Informed Transitions of Care Using Direct

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1 Informed Transitions of Care Using Direct Holly Miller, MD, MBA, FHIMSS Chief Medical Officer, MedAllies 1

2 First Do No Harm 2

3 Treating Patients Requires Information 3

4 Hospital Discharge to PCP? The Hospital told me I had Smiling Mighty Jesus 4

5 Remember the Game of Telephone? Remember the Game of Telephone? 5

6 Meaningful Use Stage 3 Stage 2 Stage 1

7 The Hudson Valley

8 Certified EHR Adoption in the Hudson Valley 18% in % EHR a: yes, we only use an b: no, but we plan to a c: no, we have no plan N = 3138 Total of 85% EHR Adoption in 2012 no response other

9 Demand for Direct Best patient care requires communication Physicians need information as patients transition across care environments EHR adoption creates a physician demand for push interoperability across disparate EHR systems in the community 9

10 Meaningful Use Stage 3 Stage 2 Stage 1

11 Connect Disparate EHR Systems MU requirement for information exchange has created cooperation among EHR vendors MedAllies Direct Pilot includes 7 major vendors 11

12 It Has To Be Easy Make it consistent with existing clinical workflow 12

13 The Right Amount of Data to Care for the Patient 13

14 Core and Variable Data Core Data every ToC Variable Data selected by the sending clinician depending on the clinical ToC circumstance

15 Core Data for Every ToC Demographics Reconciled Active Problems Reconciled Active Medications Allergies/Intolerances 15

16 Variable Data Office of the National Coordinator for Health Information Technology 16

17 Core and Variable Data an Example Cardiologist Core Data PCP Dermatologist 17

18 Data Standards Interoperable 18

19 Transcription 19

20 Direct ToC in the Hudson Valley Hospital Discharge to PCP 20

21 Timing is Everything ToC and advanced primary care Taking care of high risk patients 21

22 Closed Loop Referral Direct ToC in the Hudson Valley 22

23 Crawl, Walk, Run 23

24 The Long Term Vision Hospital Home Health Patient LTPAC Settings (SNF, Other Professionals etc.) Patient Centered Medical Home Specialist 24

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