NR 515 Week 7 Integration Proposal, Consult Notes Example

Integration Proposal: Direct Secure Messaging of Signed Cardiology Consultation Notes Into Our Family Practice Record, With the Second-Year Price Quoted Beside the Build

Student Name

College of Nursing, Chamberlain University

NR 515: Informatics in Healthcare

Instructor Name

Month Day, Year

Integration Proposal: Direct Secure Messaging of Signed Cardiology Consultation Notes Into Our Family Practice Record, With the Second-Year Price Quoted Beside the Build

The Request

I request approval to set up one electronic link: signed consultation notes from the regional cardiology group sent by Direct secure messaging into our practice's EHR, where they file to the patient's chart as structured documents instead of arriving as fax images. The link covers one document type moving in one direction between two named organizations. The first-year cost is estimated at $3,900, and the second-year cost at about $1,600 plus roughly two hours of staff time a week, both explained below. Approval is needed from the practice administrator and the medical director, and from the cardiology group's practice manager, who has agreed in principle.

The Current Route, Briefly

The Week 6 route map showed that a cardiology consultation note reaches our physicians through three waiting states: dictation and signature at the cardiology office, a fax to our e-fax inbox, and manual indexing to the chart by the referral coordinator, followed by the physician's inbox. The last two legs take a median of about three days and depend on one person. The note arrives as an image, so medication changes and recommendations cannot be reconciled electronically, and there is no record of which notes we should have received but did not. Mehrotra et al. (2011) described poor information transfer as one of the central weaknesses of specialty referral, and in our practice the consultation note is where that weakness shows.

What Is Proposed, and What Is Not

In scope. Signed outpatient consultation and follow-up notes from the cardiology group's EHR to ours, sent as structured clinical documents over Direct secure messaging. Both vendors have confirmed their certified systems can send and receive such messages and attach them to the correct patient. Incoming documents will file automatically when the patient is matched, and go to a reconciliation queue when not.

Out of scope, written down so nobody assumes otherwise. Outbound referral packets, which will stay on fax for now; echocardiogram and stress test reports, which come from the hospital; the cardiology group's hospital notes; and any other specialist. Each can be a later request if this link works.

The Build

The build has three parts. First, the vendor configures our EHR to accept Direct messages from the cardiology group's address and to file consultation notes to the chart; quoted at $2,400 one time. Second, the cardiology group's vendor sets the equivalent sending rule on their side, a cost the group has agreed to carry. Third, our staff test the link: the referral coordinator and I will send test documents for ten test patients, confirm that each files to the right chart, and confirm that an unmatched document lands in the reconciliation queue. Staff time for testing and training is estimated at 20 hours, about $700. A small subscription for message services adds about $800 in the first year. The link would go live within about six weeks of approval.

Year Two: Who Keeps It Working

This section is as long as the build section on purpose, because the ongoing work is what integrations usually leave unfunded.

Certificates and addresses. Direct messaging depends on security certificates and directory entries that expire and change. The vendor will renew our side as part of the subscription, about $800 a year. The cardiology group's practice manager is named as the contact for their side.

Monitoring. The Week 4 stoppage showed that a silent link is dangerous. Each Monday, the referral coordinator will compare the number of cardiology notes received by Direct in the past week with the number of cardiology appointments on our referral list whose dates have passed. A gap triggers a call to the cardiology office. This takes about 20 minutes a week.

The reconciliation queue. Some notes will not match a patient automatically, for example when a name is spelled differently. Someone must work the queue daily. The referral coordinator is the named owner, with the clinical nurse as backup. Based on the cardiology group's volume of about 25 notes a month from our patients, we expect a few unmatched items a week.

Changes at either end. If either organization upgrades its EHR or changes vendors, the link may break. The practice administrator will add the link to the list of interfaces reviewed before any upgrade.

The total second-year cost is about $1,600 in fees, plus roughly two hours a week of staff time for monitoring and the queue. Sittig and Singh (2010) emphasize that health information technology succeeds or fails through its people, workflow and organizational policies as much as its software. This budget funds those parts.

Expected Benefit and How It Will Be Measured

The link should shorten the time from signed note to physician inbox from about three days to under one day, remove manual indexing for these notes, and give the practice a record of which notes arrived. The measures will be the median days from the cardiology appointment date to the note being filed, taken monthly, and the number of referrals each month with an appointment date in the past and no note on file. Patel et al. (2018) found that a minority of referrals in a large system ended with a documented completed appointment; this second measure will tell us, for the first time, how our own cardiology referrals compare.

The Cures Act regulations also set expectations for timely electronic access to health information (Office of the National Coordinator for Health Information Technology, 2020). A link that moves consultation notes as structured documents is consistent with those expectations, though the proposal does not depend on them. Its case rests on what the practice itself will see: fewer days lost between a cardiologist's signature and our physician's reading, and a list of overdue notes that today does not exist anywhere.

A named owner for each part of this work is the condition of the request, not a detail to settle after go-live. If the practice cannot name the coordinator and a backup for the queue, the proposal should wait until it can.

Decision Requested

Approve the build at an estimated $3,900 for year one and the ongoing cost of about $1,600 a year, and approve the named owners for monitoring and the reconciliation queue. If the monthly measures show no improvement after six months, the link should be reviewed and, if necessary, switched off.

References

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. The Milbank Quarterly, 89(1), 39-68. https://doi.org/10.1111/j.1468-0009.2011.00619.x

Office of the National Coordinator for Health Information Technology. (2020, May 1). 21st Century Cures Act: Interoperability, information blocking, and the ONC Health IT Certification Program. Federal Register, 85, 25642-25961. https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification

Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the referral loop: An analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine, 33(5), 715-721. https://doi.org/10.1007/s11606-018-4392-z

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085