ReliantMedical GroupAtrius Health

LCC Pilots SubworkgroupS&I Longitudinal Coordination of Care Workgroup

March 10th, 2014

Larry Garber, MDMedical Director for InformaticsReliant Medical Group

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•300+ provider multi-specialty group practice •23 sites in central Massachusetts •Not affiliated with any hospitals•Not-for-profit•At financial risk for 70% of our patients•Member of Atrius Health/Pioneer ACO

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St. VincentHospital

Reliant MedicalGroup’s Epic EHR

Outside Record Icon in MedHost Bedboard

CCD with SVH MRN

ADT for Reliant

Patients

CCD with SVH MRN

30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR

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ER and Hospital encounters automatically created in EHR from ADT

ER and hospital Discharge Notes file into EHR as well as InBasket of PCP, PCP’s RN, and Care Manager

ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge (based on ADT) which also go to physician InBasket

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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 PCP’s appointment secretary

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3 Days after hospital discharge, medication claims data are reviewed along with past and future labs

Alerts sent to PCP’s InBasket suggesting dose checking, monitoring or discontinuation

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IMPACT

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Sites with EHR or electronic assessment tool use LAND (“Local” Adaptor for Network Distribution) as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR

Non-EHR users receive, edit and send documents using a web browser to access their “Surrogate EHR Environment” (SEE)

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LAND

Hospital

PCP

SEE CCD+

MDS

Billing Program MDS

KeyHIE TransformCCD+

CCD+

CCD+ = Transfer Summary

Nursing Facility

LTPAC Communication using LAND & SEE

Home Health

CCD+

CCD+

LAND

LAND

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Lawrence.Garber@ReliantMedicalGroup.org