Service Coordination Using Health Information Technology

Minnesota Department of Human Services

7/30/2019 mn.gov/dhs 1

Today’s Session:

1. Discover lessons learned from use of a Personal Health Record for MA Beneficiaries

2. Identify multiple ways the MN Encounter Alert Service will improve care coordination

3. Describe an electronic Consent tool which can make sharing information more effective

4. Add new acronyms to your vocabulary

5. Sneak a peak into the future

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Lessons learned from use of a Personal Health Record for MA Beneficiaries

• TEFT = Testing Experience and Functional Tools grant

• A Personal Health Record (PHR) for Beneficiaries, Case Managers and Providers that’s populated with data from MMIS

• A draft standard for exchanging Long-term Services and Supports (LTSS) data electronically

• Progress on a new MMIS Enterprise Service Bus (ESB)

Methodology was focused on something that would be person centered and improve workflows for all involved.

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PHR for LTSS- Why a PHR?

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Improved Data Sharing and

Analytics

Improved Care Transitions

Improved Care Coordination

Person-Centered Care

Health Information Technology (OHIT & SIM)

TEFT GOAL

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• For seniors• For people with disabilities

Accessible

• For beneficiaries/legal representatives

• For case managers

Useful

• Where beneficiaries access the Internet

• Through a mobile-first platform

Securely Available

Prove we CAN share information from DHS systems in a way that is:

Screenshot1 of PHR

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Screenshot2 of PHR

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Mobile Interface

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Profile Page

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Demo Data

Current Version9/17/2018

PHR Conceptual Architecture

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Case Manager Access

Existing Providers sharing Clinical Data

Community Collaborative

Collaborative PHR hosting DHS data

DHS securely “publishes” data to Collaborative’s“subscribe” mechanism Data Aggregator (managed by

DHS)

Data being sent to DHS from Providers today

Existing DHS Data Systems

TEFT – Experience with electronically enabled coordination of care and services

• Care/service coordination in the acute health care space are common and use health industry standards

• LTSS has been left out until recently

• Data sharing requires health interoperability technologies; the TEFT PHR and eLTSS effort are intended to improve service delivery to beneficiaries (and their families) and coordinate efforts between the beneficiary, service providers and other agencies

• Collaboration with the State Innovation Model (SIM) grant for the implementation of the admit-discharge-transfer notification system called the Encounter Alert Service (EAS)

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Ways the MN Encounter Alert Service can improve care coordination

• Expand Encounter Alert Service for:• Tracking drug overdoses for Substance Use Disorder (SUD) service recipients

• Tracking homeless population through emergency department visits

• Providing timely follow-up for recipients served by a Managed Care Organization (MCO)

• Click here (while in presentation mode) to read more information regarding the Minnesota EAS.

• Steal slides from this presentation – EAS diagram, other relevant info (i.e. list of organizations that are signed up)?

• Add slides about the ISBM, show how these strategies fit with ISBM philosophy

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Encounter Alert ServiceOverview

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Encounter Alert ServiceUsers

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IHP/Organization EAS Agreement ADT Workflow PROMPT Workflow / EMRNo data

Signed26Feb2018

Live20Apr2018

Baseline Complete

Live1May2018 Starting w/ PROMPT

No data

Signed28Feb2018

Live14Jun2018

Baseline complete

Live11May2018

Working to integrate into Epic (mid-Aug2019)

No data

Signed14Aug2018

Live 20Nov2018

No data

Live19Sep2018

Working to integrate into Epic (mid-Jul2019)

No data

Signed18Sep2018

Live06Nov2018

No data

Live8Oct2018 Starting w/Prompt

No data

Signed5Sep2018

Live12Feb2019

No data

Live17Oct2018

Starting w/PromptAnd CSV download

No data

Signed18Dec2018

Live27Mar2019

No data

Live 9Jan2019 Starting w/Prompt

No data

Signed10Sep2018 N/A No data

Live28Nov2018

Starting w/PromptScoping Allscripts

No data

Signed30Aug2018 N/A No data

Live 12Nov2018

Starting w/Prompt& eMail Ticklers

No data

Signed31Oct2018 (Koble)13Dec2018 (FUHN)

N/A No data

Live24Jan2019

Prompt DownloadsAlso Live via Koble HIE

No data

Signed8Feb2018 N/A No data

Live4Jun2019 Starting w/ PROMPT

No data

Signed20Nov2018 N/A No data

Live7Dec2018 Starting w/ PROMPT

MCHN Reviewing QSOA(Canvas, MHR, Avivo) N/A No data No data No data

No data

Signed 17Apr2019

Target live: 7Aug2019

No data No data No data

No data

Signed04Mar2019

Live25Jun2019

No data

Live2May2019 Starting w/ PROMPT

No data

Signed13Mar2019

Target Live: 31Jul2019

No data No data No data

No data

Signed11Apr2019

Target Live: 10Jul2019

No data No data No data

No data

Signed16May2019

No data No data No data

Working to integrate into SimplyConnect

10Jul2019

EAS Monthly Metricsmneas.org

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EAS Monthly Metrics# Hospital Sources Connected

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EAS Monthly MetricsRoster Sizes

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306,726

Source Code Subscriber Name Last Upload Date Active Patients OnboardedAH_P Allina Health 5/9/2019 62,336 62,336FHS_P Fairview Health Services 5/9/2019 50,767 50,767CHS_P CentraCare Health System 5/9/2019 44,247EH_P Essentia Health 5/9/2019 41,554

HHSI_P Hennepin Healthcare System Inc 4/4/2019 36,469 36,469FUHN_P FQHC Urban Health Network 5/13/2019 31,281 31,281CHN_P Community Health Network 5/9/2019 31,117 31,117CHC_P Childrens Health Care 5/9/2019 30,860 30,860

NMHC_P North Memorial Health Care 4/4/2019 28,084 28,084NHA_P Northwest Health Alliance 5/13/2019 20,070WH_P WIlderness Health 5/9/2019 17,306

Altair 10,000 10,000MC_P Mankato Clinic 4/4/2019 9,143 9,143

MAYO_P Mayo Clinic 4/4/2019 8,506AVH_P Avera Health 5/9/2019 7,517SPCC_P Southern Prairie Community Care 4/4/2019 5,899LHS_P Lakewood Health System 5/13/2019 4,435 4,435BPS_2 Bluestone 2 5/1/2019 4,373 4,373LRH_P Lake Region Healthcare 5/13/2019 4,322FVP_P Fairview Partners 5/28/2019 4,316 4,316IHN_P Integrity Health Network 5/13/2019 4,274WHS_P Winona Health Services 4/4/2019 4,067TCHC_P Tri-County Health Care 5/13/2019 3,120NMN_P Northern Minnesota Network 5/13/2019 2,460

PH_P Perham Health 4/4/2019 1,742GCSH_P Gillette Childrens Specialty Health 5/9/2019 1,676 1,676BPS_P Bluestone Physician Services 5/9/2019 929 929

GUILD_CC Guild Care Coordination 5/1/2019 357 357OPIOID OpioidUseCase NULL 263 263

GUILD_BHH Guild-Behavioral Health Home 5/1/2019 192 192GUILD_DS Guild Delancey Street 5/1/2019 81 81

GUILD_H2H Guild Hospital to Home 5/1/2019 47 47TSTP Test Participant - Web Transaction Monitor 4/5/2019 2

Roster Sizes and Recent Panels

EAS MetricsMessage Counts

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EAS Monthly MetricsSum of Discharge Alerts

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~4,500 Admits & Discharge Alerts per Week (IP and ED)~150,000 since EAS inception

EAS Monthly MetricsOpioid Overdose Alerts

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NOTE: the upward trend appears to align with the “suspect heroin” news story (and this is confirmed NOT to be adding new data sources).

St Paul Police Issue Alert after 4 people OD on suspected heroin

Opioid Crisis: potential use of EAS for Overdose Alerts (not live)

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Hospital

BeneficiaryPanel

HL7 ADT

ED Admit

ED

AlertChief

Complaint

Care Coordinator

UseCase #1Previous Overdose Alert

UseCase #2Care Coordinatoror Community-Based

AlertD/C

Diagnosis

UseCase #1B, 2BPayor-basedCare Coordinators

Pushor

ExtractDischarge

Describe an electronic Consent tool which can make sharing information more effective

• Piloting Consent-to-Share (C2S) for:

• Properly managing consent internally and externally for SUD, Mental Health, and other Medical Assistance (MA) recipients

• Designed to enable compliance with 42 CFR Part 2 (Stringent privacy standard for SUD)

• Explore the Data Segmentation for Privacy (DS4P) standard for properly managing data at the individual data field level to ensure that only appropriate parties can view just the segments of data for which they have authority.

• Piloting Omnibus Care Plan (OCP) for:

• For coordinating care and services on one platform across multiple different organizations and providers

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Consent To Share (C2S) and Data Segmentation for Privacy (DS4P)

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C2S was deployed within Prince George’s County, MD Health Information Exchange (HIE)

Open-source application for consent management and data segmentation developed using the Data Segmentation for Privacy (DS4P) Implementation Guide that:

Integrates with electronic health records and health information exchange systems via interoperability standards.

Allows clients control over which health information they share, and with which providers.

Is compliant with privacy and confidentiality regulations, including 42 CFR Part 2

Leveraging C2S and DS4P at DHS

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• External opportunity

• Implement granular consent to enable safe, secure and compliant exchange of electronic health data between providers in a community –particularly to improve communication between clinical providers and SUD and Behavioral Health providers

• Internal opportunity

• While these standards were developed to support external interoperability between organizations, the existing C2S application and DS4P rules could be adapted for internal systems

C2S Demonstration

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• Otter Tail County Collaborative

• DHS is contracting with Otter Tail County to test Consent2Share in the real world.

• This will give us an opportunity to learn about the C2S tool, as well as an additional tool called the Omnibus Care Plan (OCP) which has been developed by the C2S vendor.

• These tools will be the first DHS encounter with a Fast Health Interoperability Resources (FHIR) enabled tool.

A Peek into the Future

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“Substitutable Medical Applications and Reusable Technology”“Fast Health Interoperability Resources”

• EHRs will become more like “platforms”which have transformed other industries

• EHR-as-Platform: EHR responsible for:• User and patient management• Core workflows (orders, etc.)• Legal medical record (data persistence)• Regulatory requirements

• Platform extensions to:• Address functional gaps• Increase user choice• Encourage innovations

Apple Health iPhone App

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Apple Health iPhone App – Health Records

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Apple Health iPhone App – Search for Providers

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Apple Health iPhone App – Allina Health Example

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Apple: Empower Your Patients with Health Records on iPhone

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The Health app makes it easier than ever for users to visualize and securely store their health records. Now your patients can aggregate their health records from multiple institutions alongside their patient-generated

data, creating a more holistic view of their health.

Apple: Put Your Patients at the Center of Care

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Connecting to the Health app has the potential to drive additional awareness and adoption of your patient portal because authentication through the Health app can be set to use the

same patient login credentials as your portal. And this can help your patients discover additional services you offer.

Apple: Compliment Your Patient Portal

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Enabling your patients to get their health records on iPhone can help them more actively participate in their healthand help drive overall awareness of your patient portal.

Epic App Orchard - 14 FHIR Apps

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Benefits of Health Information Exchange/Data Interoperability

1. More robust Person and Family-Centered services by making more data readily available to the person

2. More efficient and effective communication for Counties and LTSS Providers

3. Compliance with CMS direction implied by the new proposed rules

4. Improved health outcomes for Medicaid recipients through better care coordination and service coordination

5. Cost savings for the Medicaid program from improved care coordination and better health outcomes

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Person Centered Design

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NOTE: This graphic represents a possible future state

EHR

Additional Information

• Tom Gossett tom.l.gossett@state.mn.us

(651) 431-2601

• Ilya Garelik Ilya.Garelik@state.mn.us

(651) 431-2601• Rolf Hage rolf.hage@state.mn.us

(651) 431-259

• Jody Lien jlien@co.ottertail.mn.us

(218) 998-8338

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