Transitions of care (TOC) refers to the movement of patients between healthcare providers, settings and home as their condition and care needs change. The State Health Alliance for Records Exchange (SHARE) is Arkansas’ only statewide Health Information Exchange (HIE). Connecting to HIE’s like SHARE can enable providers to work as a team by having consistent up to date information during transitions of care of their patient population.
1. Access to a more complete health record
HIE’s are connected to many other local and national healthcare providers. Being connected to SHARE can allow real time updates on patients that receive care at another hospital or clinic connected to SHARE. Currently SHARE is connected to over 1,500 Arkansas Hospitals and Practices, over 90 Hospitals in Missouri and Oklahoma, and 22 HIE’s across the US.
2. Reduce readmission rates
Connecting to HIE’s can allow hospitals to track patients and eliminate any miscommunication that may occur during transitions of care. SHARE offers 30-day readmission notifications which allow hospitals to receive a secure message when a patient that discharges from their facility, was readmitted into any SHARE participating hospital within a 30-day timeframe.
3. Receive patient information in real time
No more time consuming phone calls to other physicians or waiting on a fax. You can send patient information in real time using SHARE. HIE data is digitally shared, meaning that the most up to date information is available as soon as it is uploaded. This contributes to the timeliness of the information needed during transitions of care.
4. Send and receive information using a secure network
SHARE complies with all Federal and state privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and the Arkansas Personal Information Protections Act, which are designed to protect information. Providers can ensure their patients privacy when sending and receiving critical data needed during the transitions of care process.
5. Eliminate the hassle and cost of transporting medical records
HIE’s take some of the burden off providers having to send patient information through mail, courier or fax. Using HIE’s like SHARE enables providers to view all of their patient’s information in the same place without sifting through piles of paperwork or logging into multiple hospitals or provider systems. Healthcare providers can query SHARE and pull up patient records into their local electronic medical records (EMR) system via a Continuity of Care Document (CCD).
On Friday October 19, 2019 SHARE attended and exhibited to 178 provider practices in Benton, Arkansas. Comprehensive Primary Care Plus (CPC+) program. CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.
CPC+ includes two primary care practice tracks with advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S..). CPC+ includes two primary care practice tracks with advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S..). The care delivery redesign ensures practices in each track have the setup to deliver better care to result in a healthier patient population.
The multi-payer payment redesign gives practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ provides practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback, to guide their decision making.
Providers and care coordinators in the program can use the Health Information Exchange (HIE) to be notified in the last 24 hours of when their Medicare patients have been admitted/discharged from the emergency department (ED) and inpatient discharged in real-time, see more here : http://sharearkansas.com/providers/comprehensive-primary-care-plus-cpc.
There are 2,900 primary care practices currently participating in Comprehensive Primary Care Plus (CPC+) in 18 regions: Arkansas, Colorado, Hawaii, Greater Kansas City Region of Kansas and Missouri, Louisiana, Michigan, Montana, Nebraska, North Dakota, Greater Buffalo Region of New York, North Hudson-Capital Region of New York, New Jersey, Ohio and Northern Kentucky Region, Oklahoma, Oregon, Greater Philadelphia Region of Pennsylvania, Rhode Island, and Tennessee. (List)
See more here about CPC+ initiative: https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus/
The OCH Health System is a regional safety-net healthcare provider serving both urban and rural communities throughout the Ozarks. The Hospital is located in Gravette, Arkansas, and clinics located in Missouri and Oklahoma is dedicated to providing advanced healthcare in Northwest Arkansas, West Oklahoma and Missouri through inpatient and outpatient services as well as community outreach. OCH Health System provides acute inpatient, outpatient, and long-term care services, behavioral health, cancer, cardiac, emergency, neurology, respiratory, recuperative, and women's health care; and nutrition counseling, pain management, pediatrics, radiology, surgery, therapy, rehabilitation, urology, weight reduction, wound healing, and mammography services, as well as services for ear, nose, and throat problems.
The following Hospital and Clinics are integrating with SHARE to exchange Continuity of Care (CCDs) to improve transitions of care and improve the quality of care they provide.
- Gravette Hospital & 24 Hour Emergency Room
- OCH of Gravette Clinic
- OCH of Gravette Specialty Clinic
- OCH Anderson Rural Health Clinic
- OCH Goodman Family Clinic
- OCH Noel Clinic
- OCH Pineville Medical Clinic
- OCH Polk County Clinic
- OCH Jasper County Clinic (Carthage)
- OCH Jay Family Medicine Clinic
- OCH Wellpointe Family Medical Clinic (Marshfield)
- OCH Southwest City Community Clinic
- OCH Sparta Clinic
- OCH Lawrence County Clinic (Mt. Vernon)
- OCH Webster County Clinic (Rogersville)
- Webb City Community Health Clinic
- OCH Behavioral Health Clinic (Springfield)
- OCH Evergreen Clinic (Springfield)
- OCH Pain Clinic at Evergreen (Springfield)
- OCH Christian County Clinic (Nixa)
About OCH of Gravette
At the OCH Health System, they take pride in standing out. They are simply not a traditional healthcare system, here’s why:
They care. They are an organization that takes pride in what they do, how they do it, and who they serve. They are dedicated to providing care to a high percentage of governmental and uninsured patients and strongly believe in helping the underserved.
Their culture is contagious. Patients who have only visited them once can immediately feel how the OCH Health System is unique. Their hospital staff treats patients like patients, not like numbers in a system. At the OCH Health System, every employee is member of their hospital family and they work hard to extend that relationship to every patient who walks through their door.
Learn more about OCH of Gravette here: http://www.ocholine.com
The pace of change in healthcare is rapid, and even more far reaching change may be on the way. Washington Regional realizes the importance of exceeding expectations for comprehensive healthcare services from birth through end of life care. Every plan they make, every action they implement, is driven by the desire for quality and is focused on the following central beliefs:
- Providing outstanding clinical quality
- Being good financial stewards
- Providing a rewarding place for our employees to work
- Building, nurturing and preserving a strong partnership with the physician community
A vital component in Washington Regional’s quest for quality is the constant investment in their people, facilities, and technologies. Washington Regional believes that the best outcomes for their patients can be achieved when they coordinate care across a broad scale, from clinics and hospitals to home care, rehabilitation, social services, and pharmacy services. Quality is their passion and energies will remain dedicated to it. If there is a constant in healthcare, it is change. They are proud of the ability to adapt in a way that benefits their patients.
Washington Regional’s Mission, Vision, and Values
Washington Regional is committed to improving the health of people in communities they serve through compassionate, high quality care, prevention and wellness education.
To be the leading healthcare system in Northwest Arkansas --- the best place to receive care and the best place to give care.
To treat others – patients and their families, visitors, physicians, and each other – as we would want to be treated.
Learn more about Washington Regional at: https://www.wregional.com/main/about-us.aspx
SHARE Value/Benefit to Hospitals
- The hospital referral network is able to securely communicate between providers using SHARE’s Direct Trust Secure Messaging to send Continuity of Care Documents (CCDs).
- Hospitals use SHARE to send Immunizations, Syndromic Surveillance Data, Electronic Laboratory Reporting, Cancer Reporting to Arkansas Department of Health which assists with Interoperability Program Public Health Objective 6 (listed below). This allows hospitals to meet this objective and be eligible to receive $63,750 in total per Medicaid Eligible Professional (EP) or $43,480 in total per Medicare EP (depending on patient population) in 2018.
- SHARE assists hospitals in meeting Health Information Exchange Interoperability Program Objective 5 (listed below) by providing a summary of care record (CCD) for hospital transition of care (TOC) or referral. This allows hospitals to meet this objective and be eligible to receive $63,750 in total per Medicaid EP or $43,480 in total per Medicare EP (depending on patient population) in 2018.
- Hospital referral clinics connected to SHARE are able to see the longitudinal record of a patient that was seen by other facilities throughout the State.
- Hospital providers are able to access a patient record through the Virtual Health record to view patient summaries and results – (query based exchange) or query SHARE for your patients results- CCDs (Query and Response using xds.b or xca protocol).
- Clinics throughout the State will receive a daily report from SHARE connected hospitals. The clinics participating in Arkansas Medicaid Patient Centered Medical Home (PCMH) receive daily reports when a patient is admitted and discharged from the Emergency Departments and/or an Inpatient admission. These daily reports are sent in real-time to clinic care coordinators in their email.
Data Types Sent/Receive: CCDs, Admission, Discharge and Transfers (ADT), Radiology Reports, Transcribed Documents, Laboratory Reports and Immunizations
SHARE Sending to Referral Partners: SHARE receives CCD/HL-7 messages from hospitals. CCD/HL-7 messages include ADT’s, Radiology Reports, Laboratory Reports, and Transcribed Documents. Transcribed documents include discharge summaries and progress notes and other reports that supports clinics around Arkansas.
Hospital Objectives and Measures for 2018
Updated: June 2018
Stages of Promoting Interoperability Programs: First Year Demonstrating Meaningful Use
The Centers for Medicare & Medicaid Services (CMS) established the Promoting Interoperability Programs (formally named the EHR Incentive Programs) in 2011 to encourage eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) to adopt, implement, upgrade and successfully demonstrate meaningful use of certified electronic health record technology (CEHRT).
NOTE: The last year an EP, eligible hospital, or CAH could begin receiving Medicare incentive payments was 2015. The last year an EP, eligible hospital, or CAH could begin receiving Medicaid incentive payments was 2016. In 2016, Section 602 of the Consolidated Appropriations Act of 2016 added subsection (d) hospitals in Puerto Rico as eligible hospitals under the Medicare program, and extended the participation timeline for these hospitals.
The Medicare and Medicaid PI Programs were designed to measure the use of CEHRT in three stages:
Stage 1 established requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information.
Stage 2 expanded upon the Stage 1 criteria with a focus on advancing clinical processes and ensuring that the meaningful use of EHRs supported the aims and priorities of the National Quality Strategy. Stage 2 criteria encouraged use of CEHRT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible.
In October 2015, CMS released the Medicare and Medicaid Programs Electronic Health Record Incentive Program-Stage 3 and Modifications to Meaningful Use in 2015 through 2017 final rule, which modified Stage 2 requirements to streamline reporting requirements on measures that had become redundant, duplicative, or topped out.
Stage 3 was established in 2017 as a result of the 2015 final rule and focuses on using CEHRT to improve health outcomes. The table on the next page outlines the appropriate stages of the PI Programs based on providers’ first year demonstrating meaningful use.