Episode 12: Creating Efficiency and Improving Patient Outcomes Through Health Information Exchange with Dr. Emel Hamilton 
Health care providers throughout the world are working together to share key clinical information to improve patient quality, safety and efficiency of healthcare. Dr. Emel Hamilton joins Field Notes to share the details of how FMCNA is leading the way in improving care transitions for chronic kidney disease patients.

Brad Puffer: Welcome, everyone, to this episode of Field Notes. I'm Brad Puffer on the Medical Office Communications team at Fresenius Medical Care North America, and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

Fresenius Kidney Care recently launched a new health data exchange system that will enable near real-time sharing of individual patient health information. Our care team members will now be able to locate, exchange, and view patient health documents from more than 600,000 providers and 2,800 hospitals across the country. For example, this might be a hospital discharge summary, a recent dialysis treatment, or an emergency room visit.

Too often, health records from different providers are in different systems that are not directly connected. So a data exchange makes sharing that important health information much easier and faster. At the end of the day, that helps us better coordinate care for patients with kidney failure.

To help us understand the important role and evolution of health information exchange networks and how they have the potential to improve outcomes for all patients is Dr. Emel Hamilton. Dr. Hamilton is the vice president of Clinical Support and Informatics at Fresenius Kidney Care and has been leading this new initiative to improve the company's health information exchange systems. Dr. Hamilton, thank you for being here. Welcome to Field Notes.

Dr. Emel Hamilton: Thank you, Brad. I'm happy to be here.

Brad Puffer: Well, we've talked on the Field Notes podcast before about using health data to drive good clinical decision-making, so how important is having access to up to the date health records, especially for our patients with kidney failure?

Dr. Emel Hamilton: So Brad, as you know, an estimated 30 million Americans live with chronic kidney disease, and ESRD patients have higher rates of hospital admission and readmissions and higher rate of mortality compared to the overall Medicare population. ESRD patients visit multiple providers. They take multiple medications, and they're under multiple care pathways, which can be very challenging for the patient and the teams trying to care for the patient.

Brad Puffer: So how important is it, then, to have all of this record for improving care coordination and reducing all of this fragmented care that's out there?

Dr. Emel Hamilton: Well, over the last decade, there has been an increased focus on value-based care models with a triple aim to provide better patient care, improve outcomes, and reduce health care costs. If we want to achieve all of that, improve patient care quality and efficiency, then ultimately, we must focus on care coordination.

Brad Puffer: So why now? Why do we feel like this is the time when we really can move the needle by rolling out this health data exchange?

Dr. Emel Hamilton: Well, the first step towards care coordination was to implement electronic health records across the nation. This initiative was led by the Office of the National Coordinator, ONC, through various federal incentives. In fact, ONC data briefs tell us that the US is doing very well EHR adoption. 96% of the hospitals are using certified EHRs across the United States. However, also according to ONC, interoperability lagged behind. Roughly 6 out of 10 hospitals reported that they do not have the necessary patient information electronically available from care settings outside of their systems.

Now, of course, interoperability challenges are not unique to the hospitals. They are also prevalent in dialysis facilities, nursing homes, and physician practices. So I believe fragmentation of systems is clearly one of the biggest challenges in health care technology today. If we want to achieve optimal care coordination and improve patient care quality and efficiency, now that we have wired the nation, it's time to focus on interoperability.

Brad Puffer: So the bottom line is you have all these EHRs, electronic health records, out there. Different hospitals, different clinics have different systems. They're working really well to gather all this data, but they're not talking to each other. So tell me a situation where this timely access to data on another EHR, for example, is so important, and what have the challenges been in the past to getting a hold of that information?

Dr. Emel Hamilton: Well, you're right, Brad. Nurses and doctors every day, clicking away and documenting patient care, and creating billions of electronic health records. But we need to harness this information to create opportunities to address care coordination issues in health care. So basically, you want health care information to follow the patient as they connect with different providers.

When a patient walks into your dialysis clinic, you want to know some key information. So for example, who's managing the patient's diabetes or cardiac status? Or what vascular access procedures have been performed? What medications have been prescribed? So you would like to know all of these pieces of information from different providers, and those providers would also like you to know about it. Likewise, when our patients are admitted to the hospital or are seen at the physicians offices, we want to share key information about the aspects of their dialysis care. That's essentially what health information exchange is about-- trying to put together fragmented information in health care to make it safer, better, and more efficient.

Brad Puffer: Well, Dr. Hamilton, in the past, if a patient had an emergency room visit, for example, at a local hospital and came to our dialysis center for treatment a few days later, how have we traditionally gone about getting a hold of those records to know what happened?

Dr. Emel Hamilton: Well, a lot of times, as you know, Brad, staff were on the phone with the hospital, trying to obtain discharge records. And even if the clinician received faxes of discharge summaries or office notes for wherever the patient has been. These records were often incomplete and missing important details of the patient's medical history.

Brad Puffer: And so that can be really frustrating, if you're a clinician and trying to make some decisions and timely decisions about how to treat a patient and you don't have the whole record.

Dr. Emel Hamilton: Of course.

Brad Puffer: Do you have examples that demonstrate why this better sharing of information is so important? I understand the new health data exchange system has already been rolling out in our dialysis centers across the country. How practically is it working, and why is that so important to have that underway?

Dr. Emel Hamilton: Brad, we're launching the HIE project in waves. We're rolling it out in select states and dialysis centers. We're trying that approach first, because we want to take our time to listen to the clinicians and receive their feedback from the first wave of deployment to ensure that the presentation of HIE information fits well into the clinician's workflow.

Majority of the pilot clinics told us that they are saving valuable time by retrieving the electronic documents from HIE instead of having to call hospitals or fax documents back and forth. They're also very excited, actually, to receive near real-time updates of reports, such as discharge summaries, history and physicals, vaccination records, vascular access surgery information, documentation from transplant centers, et cetera. So overall, the clinic response has been very positive.

Brad Puffer: Yeah, it's amazing to believe that there's all of this information out there for a patient and how critical that information is to their care, and yet it was so hard, and has been so hard, to get a hold of it, to really know what's been happening with that patient outside of their care in the dialysis center. It really seems exciting. I wonder just how this all works. Where is all this information now going so that we and others can access it? How does an exchange come together?

Dr. Emel Hamilton: We can't do it alone. There are partner organizations here. Fresenius Kidney Care has joined the Commonwealth Health Alliance Network, which in turn gives us access to the Care Quality framework. And as a result, clinical staff will now have the ability to view documents from more than 600,000 participating providers in over 2,800 hospitals across the nation.

Brad Puffer: And so how, practically, does a clinician access these records? For example, you've heard about that person who was at the emergency room over the weekend, and you want to get their records. And instead of picking up the phone to call the hospital or faxing back and forth or trying to get those documents, how would a clinician actually get access? Is it within our existing systems already in place?

Dr. Emel Hamilton: It is, Brad, because simply joining an HIE is not sufficient. So busy clinicians do not have time to log into separate portals to retrieve patient information. So in order to reap the benefits of our investment and to generate value, we needed to put this information coming in from HIEs right in front of the clinician at the point of care. So we were able to accomplish this easy access to exchange documents through the company's existing Cerner technology for managing patient health records.

Brad Puffer: And do you think this will evolve over time? Do you think it's going to become easier and easier to access these records and more seamless into the clinician's day to day process?

Dr. Emel Hamilton: I believe so, Brad, because the systems have matured over the last decade if we take a trip down memory lane and think about where we were 10 years ago, the idea of a national level trust framework such as Care Quality was still being incubated in CMS by the ONC. It started with about 35 members, and today, Care Quality has members or supporters from a diverse spectrum of government and private sectors. So it makes the collaborative much more consistent over the years and of course, much more valuable. So with the availability of a maturing comprehensive framework such as Care Quality and nearly 100% adoption across the United States, we felt the time was right to roll out our national interoperability initiative at Fresenius Kidney Care.

Brad Puffer: What do you think it will take to make sure this technology is actually being used in practice? I imagine there's going to be a lot of education to be done to make sure it's working correctly, to make sure, as you say, it's easy and seamless for doctors and nurses to use the exchange. How are we helping to make that process really work well?

Dr. Emel Hamilton: By listening to the users. My team spends a good bit of time understanding what drives the decision to use the HIE or to abandon. So we conduct qualitative interviews with the clinicians. We have discussions about when and how the documents retrieved are useful, and we learn about barriers to adoption and any pain points. I believe it's extremely important that we develop use case scenarios based on the experiences of the first wave implementers. We need to share this knowledge with other facilities as we roll out the HIE across the organization.

And we're also looking to capture quantitative data. For example, the number of users. Which clinician group is using HIE the most? How often HIE is being accessed, which documents are most popular, those types of things. So we can do qualitative and quantitative evaluation and build use cases that support the nurses and the doctors taking care of the patients, and we continue to chip away at the barriers to adoption based on user feedback. Then we will get to a point where health information exchange becomes the standard of care.

Brad Puffer: Well, that takes me to my last question, which is, when will this be the norm across health care? Are we getting closer to the point where every health care provider we visit can get access to our other important health records, even if from another provider?

Dr. Emel Hamilton: Well, Brad, if you envision interoperability as a marathon, I believe we're in the final stretch here. However, due to numerous and stubborn structural and technical challenges around HREs, as well as barriers to acceptance and sustainability, I believe we're about five to seven years out from complete national interoperability. Our progress, of course, will depend on active collaboration between the health care community, federal government, and information technology organizations.

Brad Puffer: Well, I think it's really exciting to think about that time when we get to that point, because I think anybody who's ever been a patient can understand and appreciate how frustrating it is to go from one doctor to another or one center to another and not have a window or have that provider have access to all this information. So it is really exciting to kind of think about where we are going as Fresenius Kidney Care to help make this possible for our patients, and where the future is going for all patients. So it's really been great discussing this important topic with you, Dr. Hamilton. Thank you so much for taking the time.

Dr. Emel Hamilton: Absolutely, Brad. I'm very grateful for the opportunity.

Brad Puffer: And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play, or right here at fmcna.com, where you can also find our annual medical report and other featured articles. We hope you'll come back and join us, as we have many more topics to discuss in the weeks ahead. Until next time, I'm Brad Puffer, and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.