CRISP is taking an incremental, value-based approach to buidling the statewide health information exchange.  This means that services are being implemented in an order that considers the level of clinical impact the service will have on patients and providers, the cost, and the technical hurdles that must be overcome.  

What follows is a list of some of the services CRISP intends to implement over the coming years:

Summary

Over the past year, CRISP has been conducting a pilot project to deliver electronic medication history information to Maryland emergency departments. Due to the fact the service is already being piloted, delivery of medication history is anticipated to be chronologically the first Use Case for the standards-based HIE in Maryland. CRISP believes that medication history information can be delivered through multiple mechanisms - for example as an independent message or as part of a CCD document. In the initial rollout it will likely be sent as an independent message, with integration into a CCD a goal for the future.

The existing electronic medication history service now in pilot functions when, at the time of hospital registration, a query is sent to an HIE infrastructure and then routed to RxHub / SureScripts, which in turn queries the PBMs in the network, and returns a list of prescription medications to a printer at the hospital. The communication occurs across a secure VPN connection. The prescription medication list is derived from insurance claims information and does not have 100% coverage of all medications a patient may be taking; some patients are not in the system and some medications may have been obtained in a manner that is not captured by PBMs. Rather, the list is an aid to the physician during the medication reconciliation interview required by JCAHO, helping to create a more accurate medication history than could otherwise be obtained. The first location is returning results for approximately 60% of patients who consent to participation. RxHub / SureScripts is currently integrating their independent networks to allow both PBM and pharmacy data to be accessed by the medication history service, likely driving up the completeness of the medication list and the percent of positive results in terms of patient coverage.

A medication history service could be purchased by a hospital independent of an HIE. However, working through the HIE will provide several advantages:

• The HIE will be able to purchase and coordinate the service at a lower cost than hospitals would receive independently.
• The HIE will be able to drive up the ‘hit rate’ by encouraging the participation of additional Maryland health plans, and possibly by incorporating data directly from Maryland providers into the list.
• In the long run, the HIE will be able to integrate the medication history list into a broader clinical summary document, making the information easier for physicians to consume.
• Most importantly, connecting to the HIE for medication history services will be a ‘foot-in-the-door’ for adopting other Use Cases within Maryland hospitals.

Clinical Value

The core clinical value and the primary objective of the medication history service is to streamline the mandatory process of reconciling medications when a patient presents in a number of care settings. This process customarily begins when a caregiver asks the patient (if the patient can respond) what prescription and non-prescription medications s/he is taking. The data collected is often inaccurate, as patients are frequently forgetful and rarely know the exact names and doses of their current and recent prescriptions. At times, the first source of data is a patient’s description of the color or characteristics of a certain pill without its brand or generic name. This interaction—however useful or not—is typically the first source of data. Next, the clinician might pull charts or search other hospital data or internal systems if available. Or they might even try to call a pharmacy to obtain records (assuming the pharmacy is open). Typically, all of this information is fragmented, requiring a cumbersome, time-consuming, and challenging process with highly variable results. By delivering ED providers a robust electronic medication history, the medication reconciliation process is meaningfully improved and thus care is improved.

Summary

One of the most financially successful services deployed by RHIOs and HIEs around the country has been that of lab results delivery to physicians and clinics. Most of the large national laboratories (including LabCorp and Quest) already offer electronic delivery of results to ordering physicians through proprietary portals. The services offered through CRISP would include the national labs, as well as hospital and local/regional laboratories. By consolidating multiple sources to a single report, physicians will realize efficiencies by not having to access multiple portals, faxes, or mailed reports to obtain results for patients. As far as hospital labs are concerned, they are mostly utilizing paper to mail results to physicians today. By enabling electronic delivery, hospitals can reduce the administrative costs of paper and postage.

This service would simply route lab results from the processing lab to the ordering physician, along with any requested copies to other physicians. Because this is a direct “push” of data from one provider to another, there would be no need to access the EMPI or Patient Registry.

Clinical Value

While realizing tremendous administrative savings and simplifying workflow, there is no direct improvement in clinical value realized through delivery of lab results. This Use Case replaces an existing function with a more efficient one, but no new clinical value is derived. Yet, if clinicians around the state begin to use a common portal, the HIE will have successfully laid the foundation for other valuable services, which can be used even by physicians who are mostly paper based. This Use Case could serve as a foundation upon which the HIE can introduce other services.

Summary

In the “Discharge Summaries to Physicians and Clinics” Use Case the recipient of information is another emergency department or hospital, removing the element of ER diversion that is present below in sharing discharge summaries among physicians and clinics. This Use Case delves into hospital-to-hospital data sharing, which the CRISSP group believes to be viable but perhaps more difficult due to limited natural incentives for participation. This Use Case lends itself to alternative consumer-centric delivery models, such as health record banks. Yet, a health record bank infrastructure is not “shovel ready” for immediate implementation. The hybrid model proposed by CRISP is intended to accommodate either approach, and a number of consumer-engagement strategies can ultimately be supported.
In specific regions, such as Montgomery County, emergency departments have already expressed an interest in participating in an exchange of discharge summaries. This willingness is in part driven by the frequency with which these hospitals go on “bypass”, resulting in a repeat patient at one hospital suddenly showing up at another. In other regions, providers have already begun to coordinate, as in the case of St. Agnes, LifeBridge, and Erickson. CRISP will develop an infrastructure for this Use Case that can serve all of the state’s hospitals, but we expect to focus early implementation at the hospitals within regions where the expressed willingness and incentives to participate are highest. Successful implementations of limited scope may help drive broader adoption.

Clinical Value

The clinical value of this Use Case is the ability to inform emergency room providers of critical information that may not otherwise be available. This Use Case expands upon the value of the electronic medication history service by expanding the scope of the health information delivered to the point of care, increasing the ability for providers to quickly respond and provide care to patients who may be unable to communicate effectively or may not recall their past encounters.
 

Summary

Delivering emergency department and hospital discharge summaries to physicians and clinics is a critical Use Case that enables the transfer of key information following an acute health event so that appropriately informed follow-up care can take place. However, not all emergency room care is for emergent situations. By supplying physicians and clinics with detailed discharge information, this Use Case will support appropriate use of emergency rooms. Clinics will be informed of patients who may not have a primary care physician, allowing for outreach efforts to be employed seeking to discourage non-emergent use of the ED and promote primary, clinic-based care when appropriate. If workflows and incentives are properly implemented, adoption of the Use Case will result in fewer readmissions – a goal which is currently receiving attention within the Maryland hospital community.

Clinical Value

The inclusion of emergency room discharge information is powerful during follow-up care to ensure an accurate understanding of the previous episode of care is conveyed to the next provider. Enabling this improvement in the continuity of care through sharing of discharge summaries is a clear example of the core clinical benefits of health information exchange.