(P29) The Future is Now: Enabling Greater Post-Acute Care Interoperability

Presenting Author(s)

Maria D. Moen, BPS (she/her/hers)

SVP Innovation and External Affairs
ADVault, Inc.
Nashville, Tennessee, United States

Author(s)

Lynda S. Hoeksema, DNP, FNP-BC, RN-BC, FAMIA, ACHIP (she/her/hers)

Principal, Health Informatics and Clinical Quality
MITRE Corporation
McLean, Virginia, United States
LW

Lorraine Wickiser, BA, RN, BSN, CPC-A

Interoperability and Data Library Lead/Coordinator
Center for Medicare and Medicaid Services
Baltimore, Maryland, United States
Maria D. Moen, BPS (she/her/hers)

SVP Innovation and External Affairs
ADVault, Inc.
Nashville, Tennessee, United States
ME

Matt Elrod, PT, DPT, MEd

Clinical Informaticist
MaxMD
Fort Lee, New Jersey, United States
CP

Chris Pugliese, n/a

Director of Product Interoperability
ResMed SaaS
Peachtree Corners, Georgia, United States
TW

Tina Wilkins (she/her/hers)

Health Systems Engineering and Process Integration, Lead
MITRE Corporation
McLean, Virginia, United States
DH

David Hill, n/a

Health Technology, Principal
MITRE Corporation
McLean, Virginia, United States
Karl Naden

Lead Health IT Software Engineer
MITRE Corporation
McLean, Virginia, United States
CS

Corey Spears, n/a

Health Technology, Principal
MITRE Corporation
McLean, Virginia, United States
BM

Brian Meshell, n/a

Software Engineer, Senior
MITRE Corporation
McLean, Virginia, United States
Jessica Skopac, PhD, JD, MA (she/her/hers)

Senior Principal/Chief Engineer
MITRE Corporation
McLean, Virginia, United States

Primary Author(s)

Maria D. Moen, BPS (she/her/hers)

SVP Innovation and External Affairs
ADVault, Inc.
Nashville, Tennessee, United States

Author(s)

HC

Howard Capon, MPH, NRP

Health Program Analyst
The MITRE Corporation
McLean, Virginia, United States

Objective/

Aim: To establish a framework for HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide (IG) development to facilitate health information exchange across Post-Acute Care (PAC) settings and other entities exchanging PAC information. Focus is on Functional and Cognitive status, identification of Reassessment Timepoints, Speech-Language-Swallowing-Cognitive Communication-Hearing (SPLASCH), and Advance Care Planning documentation.

Design/Methodology: A multidisciplinary group used a consensus-driven process to develop data models for five use cases, from which they based FHIR IGs to support them. The IGs were tested at HL7 and CMS Connect-a-thon events to create, exchange, and query patient information between different health IT (HIT) systems.

Results: 20+ participant entities created, updated, exchanged, and queried information between disparate HIT systems in a consumable format to facilitate patient-directed, securely-delivered health data sharing between clinicians, patients, caregivers, and families. Teams created over 800 FHIR resource instances, including 610 data observations, 21 conditions, 9 goals of care, and 33 practitioners across 8 locations to build a cohesive and medically accurate clinical scenario. Participants demonstrated proof of concept for sharing data generated from diverse sources using 9 FHIR IGs, which enabled data to follow patients through transitions and time points in care (including Skilled Nursing Facilities and Home Health) and across multiple states. These activities established new best practices for organizing integration testing of multiple IGs illustrating a holistic view of a person’s healthcare journey. One challenge surfaced related to effectively informing care when the data was integrated from multiple sources.

Conclusion/

Discussion: Patient care data in PAC settings are difficult to move between settings, which leads to suboptimal and sometimes catastrophic patient outcomes, duplications of effort by doctors, nurses, therapists (speech, physical, occupational), and other allied providers. Furthermore, these inadequacies are represented by incomplete health records trapped on paper, financial burdens that arise at the intersections of these activities, and stress and frustration for patients and their caregivers. Current efforts will be described to make these records and associated datasets interoperable across the diverse PAC, acute, and ambulatory settings, which consist of numerous types of providers and specialists serving patients in those settings. This poster is a report out to the PAC community and an invitation to join ongoing efforts involving health information interoperability between systems and applications using HL7® FHIR®.