Healthcare-associated infection reporting to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) via manual data entry is time consuming and introduces the possibility of human error, which compromises data quality.

While submission directly from electronic health record systems addresses these issues and is increasing, there is no mechanism today to submit health records electronically from long-term care facilities. NHSN is partnering with EHR vendors and provider organizations to change this situation, opening the door to electronic submission of records. 

That’s good news, as NHSN is the largest HAI surveillance system in the United States. Organizations and healthcare facilities use HAI data to pinpoint areas where infections are problematic and identify a focus for measuring progress in prevention. Long-term care stakeholders face several challenges:

  1. Frequent staff turnover, which creates steep on-the-job learning curves for staff newly assigned to report data to NHSN
  2. Gaps in knowledge of infection prevention and surveillance
  3. Multiple duties and competing priorities
  4. Little or no access to laboratory and administrative data needed for Clostridioides difficile infection (C. diff) reporting; and
  5. Concerns that NHSN reporting duplicates other processes and disrupts workflows.  

Electronic options for HAI data submission can improve efficiency and reduce overall cost for the facilities by streamlining the reporting process. Federal incentives have spurred adoption of EHRs in acute-care hospital settings where more than 95% possessed an EHR in 2017. In contrast, 64% of skilled nursing facilities were using an EHR in 2016 and long-term care settings have adopted EHRs at an even slower pace..Unlike other settings, there are no federal healthcare information technology financial incentives for skilled nursing EHR adoption, nor are there standards for electronic reporting of HAI the way there is for hospitals.

Further complicating reporting, facilities often use off-site laboratories and pharmacies, which leads to interoperability challenges that affect the availability of data for clinical and surveillance purposes. Increasing the use of EHRs and federal data standards in long-term care facilities can address these challenges. 

CDC’s experience with electronic HAI data submissions from acute-care hospitals, coupled with CDC’s 10-year partnership with vendor implementers and the Health Level Seven (HL7) standards development organization, are important precedents. They offer a valuable foundation for a new collaborative effort aimed at developing technical specifications and capacity for electronic reporting in the long-term care sector. CDC also has partnered with Lantana Consulting Group to develop electronic HAI reporting standards for the sector based on the almost 20-year-old Clinical Document Architecture (CDA) and newly normalized Fast Healthcare Interoperability Resources (FHIR) standard.

Working with the alternative standards supports vendors and institutions with a current CDA infrastructure, as well as let providers move directly to the newer FHIR standard.

Successful development of an electronic reporting standard and implementation guidance call for a collaborative effort that takes into account vendor systems, their functionality, and the workflow of system users. As a first step, CDC listened carefully to stakeholders and gathered input from vendors, providers, infection control professionals, and HIT experts in one-on-one feedback sessions aimed at identifying challenges and opportunities for standards development and their adoption.

Initial findings revealed variation in laboratory interface exchanges that impact information sharing with vendors and different definitions for similar data elements required for reporting to payers (e.g. Medicaid and Medicare). For example, Medicare defines readmission as occurring less than 3 days from the hospital stay; whereas NHSN/CDC defines readmission in the HAI report as occurring in less than 2 days.

Next steps

The CDC-led collaborative standard development project is under way and on track. But a lot of work is still ahead. After incorporating feedback gathered from the stakeholder sessions into a draft standard, plans call for submitting the draft to HL7 balloting. The draft standard will require HL7 approval before final publication and, once approved, will need ongoing testing as a draft specification, and wider adoption as the standard matures. As the draft standard is put to use, additional areas of refinement may surface which may lead to a second ballot. 

While adoption of EHRs and other electronic systems in LTCF lags behind other settings, the possibilities for public health to partner with technology developers and implementers — and collaboratively influence the design and use of systems as they evolve in the LTCF arena—is in many ways greater than in the acute-care sector. HIT vendors in the LTCF market will benefit from electronic reporting leveraged content that yield benefits for surveillance and prevention.  

Jeneita M. Bell, M.D., is the long-term care lead at NHSN. Zabrina Gonzaga, RN, MSN, is the manager of Clinical Analysis & Policy at Lantana Consulting Group.