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Pivotal hearing on ICD-10 implementation today: Time to join 'the rest of the world'
Pivotal hearing on ICD-10 implementation today: Time to join 'the rest of the world'

By now, long-term care operators have likely heard about achieving interoperability across their electronic health record solutions and with their referral partners. Unfortunately, there are a number of obstacles.

For starters, there's lingering confusion in the industry as to what interoperability means. Some assume that it is synonymous with information technology connectivity or interfacing. It's actually quite different.

“Interoperability requires exchange, but exchange doesn't assure interoperability. To achieve interoperability, there must be exchange of information across systems, and once exchanged, the information has to be usable,” explains Deborah Green, MBA, BS, RHIA, operations executive vice president and COO for the American Health Information Association. 

Exchanging data across systems requires specific formats and communication, and for those systems to effectively interoperate, the data must mean the same thing in these systems, she notes.

Achieving interoperability helps long-term care providers, referral partners and, above all, residents. When providers become truly interoperable, it will open unprecedented access to information among venues of care, says Steve Herron, managing director, long-term care for Cerner Extended Care. “True interoperability means there is one person-centered record, and the information in that record follows the patient between venues of care.” 

As a patient transitions, that record ensures that all care team members have access to the latest data — medications, allergies and diagnosis lists, along with advance directives, clinical notes and summary reports — and the latest results from lab test and other diagnostics, adds Majd Alwan, Ph.D., senior vice president of technology for LeadingAge and executive director for the Center for Aging Services Technologies. 

The record would include information about cognitive and functional status. 

“The impact of interoperability in action is improved care quality and health outcomes, reductions of healthcare utilization, such as emergency department visits, hospitalizations and hospital readmissions, and reduced costs,” Alwan explains.

It's a benefit that Westminster Ingleside Retirement Communities has experienced firsthand. In the past, when a resident arrived from a hospital, the receiving facilities typically collected pertinent information via phone or fax, which was neither reliable nor timely, according to Westminster Ingleside CIO Dusanka Delovska-Trajkova, CASP. 

“Now, we have our residents' information, including pharmacy, laboratory and other test results data, at our fingertips, regardless of the IT system where it originated. We have been able to improve efficiency, which allows our staff to focus more intently on resident care,” she says.

Getting there isn't easy for many long-term care providers, however. Limited financial resources are partly to blame. Acute care providers have access to Medicare & Medicare EHR incentive programs, but long-term care providers don't. “This lack of funding is a real challenge for many long-term care providers. They have to do the same amount of work as hospitals in regard to [EHR and interoperability], but they're having to pay for the systems on their own,” says John Ederer, NHA, president of America Data. “That has caused many long-term care providers to sit back and wait.”

While there also are privacy and security concerns, many solutions have progressed to the point where providers can put aside those fears, says Delovska-Trajkova.

Perils of procrastination

Whatever's behind long-term care operators' hesitation, experts agree underestimating the importance of EHR interoperability will make it tough to compete. 

“With the introduction of accountable care organizations, managed Medicaid, the desire to prevent avoidable readmissions, and the transitions of care across multiple sites and levels of care, the proper sharing of accurate, timely information is mandatory,” says Robert Davis, CEO of Optimus EMR Inc. “Any LTPAC organization that's not prepared or capable of true interoperability will quickly lose patient referrals.”

Already, hospitals are actively seeking referral partners that share interoperability goals. To achieve the Stage 2 Meaningful Use requirements, hospitals must provide — through a certified electronic medical record — an electronic summary of care record for more than 10% of all transitions or referrals, explains Gerry McCarthy, chief strategy officer at HealthMEDX. 

Since interoperability is needed in the long-term care network, that's driving hospitals to align and partner with long-term care providers that utilize certified EMRs, he notes.

The industry is seeing large delivery networks building an approved list of referral partners, confirms Herron. Being on the losing end can cost a long-term care provider hundreds of dollars per bed per day, he warns.

In today's environment of ACOs and bundled payments, the government is reviewing healthcare costs as an episode of care, beginning with a few days prior to an inpatient acute care stay to 30 days after discharge from the acute care facility, says Jeannette Petten, chief nursing officer, IT Product Owner and co-founder of eHealth Data Solutions. 

“For facilities to be included, they must [also connect with] ancillary services, such as lab and imaging, so they receive the most up-to-date information in real time,” she notes.

Charting the course

Moving toward interoperability may seem daunting, but taking steps now is wise. 

“Education is the key to overcoming some of the unknown and deciding whether to go forward or sit on the sidelines,” says Faye Gregory-Yuppa, director of client services, LINTECH.

Facilities that haven't yet adopted an EHR product should start there before jumping into plans for a full-blown interoperability initiative, experts suggest. 

“We first want to recognize the value of moving from paper to paperless, digitizing resident management within long-term care facilities,” says Karsten Russell-Wood, Remedi Senior Care product manager. “Once resident information and financial data is digitized, electronic interfaces can then be built to support the mutual exchange of information between providers.” 

Two-way communication between the pharmacy and the facility's EHR vendor is just one example of interoperability. 

“The initial planning phase may seem to take a long time, but every minute spent will pay dividends,” Russell-Wood says.

Many of today's interoperability discussions focus on health information exchanges across the care continuum, but experts say that effective use of data and information across systems within a single facility is equally crucial. As Green points out, a single facility may have separate systems for resident information and census, clinicals/electronic health records, orders, pharmacy, ADLs, therapy, MDS/MDS transmission, lab results reporting, billing and claims editing, and more.

“Without interoperability across disparate systems within a facility, there's an ongoing need for review and reconciliation of data across these systems,” she says, adding that a lack of system interoperability can diminish care quality, impact accuracy of RUGs calculation and reduce payment.

The risks don't end there. According to Michelle Markey, senior marketing manager for CommuniTech, duplication of effort and dual data entry between incompatible applications increases potential for error, while also increasing “downstream maintenance headaches and vendor finger-pointing.”

Facilities should be asking their current and prospective vendors about interoperability, their implementation of interoperability standards and certification, and the vendor's efforts and plans on these fronts. 

“Only then can facilities create an actionable plan to move toward full integration. Plans should include hardware, networks, software and staff training resource allocations — and, of course, a realistic budget and timeline,” says Gina Timmons, vice president of customer facing technology at Omnicare Inc. 

Providers should seek certified solutions, too. “A certification from the Certification Commission for Health Information Technology assures that the EHR system is capable of interoperability,” notes Davis. 

Solutions certified through the Office of the National Coordinator for Health Information Technology Certification program ensure that EHR technologies meet standards that enable exchange and can send, receive and use the Continuity of Care Document, Green adds.

Long-term care providers should develop data dictionaries to define data elements across their systems and consistent use. 

“Where data elements are used in common across systems, only one definition should be used,” says Green. 

Facilities also should reach out to regional and state HIEs to obtain minimum data sets requested for exchange and determine which can be produced by their systems. Data definitions used and promulgated by the HIEs should be obtained, and vendors must be asked what they can or do produce for their customers' exchanges with HIEs, according to Green. 

“Even if HIEs don't appear ready to accept data from post-acute care settings, understanding their data sets and definitions will move LTPAC providers in the right direction,” she points out.

When the HIE that Westminster Ingleside had been participating in stopped delivering lab and radiology reports, Westminster  Ingleside engaged both its EHR provider, AOD Software, and management service organization, ZaneNet, to help build an interface. 

“We found that some service providers didn't have the time to integrate with our system due to other pressing projects, so we found other partners that would,” recalls Westminster Ingleside's Delovska-Trajkova. 

While many vendors are not quite there in terms of full interoperability, it's still important that long-term care providers understand how vendors view interoperability and what their approach will be in the future, says Mark Woodka, CEO, OnShift Inc. “If systems don't talk to one another and interoperate in a coordinated, standards-based fashion, then the clinical, financial and operational benefits that the technologies set out to achieve will be limited,” he says.

CommuniTech's Markey urges providers to benchmark potential solutions against their current and future workflow. 

“Don't just put your trust in spec sheets,” she says. Seek advice from technical staff, those who “know the difference between good and bad integration.”

Avoid vendors that approach interoperability through point-to-point integrations, says Kim Ross, senior director of marketing at MDI Achieve. 

“This approach is expensive and fraught with risk because when either system changes, the point-to-point communication often breaks,” she says.

Only a few of the many EHR systems available to LTPAC providers are capable of delivering true interoperability, according to Davis. “This is also true with the acute hospital systems. Most are capable of interoperability but are not actually sharing information with LTPAC at this time.”

If providers don't receive satisfactory answers to questions about interoperability, consider switching vendors, says CAST's Alwan.

A place at the table

Seminars, blogs and trusted LTPAC advisors can help steer the interoperability process, assures  LINTECH's Gregory-Yuppa. 

Cerner's Herron adds the best thing LTC providers can do is ask their acute care partners what data they could share to make the transitions of care more seamless. They should outline all other providers they work with, including pharmacy, rehab, home care, radiology, laboratory and others.

One thing remains certain: The degree of engagement and commitment will directly impact a long-term care provider's ability to stay competitive.

Interoperability “is crucial to the survival and success of not just long-term care providers, but all providers across the continuum of care,” says MDI Achieve's Ross. 


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