Massache - MassTech

Massache - MassTech

IMPACT 2.0: Improving Massachusetts Partnering And Care Transitions MeHI Grantee Forum November 1st, 2016 Reliant Medical Groups Interfaces to non-Epic Sites other to 50+ Community MDs 1 Home Health Agency IHE XCPD XCA CDAs Direct C DAs

5 Hospitals + 8 SNFs Ancillaries (Surescripts, Quest Lab, MUSE EKG, Infinitt PACs + Powerscribe) to Sites Mckesson & Reliants EHR & Data Warehouse Patient References Clark

Mailing Service ~40% Patients Clinician References Transcription and Dragon 4 Payers MA DPH Immunization Registry MAeHC Specialized Registry Appt Reminder IVR Reliants Electronic Exchanges

As of September 2016 High volume because of Hassle-Free HIE Improving Communication with ER 90 seconds after ED registration, Reliants CCD is automatically loaded into EDs EHR ADT for Reliant Patients St. Vincent Hospital & Milford Regional Med Ctr Reliant Medical Groups EHR CCD with Hospital MRN ED Registration

Outside Record Icon in SVH MedHost Bed Board blinks CCD with Hospital MRN Automated ToC/Summary Discharge Planner enters name of SNF which sets the Direct address for SVHs CCD St. Vincent Hospital Discharge CCD Discharge CCD

Webmail - SNF Webmail - SNF Discharge Planner Webmail - SNF Coordinating Care with Hospital ER and hospital Discharge Notes file into EHR as well as InBasket of PCP and Care manager ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge which also go to physician InBasket Alerts for follow-up appointments Hospital ADT monitored for hospital discharges 3 Days later, EHR checks to see if follow-up appointment took place or is

scheduled If none, an InBasket message is automatically sent to PCPs appointment secretary Alerts for monitoring of medications After hospital discharge, medication claims data and CCD are automatically reviewed along with past and future labs Alerts sent to Pharmacist to do home visit Alerts sent to PCPs InBasket suggesting dose checking, monitoring or D/C LOOKING TO THE FUTURE: HASSLE-FREE HIE ACROSS CENTRAL MASSACHUSETTS AND METROWEST WITH IMPACT 2.0 AND Federated Opt-In Consent HIE since 2009

Connects Reliant with UMass HealthAlliance Master Patient Index and Relationship Listing Service has >1 Million patients ~5,000 patients consented to exchange medical records ~150,000 documents exchanged 10 tools for IMPACT Master Patient Index (MPI) uniquely identifies each consented patient in the community Relationship Listing Service (RLS) records which organizations a patient has a relationship with AND consented to release their records Significant Event Notification Documents (SEND) sends alerts (ADT or C-CDA +/- Youve Got Mail email) based on the event (e.g. ER visit ADT, or specialist visit CCD), RLS consents, and each organizations subscription to information

Gather Event-Triggered data (GET) sends query alerts and sets up time-limited subscriptions for data to automatically be sent as the result of an event (e.g. ER visit) based on RLS consents 11 Subscriptions Care Manager PCP CCD Spec ialist SEND/GET CCD Consent EMS

PCP & note s Home Health SEND CCD SAFEHealth MPI/RLS/SEND/GET CCD Acute and 42 CFR Part 2 Hospitals Webmail

CCDS Registration (ADT) CCD via MA HIway (Direct message) Nursing Facility Subscribed Alerts CCD to EMS Before Seeing Patient Paramedics EMS Database Dispatchers IMPACT 2.0 Nam e

/DO B/A ddr Pro ess blem SAFEHealth MPI/RLS/SEND/GET Reliant Med Group CCD Patient Summary PMP Query PCP Care Manager MA Prescription Monitoring Program IMPACT 2.0 Collaborators

Reliant Medical Group Family Health Center Worcester Vital EMS Care Manager PCP CCD Spec ialist SEND/GET CCD Consent EMS PCP &

note s Home Health SEND CCD SAFEHealth MPI/RLS/SEND/GET VNACare Network CCD Acute and 42 CFR Part 2 Hospitals AdCare Hospital MetroWest Medical Center Milford Regional Medical Center

St. Vincent Hospital UMass Memorial Medical Center Webmail CCD Registration (ADT) CCD via MA HIway (Direct message) Nursing Facility Subscribed Alerts Holy Trinity, Notre Dame, Jewish Healthcare, Life Care Center Auburn Worcester Rehab, Beaumont Westborough (controls) Metrics

# and % of patients consented (>10K so far) # and % of notifications sent # and % of documents transferred # and % of EMS transports avoided Total cost of care ED visits Hospital admissions 30-day hospital readmissions Quantity of opiates prescribed in ERs compared to controls 15 IMPACT 2.0 Status

St. Vincent Hospital - Live Milford Regional Medical Center Live UMass Memorial Medical Center - Testing MetroWest Medical Center Testing AdCare Hospital Testing Other sites Planning Fully live March 2017 16 Questions? Powered by

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