Thursday, November 07 | EHR Solutions and Operations, Thought Leadership, Care Coordination, Interoperability

4 Keys to Post-Acute Interoperability

By AJ Peterson, SVP and GM, CareGuidance

Most likely, every one of us has a story about how we or a family member was not getting appropriate care because important health information was not available. Or the information was incorrect. Or not timely. For some, the result might have been tragic.

The riskiest time for misinformation to occur is when a person is discharged from the hospital and transitioned to different care settings, such as a skilled nursing facilities (SNFs), home care or hospice agencies. 
People age 65 or older with complex health needs are most vulnerable during care transitions. As a result, they are at risk to being readmitted to the hospital. The culprit is almost always because important information was not communicated to the right place, at the right time, in the right format for the right person. 
Consider these statistics: After being released from the hospital, one in five Medicare beneficiaries will be readmitted within 30 days.1 Hospital readmissions cost Medicare about $26 billion annually, with about $17 billion spent on avoidable hospital trips after discharge.2
In no other industry is access to critical information more vital than in healthcare. A health event that triggers a change in medication but is not communicated to the right provider at the right time can be the difference between life and death. 
This is why “interoperability” – defined by Healthcare Information and Management Systems Society (HIMSS) as “the ability of different information systems, devices or applications to connect, in a coordinated manner, within and across organizational boundaries to access, exchange and cooperatively use data amongst stakeholders” – is such a hot button in our industry.
Put simply, interoperability is the engine to access and share information. It allows data to be readily available anywhere, at any time – and in a usable format to drive clinical and operational workflows and efficiencies. 
The result? Providers can deliver the most appropriate care, patients can experience safer transitions between the hospital and other care settings, and hospital readmissions can be reduced. 
What is true interoperability? 
The struggle today, however, is that many post-acute care providers are not adopting health technology that allows for a more seamless flow of data across all care settings. 
Every time we use our mobile phones, we see interoperability in action because we can call each other no matter the make, model or operating system of our carrier. However, in post-acute care, we still have work to do.  
The majority of post-acute providers – 66% – still access patient records from referring facilities via fax machines, according to a 2018 report from KLAS Research. 
“I consistently hear that post-acute organizations are about 10 to 15 years behind acute-care organizations when it comes to technology adoption and sophistication.” -Erik Bermudez, vice president of emerging healthcare markets at KLAS Research
Are you set up for success? 
In order to achieve the person-centered, value-based care CMS is now requiring, acute and post-acute care settings can no longer work in isolation. 
How can post-acute care providers achieve true interoperability, so data can freely flow across multiple settings and disparate networks driving person centered care? 
They need to adopt interoperable technology that can send, receive, find and integrate patient health information. 
Without all four of these capabilities, it becomes difficult to understand the full health picture of an individual. And without a full health picture, providers can’t accurately treat and care for their patients. (watch video: How to Connect with Other Providers Across All Care Settings
A successful interoperability strategy for post-acute providers should include the ability to:

1. Send

Not all care happens inside your organization, so sending patient information to other providers is critical to minimizing the risk of readmission. 
Only 41% of SNFs and 52% of home health agencies can send patient information to other providers.3
2. Receive
When your organization receives a new patient from a referral partner, can you electronically receive the referral information into your electronic health record (EHR)? 
Many organizations are still managing this process through printing, scanning and manually inputting this information. Only 53% of home health agencies and 41% of skilled nursing facilities are integrated to receive patient information.4

3. Find
It’s common for a referral or a Continuity of Care Document (CCD) to have limited or incomplete patient information. 
In order to prevent readmissions or negative patient experiences, providers need interoperability to search national health information exchanges and frameworks, like Carequality, to pull complete patient information directly from other providers. 
By electronically consolidating missing patient information into the EHR, providers can create a longitudinal view of the individual and their needs. 
Only 27% of skilled nursing providers and 42% of home health agencies are able to search for missing information.5
4. Integrate
Your EHR should be able to electronically receive, send, query and integrate patient information from outside sources. 
A Stratis survey found that in a disconnected model without interoperability, it can take a skilled nursing facility as much as 9.75 hours to reconcile medications versus 1 hour when the SNF is integrated with the referring partner. 
Currently, 18% of skilled nursing providers and 36% of home health agencies can integrate patient information from outside sources.6
Without true interoperability, “very soon hospitals, ACOs and MCOs are highly unlikely to partner with any post-acute providers incapable of sharing patient data electronically.” -Tim Rowan in a recent Healthcare at Home: The Rowan Report. 
There are so many ways interoperability can improve care for senior populations. (see The 15-point Interoperability Checklist
Take medications, for example – an area where post-acute providers have struggled. We’ve found that a senior may have seen up to 18 different providers and could be on 16 different medications. Leveraging interoperability to aggregate medications from disparate sources not only saves time for nursing staff, but improves accuracy and safety.
Put the person at the center
When it comes to our health and well-being, nothing is more important than ensuring our medical information is securely available to anyone treating and caring for us. Therefore, we must accelerate interoperability if we want to improve health, improve care and lower costs. 
Health data interoperability that can send, receive, find and integrate patient health information helps assure that individuals receive the best care possible as they move from one provider to another. And it assures that no matter what care setting they move to (hospital, home, SNF, hospice, etc.) their information follows them. 
AJ Peterson leads the interoperability team at Netsmart, a healthcare IT company that provides EHRs and business services to more than 30,000 post-acute care and human services organizations. Peterson is on the advisory council for The Carequality Project, which is intended to serve as the interoperability framework for keeping health information data moving uninterrupted, unimpeded by geography or network endpoints.
To learn more about how Netsmart can advance your interoperability strategy, visit here.
4 Ibid.
5 Ibid.


Meet the Author

AJ Peterson · SVP and GM, CareGuidance


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