Move toward certifying electronic health records must include long-term care

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John Derr
John Derr

One of the greatest healthcare challenges today is coordinating care for patients treated in long-term and post-acute care (LTPAC) settings. Unlike traditional acute and ambulatory healthcare settings—primarily hospitals and physician offices—LTPAC patients may be cared for in a wide variety of environments, depending on the individual patient's changing needs. LTPAC care sites include skilled nursing, nursing and assisted living facilities; home, independent and adult care environments; rehabilitation facilities; long-term acute care hospitals; and hospice.

In the past, the general terms “long-term care” (representing skilled nursing facilities) and “home care” (representing home health agencies) were commonly used to describe available options. These labels are not inclusive of all facets of LTPAC, however, and do not fully represent the many healthcare settings currently in use.

Today's clinical environment requires caring for an individual in the right care setting, at the right time, for the right medical condition and at the right cost. We now see LTPAC patients move from care setting to care setting depending on their individual care requirements for chronic disease, short-term rehabilitation or management of an episodic incident.

This new world demands that our industry create a person-centric, integrated electronic health record (EHR) using health information technology (HIT) that meets the need for functionality, privacy of patients' information and the ability for information to be exchanged between multiple health care organizations.

The Centers for Medicare & Medicaid Services has recognized the need for this person-centric integrated connectivity with the demonstration of the Continuity Assessment Requirement Evaluation (CARE) tool, which will follow patients and their outcomes across multiple transitions of care and settings.

The state of EHRs

The National Alliance for Health Information Technology has defined an EHR as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one health care organization.”

By this definition, there are few, if any, LTPAC standardized EHRs on the market, and most clinical and financial applications are provider-specific. Today, LTPAC is siloed. When a patient or long-term care resident moves to a new provider, it is usually with a paper medical record that is often incomplete. In the case of a new provider, a new medical record is initiated. All too often, the result is less-than-optimal health care delivery that is fragmented and duplicative. This cumbersome and inefficient, non-standardized paper exchange has prompted leaders in the industry to come together to work toward creating an EHR and establishing a national HIT infrastructure for LTPAC.

In 2004, a group of representatives from the LTPAC community (**see representatives below story) formed the HIT LTC Collaborative in response to the Presidential Executive Order to establish the National Coordinators Office under the Secretary of Health and Human Services to develop the national EHR program and infrastructure.

In 2008, the Collaborative approached the Certification Commission for Health Information Technology (CCHIT®) to consider developing a certification program for LTPAC EHR technologies. The CCHIT Certified® mark indicates that an EHR meets a standards-based, consistent benchmark. By looking to products with the CCHIT Certified seal, providers can reduce their risk when investing in this technology. The certification criteria are designed to ensure that products provide necessary functionality, will evolve to be interoperable with other systems, and include security features that protect the privacy of personal health information. To be certified, a product must comply with 100% of the CCHIT criteria. As of today, CCHIT is the only federally recognized EHR certifying organization. It has a five-year track record of developing criteria for certification, testing the criteria and then certifying EHR technologies.

Timeline for certification

The Certification Commission recognized the need for EHR criteria throughout the healthcare system and placed long-term care certification on the Commission's certification “road map” for 2010. An advisory task force, including representatives of skilled nursing facilities, assisted living, home care, hospice, health information technology, government and consumers, was formed to provide direction and set priorities. On June 16, the task force completed its work and delivered its recommendations to the board of commissioners, which approved them unanimously.

Among the recommendations:

* A strong focus on the EHR technology requirements of the American Recovery and Reinvestment Act (ARRA)

* Identification of core certification criteria for four settings for use in the initial EHR certification:

– Skilled nursing and nursing facilities

– Medicare certified home health agencies

– Inpatient rehabilitation facilities

– Long-term acute care hospitals

* Reusing or adapting existing criteria from other CCHIT certification programs

* Identification of additional criteria specific to each care setting

* Inclusion of a roadmap indicating when the criteria are expected to be implemented

Final recommendations of the task force are available at

A work group was appointed and in July 2009 began the process of developing criteria for certification of LTPAC EHRs. Preliminary criteria will address privacy, security, interconnectivity and interoperability. EHR certification for the first two settings, skilled nursing facilities and certified home health care, is expected to be available in 2010 during a phased rollout of the commission's newly developed 2011 EHR certification programs.

Why certified EHRs are important

Today, very few LTPAC providers are electronically connected with each other or with hospitals and physician offices. Without standards, it will be very difficult to connect because the interfaces between varying technologies and operating systems will be uncoordinated and expensive. Without certification, how will providers know when purchasing an application that they will be able to connect to and exchange information with other providers and a patient's EHR?

The momentum toward certified EHRs was given a boost with the estimated $20 billion allocated to HIT in the ARRA legislation, which offers incentives for providers who can demonstrate meaningful use of certified EHRs such as measuring quality and exchanging information. At the writing of this article, LTPAC providers are not included under the ARRA program. In the future, this is bound to change as hospitals and physicians discharge some 40% of their patients to LTPAC settings. So we are working together on LTPAC quality measurements preparing for the future. I serve on the HHS Federal Advisory Committee on HIT Standards

LTPAC providers need to pay attention to certification and standards to avoid isolation and the inability to connect with other providers. Most importantly, we need to embrace certified EHRs because it's the right thing to do. With certified standards-based EHR interconnectivity and interoperability there will be a higher quality of care and a higher quality of life for the individuals we serve.

**American Association of Homes and Services for the Aging, American Health Care Association, American Health Information Management Association, American Society of Consultant Pharmacists, Centers for Aging Services Technologies, Commonwealth Fund, National Association for Home Care, National Center for Assisted Living, National Association for the Support of Long Term Care, American Medical Directors Association

John Derr is chief technology strategic officer and senior vice president for Golden Living. He is also a commissioner for the Certification Commission for Health Information Technology.


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