tronically generated by the hospital, they
are often printed or faxed to the LTPAC
facility. Moreover, because of the relatively
new use of electronic summaries of care,
there can be information missing or items
left blank in the form, making it difficult for
the LTPAC staff to interpret (Meehan, 2015).
Use of HIE holds promise to streamline this
process. Through proposed federal mandates (CMS, 2015) and pressures regarding
the Meaningful Use program (HealthIT.
gov, 2015, ARRA, 2009, HITECH, 2010),
acute care providers and LTPAC are being
required to use HIE to provide visibility of
electronic health data to care providers in
LTPAC settings. Although HIE is still evolving and is relatively new to LTPAC environments, it can be seen as a catalyst for continuity of care, particularly for older adults
managing multiple co-morbidities, and who
are likely to be admitted, discharged, and readmitted from acute care to long term care,
and back again.
Consider an example:
Vivian is a 94-year-old woman living in
a skilled nursing facility. She has no local
family members, but she has a niece living
a 4-hour car ride away. Vivian is allergic
to penicillin and latex, is recovering from a
hip fracture from the previous year, and is
managing diabetes. She has recently contracted pneumonia, and after being treated
on site at the SNF, the symptoms are not
improving, so she is transferred to the emergency room at a local hospital. After evaluation in the ER on a Wednesday afternoon,
Vivian is admitted to the hospital to bring
her blood oxygen levels up and to treat the
pneumonia. Her niece is alerted about the
transfer, but, because of work obligations,
she cannot get to the hospital right away.
Instead, she plans on making the drive to
see her aunt within the next couple of days.
Vivian makes good progress in the hospital,
and is discharged two days later, back to the
SNF, on Friday evening.
In order to ensure that Vivian is not given
anything to cause an allergic reaction, and
for the staff to give her the best care, it is
essential for ER and hospital staff to have
visibility into Vivian’s health record indi-
cating her current health, allergies, medical
history, medications, and social support. In
a reciprocal manner, when Vivian is dis-
charged from the hospital, back to the SNF,
it is essential that the SNF nursing staff
can clearly see her summary of care, list
of medications, and other pertinent notes
on her follow up protocol. Vivian’s Friday
night return to the SNF may be challeng-
ing as there may be fewer staff members to
receive and re-admit her. Moreover, newer
staff may greet her. High levels of staff
turnover in long term care settings exac-
erbate issues with maintaining continuity,
resulting in different staff members caring
for the same older adults who go in and out
of acute care and back to long term care set-
tings (Mukamel, et al, 2009).
HEALTH INFORMATION
EXCHANGE IN LTPAC
Lack of financial incentives through the
Meaningful Use program (ARRA, 2009,
HITECH, 2010), has stymied widespread
health IT in LTPAC. Yet, there is an
increased prevalence of use of electronic
health records (EHRs), HIE and other
health IT by LTPAC providers. Doughtery
(2011) examined what is known about HIE
in relation to LTPAC, including barriers
and accelerators to adoption. Among other
influences, limited HIT capacity and lack of
awareness of HIE standards, may impede
care coordination and effective transitions
of care (Doughtery, 2011). Thus, continuity
of care for these patients is directly impacted
by advancements and use patterns of HIE in
LTPAC settings.
HIE has been defined as the “ electronic
exchange of clinical information allowing
clinicians to access and securely share a
patient’s vital medical information elec-
tronically- improving the speed, qual-
ity, safety, coordination and cost of patient
care.” ( HealthIT.gov, 2013). Two forms
of health information exchange currently
used by LTPAC organizations are directed
exchange and query-based exchange. The
HealthIT.gov (2015) website defines direct-
ed exchange or messaging as that which is
“used by providers to easily and securely
send patient information—such as labora-
tory orders and results, patient referrals, or
discharge summaries—directly to another
healthcare professional.” Similar to sending
a secured email, directed exchange uses the
internet to send information in an encrypted,
secure manner. Typically, this information is
shared among healthcare professionals who
already know and trust each other, and is
commonly compared to sending a secured
email ( HealthIT.gov, 2015). The HealthIT.gov
(2015) website defines query based exchange
as that which is used to search and discover
accessible clinical sources on a patient, often
used when delivering unplanned care (e.g.,
ER visit). Byrne & Doughtery (2013) describe
that many LTPAC providers actively
exchanging health information using HIE
were recipients of federal or state funds.
The Office of the National Coordinator
for Health Information Technology (ONC)
sponsored Beacon Community grants and
State HIE initiatives through which states
are providing assistance to involve LTPAC
providers in HIE. (Byrne & Dougherty,
2013). Beacon Community projects demon-
strate innovative ways that LTPAC facili-
ties are already sharing information and
improving quality. One innovation advanc-
ing how LTPAC can be involved in HIE is
the KeyHIE tool, developed by The Key-
stone Beacon Community in Pennsylvania.
The HealthI T.gov website for the Keystone
Beacon Community (2012) describes this
application as one that “extracts clini-
cally relevant information from required
reports, like the minimum data set (MDS),
that long term care facilities submit to the
Centers for Medicare & Medicaid Services
(CMS), and then converts the information
into a standardized document, which can
be incorporated into any HIE for access by
other clinicians.” These files contain data
elements including the patient’s clinical,
physical, psychological and functional sta-
tus (including activities of daily living), as
well as life care wishes (Hassol, et al, 2014).
Other related initiatives include the State
HIE Cooperative Agreement Program
Challenge Grants funded through ONC to
improve LTPAC transitions. Specifically,
Oklahoma, Maryland, Massachusetts and
Colorado were awarded grants to improve
care transitions for LTPAC residents
( HealthIT.gov, January, 2013). Throughout
their research and efforts, these grantees
have advanced communication processes
FALL 2015 n VOLUME 29 / NUMBER 4 n www.himss.org 16
