“There has to be an easier way.” Most utterances of this phrase are followed by a shrug of the shoulders and a continuation of the status quo.

However, when a physician at UPMC suggested an “easy button” for physician referrals to home health, the interoperability team rolled up its collective sleeves and got to work, designing a mostly automated system that reduced the amount of time required to make a referral from 97 minutes to just 11. The number of steps physician practice staff need to make a referral dropped by 57%.

Where once referrals went into the ether, now each one is electronically tracked from beginning to end, closing the care loop for each patient as the referral is made and alerting the physician to the patient’s next care step. The result is a greatly improved care coordination process, less physician time to make a referral, and reduced homecare patient leakage through UPMC providers. Interoperability plays an oversized role in UPMC’s success, including the use of Direct Secure Messaging.

A Long History of Interoperability

Based in Pittsburgh, UPMC has grown from a single hospital to a $21 billion integrated finance and delivery system that has more than 40 hospitals and 800 practice and outpatient centers across Pennsylvania, in Maryland and New York, as well as outposts in Ireland and Italy. The system has 8,500 licensed beds, with 6,000 affiliated physicians and nearly 4,900 employed physicians. The system sees about 1.1 million ED visits years and 30,000 hospitalizations, says Dr. Kristian Feterik, Medical Director of Interoperability. In addition, UPMC Health Plan is Western Pennsylvania’s largest medical insurer.

“We started our journey with interoperative health records decade ago,” Feterik says. “We have a best-of-breed ecosystem with multiple applications tied together with a single sign-on and patient contact management.”

The Community Provider Services (CPS) division of UPMC comprises pre- and post-acute provider organizations covering all of western and central Pennsylvania, explains Raymond Lutz, Senior Director, Community Provider Services, IT. CPS programs and providers include homecare and hospice, private duty, community services, skilled nursing, assisted living, independent living, institutional pharmacy, retail pharmacies, infusion pharmacies, specialty pharmacies, community life program, inpatient and outpatient rehabilitation, advanced illness care, remote patient monitoring, in-home urgent care, and a DME and oxygen partnership.

In conjunction with the health plan, UPMC launched the Innovative Homecare Solutions Group “designed to implement innovative and accountable post-acute and community-based programs that improve patient care, enhance patient outcomes, and lower the total cost of care,” Lutz says.

Lutz is part of the CPS IT organization, a small group of highly experienced IT professionals who support CPS organizations and the homecare solutions group, under which care transitions and referral activities fall. Nurse liaisons work in direct support of care management in select facilities to handle internal and external referrals for homecare, hospice, infusion, DME, oxygen, and community services. Nurse liaisons use an internal application called Care Transitions Manager (CTM) that’s tightly integrated with UPMC’s acute, ambulatory, and post-acute EMRs. Developed about a decade ago, CTM proved a foundational component of this project, Lutz says.

An ’Easy Button’ for Referrals

The conditions pre-initiative were nowhere close to the envisioned “easy button,” says Lisa Lewis, Director, Community Provider Services, IT. On average, it took 97 minutes to arrange a referral. “Multiply that by X patients per day, and you realize you’re spending an awful lot of time on the phone trying to arrange care,” Lewis says. Other factors included a shortage of nurses and recognition that certain agencies couldn’t take patients in certain ZIP codes, so-called curtailment.

“There was a lot of faxing of documents back and forth, a lot of phone calls back and forth, a web of communications going back and forth,” says Lewis. “Our physician practices needed our help. So they came to their IT partners and said, ‘What can you do to help us?’”

The UPMC homecare agencies wanted not only to increase overall referrals, but also to better understand the sources of leakage, explains Tracy Quinn, System Analyst, Community Provider Services, IT. Physicians wanted one simple process for referrals, regardless of whether patients sought care inside or outside the UPMC system. The new system was piloted at three physician practices before it was rolled out across the health system in November 2019.

Physicians use the familiar EpicCare EHR system to send referrals to a single Direct Secure Messaging inbox, aggregating referrals in a central location. Referrals are automatically generated from the Direct inbox, using data pulled from the Continuity of Care Document (CCD). However, the CCD doesn’t contain every piece of data needed to complete the referral, Lewis says. Working with interoperability partners within UPMC, the group created a web API to pull additional information from the EHR. By the time the referral arrives to the central intake group, it includes nearly everything required for the referral.

The central intake group have specialized skills, and they understand the intricacies of homecare referrals and curtailments. Using that advanced knowledge, referrals can be made quickly. Internal referrals are directly sent to the homecare management software, while external referrals are sent by digital fax. Once the referral is accepted, physicians are notified through UPMC Notify, an internal messaging system, and a message is sent to the EHR with such details as agency, contact information, start of care, and special instructions. To ensure that no referral falls through the cracks, a report is run twice-daily that reconciles patients against CCDs.

“Having that patient’s longitudinal record at the point of care is so vital for us because it gives the providers the information that they need to more accurately diagnose the patient and prescribe their care,” says Diane Michalec, Director, Interoperability. “But we have also found that it helps to decrease those unnecessary tests, which are not good for the patient and also can have additional cost involved.”

Better Understanding of Referral Trends

Automating much of the referral process and moving referrals from physician offices to a specialized central intake group decreased the time spent on each referral by nearly 90%, from 97 minutes to 11. Physician practice staff now need 57% fewer steps to make a referral, and they gain better insight into the next healthcare steps for their patients.

On the homecare side, agencies better understand the source of referrals, which includes 25% from UPMC physicians. Referral volume increased by 4,200 between 2020 and 2021, says Quinn. Agencies also have a much better handle on leakage, including by ZIP code, insurance provider, physician, and physician practice. Using that data allows potential service tweaks, including adding ZIP codes, working with physicians who aren’t referring internally, and possibly accepting other types of insurance.

More than 1,300 unique physicians from 579 practices use the homecare referral process. Interoperability staff note that extensive education was required not only on how the new referral process worked but also what can and cannot be ordered, such as home health aides that don’t qualify for home health services.

Applying Lessons Learned

“When we first started, our integration began primarily as HL7 interfaces and has expanded today to include a variety of query-based exchanges, including local, state, and national health information exchanges,” says Sandra Sentner-White, Senior Manager of Interoperability.

“Our most recent technologies include Direct Secure Messaging and real-time patient event notifications, which leverage Direct as its communication method. Also, over the years, we have developed a vocabulary management program which helps to harmonize the data across the systems and to ensure the information is meaningful and actionable where needed.”

Promoting interoperability is a true partnership between IT and clinical teams, says Michalec, Director, Interoperability. “When I think about it overall, interoperability is key to us because it really continues to help us deliver that safe, quality care to our patients, and it really helps to meet the needs of everybody, our providers, patients, and our families,” Michalec says.

It’s this spirit that earned UPMC recognition as an Interoperability Hero, an initiative from DirectTrust with the goal of recognizing the people and teams making true advancements in interoperability. See UPMC’s Interop Hero interview here, and learn more about the program, including seeing other Interop Heroes here.