Healthcare Technology and Coordination of Care

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Chapter9-CareCoordinationandHealthInformationTechnology.docx

Chapter 9

Care Coordination and Health Information Technology

Rosemary Kennedy, PhD, RN, MBA, FAAN; Patricia S. Button, EdD, RN; Patricia C. Dykes, PhD, RN, FAAN, FACMI; Laura K. Heerman Langford, PhD, RN; and Lipika Samal, MD, MPH

Health information technology (HIT) is a necessary requirement for high quality, safe, and effective care coordination. Irrespective of the various models and methods of care coordination, all require effective communication and decision-making across care settings, providers, and receivers of care. Furthermore, with advent of the health care home, the setting of care coordination is frequently the home, community, school, and workplace, requiring ubiquitous information exchange.

HIT can support the activities related to care coordination, facilitate transfer of information, enable communication between parties in different locations, and provide real-time decision support. HIT can reduce unnecessary and costly duplication of services by sharing service results across settings of care. The electronic health record (EHR) can prevent medication errors by informing clinicians of patient allergies, providing patient education information, and reconciling medication lists as patients move from one setting of care to another (Congressional Budget Office, 2008). Care coordination models vary, but typically, they utilize case managers, care transition programs, disease management, HIT, and other strategies to manage service delivery and support patients and providers. Care coordination combined with the use of HIT has the potential to reduce cost and improve outcomes for all populations in all health care settings; the most impressive outcomes occur in high-risk populations whose complex health issues involve costly treatments and repeated hospitalizations (NQF, 2010). The purpose of this chapter is to describe the rapidly evolving role of HIT in advancing the goals of care coordination, and to propose strategies for nurses and other professionals to anticipate and influence future developments in the field.

DEFINITION OF HIT TERMS

HIT, as an important component in care coordination, is the application of computers and technology to the provision of healthcare in all settings, including all stakeholders involved in health (Hersch, 2009). Since HIT plays a critical role in communication, frequently the term information and communications technology (ICT) is used along with HIT. There are different technologies that are included under the umbrella term of HIT. One of national importance is the EHR, which includes comprehensive and longitudinal information about the patient’s supporting care across all settings (acute, home-care, ambulatory, clinic, etc.). The Healthcare Information and Management Systems Society (HIMSS) define EHR as a secure, real-time, point-of-care, patient-centric information resource for clinicians (HIMSS, 2003). The EHR ideally facilitates care coordination by providing ubiquitous access to information and evidence-based alerts and reminders across people, function, and sites over time. HIT plays a key role in the major domains of care coordination as defined by the National Quality Forum (NQF), including the health care home, creation of a proactive plan of care, and follow-up, communication, and transition of care or hand-off support (NQF, 2006).

The EHR automates and streamlines care coordination workflow, closing gaps in communication and responses that can cause delays in care. EHRs are typically tailored for the specific needs of a respective facility and the operations of that facility. Therefore, in order to support care coordination between and among facilities, health information exchanges (HIEs) are needed. Linking all of the HIT systems within a region or community is essential in order to exchange important health information across different EHRs spanning different healthcare delivery organizations. HIEs enable the digital exchange of health information across organizations within a region or community of care (Alliance for Health Reform, n.d.).

Personal health records (PHRs) store healthcare information that is entered and managed by the patient and/or consumer of health care (HealthIT.gov, n.d.-a.). PHRs typically contain patient reported care compliance, clinical status, and outcome information that is critical data for effective care coordination. Patient access to the information in their electronic health records is very important and with patient portals, patients have secure, online, 24-hour access to personal health information, such as medications, laboratory results, and care plans, from any location through the Internet (HealthIT.gov, n.d.-b).The data contained within EHRs and PHRs can be downloaded onto mobile technology platforms, such as iPads and smartphones. This facilitates exchange of information between not only nurses, physicians, and care team members, but also the patients, thereby making them part of the care team. Care coordination requires HIT that supports on-demand access to information, on any device (phone, laptop, tablets, workstations), serving multiple users at once (nurse, physician, patient, consumer), and using technology so the users do not have to be concerned about where the information is stored. This is the essence of cloud computing. The major advantage of cloud computing for care coordination is “on demand” access to information without requiring human interaction with individual service providers. The advent of cloud computing allows for ubiquitous, convenient, on-demand network access to a pool of applications, servers, and services that can be accessed with minimal effort (Mell & Grance, 2011). With the appropriate security and patient privacy software, cloud computing can be a tool to facilitate information exchange across geographical settings, providers, and patients.

Also, the Internet serves as a valuable source of education information that can be used to support care coordination activities, particularly when patients move from one setting of care to another. As nurses advise and educate patients, it is important to assess the Internet sources of education using criteria ensuring the entity posting the information is a valid and reliable source of evidence-based content, that original sources of publication are provided, and that the information is reviewed by someone with the appropriate credentials before it is posted (National Cancer Institute, 2012).

The science that goes into HIT focuses on the specialty of informatics. As defined by the Nursing Informatics (NI) Special Interest Group of the International Medical Informatics Association (IMIA), nursing informatics science and practice “integrates nursing, its information and knowledge, and their management with information and communication technologies to promote the health of people, families, and communities world-wide” (IMIA News, 2009, paragraph 2).

THE ROLE OF HIT IN CARE COORDINATION

The National Quality Strategy’s (NQS) aims of better care, affordable care, and healthy people and communities set forth a unified vision of the healthcare system (NQS, 2012). In 2011, the NQS focused national attention on care coordination, aligning efforts on the use of HIT to focus on effective communication to coordinate care. Integral to these efforts is the use of HIT to capture, aggregate, and report data to enable more standardized and efficient care delivery at both the patient and population level.

The use of HIT is important to the NQS and, to this extent, the Health Information Technology for Economic and Clinical Health Act of 2009 fosters adoption of meaningful use (MU) of certified EHRs to improve quality and reduce healthcare costs through financial incentives (Harle, Huerta, Ford, Diana, & Menachemi, 2013). This has significant implications for care coordination, as MU requires the exchange of electronic health information with other systems and to also integrate the information into care delivery (U.S. Government Printing Office, 2009). The exchange of information within and between sources of care, whether HIT or providers of care, is an integral function of care coordination; therefore, the MU requirements are aligned to support care coordination activities.

Concurrently, the Agency for Healthcare Research and Quality’s (AHRQ) care coordination framework diagrams key domains that are important for care coordination (AHRQ, 2011), while also providing a mechanism for describing the use of HIT. The AHRQ framework identifies coordination activities hypothesized or demonstrated to facilitate both the care coordination activities and the broad approaches that are commonly used to improve the delivery of health care, including improving care coordination. This framework identifies “health IT-enabled coordination” as a broad approach to support coordination (AHRQ, 2011). Health IT tools, such as EHRs, patient portals, or databases, can be used to communicate information about patients and their care between healthcare entities or to maintain information over time. Table 1 shows the components of the framework along with examples of how HIT supports the framework.

Table 1 AHRQ Mechanisms for Achieving Care Coordination (Domains) with HIT Examples

Coordination Activities

HIT Examples

Establish accountability or negotiate responsibility

■ Electronic tracking of patient consent forms across settings of care.

■ Worklists showing all members of the clinical team and respective areas of responsibility to facilitate patient understanding as they transition from acute care to home care.

Communicate

■ Patient access to a plan of care that displays reminders for medications.

■ Patient entry of reported outcomes (blood pressure, blood sugars) into smartphones that automatically alert the nurse in the clinic if the result is out of range for real-time communication between patient and provider.

Facilitate transitions

■ Seamless and secure exchange of patient summary information between the acute care nurse and the home care nurse to support transitions of care.

■ Home case nurse has electronic access to the patient care plan prior to hospital discharge to allow for care coordination and management.

Assess needs and goals

■ Evidence-based suggested problem list based on nurse documentation of an admission assessment.

■ Integration of data entered into a PHR with data entered into an EHR so a nurse can develop a person-centered care plan in accordance with patient preferences.

Create a proactive plan of care

■ Use of clinical decision support to create a proactive plan of care based on assessment documentation from all members of the clinical team.

Monitor, follow-up, and respond to change

■ Use of electronic alerts so when a physical therapist visits a home care patient and identifies a high fall risk score, an alert is sent to the home care nurse for immediate follow-up.

Support self-management goals

■ Integration of patient documented goals (from a PHR) into the EHR to provide a comprehensive list to the home care nurse before the first home care visit.

Link to community resources

■ Easy access from the EHR to community resources that fit the patient’s needs based on data entered into the EHR (diagnoses, conditions, age, etc.).

Align resources with patient and population needs

■ Transmission of patient data to home care nurses prior to discharge for appropriate alignment between patient needs and nurse expertise.

■ Electronic systems can determine where failures in care are occurring by mining large databases to determine which nursing interventions have the highest impact on outcomes across populations.

Broad Approaches

HIT Examples

Teamwork focused on coordination

■ Use of a clinical summary seamlessly transmitted between physician provider, home care nurse, and pharmacist for care coordination in the community so all stakeholders have access to the most up-to-date information. See Case 4.

Health care home

■ Real-time communication of pertinent home care nurse documentation to the physician provider prior to the initial office visit after a hospital discharge.

Care management

■ Engaging patients in use of technology to enter patient reported outcomes, receive reminders related to medications, and with real time communication to providers if patients are not following the care plan. See Case 2.

Medication management

■ Patient entry of actual medication use through interactive phone voice technology that feeds a dashboard for early intervention by a nurse if the medication is not being followed as ordered. See Case 3.

Health IT-enabled care coordination

■ Use of health information exchanges whereby patient information is securely communicated between providers using disparate EHR systems. This facilitates care coordination when a patient receiving care from one system is admitted to a facility in another system. The HIE ensures that nurses have access to all the patient information. See Cases 1 and 5.

Source: Domains (left column) from AHRQ, 2011

Essential national efforts underway are fostering the development and implementation of HIT to support care coordination with the intent to increase quality, safety, and effectiveness. HIT enabled care coordination includes:

■ Development and adoption of databases that store important information related to nursing practice (evidence-based care plans), patient specific information (assessment findings, medications, laboratory results), financial information (insurance data), and administrative information (past visits, locations, and providers). All of this information is vital to care coordination as the database can support an episode of care, as well as transitions of care between acute and home care settings.

■ Software applications that provide the functionality necessary to view patient data, enter patient data, generate reports, and communicate with both the patient and the interprofessional team.

■ Clinical decision support tools that foster decision-making based on current research and best practices, as well as providing the ability to assess the impact of nursing care across patient populations, ultimately generating new knowledge to advance nursing practice.

■ Development and adoption of data standards starting with the use of a consistent standardized terminology, which serves as the infrastructure behind the use of HIT for care coordination. Consistent use of terms for concepts (pressure ulcers, pain, etc.) is critical for the exchange of data between disparate HIT systems across geographical settings. If the systems use different terms, it will be extremely arduous trying to send data between the hospital system and the home care system. Without this consistent representation using standard codes, nurses will have to interpret the data between different systems, thereby hindering efficiency, quality, and safety.

HIT IN CARE COORDINATION: SOME CASE EXAMPLES

In the previous section, we discussed HIT solutions that could support effective care coordination and care transitions within settings and across the continuum. Consider the following cases and how lack of information can lead to suboptimal outcomes. Also consider how information exchanges might differ in primary care, hospital, or post-acute settings and how this will influence effective care coordination.

Case 1. Pediatric Care

An eight-year-old child cared for by a PCP in the community has frequent admissions to an acute care hospital for a pulmonary condition. While on vacation, the child becomes acutely short of breath and the family takes him to a local ED. The ED has no information on the child’s chronic medical condition and the child is given nebulizers with no improvement. The child is admitted to a general pediatrics unit in the hospital. The inpatient team does not have access to a current problem list, a current list of outpatient meds, or an emergency care plan. They gather information from the family about the patient’s condition and medications, but the information is not specific enough to assist in diagnosis and treatment of the acute exacerbation. The patient’s specialist is not reachable by phone. Fortunately, the child does not need to be intubated overnight and the inpatient team receives a call back from the specialist the following morning, at which time a recent note is faxed over that helps the inpatient team to diagnose and treat the patient.

■ How would a health information exchange have improved care transitions for this patient?

■ What health information technologies could be used to enhance follow-up care and greater engagement of the child and family in self-care?

Case 2. Acute Care

A 76-year-old patient with heart failure is brought by ambulance to an ED at a community hospital after being seen there and discharged one week ago with medication changes and a recommendation to follow-up with the primary care provider. The patient presents with a weight gain of seven pounds, shortness of breath, and fatigue. The patient gives a medication list to the ED nurse that was prepared three months earlier by the visiting nurse. The medication list is not reconciled to reflect the changes from the previous ED visit. The patient says that he did not follow-up with his primary care provider because he was feeling too weak to leave the house. The patient reports that he has several self-management plans: one from the ED, another from the visiting nurse, and one from the hospital, but he is unsure which one he should follow. He had not been weighing himself at home so had not noticed the weight gain, but called the ambulance because his ankles were swollen and he was having difficulty breathing.

■ How would patient activation by entering daily weights into a tele-health application improve the outcomes for this patient?

■ How might health information technology be tailored to the needs and preferences of this vulnerable patient?

Case 3. Home Care

A home care nurse visits a 68-year-old patient who was recently seen in a major academic medical center with a pressure ulcer. The nurse has a brief referral from the specialty practice requesting wound care and pain management, but no information related to the progression of the wound or how pain has been managed. When the home care nurse arrives, the patient is in bed and complaining of a pain. Upon assessment, the nurse finds that the patient has a pain level of 7/10 and is constipated. The pressure ulcer on the patient’s sacrum is unstagable with green purulent drainage. The patient reports that her daughter is ill so she was unable to go to the pharmacy to pick up her prescriptions. Therefore, patient does not have any of the medications that were ordered for her. The patient reports that she was given a packet of papers as she was leaving the specialty clinic but that she left them in the ambulette and, therefore, does not have a copy of her medication list or her instructions.

■ How would patient entry of actual medication use through interactive phone voice technology have triggered support for this family and patient adherence?

Case 4. Primary Care

A 47-year-old woman calls and makes an urgent care appointment. When she arrives, she tells the nurse practitioner that she has been having chest pain. The NP has never seen the patient before. From the electronic problem list it is clear that the patient has a history of CAD and sees a cardiologist in the community. However, there is no interoperability between the specialty clinic and primary care clinic. There are no stress test results, and no information about past reports of angina or how they were managed. On further questioning, the patient reports that she was told by her cardiologist to take nitroglycerin for chest pain. The NP at the primary care office places multiple phone calls to the cardiologist who is out of town and must decide whether to admit the patient to the hospital. There is incomplete information there as well, which is likely to lead to unnecessary duplicate testing.

■ How would a clinical summary improve the NP’s ability to effectively triage the patient and potentially avoid a hospital admission, given the severity of her complaint?

■ How might this patient be involved in the development of the clinical summary?

Case 5. Long-Term Care (LTC)

An 88-year-old LTC patient and family complete an advanced directive (AD) with the LTC physician and the nurse director. The AD form is scanned and stored in the historical progress note section of the EMR. One week later, the patient develops a fever, cough, and new disorientation at 11 p.m. The nurse on duty looks for the AD but cannot find it in the EMR. A decision is made to send the deteriorating patient to the ED of a local hospital and the patient is transported without knowledge of an existing AD. The patient desaturates in the ambulance, is intubated in the ED, and then admitted to the intensive care unit (ICU). The family comes in the next morning and says that they want the patient sent back to the LTC facility with comfort measures only. The family is upset that patient was intubated as they took a day off from work to complete the advance directives form a week earlier to prevent this type of situation from occurring.

■ How would a health information exchange ensure that the patient’s goals of care are met?

Summary of Case Studies

In each of these cases, information was not available to the provider or patients and families at the right time leading to suboptimal care coordination. In each situation, health information technology could have enhanced patient engagement and improved the outcomes. As noted in Table 1, different types of HIT are useful and available to support a range of care coordination activities.

NURSING’S ROLE IN HIT ADOPTION

Clearly HIT is a critical mechanism to effective care coordination. However, it is important to have insight into the current status of HIT development and adoption. To that end, in 2012, the NQF contracted with Brigham and Women’s Hospital in Boston to conduct both a literature review and site visits focused on the current HIT status designed to improve transfer of information during transitions of care, with a focus on quality measurement (Samal et al., 2012).

The main objective for this project was to assess the readiness of respondent organizations to transmit electronic data, to use HIT systems to perform the data capture, to standardize data, to communicate a patient-centered care plan, and use data for quality measurement. The results indicate that organizations are working to address care coordination demands, but are struggling with a patchwork of homegrown and commercial systems across settings, few of which connect and exchange data. Many organizations are still working to transfer basic discharge summaries electronically between settings, and organizations are using multiple methods for communicating and extracting the data that they need for care transitions. Where more comprehensive electronic methods do exist, they tend to be discipline-specific and focused on high-risk patients (Samal et al., 2012).

HIT in the broadest aspect has the potential to facilitate care coordination across all care settings. However, there are both technological and human factors that have slowed both the development and adoption of HIT. Technology factors related to matching devices to workflow, standards for interfacing infusion pumps and other medical devices with EHRs, user-interface design to support the task at hand as well as the role of the user (nurse, patient, consumer), and costs of technology all play a role in HIT adoption. This is further complicated by the inherent complexity of care coordination activities, which makes integration of HIT complex. Many of the existing EHRs fail to interoperate across different care delivery organizations. This is a huge barrier since as patients transition from acute to long-term and home care, the data from the EHR fails to move with the patient, putting the receiving care delivery team at risk when caring for patients. For this reason, many of the hand-offs that occur during care coordination are dependent on nurses to manually exchange, either through phone, fax, or hard copy documents, the information necessary for transferring responsibility of the patient.

Nurses play an important role in the development, implementation, and sustained adoption of HIT to support care coordination. This role is at the policy, care-delivery, and interprofessional levels. Nurses design, implement, and evaluate HIT projects to ensure all aspects of HIT support evidence-based, person-centered nursing practice. This involves leadership roles within organizations; providing input into the technical design by working with engineering experts; teaching nurses, patients, and consumers how to use HIT to support care coordination; providing testimony at the national level to guide future policies on HIT adoption; and conducting research to evaluate the impact of HIT on care outcomes.

Nurses also play a strong leadership role in vendor settings, pushing for the development of HIT that exemplifies nursing practice, while also showing the return on investment for such development. Through research nurses are participating in the development of new models for care coordination, using HIT as the foundation to bridge current care coordination gaps. The aforementioned areas are the responsibility of every practicing nurse, not just those formally involved in HIT or informatics roles.

FUTURE DIRECTIONS FOR HIT IN CARE COORDINATION

The development and integration of HIT within health care offers great promise. The explosion of mobile devices is providing a powerful tool for both patients and providers to track patient progress, share information, and communicate as patients move between office visits, the home, and inpatient settings. The increase in patient use and adoption of HIT is supplementing existing repositories of EHR data, thereby providing tremendous opportunities for data mining and healthcare analytics. Through this mining, nurses are able to identify which patients will benefit from care coordination and interventions that have the highest impact on outcomes.

HIT is no longer confined to care delivery settings as patients have mobile devices in their homes for tracking blood glucose and blood pressure and are even wearing these devices for continuous monitoring and transmission of the data to EHRs for real-time analysis. The future will bring a greater degree of connected devices allowing for robust data analytics. This is occurring in parallel with the advancement of data standards to support a nationally accepted structure for care plans, which is an important underpinning of care coordination. As these advances unfold, the role of nursing is essential as nurses bridge the space between the interprofessional team and patients and consumers across all domains of care.

HIT is evolving rapidly to advance care coordination through information exchange and decision support across multiple providers and settings. It can be expected to have a profound influence on the future of care coordination. As HIT is infused into care coordination processes, we will learn much about its role in supporting and facilitating this work. The data it provides will be a vital source of new knowledge to drive improvement and innovation. Nurses and other professionals engaged in care coordination can anticipate many important opportunities to shape future refinements of HIT and to champion its adoption and full integration into practice.

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