collaborating with your hie · 11/15/2017 · •in the longitudinal health record, patient is...

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Collaborating with your HIE

©2017 Quality Health Network (QHN) – All rights reserved, QHN proprietary and confidential not for further redistribution.

Sherri Corey, QHN Sr. Clinical Account Manager

Scott Wallace, CORHIO Outreach Development Manager

Lauren O’Kipney, CORHIO Transformation Services Manager

HIE in Colorado

• CORHIO and QHN are the two HIEs in the state.

• We’re working on bidirectional exchange to connect the two HIEs

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Value Based Payment

Technology Platform (HIE) Master patient index | Master Provider Index

| Data Collection/normalization tools

(Basic HIE Functionality) Results Delivery

QHN Direct | HISP Services Referral Network

Population Health Management | Gaps in Care Registry Tools / Subscription

Shared Care Plan

CQMs Analytics

Claims & Clinical Data Patient notes | CCD | CCDA

Risk Stratification Billing | Clinical Data

Predictive Modeling Patient | Provider Engagement

Care Coordination Multi-Stakeholder

• Improved Patient Experience

• Enhanced Population Health

• Reduced Healthcare Costs

HIE Value Pyramid

Longitudinal Health Record Alerts | Subscription | Images | Advanced Directives

Support for Clinical Integration:

QHN Connects: • >95% of all

medical providers

• >85% of the healthcare organizations

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QHN EHR Connectivity Matrix

30 Products Interfaced

2 EHR Products in

development Queue

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CORHIO Dashboard Live/Completed In Development In Queue

State/HIE HCPF: Outreach for Medicaid EHR Incentive Program

- ongoing

HIE: CORHIO data to QHN; HISP to HISP connections

with Surescripts, Kansas HIE (KHIN), New Mexico HIE

(NMHIC) and Cerner

CDPHE: Cancer Registry, Immunizations (CIIS),

Newborn Screening (results delivery), Electronic Lab

Reporting, Syndromic Surveillance (CDC)

HCPF: Accountable Care Collaborative and

Regional Care Collaborative Organizations,

Medicaid expansion, eReferral/eConsult,

TEFT PHR for Medicaid clients, State

Innovation Model grant

HIE: Bi-directional connection with QHN

CDPHE: Newborn Screening (orders),

and e-Referrals for Colorado Tobacco

QuitLine (w/Denver Public Health),

public health services added with

federal Medicaid expansions

Hospitals 63 hospitals connected to HIE 8 hospitals connecting to HIE 3 hospitals under agreement for HIE

Doctors/Providers 4,793 providers connected to HIE

(897 physician offices)

Behavioral

Health/Labs/

Long-Term Care

• 149 long-term care, skilled nursing, home health

and hospice facilities

• 38 behavioral health centers

• 7 labs

• 2 imaging organizations

• 5 labs/imaging organizations

Payers/ACOs • Bright Health

• CCMCN/CACHIE

• Colorado Access

• Community Health Partnership (CHP)

• FullWell

• HCPF

• Kaiser Permanente

• Optum Medical Services

• Physician Health Partners (PHP)

• Rocky Mountain Health Plans

• Anthem

• Carent/United Health Care

• ICHP

• Aetna

• Humana

• United-Secure Horizons

Consumers • 4,000,000+ unique patients in the HIE

• 9Health Fair

• Behavioral health granular consent patient opt-in

project

• TEFT - PHR/patient portal project

Last updated 11/15/17

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Last updated 12/4/17

EHR Connectivity Status

CORHIO empowers people, providers, and communities by providing the information they need to improve health.

Green: Connected to

CORHIO

• AllMeds

• Allscripts Pro

• Allscripts TouchWorks

• Amazing Charts

• American Medical Solutions/Helios

• Aprima

• AthenaHealth

• CareCloud/Charts

• CareTracker

• Cerner Millennium/ PowerNotes

• CoCentrix(formerly UNI/CARE)

• CureMD

• eClinicalWorks

• e-MDs

• Elekta Mosaiq

• Epic

• GE Centricity

• Greenway/Prime Suite

• Greenway/Vitera

• HealthFusion/MediTouch

• HealthTronics/UroChart

• MatrixCare (formerly Answers on

Demand)

• McKesson Practice Partner

• MediMobile

• Meditech

• MicroMD

• ModuleMD

• Office Practicum

• Point Click Care (CCDs only)

• Netsmart

• NextGen

• Red Planet

• Sevocity

• SRSoft/SRS EHR

• unisonMD/CodeHERO

• Allscripts Homecare/ECIN

• DocuTap (CCDs only)

• Flatiron Health/OncoEMR

• Greenway/Success EHS (CCDs only)

• ZOLL ePCR

Yellow: In process to connect to

CORHIO

Red: Unlikely to connect to

CORHIO in the near term

• Homecare Homebase

• MacPractice

• Practice Fusion

What type of data is exchanged?

• Hospitals • ADT Info • Transcription Notes • Consult & Operative Reports • Lab/Rad Results

• Laboratories & Radiology Centers • Lab Results • Pathology Reports • Radiology Reports

• Public Health Departments • Newborn Screening Results • Immunizations • Reportable Conditions

• Ambulatory Providers • CCDs

• Department of Defense/Colorado Springs Military Health System and Kaiser Permanente

• CCDs

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Hospitals

Public Health Departments

Laboratories

Radiology Centers

Data Available in the HIE QHN Longitudinal Health Record / CORHIO PatientCare

360

Patient Event Notifications (ADT)

Behavioral Health Integration

Image Exchange

Subscription

Care Coordination

Access to patient documents across the continuum of

care, i.e. Pain Contracts, ACP documents

Improving Care Coordination

Longitudinal Health Record

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Share & Send to Me

Connection to CORHIO PatientCare 360®

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PatientCare 360 gives you access to the Community Health Record, where

providers search for and view a patient's consolidated, longitudinal health record. It

allows you to look up a patient and search the system for recent lab results,

hospital ADTs, face sheets, treatment plans and ambulatory data.

Results Delivery and Subscription Driven Alerts/Results

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Results Delivery Considerations Results are routed by:

• ordering physician

• Listed PCP

• Noted referring physician or

• Patient being “subscribed” to a patient panel

Results may be filtered

Results may be sent directly “into” your EHR via an interface

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How Subscription Works Results/alerts (patient event notifications) are typically

triggered based on the designated primary care provider

(PCP).

However, they may also be triggered based on the

subscription of a patient panel from a provider or healthcare

organization.

Subscription* allows the organization/provider to receive

results/alerts based on the patient panel to which the patient

is attributed.

*Patients may also be subscribed to an organization so results, care notes, etc. are automatically “pushed” to the organization.

Connection to CORHIO Results Delivery

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Secure, electronic connection between your EHR and the CORHIO network. Enables your patients' hospitalization and test results to seamlessly route into the EHR you use every day, so workflow changes and training requirements are minimal.

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Why Are Alerts (Patient Event

Notifications Important?

Patients move from one healthcare setting to another as their healthcare requires. However, often essential parties in their care are unaware the transition has occurred.

Connection to CORHIO Patient Event Notifications

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Through an electronic report or HL7 interface, we can notify you when a

members are hospitalized or visit an emergency department. This timely

information can be used to improve care management for members,

prevent hospital readmissions, improve disease management programs

and inform quality improvement programs.

Sample report

Connection to CORHIO

This service allows the participant to receive reports and/or direct feed from CORHIO for specific

clinical data points.

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© 2015 CORHIO – All Rights Reserved –

CORHIO Proprietary – Not For Redistribution

2160-0 "CREATININE [MASS/VOLUME] IN SERUM OR PLASMA"

2339-0 "GLUCOSE [MASS/VOLUME] IN BLOOD"

2345-7 "GLUCOSE [MASS/VOLUME] IN SERUM OR PLASMA"

24321-2 "BASIC METABOLIC 2000 PANEL - SERUM OR PLASMA"

24323-8 "COMPREHENSIVE METABOLIC 2000 PANEL - SERUM OR PLASMA"

24331-1 "LIPID 1996 PANEL - SERUM OR PLASMA"

24356-8 "URINALYSIS COMPLETE PANEL - URINE"

2571-8 "TRIGLYCERIDE [MASS/VOLUME] IN SERUM OR PLASMA"

2601-3 "MAGNESIUM [MOLES/VOLUME] IN SERUM OR PLASMA"

26444-0 "BASOPHILS [#/VOLUME] IN BLOOD"

26449-9 "EOSINOPHILS [#/VOLUME] IN BLOOD"

26450-7 "EOSINOPHILS/100 LEUKOCYTES IN BLOOD"

26453-1 "ERYTHROCYTES [#/VOLUME] IN BLOOD"

26464-8 "LEUKOCYTES [#/VOLUME] IN BLOOD"

26474-7 "LYMPHOCYTES [#/VOLUME] IN BLOOD"

Examples: Use Cases

As an ACO contract manager, I need visibility into patients that are not following their provider prescribed care plans for target chronic conditions that require monitoring.

As a clinical coordinator or care manager, I want the ability to track and trend adherence to care plans using lab/imaging result values/occurrences for patients with indicated diagnoses.

As an administrator, I need to support Quality Reporting by targeting high-value CQM measures, such as post-partum follow-up for new moms.

Clinical Event Notifications

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To enhance care coordination

Critical information is provided for proactive, timely patient follow-up and

communication among the patient’s providers.

To improve tracking of high-risk patients

Improve treatment of patients who are medically frail or have chronic conditions,

utilize the system inappropriately, or are at risk for hospital readmission.

To improve population health

Community service providers, health plans and care coordinators may identify and

track a panel of patients requiring close monitoring due to complex care requirements.

To support new care delivery models

ACOs, PCMHs and other models are tying financial success to effective care

coordination - tracking patient encounters outside of their medical home is critical.

How Are Alerts (Patient Event Notifications) Used?

- Christa Peacock, Case Manager

Longmont Community Health Network

“For one client, we found out she had an ED pattern and was requesting medication each time she went in. I was able to bring in mental health support and help her manage her symptoms the right way.”

“Now I can access the CORHIO face sheets, labs, H&P and discharge summaries and make that part of my client’s record with us. I’ve had to wait up to 7 days for records before, so this is really helpful.”

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Customer Comments

Connection to CORHIO

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• Electronic Lab Reporting – electronic HL7 transmission of reportable lab results from hospitals to the public health department via CORHIO.

• CIIS Immunization Delivery - electronic HL7 transmission of immunization records to the public health department via CORHIO

• Syndromic Surveillance - electronic HL7 transmission of hospital and urgent care syndromic outbreak data to the county health departments via CORHIO.

• Newborn Screening - the receipt of HL7 information from CDPHE to CORHIO for distribution to CORHIO participants

Public Health Services

Continuity of Care Documents (CCDs)

• CCDs provide clinical summary information documented during an ambulatory encounter

• CORHIO will work with practice to fit CCD generation into clinical workflow

• CORHIO will facilitate the secure transfer of CCD files into the HIE to be shared with the community through PatientCare 360

CCDs

1. 2. Automated

Your EMR

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Shared vision to improve the community standard of care

QHN Board authorized expense, process/agreement changes and potential liability risk to pursue QSO with MSH • eCommerce agreement changed for all participants

• Policy updates and extensive legal work

New QHN HIE platform • Allows information to be associated to only authorized providers

• Supports Prohibition of Redisclosure Notice “wrapper,” consistent with 42 CFR Part 2, on all BH reports/notes either Pushed or Pulled via HIE

Behavioral Health Reports are delivered, as other results, directly to providers EHR’s

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Behavioral Health

Behavioral Health Exchange

© 2015 CORHIO – All Rights Reserved –

CORHIO Proprietary – Not For Redistribution 25

Colorado Advanced Interoperability Initiative • CORHIO and QHN received grant to improve

interoperability via CCD exchange between behavioral health, long-term care, home health and physician practices

• CORHIO to create a consent management portal for patients at a behavioral health pilot site

Prescription Drug Monitoring Program

• Pilot with HealthONE underway, expected to be concluded in 2018

• If pilot is successful, CORHIO qualified participants will be able to access prescription drug data will through PatientCare 360® web portal

• In the longitudinal health record, patient is queried, the real-time PDMP data will show on medications tab as a list of PDMP-specific drugs that have been filled, in a history format, beginning with most recent

26 CORHIO empowers people, providers, and communities by providing the information they need to improve health.

Image Exchange

28 ©2017 Quality Health Network (QHN) – All rights reserved, QHN proprietary and confidential not for further redistribution.

Enabling immediate access to

diagnostic quality images from

any location

Benefits to Providers

Minimizes the delays in patient treatment

Reduces the need for duplicative exams

Limits the unnecessary radiation exposure for patients

Diagnostic quality viewer from any location

Decreases the risk of medical errors

Eliminates the need for hand-carried images

Providers in different locations may compare current and

past diagnostic tests

Image-Enabled Results Report

https://secure-ehvzf.ehgt.com/eHealthViewerZF.aspx?msgId=44444444-4444-4444-4444-444444444444

https://secure-ehvzf.ehgt.com/eHealthViewerZF.aspx?msgId=44444444-4444-4444-4444-444444444444

Radiologist's Perspective

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Michael Neste, MD Director of Radiology

Colorado Canyon Hospital &

Medical Center

“The ‘Image Exchange’ feature in QHN is a great

enhancement to medical information delivery. Any

medical provider with access to QHN can view their

patient’s Radiologic images, from connected

hospitals, on their personal computer.

There is no longer a need for direct access

to a hospital PAC system. It is as simple as

clicking a link embedded in the Radiology

report in QHN.

A great advantage is the interactive tool that provides

the opportunity for the Radiologist and medical

provider to collaborate real-time while viewing the

images simultaneously.”

Direct Secure Messaging

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Supporting Secure provider

to provider HIPAA compliant

communication

QHN Direct

Allows for secure provider-to-provider information

exchange.

Providers and care team members can securely send

patient information directly to other healthcare

professionals.

Information is encrypted and securely sent via the

Internet using the QHN HISP (Health Information

Services Provider).

QHN Direct is embedded in the System

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Direct for Data Transmission ADT alerts may be sent to recipient’s QHN Direct mailbox.

Organizations CCDs (Continuity of Care Documents) may be

sent via Direct for inclusion into EHRs.

Clinical results may be sent to recipient’s QHN Direct

mailbox.

Patient Documents

CORHIO Transformation Support Services

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• Meaningful Use Objectives and Reporting - provide assistance to organizations to help meet Meaningful Use goals

• Quality Reporting - identify ideal workflows for meeting quality measures

• Medical Home Recognition - help organizations meet specific guidelines for NCQA Medical Home Recognition

• Practice Transformation - assist with grant qualification (SIM, TCPI)

Q4 2017 Q1 2018

CORHIO HIE Product Roadmap

Confidence: Committed Target

Portal Services

Receiver Services

Medicity Upgrade: Active Directory &

SAML SSO

Sender Services

Intelligence Services

PC360 PDMP Access

UniPath

Estes Park TRANS

Millennium Labs

Patient Event Notifications 2.1 (Patient Class ETS)

Patient Event Notifications 3.0 (Ambulatory too)

Clinical Event Notifications 2.0 (Top 200 Labs ETS)

Q2 2018 Q3 2018

Penrad

Q4 2018

Clinical Event Notifications Labor

& Delivery !

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Product Roadmap

Q4 2017 Q1 2018

CORHIO HIE Product Roadmap

Confidence: Committed Target

Patient Engagement

Services

Public Health Services

Transform. Support Services

Interoper-ability

Services

QHN XCA

SSA XCA

VA XCA

TEFT PHR Expansion

CIIS Immunization Query

Q2 2018

Super CCD SIM/eCQM Quality

Behavior. Health Expansion

Delta Dental Pilot Expansion

EvidenceNow Completion

Q3 2018

Medicity – MedFX XCA

SIM Cohort 3 Recruitment

Q4 2018

IT MATTRs Kick Off ! !

Delta Dental Wave 2 !

SIM Cohort 3 Kickoff !

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Product Roadmap

Prescription Drug Monitoring Pilot • Pilot with St. Mary's expected to be functional by February

28, 2018 • Access to PDMP via the QHN HIE portal over the St. Mary’s SSO

• Once initial pilot complete QHN will work with other pilot sites to initiate the PDMP integration process

• Projected date for full PDMP / QHN integration: December 2018

• When authorized QHN Users log into QHN patient summary the PDMP can be accessed and will return PDMP data to the User.

• Those with SSO capability will access PDMP data directly from provider’s EHR.

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PDMP / QHN Integration

Contact Us… Sherri Corey:

• Sr. Clinical Account Manager

[email protected]

Scott Wallace:

• Development and Outreach Manager

[email protected]

Lauren O’Kipney:

• Transformation Support Services Manager

[email protected]

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mailto:[email protected]

Questions

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