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Interoperability Proving Ground (IPG) submissions within the ONC Tech Lab are submitted by healthcare, technology and development organizations that are invested in Health IT and Interoperability and want to share, learn and collaborate with similar stakeholders in the US, and around the world.

To view all submissions, please view the IPG link located within the ONC Techlab.

Reduce Skilled Nursing Facility Readmissions

Objective:  Assist health systems to reduce readmission rates in bundled payment arrangements by providing community-wide SNFs who continue to fax with an easy & affordable standards-based interoperability solution. 

Description:  A longstanding barrier to broad connectivity has been the awareness of interoperability and EMR capabilities of external providers, particularly in post-acute setting –skilled nursing, assisted living, behavior health, therapies and others.  Health systems, HIEs & large physician groups are challenged to meet interoperability measures as they transition to value based care.   Without interoperability, they struggle to gain visibility to care delivered outside their four walls –which is necessary to meet MU & ACI measures under MIPS/MACRA, but also for the greater goal of improving care coordination with these valued partners –resulting in better patient outcomes while they shift to alternate payment models. 
Kno2.iQ™ is a data-driven service offered to health systems & providers to quickly drive connectivity & interoperability adoption throughout a community using referral patterns as the driver.  Kno2.iQ collects, analyzes & reports on data from many different sources, including CMS, to quickly identify the best connection option available between providers in a given geography or health referral region.

This particular project centers around connecting skilled nursing facilities (SNF) to the health system.  It streamlines referrals and helps patients move out of the hospital (ie the most expensive venue of care) to the appropriate venue in a more timely & efficient way.  It also gives doctors at the hospital (who are ultimately responsible for the cost & quality of care) a direct line of sight into what is occurring at the SNF.  By streamlining the flow of information bidirectionally, they can coordinate care more effectively, shortening the length of stay & reducing readmission rates while ensuring patients are managed appropriately. 
Start Date
Projected End Date

Project Tags
  • ACO
  • bundled payments
  • direct secure messaging
  • EHR
  • Health Systems
  • interoperability
  • Kno2
  • Kno2.iQ
  • narrow networks
  • post-acute
  • reduce readmissions
  • Skilled Nursing Facilities
  • SNF
  • Value-based Care
Project Point of Contact:
Project Results
Expected Outcomes: 
•	Provide connectivity reports to health systems throughout CA, LA, MO, OK, PA, and WA states  
•	Improve access to information to improve referral response rate
•	Improve speed to facility
•	Better informed SNFs to appropriately assess patients/appropriateness
•	Reduce readmissions through improved hand-offs and transparency