EHR usage still too slow

Long-term care providers are feeling pressure to implement an EHR, despite facing hurdles like costs and resources. Many complain about a lack of options allowing interoperability with hospitals and o
Long-term care providers are feeling pressure to implement an EHR, despite facing hurdles like costs and resources. Many complain about a lack of options allowing interoperability with hospitals and o

Nursing homes and their counterparts in assisted living and other senior living settings may be sluggishly dipping their toes into the waters of electronic health records. 

But that hasn't stopped a highly motivated and, arguably, savant-level vendor community from building what many see as a linchpin of the new caregiving world.

Despite the bells, whistles and some amazing new features and efficiencies, however, adoption is not going fast enough for many.

Persistant hurdles

“The three top challenges that long-term care providers still face are time, money and resources,” says Teresa Chase, president of American HealthTech, echoing what many still grumble about when the subject is raised.

Indeed, the list has been covered extensively. Providers have been beset by costs (especially since most long-term care providers have been excluded from Meaningful Use incentives), interoperability issues, concerns over data security and privacy, attention-addled and razor-thin staffs, and more.

Nickolo Villanueva, chief operating officer for VCP, says his firm still sees “several major challenges providers face when implementing an EHR. Most of the challenges are unexpected and result in a reactive solution that was oftentimes not budgeted,” he adds. 

Other hurdles include woefully inadequate IT infrastructure at many facilities, either from a power or security standpoint, or both, he adds.

Interoperability remains a huge unmet need for many providers, believes Rodolfo Alvarez del Castillo, M.D., chief medical officer at Yeaman + Associates, and a long-time supporter and speaker at the American Health Information Management Association's Long-Term & Post-Acute Care Health IT Summit.

“One of the biggest challenges we face in today's healthcare is the growing demand for accurate, efficient and proactive care transitions in order to avoid readmission penalties,” Castillo says. “Certainly, elements of decision support [tools] play a significant role in the prevention of avoidable transitions of care. However, in order to better engage in an efficient workflow, a successful exchange of critical data elements is necessary whether it's via direct or as a full bidirectional connection or feed into a health information exchange [HIE] or with a record locator system.”

Adoption pressures mount

Still, long-term care providers are clearly feeling the heat to adopt, and to do so thoroughly.

In the wake of calls to give more transparency and accountability in EHR certification, for example, the Office of the National Coordinator for Health Information Technology in October announced plans to begin heavily scrutinizing electronic health records, moving away from using private contractors. The harshest warning: The ONC would revoke health information technology certificates if EHR systems were found to present health and safety risks. The news rattled many in the nursing home and senior living business, according to published reports.

Meanwhile, the adoption curve isn't exactly shooting 90 degrees north. 

Though the last formal industry-wide nursing home survey
was done a dozen years ago,
LeadingAge is keeping a close eye on EHR implementations among its members, says Majd Alwan, Ph.D., senior vice president of Technology for LeadingAge and executive director of the Center for Aging Services Technologies. Among the organization's 150 largest members, roughly 75% have some form of electronic medical record keeping. Of those, a little more than half of deployed EHRs have advanced health IT functionality, he says. The remainder have “basic functionality” driven by regulations around electronic assessment, documentation of care and submission of billing.

Last fall, the Centers for Disease Control and Prevention's National Center for Health Statistics announced that about one-fifth (19%) of assisted living and residential care providers were using some form of electronic health records. EHR implementations were most prevalent in Utah, North Dakota, Minnesota, Idaho and Nebraska, and least in Arkansas, Louisiana, Alaska, Arizona and Nevada. About 17% of the nation's assisted living communities reported having computerized support for HIE with pharmacies, while 11% had it with physicians, and 7.9% with hospitals.

That doesn't mean certain EHR components aren't being broadly embraced. 

Suresh Vishnubhatla, executive vice president, Long Term Operations for PharMerica, says EHR adoption has been “fairly brisk” over the past 18 months based on the “uptick” his company is seeing in the use of electronic medication administration records, which are necessitated by care plans and MDS. 

“The cost isn't necessarily going down that much, but what's driving it is the need to get out from under some of the paperwork,” he says. “And keeping that paperwork updated isn't free.”

Proving its mettle

As the EHR train continues gathering steam, more and more success stories with long-term care providers are coming to light.

CAST and PointClickCare recently studied broad EHR implementation across Avanté Group's 20 skilled nursing communities. They used a seven-stage adoption model that begins with fundamentals such as admission, discharge, and transfer, MDS, care plans; basics such as assessments, point of care documentation and advanced clinical document; and up through orders management, physician engagement and interoperability, the highest stage.

Among the outcomes: EHR utilization increased by 80%, virtual elimination of duplicated reports, and a tripling of data collected at the point of care. Other positives included reduced medication errors and improved occupancy rates attributed to the use of intake and referral management, according to Alwan.

Although EHRs are still relatively new, systems have indeed come a long way in a very short period of time.

Only recently have systems begun touting powerful analytics on information such as census, prevalent diagnoses or DRGs, readmission rates, interventions, claims, risks and referral sources “at both the patient, facility/operation, even the population level,” says Alwan.

LeRoy Boan, senior sales representative for NTT DATA Long Term Care Solutions, agrees. “Resident population management based on patient outcomes is starting to gain traction in all sectors of healthcare,” Boan says. “Facilities that can utilize their EMR software to project patient outcomes using predictive analytics can set themselves ahead of other facilities by better managing census and care delivery.”

Other notable recent innovations, according to Alwan, include clinical decision support tools, physician engagement features, care coordination tools, provider integration capabilities, even interoperability and health information exchange capabilities. 

“Many facilities now are also implementing cross-referencing, or single patient ID, to facilitate transitions of care across various care settings within the same organization,” he adds. 

Alwan knows of several regional health information exchange organizations and repositories that use different patient-matching algorithms to create a single EHR summary record for a patient from EHR systems of regional hospitals, clinics, nursing or rehab facilities and pharmacies that have served the individual.

Few discount the efficiencies EHR systems are promising, in spite of a recent Annals of Internal Medicine study that revealed a startling time drain among doctors. Researchers studied 57 physicians in family and internal medicine, cardiology and orthopedics, and discovered as a group, they spent nearly half (49%) of their office days on EHR and desk work, compared to less than 30% on direct face time with patients.

Once a critical mass of clinicians successfully leaps the implementation curve, those numbers will likely change, says Maria Arellano, clinical product manager for American HealthTech.

“EHRs are migrating toward effective ways to increase the efficiency of workflow management for the interdisciplinary team,” she says. “That efficiency is the key to lowering costs, improving care and surviving in the new world and payment models.” 

Arellano says clinicians will soon spend the majority of their time providing direct care to patients as “the EHR increases this patient-interaction time and consequently the quality of care delivered.”

For companies such as PharMerica, the efficiency gains are already benefitting providers and vendors. 

“For a lot of vendors, the pharmacy integration piece didn't exist two years ago,” says Vishnubhatla. “They're beginning to delve into formulary management, which is something they couldn't do before. Now when a new resident is admitted into the nursing home, we've already received all of the admission info electronically. That saves us time in terms of data input and order processing.”

Eliminating manual data entry is not only a boon for efficiency, but accuracy, and pharmacy companies get this more than anyone right now. The ability for providers to scan medications into EHR systems is one example. 

“Being able to scan your medications into the system, being able to more effectively manage their medications is something you can't do very well on paper,” Vishnubhatla says. The efficiency on the pharmacy's end cannot be overstated, particularly because of the way it streamlines the pain medication prescribing, dispensing and administration. It also benefits residents in other ways. 

“ePrescribing allows facilities to process discharge scripts electronically to the pharmacy of the resident's choice,” says Kristal Wood, director of marketing for SigmaCare. “Gone are the days of having to find a physician to fill a multitude of physical scripts. Using an ePrescribing system allows for a safe process of script creation and seamless processing, ensuring the orders are filled and administered in a timely fashion.”

One of the more exciting innovations to emerge is the ability to store huge amounts of multimedia like audio and video into the electronic record, although privacy hurdles are still being worked out.

Alwan says several vendors now can store resident photos, “and many can handle unstructured data like scans, X-rays and wound images.”

AHT's Chase says she sees a lot of benefit of multimedia in telehealth applications.

“With growing interest in telehealth and some states providing some reimbursement for these services, there are those who would like to store the video files of the tele-visit in their EHR, connected to the patient's medical record, so it is easily accessible to physicians and the rest of the care team,” she says. Boan adds that he believes “the use of graphical images in identifying wounds and monitoring wound progression is becoming more commonplace.”

Integration is another piece of EHR that has many excited. 

“While the EHR is the foundation and repository of good, relevant clinical data upon which clinicians make good clinical decisions, it cannot address all of the issues skilled nursing centers face every day with rising patient acuity, shorter lengths of stay and discharges to home and community,” Chase says. “That means good integration or what we call ‘meaningful connections' between the EHR and other systems such as disease management tools, evidence-based assessment tools and others are based on effective clinical workflows and presenting the data to the staff in the right workflow at the right time.”

Finally, many EHR systems are now able to be accessed via mobile devices, making it a huge time saver for thin staffs. 

“The use of mobile devices has improved both the quality and the timeliness of information being captured, which is having a positive impact on quality of care and resident safety,” says Jayne Warwick, RN, HBScN, director of Industry Insight for PointClickCare Technologies. “By enabling care providers to easily capture information at the point-of-care directly into the EHR, as opposed to taking notes and transcribing at a later time, the risk of error has decreased and the level of detail and accuracy of the information being captured has improved.”

Pleasant surprises

As much as providers now know about EHRs, many would be pleasantly surprised about lesser-known enhancements.

Thanks in part to a plethora of new standards, EHR data can now be accessed and stored in the cloud, according to Alwan. 

“Most products are offered as Software as a Service (SAAS), which means providers don't need to invest in server rooms and backup storage,” he says. “That means changes and updates are made once in the cloud and their effect is immediate.”

Providers also could be surprised to learn of the number of “secondary EHRs” they can now connect with today, says Wood.

“Interoperability with EHRs has made great strides in the last year or two,” she explains. “Ancillary systems like dietary, rehabilitation, laboratory and radiology systems, to name just a few, can now easily exchange data in real time with EHR systems.”