In this year of presidential politics, I am reminded of Clara Pela from the old Wendy’s Restaurant TV commercial. Clara was a tiny little old lady who would open a competitor’s burger bun, glance at the diminutive beef patty and yell “where’s the beef?” The slogan made it into popular culture and was used as an attack line in the presidential race later that year.
Well now it’s my turn. On behalf of discharged patients and their caregivers everywhere who open a Continuity of Care Document (CCD) I’m exclaiming “Where’s the discharge instructions?” On behalf of the providers trying to send CCDs to inpatient settings I’m asking “Where are the receivers?”
While interoperability is gaining traction and Direct addresses are proliferating, HIE networks are not even coming close to achieving their potential for supporting improved care coordination and clinical outcomes. Many hospitals are sending CCDs without the discharge instructions or a Discharge Summary, which are arguably the most important pieces of information for care coordination. Worse yet, a CCD for a discharged patient often includes pages upon pages of clinical notes from an extended inpatient visit that have little or no relevance for the next provider in the care continuum. I have worked with several post-acute care settings who have refused to accept any more electronic discharge documentation until these issues have been remediated.
On the inpatient side, many hospitals have not yet developed effective protocols for processing incoming CCDs for their Emergency and Admissions departments turning the whole concept of exchange into a very one-sided proposition indeed.
There are several reasons for this state of affairs:
- To date, interoperability activities have been largely the domain of the IT departments and have not adequately included the operational and clinical teams needed to retool clinical and administrative workflows.
- Leveraging the interoperability of EHRs for care coordination and improved quality outcomes seems to have taken a back seat to the Meaningful Use (MU) “check the box” mentality for collecting incentives and avoiding penalties. Workflows governing the generation of transition of care summaries, often times, do not account for the content and processing needs of the recipient caregivers.
- Meaningful Use incentivizes the senders of transition summaries but it does not directly incentivize providers and organizations to become meaningful receivers of that content.
- During this transition multiple parallel communication channels have to live side by side (e.g., Magic buttons, faxes, and vendor-based exchange channels) which is confusing and is leading to a transitional period of more (rather than less) disjointed and inefficient workflows.
- Each EHR has its own workflow, document settings, configurations and triggers for sending transition of care information. This workflow is often poorly understood and is likely not optimized.
- Eligible Hospitals participating in MU are required to include the discharge instructions at transitions of care if available.
- Many EHRs automatically release the CCD within a predefined period of time post discharge, regardless of whether or not the discharge instructions have been completed. Many inpatient settings are not sending the discharge summaries electronically or are using other forms of transport to send them to their intended recipients.
Before sharing our approach to remediating these issues, it’s helpful to understand a little about Consolidated-Clinical Document Architecture (C-CDA), the standard used to generate documents to meet MU criteria and care coordination in general. Here are the basics…
- 2014 Certified EHRs have C-CDA capabilities. C-CDA is a standard which provides a common architecture, coding, semantic framework, and markup language for the creation of electronic clinical documents. C-CDA includes nine basic document templates including the CCD and Discharge Summary.
- The 2014 certification testing process does not specify which document type should be used for each setting of care (e.g. ambulatory vs inpatient). Most vendors and implementers have defaulted to using a CCD for their transition of care summary document.
- C-CDA documents are “open” templates, which means that, in addition to the template’s required and optional sections, additional C-CDA Sections and other information may be added in order to satisfy Meaningful use or a specific clinical use case. The extent of modification allowed may be limited by the vendor.
- The CCD tends to be the best fit for outpatient providers since it includes the structured medications, allergies, problems, procedures and results that are required for MU2. Discharge Instructions are not required in the CCD and are not required by Meaningful Use for transitions of care from ambulatory providers.
- Many hospitals also use the CCD for their transition of care summary document. Meaningful Use specifies that the discharge instructions be included if available. However, many inpatient settings have not carefully considered the workflow or configuration requirements necessary to ensure that discharge instructions are included in that document.
- In some respects, the Discharge Summary document template might be a better choice for hospitals to use at transitions of care since it does contain the discharge instructions, history of past illness and reason for hospital visit which the CCD does not.
Here are some of the tactical approaches that we are using to improve the quality of health information exchange for improved care coordination and operational efficiency in our work in Massachusetts with the Mass HIway statewide HIE:
- We are encouraging the creation of process improvement teams at major hospitals comprised of IT, clinical, operational and vendor representatives. These teams collaborate to optimize the C-CDA document templates and the data elements that they are configured to include. These teams evaluate and design workflows and system triggers intended to enable the appropriate information to be sent within a clinically relevant timeframe. The solution may be as simple as adjusting the period of time before a C-CDA document is released.
- We are “matchmakers” and actively work to help our HIE Participants find other providers and organizations who share in the care of their patients and who are ready to electronically share information about their patients.
- We facilitate “face to face” communications between potential trading partners to help ensure that Direct addresses are actively being monitored and that the ”owners” of those addresses are ready to use the new process. This is important because it minimizes the probability of health information being sent to an unattended address or to the wrong address.
- We not only encourage our Participants to publish their provider and departmental Direct addresses, but also remind them the process is new for most end users and therefore they will require training. This often means a staged approach to bringing providers on line for clinical information sharing.
- Where possible we share lessons learned among the various HIE participants with the realization that this is new technology with ever evolving processes.
- We encourage streamlining redundant and overlapping systems (e.g. discharge planning systems, cross entity viewers, etc.) over time. We recognize that multiple systems are needed during transition but that simplification over the mid-term is required.
The value based incentives included in MACRA, and the forthcoming electronic sharing of quality measures required under IMPACT legislation for post-acute care setting should nudge providers and caregivers away from the MU checkbox mentality and instead encourage meaningful exchange of health information leading to improved care coordination and clinical outcomes. All of these efforts, coupled with emerging technologies and standards like FHIR and networks like CommonWell will no doubt make sharing of the right PHI at the right time with the right providers the norm in the not too distant future.
For now, we need to remember that it’s easy to build the IT pipe for Direct messaging. However, in order to improve care coordination and outcomes, the challenge is to create meaningful, sustainable processes and workflows that govern the exchange of that information. Interoperability, clinical improvement, and efficiency will naturally follow. In the meantime, let’s keep asking “Where’s the beef?” until we get a satisfying answer.