A roadmap for EMRs: strategies and starting places for long-term care

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A roadmap for EMRs: strategies and starting places for long-term care
A roadmap for EMRs: strategies and starting places for long-term care
Electronic medical record adoption has been a widely discussed topic in recent months, but that hasn't necessarily meant that long-term care operators have been eagerly hopping on the bandwagon. Even those that have begun to adopt EMR solutions may not be using them to their full potential and, therefore, are leaving some significant financial and operational benefits on the table, experts say.

Some lingering myths and misunderstandings, as well as some negative reports about electronic records, may be hindering the adoption and successful implementation of EMRs. One November report, for example, which reviewed roughly 4,000 hospitals from 2003 to 2007, found that health IT savings and operational efficiencies are more hype than reality. Researchers also noted that, in some cases, electronic records might actually increase administrative costs. Full findings were published in The American Journal of Medicine.

Industry experts nonetheless are urging long-term care providers not to shy away from the technology. Congress, in fact, is providing $19 billion in incentives to help light a fire under various provider organizations that have been slow to adopt the technology. Many experts stress that EMR-related savings in long-term care are indeed attainable, particularly when they're applied to several key functions.

“One is point-of-care systems that provide a stronger documentation trail that can increase reimbursement dollars,” confirmed Peter Kress, vice president and chief information officer for West Point, PA-based ACTS Retirement-Life Communities Inc. ACTS communities have been using point-of-care systems for approximately nine years and, more recently, have incorporated progress notes into the electronic records.

One EMR product vendor said that savings generated by a properly implemented electronic point-of-care system can drive the funding for other EMR and information technology investments.

“The savings that can be gained are very real,” said Jim Quasey, president of Vocollect Healthcare Systems, Pittsburgh. He added that VHS customers who use point-of-care solutions see an increase of roughly $30 to $50 per Medicare resident day.

Incorporating minimum data set, care planning and assessment components also could pay big dividends.

“The fact is that a chart review and staff and resident interviews need to be done to effectively and accurately complete the MDS, and evaluate effectiveness of the care plan interventions,” explained Kirby Cunningham, RN, manager of clinical services for AOD Software, Fort Lauderdale, FL. “If the supportive documentation is in an electronic record and not on paper, time needed for chart review by the resident assessment instrument team can be greatly reduced.”

Equally important is the use of a point-of-care activity of daily living data collection tool, which can document the “snapshot” in time that is needed for the MDS look-back period.

“This can dramatically improve resident outcomes and reimbursement,” Cunningham said.

EMR solutions that can integrate with existing software solutions and resident care technologies provide even greater savings opportunities. An EMR module that can interface with vital signs monitors and easily capture pertinent resident data, for example, can improve resident care. It also allows caregivers to capture facility-wide vitals data in roughly two hours, as opposed to a full day, according to David Pollack, president of ADL Systems Inc., Hawthorne, NY.

“Without ER they're missing out on some very big opportunities,” he said, noting that the greatest opportunity comes in resident care.

A work in progress

Among the greatest provider and vendor misconceptions is that capturing certain resident data electronically automatically constitutes EMR adoption.

“Just because a facility is capturing order entries, care plans and assessments, for example, doesn't mean that what they have is an EMR,” Pollack said. “These are components of EMR, but EMR is a much bigger picture than that.”  

In fact, Pollack doesn't believe that a true, complete EMR solution is even available today.

“There are many vendors out there claiming to have a true EMR solution, but at this point, what's really available is a partial EMR,” he said. “We're getting close to having a full EMR solution, but we're not there yet.”

He feels that a full EMR solution will have to include approximately 250 forms. “Rehab alone may have 25 or more other forms. If any of those are missing, you aren't going to have a full EMR,” he said.

Waiting for that comprehensive “silver bullet” solution may not be a wise decision, however. Not only might EMR implementation (even on a smaller scale) be a marketing boon for facilities and potentially give them an advantage with surveyors; but getting the ball rolling now will position providers for more widespread adoption if and when electronic records become a requirement.

“I see no real benefit in waiting, but I see a lot of value in implementing a strategic initiative to explore natural opportunities, identify challenges and seek out technology that can help [facilities] solve their safety, quality, financial, and risk problems,” Kress said. “Getting started today with EMR will enable us to participate richly in electronic health record exchange across the continuum. We need to understand that EMR implementation doesn't happen overnight. It involves many steps. It's a work in progress.”

Baby steps

Successful EMR adoption is a layered process indeed. And even with vendor support, many long-term care operators may not know where to start. Rushing the implementation process is among the surest routes to failure, sources warned.

“Many may feel panicked and overwhelmed, and some folks are looking for a quick solution, which just doesn't exist,” Quasey said. “It's important that they focus on developing a good plan and strategy [for implementation]. What they shouldn't do is rush the process and make a hasty decision.”

Still, “momentum is very important,” notes Mike Mutka, president and COO of Silverchair Learning Systems. “Keep things moving ahead. People can get bogged down with endless analysis paralysis.”

He also emphasizes that providers should clearly determine their goals, keep them simple enough and then resist temptation to keep piling on new things.

“We say, ‘Don't try to boil the whole ocean.' People get in trouble because they're not clear about their objectives and they try to do too much,” Mutka said. “We call it ‘creeping elegance.' You start out with x and then get enamored with y, z, a and b. Don't try to do everything. It just collapses under its own weight.”

Conducting comprehensive assessments of current processes is crucial—but it's an oft-overlooked practice that can lead to frustration and failure.

“We're working to encourage LTC providers to adopt an EMR because knowledge is power,” said Suzy Greenly, manager of product development for Keane Care, Redmond, WA. “Get as much information as possible. Know your current processes and what will change with EMR.”

The EMR evaluation process also takes time, and long-term care providers should seek solutions and vendors that advance their current processes, rather than duplicate what's already in place—a seemingly obvious strategy, but one that even vendors admit often is overlooked by providers. Part of the problem, according to Pollack, is that some operators aren't even aware of what the ultimate goal or vision should look like.

“It boils down to education. It's important to ask the vendors to help,” Pollack said.

Having a realistic implementation timeline is also essential, although some vendors and operators grossly underestimate the time it takes to reach implementation success. Further impeding success is the tendency of some operators to attempt a full-facility electronic record solution roll-out, which puts them at a severe training disadvantage and sets staff up for failure and missed opportunities.

“This is a big change and there will be some resistance and challenges along the way,” Pollack stressed. “It's not something that you can successfully implement and execute in a few days.” He said a few weeks is a more realistic time frame for staff to get the hang of the technology, and that's just for one unit—not facility-wide implementation.

“It's not an easy process,” he added. “Facilities need to understand that, at least initially, there will be an overlap with the new and existing systems, which can mean double the work. Many facilities and vendors make the mistake of not preparing [staff] for this.”

Vendor education and support are undoubtedly critical, but the facility itself also bears a fair share of the responsibility for successful implementation. Once basic implementation is complete, the learning curve for establishing and promoting best practices begins, and the speed of assimilation and benefit realization is the variable, explained Robert Davis, CEO of Optimus EMR Inc., Irvine, CA.

“Some staff members will require additional help with the use of technology, which will allow them to fully embrace the changes and eventually be successful,” Davis said. “This continuing education and full adoption process requires the use of in-house mentors who have sufficient time allotted to this function.”

Kress also advocates the use of mentors, or “champions,” to lead the implementation process, and prefers designating a clinician for that role.

It's also crucial that enough computers be available to manage the EMR effectively—a requirement that is sometimes overlooked, stressed Linda Spurrell, LPN, RHIT, CHP, clinical product manager for Keane Care.

“As operators look to improve their IT systems, it's a good idea to include portable PCs that can be used at the point of care via wireless networks,” Spurrell said. “Wall-mounted devices have proven to improve efficiency in charting by direct-care staff. MDS 3.0 could be a further catalyst for facilities to increase the number of PCs available for point of care data input of resident interviews, she added.

Good data essential

Although EMR has been credited for improving data collection and dissemination, operators must realize that errors or shortcomings likely will occur pre-implementation and continue post-implementation. It's the classic case of “garbage in, garbage out.”

“The effectiveness of the solution is going to be measured by the quality of the data,” said Jim Logan, vice president of products for VHS. “Systems will only be as good as the data within them.”

Operators still in the software solution evaluation phase should look for a vendor solution that factors in chart integrity, so charts and caregiver notes stay consistent, Pollack added.

“You don't want [staff] writing one thing in one spot and then contradicting that in another area,” he said. “A computer will not be able to stop this unless you're able to cross-reference the charts with the note.”

While there are many technical aspects and cost implications to consider when embarking upon an EMR initiative, there's one factor that sources said must always remain a top priority: the resident.

“The real barometer is how it affects the resident. If I were a resident in a nursing home, I would hope that the facility uses an electronic system that places a lot of importance on helping the facility understand my condition,” Larry Triplett, president of Resource Systems, New Concord, OH, reasoned.

“I would hope that it would have automated mechanisms to alert staff when I need attention. I would make sure that the caregivers who know me best are the ones feeding the system – not people back at a desk.”

Adds Diane Lewman, RHIT, LNHA, clinical implementation specialist for AOD Software: “The [electronic record] should be a time and information management tool that provides decision trees, not a tool that makes decisions for you,” she noted.