With that action in January 2004, the president called for “leadership for the development and nationwide implementation of an interoperable health information technology infrastructure” with the goal of establishing electronic health records for all Americans within 10 years.
Now at the halfway point to 2014, the EHR effort does not appear to be far enough along to make the deadline. Numerous barriers have materialized to impede EHR implementation, namely cost concerns, fear of technology and a lack of standards. Then there are also the issues of interoperability, leadership, return on investment data and absence of an official congressional mandate.
The popular perception is that the long-term care segment is especially behind—not only on the EHR initiative, but on information technology altogether. Yet does the industry really deserve that reputation?
Good or bad?
Hospital EHR adoption was between 11% and 18%; physician adoption was between 9% and 15%; and long-term care adoption was at about 1%, according to a September 2007 report for the National Commission For Quality Long-Term Care by McLean, VA-based consulting group BearingPoint.
From this vantage point, the numbers appear to support the assertion that the industry needs to play some serious catch-up.
Conversely, research from the American Association of Homes and Services for the Aging suggests that long-term care is unfairly maligned when it comes to technology adoption. Data analysis from the AAHSA 2004 National Nursing Home Survey found that 43% of U.S. nursing homes maintained electronic health records, compared to 25% of physician offices and 59% of hospitals (as noted in other studies). These records include notes from care providers and Minimum Data Set forms. Moreover, 48% of nursing homes had computerized physician orders, 51% used electronic systems for medication orders and 41% used electronic systems to manage laboratory information, the report stated.
“This report suggests that long-term care providers are not only aware of the importance of electronic health reporting, but that they have adopted these technologies at a higher rate than providers in other settings,” said Helaine Resnick, Ph.D., director of research at the Institute for the Future of Aging Services and the study's lead author.
Even if indeed the long-term care industry is bringing up the rear right now, there are signs that the sector is moving forward with IT and EHR adoption.
“With much smaller budgets than acute-care facilities, long-term care tends to lag behind in technology adoption as a whole,” said David Finkelstein, CEO of Gansevoort, NY-based 6N Systems. “That being said, there is evidence that the message is getting through to a number of forward-thinking long-term care providers that investment in electronic medical records technology, even in this time of financial volatility, is essential to gain a competitive advantage.”
Docs lagging, too
“Not much” has been done with IT systems in long-term care, says Jim Shearon, RN, clinical operations consultant for Pittsburgh, PA-based Vocollect Healthcare Systems.
“From an IT perspective, with many communities still running on paper, the long-term care industry is decades behind,” he said. “Many communities have only two computers – one for the administrator and one for the billing office.”
Still, while Shearon says “we've witnessed more activity” in acute care, he points to a recent Texas Medical Association study that shows the physician community struggling with IT and EHR adoption as well.
Although studies can offer hints at what providers are doing, too many variables exist to get a truly clear picture of what's going on, says Dan Cobb, chief technology officer at Ozark, MO-based HealthMedx.
“It's difficult to be certain because the studies rarely compare apples to apples,” he said. “The definition of an EHR is not yet formalized, so if you ask a provider if they have an EHR, they may respond ‘yes' even if they are only performing basic functions, such as MDS. At the other end of the spectrum, providers may respond ‘no' if they are fully automated but not interfacing with other providers. Certification of EHRs, starting in 2010 for long-term care, will create a standard definition.”
EMRs vs. EHRs
Even in the acronym-conditioned healthcare industry, there is confusion over the labeling behind electronic medical records and electronic health records.
Some clarification on the terms from Tim Quarberg, R.Ph., vice president of sales and marketing for Irvine, CA-based Optimus EMR:
EMR is a computerized patient record that resides in a system specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids.
EHR is a repository of electronically maintained information about an individual's lifetime health status and healthcare. It is stored so that it can serve the multiple legitimate users of the record, healthcare providers and health-related services.
“Therefore, the EMR must be implemented first at the facility level. Then you can branch out into a true EHR,” Quarberg said. “Ultimately, what should long-term care facility operators be doing to comply with the EHR mandate and what do they need to know? All long-term care facilities should begin the education process as to what a real EMR system is and then begin a selection process.”
Upshot of EHRs
Long-term care providers can distinguish between EMRs and EHRs, understand the benefits and are on the path to adoption, believes Thomas Fahey, president of Farmingdale, NJ –based Health Care Software. They do, however, face special considerations inherent to the nature of the industry, he added.
“EMR in long-term care differs in that the resident is there for a much longer period of time in many cases and therefore the data elements collected can be very different as compared to other levels of healthcare services,” Fahey said. “That said, the benefit of an EHR is more of a history of the resident as they transition through various healthcare settings and this information, while more general, can be useful to everyone in providing coordinated care.”
Likewise, Aric Agmon, president and CEO of Fort Lauderdale, FL-based Answers On Demand Software sees “a significant increase in clients' adoption of EHRs” and that “this trend seems to be continuing at a steady pace.”
A conceivable reason for this enlightenment? Providers see EHRs as potentially easing the worker shortage, according to Agmon.
“If you think about it, a fully automated EHR will even mitigate the turnover in certified nursing assistants that many facilities encounter by ensuring that all of the information is contained cohesively and securely inside the EHR system,” Agmon said.
In order for EHR adoption to really accelerate, Finkelstein contends there needs to be continued interest and investment at both the federal and state levels.
“With the right incentives, technology will be more affordable, standards can evolve quicker and we will be able to study the actual long-term benefits of EHRs for patients, providers and the community as a whole,” he said.
That doesn't mean providers should be sitting still, however, said Linda Spurrell, clinical product manager for Redmond, WA-based Keane Care.
“We would like to see long-term care providers be proactive and vocal with the groups that will be determining the standards, as well as their software vendors,” she said. “Vendors need their input in the development process, and when it's time to test software in the field. Providers that agree to be beta sites and pilots are the unsung heroes in the process.
“They can start preparing for the EHR today by making sure their policies and procedures align with HIPAA Security and Privacy requirements and they can budget for hardware that will support an EMR today to be ready for the EHR.”
Overcoming EHR barriers
Scrutinize clinical workflow patterns. This will validate work processes while identifying areas for improvement or streamlining.
Set reasonable goals for implementation of the EHR, prioritizing items by order of ease of use and need. This process can often promote staff confidence and assist in overcoming fear and
resistance to change.
Assess staff members' basic computer skills and provide basic training for all who need it. Training gives the staff a sense of calm and the sense of being part of the solution.
Identify the core team of users to empower the staff in overcoming fear of change. It transforms the thought process from a computer project to a team project.
Managers must understand that there will be bumps in the road. During these times, it is important that they remain positive with a “can do” attitude that will truly lead to success.
Source: Kirby Cunningham, RN, 2008
EHR alphabet soup
AHIC: American Health Information Community, a federal advisory body chartered in 2005 to make recommendations to the Health and Human Services Secretary on how to accelerate the development and adoption of health information technology.
CCHIT: Certification Commission for Healthcare Information Technology, assigned to accelerate the adoption of EHRs and healthcare IT by creating an efficient, credible and sustainable certification program.
EHR: Electronic Health Record, consisting of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and controlled by authorized clinicians and staff across more than one healthcare organization.
EMR: Electronic Medical Record, consisting of health-related information on an individual that can be created, managed and controlled by authorized clinicians and staff within one healthcare organization.
HIE: Health Information Exchange, the electronic movement of health-related information among organizations according to nationally recognized standards.
PHR: Personal Health Record, an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being accessed, managed and shared by the individual.
Source: McKnight's Long-Term Care News interviews, 2008
Key Web links
National Alliance for Health Information Technology report to the Office of the National Coordinator for Health Information Technology on defining key health information terms:
American Association of Homes and Services for the Aging report on electronic health record use in nursing homes:
BearingPoint report for the National Commission for Quality Long-Term Care:
For key legislative and regulatory issues:
Center For Aging Services Technologies www.cast.org
National Association for the Support of Long Term Care www.nasl.org
CMS states support for development of electronic health records
Healthcare IT spending set to soar under Obama administration