Health Home Performance Enhancement through Novel Reuse of Syndromic Surveillance Data

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1 Health Home Performance Enhancement through Novel Reuse of Syndromic Surveillance Data Category: Fast Track Solutions Contact: Tim Robyn Chief Information Officer Office of Administration Information Technology Services Division (573) Initiation Date: March 4, 2014 Completion Date: April 30, 2014

2 Executive Summary Improving patient care coordination and preventing unnecessary utilization of hospital services are essential if lowering overall healthcare cost is to be achieved. Timely alerts and notifications to primary care providers and case managers when patients are admitted to, transferred, or discharged from a hospital, communicates essential information that can be used to address care needs during transitions from impatient facilities to community care. This is particularly significant when dealing with populations that have multiple chronic medical and behavioral health conditions, where coordination is essential between different providers treating multiple chronic diseases. This project demonstrates how the Information Technology Services Division (ITSD) in the Office of Administration for the State of Missouri was able to facilitate the transparent use of health information technology by the reuse of syndromic surveillance emergency room (ER) visit data reported to the Missouri Department of Health and Senior Services (DHSS) to provide near real-time notifications to Missouri Department of Mental Health (DMH) and Missouri Department of Social Services (DSS) Health Home case managers of a client ER visit. Health Homes, a custom version of Medicaid Medical Homes, was designed to coordinate treatment of people with multiple cooccurring medical and mental health diseases or disorders. Health Home treatment teams, consisting of physicians, nurse managers, behavioral health specialists, and social workers are responsible for a person s overall healthcare, managing their care plan, providing transitional care support, consultation services, and service coordination between care service providers. Syndromic surveillance hospital emergency department visitation data captured by DHSS is now being reused by DSS and DMH in support of Health Homes. ITSD completed a fast track project to match the Health Home participant rolls with the realtime HL7 admit, transfer, and discharge messages received from hospitals. These messages communicate patient demographics, chief complaint, and hospital identifiers allowing the health home care coordinators to know when one of their clients has visited an ER. Leveraging health information technology is essential if we are to achieve the goals of lowering healthcare costs and improving patient outcomes. This project is just the first of many steps in Missouri s roadmap for a greater system of interoperability and integration.

3 Business Problem Missouri leadership has been very innovative in leveraging resources at all levels of state government, from IT consolidation to broader inter-agency collaboration efforts. Missouri was the first state in the nation to receive approval for its Medicaid Health Home initiative October Missouri s Health Home model is similar in characteristics to the Medical Home, but is customized to meet the specific needs of low-income patients with serious and persistent mental illness, co-occurring chronic medical conditions, or substance abuse problems. Collaborative sharing of relevant patient health information between all impacted stakeholders is seen as critical in securing lower per capita healthcare costs and better patient outcomes and experiences. Health Home providers are encouraged to leverage Health Information Technology (HIT) to facilitate coordination between providers, support patient adherence to both medical and behavioral healthcare, and prompt patient follow-ups after hospital discharges. The latter is particularly important in reducing avoidable readmissions and Emergency Room (ER) visits. However, a significant barrier existed in Missouri for the timely receiving of these notifications. Notification of ER visits through traditional billing systems was slow and did not allow for prompt patient follow-up. Solution Description During an assessment of the problem, it was determined that one approach to reducing avoidable readmissions and improving care transitions would be acquiring near real time notifications or alerts from hospitals to Health Home care managers when a participant is admitted, discharged or transferred from a Hospital. These notifications and alerts would improve the timely flow of clinical information so that case managers could quickly address the health care needs of their patients transitioning from inpatient facilities to community care. In addition to improving patient health status, these alerts and notifications would facilitate a reduction in hospital readmissions through proactive care engagement. Recognizing the potential of proactive engagement, ITSD in partnership with DHSS, DMH and DSS developed a data exchange that captures hospitalization events already being reported to the State of Missouri for syndromic surveillance, thereby laying the foundation for notifying Health Home case managers in near real-time of a client ER visit. The emergency room visit data and hospital admission events are pulled from Hospital Electronic Syndromic Surveillance (HESS) data that is already transmitted in real-time to DHSS from Missouri hospitals.

4 Syndromic surveillance is the use of non-traditional data sources in order to detect public health events earlier than possible with other methods. DHSS is authorized to collect hospital admission events data under Missouri statute 19 CSR , which requires all acute care hospitals to submit emergency department encounters in an electronic form using the Health Level 7 (HL7) Admit, Discharge, and Transfer (ADT) standard. Missouri conducts syndromic surveillance by monitoring electronic hospital emergency department visits data. The minimum data set that is to be reported must include elements such as a record type, hospital identifier, type of encounter, patient medical record number, patient social security number, patient birth date, patient sex, race, ethnicity, address and chief complaint. DHSS already received visit information on an average of 8,500 emergency room visits daily from over 92 Missouri hospitals. The State of Missouri already had the data to solve the problem; they just needed ITSD to create the data exchange. HL7 is an international community of healthcare technology experts collaborating to create standards for the exchange, management, and integration of electronic healthcare information. HL7 ADT messages are machine readable instruments for communicating updates about a patient s care transitions. Messages are triggered when a person s status has changed, such as a new admission or bed transfer. Once an event is triggered, an HL7 message is broadcast, typically in real-time, to all listening information systems within a hospital, as well as external endpoints when required. DHSS uses the Orion Health Rhapsody Integration Engine to capture and translate HL7 ADT messages. The data exchange that ITSD developed matches the Health Home participant rolls with the real-time HL7 admit, transfer, and discharge messages received from hospitals. The data is then used to generate notifications and alerts back to patient care coordinators. Now Health Home team members can view a participant s Medicaid paid claim history and pharmaceutical records; and manage prior authorizations in addition to having near real-time data access to critical events, providing clinicians the opportunity to actively collaborate in hospital treatment planning and hospital to community transitional support. Moreover, due to the complexities in treating patients with multiple chronic medical and serious behavioral conditions, active engagement by Health Homes ensures a more holistic approach to overall treatment, resulting in better options and outcomes for the patient and cost avoidance by avoiding contraindicative and potentially harmful treatments.

5 Significance Less than 100 hours of effort was required by the ITSD team to complete the data matching routines that provide the ADT data to DSS and DMH. This project aligns with NASCIO s state CIO health care priority and is innovative, not by the technology used to complete the project, but by the innovative exchange of data gathered by Missouri State Government for other purposes. This project is a prime example of what the Centers for Medicare & Medicaid Services (CMS) is encouraging states to do; leverage an existing solution though secondary use and avoid unnecessary rework and system duplication. Hospital Electronic Syndromic Surveillance data captured in support of the Centers for Disease Control and Prevention (CDC) is reused in support of Missouri Medicaid Health Homes. While most Health Information Exchange infrastructure vendors and Health Information Exchange offer complementary notification services at a price, this solution was achieved with modest effort and minimal cost, and can be customized to support different work-flow integration opportunities and notification scenarios. CMS s strategic plan outlines a strong case for the sharing of health data and knowledge between all healthcare stakeholders, public and private. Missouri, like many states, collects large volumes of valuable data that can be reused and repurposed. Integrating syndromic surveillance emergency department visit data into Missouri s claim data visualization tool is the first of many steps. Benefits The Health Home holistic care model encourages participants to seek support from their health management team first before heading to the emergency department. In a preliminary investigation, during a one month period, over 5,200 Health Home participants, or roughly 14% of all Health Home enrollees, visited an emergency department. At an average Medicaid cost of $1, per visit, the 5,200+ participants potentially cost Medicaid over $7 Million. Based on this one month measure, a full year could potentially cost well over $84 Million. Preliminary results are showing an approximate 10% reduction in ER visits which could translate to over $700,000 of potential savings per month or over $8 million in savings per year just in reduction of ER visits. Clearly a significant cost savings can be achieved by reducing hospital readmissions through proactive care engagement and this does not even include the potential cost savings that might be achieved by avoiding contraindicative and potentially harmful treatments. While the cost benefits of this project are significant, the benefits to human life are immeasurable. Prior to this project, the only electronic source of information regarding

6 an emergency department visit was from Medicaid paid claims data. However, billing data does not provide the necessary timeliness to impact emergency department utilization. Alert messages sent in real time, based on HL7 ADT events, offer Health Home providers the ability to respond quickly at times when patients are most in need of support and care coordination. For citizens with co-occurring medical and behavioral disorders, the difference between life and death can be a single piece of information. By completing this project and making hospital emergency department and admission data available to the right clinicians at the right time, lives can be saved.