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Joe and Steph discuss the barriers that skilled nursing facilities (SMITs) face in achieving interoperability with hospitals. They mention that SMITs have a lag in adopting electronic health records (EHRs) and have low interoperability with hospital systems. Technical issues and lack of certification requirements for nursing home EHRs are listed as main barriers. They also explain that meaningful use requirements for EHRs apply to hospitals, but not to nursing homes or SMITs. They discuss how poor interoperability impacts care transitions from hospitals to SMITs, causing delays in discharging patients and difficulties in accessing key patient information. They mention a conversation with Monarch, a partner of Hennepin Healthcare, who uses Epic for managing referrals and accessing patient information. They highlight the challenges in coordinating referrals and the importance of standardized processes. They also mention the timing of referrals and the use of paper discharge summaries. Hello, Joe and staff. I'm excited to have you on today's episode of Transitions in Tech, Smith Edition. Today, we're going to be discussing interoperability in healthcare, which refers to the ability of different electronic health record EHR systems, software applications, and healthcare organizations to access, exchange, and use patient data in a coordinated way, regardless of the technology, vendor, or setting. We will be specifically focusing on skilled nursing facilities that I referred to earlier, called SMITs, and what interoperability means in their EHR systems. Before we dive in, I'd like to have you introduce yourself, Steph. Why don't you go first? Yeah. Thanks, Lois, for having me today. My name is Steph, and I work in Hennepin Healthcare as an APC, an FBA, in the orthopedics department, and I additionally work on a lot of different operational efficiency goals at Hennepin and my administrative role. Great. And I'm Joe Strengfeld. I'm a hospital FBA at Hennepin. I'm excited to be on the podcast, and I'm the medical director for hospital quality. Great. Well, before we dive into the specifics of your organization, can you both briefly share what you think are the biggest barriers SMITs face in achieving effective interoperability with hospitals? Joe, why don't you start? Yeah. I'll say, just first, there's a general lag in SMITs having EHRs. They were excluded from some federal dollars when EHRs were created. There were two big nationwide surveys, one in 2016, where only 64% of SMITs had electronic health records, and then in 2018, 84% of SMITs used an EHR, but there was a lag in still maturing in that use. Wow. Additionally, SMITs have a pretty low interoperability with most hospital systems. 3% of all SMITs reported they could do all four interoperability functions, including receiving health care, searching for information, sending information, and integrating information into the electronic health records that they do have. And technical issues were listed as the main barrier for the issues with their interoperability. Additionally, AHI products for nursing homes do not require certifications, where many providers have meaningful use, where meaningful use applies. So there's less push for interoperability across the system settings because they just don't have the same expectations or requirements, which allow for different groups to fund different levels of EHRs. Great. And can you share, just for my knowledge and my users' knowledge, a little bit more about meaningful use and what that is? So that's a requirement around EHRs where there's different things that are expected from systems where meaningful use applies. So they need to have certain components of their EHR, and they're incentivized with dollars to then have those requirements met. So that applies to hospitals. That applies to Hennepin Healthcare. We need to have these certain things part of our EHR, and we partner with our vendors, Epic, for that. But those same sorts of requirements don't exist for a nursing home or SMIT. Got it. That's super helpful. Thank you both for that broad context. So now going more granular, I know you both work at Hennepin Healthcare and provide direct patient care, which includes some patients transferring to SMITs. In your experience, how does poor interoperability impact care transitions from hospitals like Hennepin to SMITs? Steph, what are your thoughts on that? So from our perspective, patient care is a huge aspect of what Hennepin cares about this initiative. So one example, well, first of all, 10% of our admissions and discharges involve SMITs, whether patients are coming in to our hospital from a nursing home or a nursing facility, or they're being discharged to them. So it's thousands of encounters a year. So communication around this care is super essential. So from my perspective, as an APC that works on a team that does a lot of discharges around extremities and patients who need to use these facilities because they're not as ambulatory or mobile as they are due to injury or elective surgeries like total joints or hip fractures, when you're discharging a patient to a SMIT, there's a huge order set that needs to be completed. It includes a lot of information that seems, for lack of better words, frivolous, and just to ensure that a patient is safe to discharge into a facility of close quarters. So sometimes there's requirements around TB testing, ensuring that there is an appropriate history and physical performed prior to admission, and all of the order sets that accompany going to a skilled nursing facility. So, for one, it's not super intuitive in our system. So when you're going to discharge a patient, it doesn't fall easily into your order set. And then additionally, if it's missed, it can delay a patient's discharges. So if you have somebody who maybe doesn't do as many SMIT discharges or is standing in to provide medical care or newer employees, this can delay care and cause a lot of issues when discharging to a SMIT. Additionally, when patients come in and let's say they have a hip fracture and then they need to be discharged into a SMIT, we have to know that pretty far in advance in order to discharge them in a timely manner. So you have to really get the teams on board and know processes to discharge, to do it efficiently. So we've had patients that have stayed two or three extra days in the hospital because we didn't involve our social care workers or coordinated care workers in a timely fashion in order to get them their prior authorization so that they need to be moving into these facilities. So there's a lot of work around discharging patients to SMIT from a hospital setting, and oftentimes it can delay care, which leads to higher costs of care. And I'll just say on the admitting side, receiving someone from another setting, now as a hospital STA, I'm often admitting someone who resides at a skilled nursing facility and they may or may not be able to engage in the history and physical. I want to know what medications they were taking, when were they last administered, make sure I have a current medication list. I'd want to make sure I know what their vitals were, what sorts of things were happening in their care, and that will be relying on paperwork that was sent along with that patient. I'll be down in the ED. It's very busy. You can imagine things sometimes get missing and it's hard to find that paper or maybe they didn't send it with, so then we need to call and have something back. So it just can be a lot of digging and a lot of sorting through a lot of pages to get to those few key things I really need, which is challenging. And then I'll just say before entering PA school, I worked as a nurse in a SNF, and it's on the other side of receiving someone like Steph was talking about from the hospital, and it's a similar process where you get that paper packet and you're trying to come up with all of their orders and find that key information. And then if there are questions or things that come up, it can be hard to get to that discharging provider to clarify questions and what's exactly needed for this patient. So outside of that exchange through our EHR or paper, having a conversation can just be really difficult to call and then reach the right person at that other setting. Wow. It sounds like there's a lot of challenges, and I know I was able to join both of you in a meeting recently with Samantha Hale-Williams, who's the referral management program manager, and then Bill Chase, the VP of business development from Monarch, which was super eye-opening, and they are one of Hennepin's biggest partners and operate 45 SNF. Their EHR is point-click care, and they also access EPIC to review admissions. Steph, can you share more about how that conversation went and what we learned from their perspective? Yeah, it was really great to touch base with them. We found that they have around 300 to 400 referrals a month, and it's best performed through EPIC, which they do have access to, as well as many hospitals in the state of Minnesota. And they found that in many other facilities, such as Alima, our health partners, they use EPIC only to manage their incoming referrals and figure out the best way to get their patients placed, or if it's not going to work for placement, communication in a timely fashion back about the denial. Whereas at Hennepin, we still use a mix of FACTS and the use of EPIC, which is kind of difficult because depending on who is putting a referral in and who is on the receiving end, if they're not looking in all of the right places or in every place, Hennepin patients may be missed. So it's really hard to coordinate when there isn't a super standardized process. And then additionally, no system should be built on who is doing the work. It should all be standardized into expectations that all of us do it the same way in order to facilitate good care. Once then we refer to MONARCH, whether it be through EPIC or FACTS, the MONARCH can access the EPIC charts and then work on timing of the referral. There's an arch to that as well in that if you ask for a referral too soon, they may still be too medically complicated to be discharged into a facility. So they could be denied because there's too many things going on and it's not safe for them to be discharging to this subacute setting. Whereas if you wait too long, like we talked about earlier, you can have delays in discharges because the prior authorization and administrative work on the front end isn't done. So it really is a combination of difficulty with managing different systems, no standardized process, as well as the art of the perfect time to referral. And then lastly, Hennepin uses – all facilities, according to meeting with the team and Samantha, use a paper discharge. And Hennepin is one of the worst ones that they deal with, having over 70 pages that we use in our discharge summary that we send along with patients. And so their employees are expected to rifle through all of these pages and all of this information, probably to find three or four key things that they need to know for care of the patient. And this is pretty apparent to us because other systems can get their discharge summaries down to approximately two to five pages. And yes, over 70 pages in a standard Hennepin discharge to a facility. Wow. And I'm just going to add one other thing that came up in that conversation with Monarch that I thought was really interesting. We talked about the upcoming team model from CMS, where now instead of hospitals just being responsible for cost of care within the hospital episode for things like bypass, joint replacement, femur fractures, hospitals are now responsible for all care received after the procedures for 30 days, which could include care they receive in a SNF. So there's some incentive for better partnership between hospitals and SNF, which I thought was really interesting. And it sounds like those conversations are still really early between Monarch and Hennepin. And then the other point that I thought was interesting was just around the hospital remissions reduction program, another CMS program where hospitals are penalized up to 3% of their Medicare payments if they have higher than expected remission. So just a couple of things that we talked about that really matter for why we collaborate well between the two settings. Yeah, that's a really good point. Two of the team issues, which include CABG or coronary artery bypass graft, total joint replacements, major bowel procedures, surgical hip or femur fractures, and spinal fusions. I work with both the neurosurgery and the orthopedic teams on discharging and coordinating care for these patients. And as part of the team work, I think that they really want to dig in to what best outcomes are. And so it will be super insightful for us to see if patients are doing better if they discharge through a SNF, if that makes their total long-term outcome better or worse, and then how that relates to the cost of care based on the utilization of these facilities. So it's going to be super important that we have really good communication between these two teams to understand how we're spending our healthcare dollars and if there's any utility in the extra spend by sending these patients in the long run to these facilities in the short-term rehab. Absolutely. It sounded like there was a ton of opportunity, but it really does center around this issue of interoperability and good communication, to your point, Steph, between hospitals, not just Hennepin and SNF like Monarch. So I'm just curious, kind of as we start to conclude our conversation, what are your solutions or potential solutions, rather, to the problems we've talked about and kind of outlined today? I think there were a few things we identified that were pretty straightforward, just do it. It seems like improving paper, not the ideal long-term solution, but it's where we're at now. And specifically for Hennepin, we can do better and match what other systems in the area are already doing and reduce some of that clutter and actually save work, like Steph was talking about with discharge and all these options you have to check, that could actually be a lot more streamlined and they don't need all that extra time. So we could save time on our end and also make the information more clear for them. It seems like it would be good for us to have some regular meetings and just a chance for more dialogue, working through problems together. And then perhaps, you know, we're talking a lot about interoperability, but also kind of stepping out of just the EHR and what's transmitted through the computer, having more of this ability to call and talk is needed to troubleshoot at the moment beyond just calling the front desk that we look up, having more of a point person for how we can communicate real time when it's just not sufficient through the EHR. Those are great suggestions. Steph, what are your thoughts? Yeah, I think that specifically with Hennepin and Monarch, we need to leverage the use of EPIC that both facilities have access to it. So we need to figure out what capabilities that Monarch has versus what capabilities Hennepin has and really work to integrate those two systems, especially if we can somehow find an integration between PointClick and EPIC. I think that those would be of high productivity and efficiency. I think that it would really improve our communication and improve our interoperability. Some examples include some in-basket functions where we know the teams that we're supposed to be sending messages to in order to facilitate good and timely communication. But it's difficult to secure the IT resources for this type of project. So, you know, probably both systems would have to make an investment in this on either side to ensure that the systems are in place, the appropriate information is either being pushed or pulled the way that it needs to be, and that it can be used and patient privacy is being protected in the process. I completely agree with that, Steph. We found some research where they proved that PointClick, CLAIR, and EPIC can integrate and talk well, but then it's that what resources does it take to implement that? It's 10% of our admissions and discharges, which is a lot, and it's 90% or not. So, you know, allocating our resources for this problem and is it big enough when IT resources are always scarce? Absolutely. Yeah, it seems like there's a lot more that we could talk about and that there's a lot of opportunity here, especially for the path forward specific to Hennepin. I think that, you know, in talking about interoperability, there's some opportunity to think about outside of the box interoperability opportunities. You know, I'd be remiss if we didn't talk about telehealth and how that can be affected, especially given that there is EPIC within the system. So, it could be coordinated to have post-discharge visits. I've been working with Dr. Ryan Delanick, who is our Chief Health Information Officer, and he's facilitated a new post-discharge visit clinic that's virtually done, and I think it gives a great opportunity for communication between patients who are in SNF and the team that's there to communicate with a primary care provider here that can help coordinate or troubleshoot issues that might come up that could help reduce readmissions or answer questions about medication changes or other things that might come up. So, that's one thing that I think could potentially increase and thinking about interoperability in a little bit different way. It's been, you know, COVID really opened the door on a lot of our telehealth services, and I think that we're still underutilizing those in terms of interoperability opportunities. Just specific to COVID, I'll be quick because I know we're almost at time. I know telehealth did expand a lot at the start in COVID. It went from under a percent of visits in nursing homes to 30% of visits, but then quickly went back down, which I think was interesting, and facilities said that that was due to time for setup and then equipment barriers, where it technically was really hard. So, telehealth seems like such a logical fit, but there's also some barriers to it in a nursing home. Gotcha. Well, thank you both so much for being here today. Any final thoughts before we wrap up? I'll just say two other things that we thought a little bit about is, like, what could make this problem better? You know, this is more of a big picture and not feasible for Hennepin, but there are systems where they vertically integrate and the nursing home is part of their system, and that increased after the Affordable Care Act, but I think it's not feasible for Hennepin, and there's mixed evidence with how that impacted readmissions. And then, Steph, did you want to say just a word on extended care? Yeah. So, we do have a group of APTs that are on our extended care service, and so what they do is they see patients that are in skilled nursing facilities or in nursing homes long-term to help provide care so that they're not going to and from a hospital so often. One problem that we have with that group is that it's not super clear if they are driven by who the provider is, where the SNF is. We know that they're Hennepin employees, but it's not very clear to us, you know, if we're not in that group specifically, what their role is. But it is an investment that Hennepin has made, and I think that by clearing up the lines and looking at how those are utilized and how that can save can really improve interoperability because they are using Epic and they're out in the facilities, and so how can we communicate with them to communicate with the SNF in order to get things done? This is another expensive endeavor on the hospital side, you know, employing providers that are going out in the community, but definitely something that can improve interoperability. Great. Well, thank you both so much, and thank you listeners for this week's edition, the SNF edition of Transitions in Tech.
