. Medication reconciliation3. Information flow and feedback (stay in plenary area; this group will split

into 3A and 3B)4. Patient and care-giver activation

*Online participants join Google+ with Brian Ahier (Twitter: @ahier, #ITrans).

Reactions from Eric Coleman, MD, University of Colorado, Denver

1. Discharge process2. Medication reconciliation3A. Information flow and feedback: ambulatory care and medical home3B. Information flow and feedback: across the medical home “neighborhood”4. Patient and care-giver activation

Read-Outs from Facilitated Sessions

Question Problem 1 Problem 2What are the most important problem statements from the patient’s and caregiver’s perspective that most require our attention?

• There is no care plan that includes my medical and social factors, coordinates interdisciplinary input (including my input), process and milestones, that’s reconciled across time and setting.

• I don’t have the ability to manage by care 72 hours post discharge, when I am at greatest risk for readmissions

Where is IT effectively addressing these challenges now (i.e., bright spots that need to be spread today)?

Get a “model” that works and implement it consistently, and make sure activity is comm. w pat and providers and that you get it to scale with technology

If you are a EHR environment, link them. If you have ability to create higher profile DC, make it usable. Make a DC more distinctive than a hospital chart.

• More effective risk stratification; make sure that social and clinical factors are incorporated into risk stratification• High touch interventions for most at-risk patients • Giving more patients and caregivers the care

plan at the time of discharge so they can self manage• Go ahead and make follow-up appointment

Where is innovation most needed now? Apps that link models together – (some are

available, payment is concern for patient – is it hospital, provider?)

• Feedback loops when things don’t happen, meds, appointments etc• Alert when medications are not picked up,• Provide patient with minimal amount of

medications to go home with

Enabler for Spread and Uptake Move from hospital-centric to larger team to

support Better measurement Match making

• Who’s paying for it• Different language for care givers and patients

Outstanding issues • There is no care plan that includes my medical and social factors, coordinates interdisciplinary input (including my input), process and milestones, that’s reconciled across time and setting.

• I don’t have the ability to manage by care 72 hours post discharge, when I am at greatest risk for readmissions

1. Discharge Process


• Technical analysis of meds, and reconciliation at key points of care

• Collaborative negotiation between patients and providers (adherence)


• Interoperable information exchange (NC Model for data repository using surescripts data + clinical data, with displays at POC and pharmacies) • Communication with prescribers and

pharmacies

• Human resources to help with the identification of patients, telephone visits, compliance with technology• Technology to ensure compliance –

EMMA• Technology to enable human f/Up

process and patient activation, combined with some Human Resources -- in this case, CardioCom

Where is innovation most needed now?

• EHR / PHR that can merge a medication record, including community pharmacies who provide medication therapy management (ala app called TripIt)

• Negotiated medication action plan needs to come back to entire care team

2. Medication reconciliation


• The care providers who may have the most insight to help with the transition have no ability to inform/see the plan: PCP, public health department, family, home health/SNFs and pharmacies

• Different caregivers cannot communicate with one another –information flow to hospital


• “iPIPE”(Johns Hopkins) solution: automatically reach out to the probable PCPs; allow PCP to self-identify and communicate w/hospital in HIPAA-compliant way to confirm provider is patient’s PCP. • Technology infrastructure exists, but non-IT challenges

result in suboptimal care transition

• For example: • BlueButton (VA)• Secure messaging network• Direct messaging


• Technology solution to improve consistency of PCP designation of patients in manner accessible to other providers

• Optimization of existing technologies to achieve improved care transition

Enabler for Spread and Uptake • Connect hospital to PCP by: email, phone• Patient carries discharge summary• Nursing homes with in-house nursing staff who look out

for patient transitions

• IT solutions: • video and mobile

technologies• EMR messages/alerts• Collaborative scheduling

Outstanding issues • Patient carries PCP information • PCP is hospital attending; PCP visits hospital and gets

reimbursed• Electronic notification on hospital admission: to

hospitalist (who is the PCP); to PCP

3A. Information Flow and Feedback


• What should every community provide to its patients who are being transitioned?

• Who owns what/who is responsible for what in the overall care transitions process?

Where is IT effectively addressing these challenges now (i.e., bright spots that need to be spread today)

• Direct email (e.g. HealthBridge)• S&I Framework, Transitions of Care-will have data

elements (addressing needs for care plan)• Pushing care plan to mobile device to inform medical

professionals in the field• PCHR

• Regional HIEs• GE/Intel: providing acute patients with

devices to interact with clinical and non clinical caregivers after discharge

Where is innovation most needed now? • What is the standard structure for a patient’s plan of

care• Need to provide patient-centered plan (in the cloud)• Links to tasks (e.g. scheduling appointments)• Ability for providers to iterate on a plan

• Delegations of authority• Discrete responsibilities for parts of care

plan• Need for information synthesis and

visualization• Address legal issues• Address data segmentation

Outstanding issues • Civil rights issues?• Certain populations for which there will continue to

be problems (mental illness, behavioral health)• Vendor-agnostic• Incorporating nonclinical information• Who owns this process and how is it funded?• Alerts for PCPs to know that patients are in hospital

• Episode vs. longitudinal (payment, tort)• More coordination/education amongst

providers• Leaving out individuals who don’t have

caregivers/someone to serve in this capacity

3B. Information Flow and Feedback


• “It’s about me” a cross continuum, mutually developed plan of care with effective feedback loops


• Patient data entry – leads to engagement • Secure electronic health records at all points of care• Sharing care plans, making them available in the cloud


-risk stratification-How do you capture voice of patient? (Video) -more tools to help support patients’ success in their own engagement -doctors need to be able to engage with patients’ data

Enabler for Spread and Uptake • Diffuse current innovations

Outstanding issues • “It’s about me” a cross continuum, mutually developed plan of care with effective feedback loops

4. Patient and Care-giver Activation

Group Prioritization Activity

Leah Marcotte, Office of the National Coordinator for Health IT

Eric Coleman, MD, University of Colorado, Denver

Participants in the room: Please check your email, click the link to complete the group prioritization activity (you may do this from a laptop, smart phone, etc). Computers in the center may also be accessed.

Online participants: When prompted, please CLICK HERE to fill out survey; you may also follow @ahier who will tweet the survey link on twitter.

http://www.surveymonkey.com/s/6VMXC8T

Conversation with Leaders in the FieldWhat are we learning? Where are we going? Getting the word out.

Farzad MD, Office of the National Coordinator for HIT (Moderator)

Chris Langston, PhD, John A. Hartford Foundation

George Bo-Linn, MD, The Gordon and Betty Moore Foundation

Scott Young, MD, Kaiser Permanente

Susan Dentzer, Health Affairs

J.L. Neptune, Health 2.0

Paul McGann, HHS Partnership for Patients (invited)

Round 1: What are

we learning?

Round 2: Where are we going? Getting the word out.

Announcements from the ONC

Doug Fridsma, MD, PhD, Director of the ONC Office of Standards and Interoperability

Jitin Asnaani, Coordinator of the ONC S&I Framework

Holly Miller, MD, Med Allies

*Online Participants: refer to additional S&I Framework PowerPoint presentation on webcast page

Taking the Work Moving Forward

Carol Beasley, Institute for Healthcare Improvement (IHI)

Barbara Balik, RN, EdD, IHI Faculty

Roger Chaufournier, IHI Faculty

You! (online participants can chime in too)

Moving to Action

The ecosystem

Prioritized agenda (from conversation and data)

Next steps/challenges

Agenda High-PointsPriority Problem Statements:• There is no care plan that includes my medical and social factors, coordinates interdisciplinary input

(including my input), process and milestones, that’s reconciled across time and setting. (57.7%)• The care providers who may have the most insight to help with the transition have no ability to

inform/see the plan: PCP, public health department, family, home health/SNFs and pharma. (52%)Existing IT Solutions to Scale-Up:• Interoperable information exchange (e.g. North Carolina Model for data repository using surescripts

data + clinical data, with displays at POC and pharmacies) (50.8%)• Get a “model” that works and implement it consistently, and make sure activity is communicated

with patients and providers and that you get it to scale with technology (43.0%)• More effective risk stratification; make sure that social and clinical factors are incorporated into risk

stratification (41.5%)Innovation Opportunities:• Feedback loops when things don’t happen, meds, appointments etc. (69.1%)• EHR / PHR that can merge a medication record, including community pharmacies who provide

medication therapy management (46.9%)

Moving to Action—Your Commitments

The ecosystem

ONC

Beacons

Other actors: Providers; Foundations; Vendors; Payers; Patient organizations; Academics/researchers; public agencies/policy makers

2-Week Challenge

Focus on one or more of the priorities identified today

Use Twitter to describe your 2-week challenge. Start your Tweet “2WC”

Before Halloween update us on Twitter or Google+ on what you did

Closing and Thanks

The John A. Hartford Foundation

The Gordon and Betty Moore Foundation

Kaiser Permanente

*Recording and documents from this convening will be archived and available online. If you have any questions, feedback, or resources you’d like to share with the Planning committee, please email them to [email protected]

mailto:[email protected]

Putting the 'IT' in Care Transitions

Health & Medicine

Transcript of Putting the 'IT' in Care Transitions