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Improve Care Coordination

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Improve Care Coordination - 2011 Objectives

Capability to exchange key clinical information (e.g., problem list, medication list, allergies, test results), among providers of care and patient authorized entities electronically. I think it would be pretty easy to leverage the reports section above for this also. The report class should be able to generate single day encounters, date ranges, or entire record. The reports could generated to html, xml, pdf and exported to paper, email, disk, or USB drive. It will be necessary to be able to export some of this this data as standard:

  • IHE Technical Profiles (PIX/PDQ, XDS.b, BPPC, ATNA, CT)
  • IHE Content Profiles (XDS-MS, EDR, XDS-SD, etc)

Interface to add the authorized providers with whom the information can be shared. Read-only access for the authorized providers. Providing read only access for patients and for remote physicians is analogous. This will require providing a logging funciton of how we and why we provide this access to certain physicians. This includes referring out to a physician for a consult. Emergency access for Emergency Department physicians. This could also include physicians working for insurance carriers who want to review the medical record to evaluate benefits. Appropriate authorization will need to be provided in terms of patinet consent. Emergency override feature in the event of appropriate physician-to-physician contact to allow access.

Perform medication reconciliation at relevant encounters and each transition of care. Requires an interface which displays all the medications the patient is taking and the provision to document the reconciliation discussion.

The Medication List already exists. To implement this there needs to a field and a button of check box that keeps track of when medication reconciliation occurs. Also requires writing a report that pulls the number of medication reconciliation per unit of time and divide by the encounters per unit of time.

Counting "transitions of care" means recording when someone goes to another physician, another facility such as a nursing home or hospital.

I am not sure why we would be required to report a 30-day admission rate. We need to make sure this is not a Hospital or Inpatient EHR requirement.

2011 Measures

Report 30-day readmission date

% of encounters where med reconciliation was performed

Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists)

% of transitions in care for which summary care record is shared (e.g., electronic, paper, e-Fax)
Information sharing among providers
Adding Medication Reconcilation Form (I don't think this requies a form so much as dcomentation that we reconciled the list?)
Adding read-only access
Report Creation