Coordinating Patient Care in an Age of Incomplete Interoperability


CMS and the Office of the National Coordinator have created programs, standards, incentives and penalties to encourage interoperability for the exchange of electronic patient health information. In spite of these efforts, our healthcare system as a whole still falls short of its potential for improving care coordination and clinical outcomes, or reducing cost through the exchange of patient health information.

Electronic health record (EHR) interoperability, as defined by technical standards and frameworks, is only the infrastructure or ‘plumbing’ for secure exchange, and significant technology and operational gaps within this infrastructure remain.

Change management, including development and testing of new workflows, is one of the most critical, often overlooked components for achieving better care coordination through interoperability.  Interoperability of EHRs is potentially transformative, but is also rapidly evolving, and will require flexibility and vigilance for people and processes throughout its evolution to maximize care coordination benefits. Meaningful Use (MU) has served as a catalyst for interoperability, but at the same time, it has created a “check box” mentality focused on achieving threshold metrics for incentive payments. In order to understand and implement the operational changes necessary to drive efficient and effective health information exchange, one must first understand the factors that got us to this point.

Direct Messaging Challenges

One of the prominent factors inhibiting efficient health information exchange is effective implementation of direct messaging, a technical standard for exchanging health information between healthcare entities. MU has been focusing incentives  on senders of health information to use Direct messaging, but has not been rewarding recipients to receive and distribute those messages appropriately, creating coordination gaps, including:

  • Providers sending patient records to hospital departments that do not have direct addresses
  • Organizations with live but “inactive” firect addresses created solely to serve as “catcher’s mitts” for senders trying to reach their MU thresholds.
  • Clinical personnel that are not aware of, or have not been trained to use their published direct addresses, even as other providers are sending critical patient information to them.

Continuity of Care Documentation

Beyond MU, it is important to consider the impact of specific EHR workflows, configurations and triggers. For instance, 2014 Certified EHRs have C-CDA capabilities. Consolidated-Clinical Document Architecture (C-CDA) includes Continuity of Care Document (CCD), Discharge Summary Document and seven other “open” document templates using common architecture, coding, semantics and markup language.

Understanding the limitations of capabilities such as C-CDA is another necessary step on the path to interoperability and improved care coordination:

  • MU has not specified which document to use for a particular use case. Many EHR vendors have limited their exchange capabilities to the CCD in order to satisfy the minimum certification requirements.
  • Discharge instructions have been optional in a CCD, so Discharge Summaries are often completed after the release of the CCD.
  • CCDs are sent via direct while the discharge summary is later faxed which creates confusing workflows for the receiver.
  • Optionality of the current standards does not ensure that CCDs from one vendor can be processed into the electronic patient records of a different vendor’s system.

Change Management Strategies to Support HIE

A solid clinical change management team is necessary to both identify the interoperability gaps that could result in negative consequences for patient care, and to maximize the probability that patient information will be available when and where it is needed.

To be effective, change management teams should be mindful of following best practices:

  • Include clinicians, administrative personnel and care management on your process improvement team. The operational challenges are often even more complicated than the IT challenges.
  • Ensure end users of published direct addresses are trained, active users.
  • Understand receivers’ content needs. Understand your vendors’ available document types, content options and release triggers to ensure that the information you are sending is useful.  Create end user workflows that lead to meaningful documentation for care coordination.
  • Understand complementary or competing technology (e.g. faxes and repositories) and develop mutually agreed-upon workflows with exchange partners. Recognize that multiple systems are needed during this period of transition but that streamlining of transport options over the mid-term is required.
  • Test with exchange partners.  Current standards do not ensure universal interoperability nor plug and play direct messaging.
  • Plan for triage of incoming electronic information. Determine which information is processed by medical records staff and which is reviewed and processed by clinicians. Train end users in how to incorporate incoming documentation into the electronic patient record.

Data Sharing’s Not-Too-Distant Future

The value based incentives included in Medicare Access and CHIP Reauthorization Act (MACRA) and the forthcoming electronic sharing of quality measures required under Improving Medicare Post-Acute Care Transformation (IMPACT) should further nudge providers and caregivers toward more meaningful exchanges of information and improved care coordination. All of these efforts, coupled with emerging technologies and standards like FHIR and new frameworks for sharing information, will no doubt make sharing of the right PHI at the right time with the right providers the norm in the not too distant future.

For now, we need to remember that it is not enough to build the IT pipe for direct messaging. To improve care coordination and clinical outcomes, the required effort is to implement processes and workflows that govern the exchange of electronic health information. Interoperability, clinical improvement and efficiency will naturally follow. Leadership should be prepared to include these resource needs in their planning.


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About Author

Len Levine

Len Levine is a practice manager with the Massachusetts eHealth Collaborative. He has assisted hundreds of providers to implement, connect, and use electronic health records. Len serves as an account manager for the Mass HIway and dedicates his time to the mission of interconnecting the providers of Massachusetts.

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