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Health IT Success Stories

Nicole Heim Uses Health Information Exchange to Reduce Patient Readmissions

'There is huge value in sharing discharge information via health information exchange.' – Nicole Heim

Nicole Heim is Chief Information Officer at Milford Regional Medical Center (MRMC), a 121-bed non-profit community and teaching hospital in Milford, Massachusetts. MRMC serves approximately 20 communities in the area as a full-service hospital. Ms. Heim and her team at MRMC are using health information exchange (HIE) to improve care transitions and reduce patient readmissions.

The Challenge of Care Transitions

Before MRMC began using HIE to improve care transitions, MRMC’s Patient-Centered Transitions Team noticed a cycle of readmissions due the complex and often confusing set of events that occur when a patient is discharged from the hospital. One number in particular stuck out to Ms. Heim: one of MRMC’s patients was admitted eleven times over the course of a year, accounting for 58 days in the hospital and 54 separate studies. The Patient-Centered Transitions Team – which includes primary and specialty providers from MRMC and other organizations in the Milford area, case managers, and quality improvement staff from the medical center – investigated the issue to determine what was causing the recurring readmissions. “What we found was that printed discharge summaries and the instructions we gave those patients were often misplaced or did not travel with the patient and thus were not given to the next care provider to continue the patient’s care,” explained Ms. Heim. With no standard method of communicating discharge information to other providers, MRMC continued to see a cycle of patient readmissions. “We gave the patients discharge instructions, but they did not always follow patients, so some patients would be admitted multiple times over the course of the year,” said Ms. Heim.

Using Health Information Exchange to Reduce Patient Readmissions

To remedy the problem, Ms. Heim and her team began to explore options with the Massachusetts Health Information Highway (Mass HIway). With Mass HIway, Ms. Heim knew the hospital would be able to electronically send discharge documentation to skilled nursing facilities, home health organizations, and other providers in the Milford area that patients were seeing after being discharged from MRMC.

Ms. Heim and her colleagues received a grant from the Massachusetts eHealth Institute to connect MRMC to Mass HIway. Using the connection to Mass HIway, the hospital’s EHR system automatically sends discharge documentation to the local organizations whenever a patient is discharged from MRMC. “The system is functioning well because it’s electronic and automatic,” said Ms. Heim. This electronic approach is helping reduce readmissions at MRMC by ensuring other providers in the Milford community receive discharge care instructions. With better information about patients, MRMC and the Milford community are working to help patients recover and prevent them from returning to the hospital.

Next Steps for Health Information Exchange

The hospital is currently working to expand the HIE connection to other provider organizations in the area. “We are excited to be a Mass HIway pioneer and share our story with other facilities and organizations,” said Ms. Heim. As MRMC begins to electronically send discharge documentation to more providers in the Milford area, the hospital has set a goal of reducing readmissions by 2% in a 6-month period during 2014.

MRMC is also planning to leverage the HIE connection to achieve Stage 2 meaningful use. “We’re looking at using the Mass HIway as part of our strategy to meet the initiatives and objectives for Meaningful Use Stage 2, which will require us to electronically send documentation on transitions of care,” Ms. Heim explained. “It’s a great opportunity.”