Continuity of Care Across Periods of Incarceration
Define the Need
During times of incarceration, historical health information may not be available to those treating inmates in the correctional system. A lack of health background information on the people involved in the criminal justice system diminishes the likelihood that correctional facilities will deliver properly targeted, often urgently needed care. Community providers may have gaps in treatment information as patients can provide unreliable historical health and treatment information, and the current method to obtain this information is often via fax. The inability to have health information regarding an inmate potentially exposes facility staff and inmate to unsafe conditions.
Response
Correctional facility participation in the NDHIN and use of the Clinical Portal to access patient records from participating providers.
Opportunity
Correctional facilities contract with healthcare entities to provide treatment to their inmates. These entities often utilize an EHR through the course of this work. NDHIN engagement with these entities via the Correctional System for health information exchange would be beneficial to this patient population (which includes a significant percentage of behavioral health patients). Having information regarding an inmate’s health readily available can enhance facility safety for both staff and inmate.
Value Proposition
Supports continuity of care and improves health outcomes for a vulnerable population.
Disaster Recovery
Define the Need
A facility has lost access to their electronic health record (EHR) data due to system failure, accidental data deletion, natural disaster, or a cyberattack such as ransomware. The facility’s goal is to restore operations as soon as possible with the least amount of disruption to their daily workflow.
Response
Staff can access their EHR data by logging into the NDHIN Clinical Portal. Staff can view lab reports, radiology reports, vital signs, allergies, patient visit reports, demographic, and payment information – all data contributed to NDHIN from the facility’s EHR and other facilities that are currently contributing data.
Opportunity
NDHIN provides the opportunity for safe storage and retrieval of patient’s electronic health records during unplanned downtime events. NDHIN can assist facilities that currently have single-sign on (SSO) capabilities through their EHR vendor to convert NDHIN Clinical Portal login identifications and passwords to web-based access.
Value Proposition
Clinical and Financial – During EHR downtime, authorized users can access their facility’s patient electronic health records to mitigate the potential impact on patient care. The facility can also continue healthcare operations avoiding gaps in providing care that could ultimately pose a financial burden on the facility.
Electronic Public Health Reporting
Define the Need
Timely and accurate reporting of public health data for disease surveillance purposes as required by federal and state regulations.
Response
Electronic public health reporting utilizing the NDHIN as data intermediary to the ND Department of Health & Human Services (NDHHS) and Centers for Disease Control and Prevention (CDC).
Opportunity
Leverage the electronic public health reporting network built utilizing NDHIN to capture additional data for other public health registries, such as autism and stroke.
Value Proposition
Onboarding through the NDHIN is an efficient process for providers (one-stop shop) that also supports Promoting Interoperability (PI) Objectives (previously called Meaningful Use) for public health reporting, including documentation and validation in case of a Centers for Medicare & Medicaid Services (CMS) audit.
Data submitted electronically via the NDHIN is routed in real-time and accessible by public health/epidemiologists in hours versus weeks or even months (historically). Epidemiologists are able to identify public health events, trends and outbreaks much more quickly in order to respond and inform the public.
Emergency Department Care Coordination
Define the Need
A patient is admitted through the emergency department (ED) of a facility. Data from the encounter is contributed to NDHIN for providers and members of the patient’s care team to access and provide follow up care.
Response
The patient’s care team including their primary care physician, specialists, and ancillary service providers can access information regarding the patient’s visit to the ED through logging onto the NDHIN Clinical Portal. The patient’s care team can view lab reports, radiology reports, vital signs, allergies, patient visit reports, demographic, payment information, and provider recommendations regarding follow up care – all data contributed to NDHIN from the ED facility’s EHR.
Opportunity
Provides the opportunity for all members of the patient’s care team to have access to patient care records and be directly informed of follow up care recommendations.
Value Proposition
Access provides the entire patient care team with valuable information for making informed decisions at the point of care. It can prevent duplication of testing, hospital re-admissions, and provide continuity of care.
HIE & Emergency Medical Services
Define the Need
Emergency Medical Services (EMS) responds to life-threatening situations on a regular basis with no background medical information on the individual they are being called on to care for and transport.
Response
EMS participation in the NDHIN. The NDHIN Clinical Portal provides access to historical and comprehensive patient health information to support improved emergency care.
Opportunity
EMS participation with technical interface to share run reports and other patient information with NDHIN. Long term integration of the EMS electronic health record with the NDHIN would provide important information to the patient’s longitudinal health record.
Value Proposition
Efficient access to an individual’s health record in an emergency life-threatening event improves care coordination and saves lives. Allows for the evaluation of Quality Improvement (QI) processes after their assessment and treatments were performed. Provides access to demographic and insurance information for invoicing purposes.
Encounter Alerts & Notifications
Define the Need
Chronic illness requires care coordination and case management to be performed in a timely, efficient manner to avoid emergency department visits and a continuous cycle of admissions and readmissions to the acute care setting. The emergency department does not provide continuity of primary care and is also the most costly setting of care. Readmissions to the hospital can lead to penalties against the hospital from Centers for Medicare and Medicaid Services (CMS). Coordination of care results in improved health outcomes as well as improved quality of life.
Response
Encounter Alerts & Notifications service through NDHIN.
Opportunity
Sign up for Encounter Alerts & Notifications service through NDHIN to receive notifications when your (selected) patients present for healthcare services outside your practice (ER, Urgent Care, Hospital admission).
Admission, discharge, or transfer (ADT) messages are the vehicle for communicating updates about a patient’s care transitions. The messages provide each patient’s personal or demographic information (such as name, insurance, next of kin, and attending physician) and notes when that information has been updated. They also indicate when an ADT status has changed — an admission or discharge, for example.
Here’s how ADT alerts work:
The alerts are triggered by an admission, discharge, or transfer (ADT) event in a hospital information system that sends a message to the health information network (NDHIN).
NDHIN routes the message to the healthcare provider who has signed up to receive per a specific patient panel. NDHIN will work with the provider’s EHR vendor to develop this functionality.
This communication notifies the patient’s care team to initiate an intervention, thus improving the post-discharge transition and follow up care of patients with chronic conditions.
Value Proposition
Patients with chronic illness greatly benefit from care coordination. Encounter Alerts & Notifications can notify the PCP that the patient has visited the ER, has been readmitted to the hospital, and when discharged. This information supports the PCP and Care Manager’s case management efforts.
Alerts & Notifications can also notify the pharmacy that the patient has been discharged from the hospital, which gives the pharmacist opportunity to reconcile the patient’s medication profile prior to the patient picking up discharge medications.
Identification of Condition Present on Admission
Define the Need
A patient is admitted to the hospital with a condition that could be deemed as an HAC (hospital-acquired condition) and could result in a penalty for the hospital if not identified as ‘present on admission.’
Response
Hospital nursing staff responsible for admission assessment should access the NDHIN to review the patient’s previous record/history at the time of the transition of care/admission (clinical summary, lab results) to identify an existing condition.
Opportunity
Hospital participation and utilization of the NDHIN; access to the NDHIN clinical portal.
Value Proposition
Financial and clinical – documentation of a condition present on admission will prevent a financial penalty against the hospital as well as promote early treatment of an existing condition.
Long Term Care
Use Case #1: Long Term Care Provider as User/Eligibility for Admission/Level of Care
Define the Need
The patient has been cleared for discharge from the acute care facility. The long-term care facility has been contacted for potential transfer. The patient’s records are not easily accessible for the long-term care facility to make an accurate determination of eligibility for admission to their facility.
Response
Participation in NDHIN with access to the Clinical Portal to review patient’s historical records including clinical documents (discharge summaries and other transcribed documents), lab results, radiology reports and images, and medications (RX filled) which assists the long -term care facility in determination of the patient’s status as well as preparation for transition.
Opportunity
Participation in the NDHIN with technical connection for health information exchange of patient records to support more complete longitudinal health records for North Dakota citizens.
Value Proposition
Support for the long-term care provider’s determination for admission eligibility.
Use Cast #2: Long Term Care Provider as User/Prevent Gaps in Care
Define the Need
The patient is discharged from the acute care hospital to the long-term care facility, and their records are not shared in their entirety, resulting in gaps in care.
Response
Access to the Clinical Portal to review patient’s historical records including clinical documents (discharge summaries and other transcribed documents), lab results, radiology reports and images, and medications (RX filled) to inform the long-term care provider and support decision making at the point of care.
Opportunity
Participation in the NDHIN with technical connection to enable health information exchange and more complete longitudinal records for North Dakota citizens.
Value Proposition
Improved transitions of care resulting in better health outcomes and potential curtailment in costs.
Local Public Health Units
Use Case #1: Local Public Health Unit as User/Medication Administration/Medication Set Up
Define the Need
The patient has been cleared for discharge from the acute care facility. The local public health unit has been contacted to assist with medication administration. The local public health unit does not have access to the patient’s records to accurately reconcile the patient’s medications.
Response
Access to the Clinical Portal to review patient’s historical record including clinical documents (discharge summaries and other transcribed documents), lab results, radiology reports and images, and medications (RX filled).
Opportunity
Participation in the NDHIN with access to the Clinical Portal.
Value Proposition
Support for local public health providers in decision-making at the point of care.
Use Case #2: Local Public Health Unit as User/Prevent Gaps in Care
Define the Need
The patient is discharged from the acute care hospital to receive assistance from the local public health unit and their records are incomplete, resulting in a gap in the continuum of care.
Response
Access to the Clinical Portal to review patient’s historical records including clinical documents (discharge summaries and other transcribed documents), lab results, radiology reports and images, and medications (RX filled).
Opportunity
Participation in the NDHIN with access to the Clinical Portal.
Value Proposition
Support for local public health providers in decision-making at the point of care.
Use Case #3: Local Public Health Unit as User/Secure Messaging
Define the Need
The patient is referred to the local public health with few medical records, resulting in a gap in the continuum of care.
Response
Participation in the NDHIN with access to the Clinical Portal and Direct Secure Messaging service.
Value Proposition
Support for the local public health unit in obtaining/exchanging patient records between clinicians in different care settings with different EHRs – eliminate sending/faxing paper documents and expediting patient treatment.
Use Case #4: Local Public Health Unit as User/eHealth Exchange
Define the Need
The patient is referred to the local public health unit. The patient is a veteran and has previously lived out of state.
Response
Participation in the NDHIN with access to the Clinical Portal, including the eHealth Exchange and Joint Health Information Exchange (JHIE) which provides the ability to query historical veteran health records from other HIEs as well as the Veteran’s Administration and Department of Defense.
Value Proposition
Support for local public health unit providers in obtaining more complete veteran health information.
Use Case #5: Local Public Health Unit as User/Routine Health Screenings
Define the Need
The patient visits a local public health unit for routine blood pressure checks, women’s health screenings (pap smear and mammography), and colorectal cancer screenings and unsure of past blood pressure readings and screening history resulting in a gap in the continuum of care.
Response
Participation with NDHIN with access to the Clinical Portal.
Value Proposition
Support for local public health providers in decision-making at the point of care.
Newborn Screening Long Term Follow Up (NBS LTFU)
Use Case #1: NBS Nurse Consultant
Define the Need
The patient is diagnosed or suspected of having a NBS condition requiring NBS Short (STFU) and long term follow up (LTFU) as well as coordination of services.
Response
Access to NDHIN Coordinate NBS Pathway to track patients with confirmed and suspected genetic or metabolic disorders. Patients are enrolled in the NBS Pathway and followed through age 6.
Access to the NDHIN Clinical Portal to review the patient’s overall health record – encounters, medications, lab results, clinical documents. STFU staff are able to view confirmation lab testing in real time and assure timely follow-up with specialists. They no longer have to get faxed results from various laboratories.
Opportunity
Participation in the NDHIN with access to the Clinical Portal and Coordinate
Value Proposition
Better coordination of care and services for patients diagnosed with NBS conditions. Ability to track all services in one place and not in 4 or 5 disparate systems.
Use Case #2: Specialist and Primary Care Provider as User
Define the Need
Patient has been enrolled in the NBS pathway and there is a need to view the information of the coordinated services and information related to the condition.
Response
Participation in NDHIN with access to Clinical Portal to review documentation of coordinated services in the Newborn Screening folder on the Patient Summary tab, including NBS assessments, services provided, contact notes and scanned documents.
Opportunity
Participation in the NDHIN with access to Clinical Portal and NBS documentation.
Value Proposition
Support for the PCP’s decision-making at the point of care. More informed communication with patient and family.
Use Case #3: NBS LTFU Program Facilitator
Define the Need
Need to monitor the data and activity of NBS LTFU patients tracked within Coordinate. Allowing for access to one system rather than 4 separate systema and multiple spreadsheet trackers.
Response
Now all cases are coordinated and there is a worklist for long term follow up to view everything needed all in one solution. Access to the NDHIN Discover NBS data dashboards.
Opportunity
Participation in the NDHIN with access to NBS data dashboards.
Value Proposition
Better management of NBS LTFU patients and activity.