The government has long agreed that interoperability is beneficial to providers. But some in long-term care are unaware of some significant changes that Congress and other agencies have made to promote the electronic exchange of data.

This includes the June debut of the Centers for Medicare & Medicaid Services’ Data Element Library (DEL), which standardizes data types so that records that move with a patient from a nursing home to rehab hospital to other settings “speak the same language,” CMS said.

“We’re excited to add this important building block to the foundation for interoperability that CMS is helping to establish,” Administrator Seema Verma says.

Federal guidelines

DEL will hopefully improve care coordination, patient outcomes, and healthcare efficiencies, and reduce provider burden, CMS said. The agency also released its Request for Information (RFI) last September as a tool to collect ideas, encourage patient-centered care and test market-driven reforms. It’s stressed that its overall goals are to promote quality while limiting regulatory burdens.

But observers also believe that CMS was sending a message to providers about how serious it is about the adoption of more electronic exchange of data.

“CMS’ Request for Information on interoperability underscores the interest in speeding connectivity and interoperability,” confirms Majd Alwan, Ph.D., senior vice president, technology, and executive director, CAST at LeadingAge.

Cerner’s Senior Director of Long-Term and Post-Acute Care, Steve Herron agrees: “CMS has given a clear indication they expect data to flow between care venues.”

Many nursing home operators, however, believe it would be wrong for CMS to require the electronic exchange of data, especially as a condition of participation in the Medicare or Medicaid programs. Unlike physicians and hospitals, LTPAC providers were not made eligible for funding when the government created its “meaningful use” program.

Yet, others feel that a requirement might be just what it takes to create a digital world, which could ultimately improve resident care.

“Information should flow freely and securely across the healthcare continuum. If necessary, CMS should take whatever measures required to ensure that data blocking does not occur,” says David Carter, LNHA, VP of Advisory Services, and LTPAC Business & Clinical Operations Analyst, Stratus Interoperable.

Currently, CMS is not requiring LTPAC to adopt more electronic exchange of data, and “it’s not clear if it’s fully in their authority” anyway, notes Cynthia Morton, senior vice president of the National Association for the Support of Long Term Care. Nonetheless, nursing home operators should remain attentive because the presence of the RFI alone means it’s under consideration. Congress, which has also made a couple of recent moves promoting interoperability, developed the 21st Century Cures Act. It was signed into law in 2016, to help accelerate medical research and the approval process for drugs and medical devices.

The Cures Act seeks to improve care coordination and workflow efficiency as patients are transferred across the care continuum, from the acute-care hospital, to the skilled nursing facility and then into home care, explains Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DSN-CT, curriculum development specialist for the American Association of Directors of Nursing Services.

In addition, the act includes IT provisions that show Congress’ exasperation with slow progress toward interoperability, says Alwan.

Congress’ efforts to define and push interoperability in the Cures Act has impacted the development of federal policies along three major topics: the network that will unite the information being exchanged, the set of data classes permitted to be exchanged, and the definition of information blocking, which helps the information flow freely without being stopped.

Trusted mission

The Cures Act required The Office of the National Coordinator for Health Information Technology to establish the Trusted Exchange Framework and Common Agreement (TEFCA), which is “the latest federal effort to create a ‘network of networks’ for facilitating health information exchange across the healthcare continuum, including LTPAC,” says Alwan.

“Using the principles established through the Trusted Framework, technology systems can safely transfer health information anywhere in the world,” Kulus says.

The Cures Act sets up a network through TEFCA, but the US Core Data for Interoperability (USCDI) contains the actual data that providers are going to exchange on that network, which includes 22 items such as name, date of birth and preferred language, among others.

“The [USCDI] establishes one language for all healthcare information, standardizing it across the information highway,” says Kulus. “Standardized interoperability also enables patients to easily obtain their healthcare information, even if they can’t remember the specifics of when and who they saw for previous care.”

This standardization is important, since the same definitions are not always used between nursing home and hospital. By establishing one language, long-term care providers can better understand residents’ health records. Moreover, the USCDI is the way to start simple with this standardization.

“We can’t exchange everything at the beginning because that’s too much. We can’t all handle that. We’re just going to exchange a few things to get started — and those few things are what is the US Core Data,” says Morton.

“It’s going to take a while for everyone to be connected and for it to be easy for data records to move,” adds Cheryl Field, chief product officer at Prime Care Technologies.

It would be beneficial if the network with this information would run smoothly, as interoperability has many benefits.

“The ability to seamlessly integrate into a connected healthcare system is absolutely essential for preserving and enhancing patient/resident flow, for overall clinical performance, and ultimately for the operator’s success,” says John Damgaard, president and CEO of MatrixCare and president of the National Association for Support of Long Term Care. 

However, experts such as Morton believe that Congress is concerned about the issue of information blocking.

“Information blocking has to do with a perception that HIT software might constrain the flow of data. Providers and software each cannot block data from flowing,” says Morton. “There are penalties in the Cures Act for providers and vendors if they are found guilty of information blocking.”

ONC is responsible for regulations to further define information blocking, which it will release later this year, according to Morton.

These guidelines have made interoperability easier to understand, but not necessarily easier to adopt.

Barriers and hurdles

Historically, there have been stumbling blocks in the way of increasing EHR usage.

Financially, long-term care facilities are not equipped to handle the push for interoperability. Some experts, like Morton, believe that this is partially because, unlike hospitals and doctors, long-term care providers were not given “meaningful use” money to buy EHR systems as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

Focusing on nursing facilities in particular, “margins are thin … It can be difficult to spin capital on EHRs,” says Morton.

The lack of financial incentives and resources is a fundamental barrier to interoperability, agree AJ Peterson, VP/GM of interoperability, Netsmart; Jennifer Gross, BSN, RN-BC, RAC-CT, senior healthcare specialist, PointRight Inc.; and Field.

“With financial margins shrinking for LTPAC providers, it will be difficult for many providers to keep up without some financial subsidy,” Gross adds.

Lack of education on technology and interoperability is also a major barrier, agree Carter and B.J. Boyle, VP of product management, PointClickCare. Not all providers know how to start the process of adopting new technology, or how to get the most out of their investment.

Additionally, some experts merely wait to be pushed to make reforms.

“Many operators, especially those in the for-profit sector, will not invest additional capital until it is absolutely required by CMS or the state licensing board,” says Carter.

Mindset change needed

Many experts feel that instead of a requirement, a change of approach is needed to encourage the adoption of EHRs.

“While CMS’ push for interoperability is essential to ensuring effective patient care between settings, their approach towards LTPAC providers has been to penalize non-compliance rather than to incentivize development,” says Gross.

Since funding, although necessary to engage in this technology, may not be easy to get, incentivizing is a valid solution.

In 2011, CMS established its Medicare & Medicaid EHR Incentive Programs “to encourage eligible hospitals and professionals to adopt, implement and demonstrate ‘meaningful use’ of certified EHR technology.

LTPAC, behavioral health and others were deemed ineligible for these incentives,” says Alwan. “Non-incentivized providers, like LTPAC and behavioral health providers, are likely to lag behind their incentivized peers, in terms of both adoption of interoperable technology as well as engagement in information exchange,” he adds.

Alwan suggests that regulatory agencies take the lead on this part, too. He thinks they should be encouraged to provide ongoing payment incentives to providers that adopt these technologies and demonstrate that they meet certain quality and cost measures.

Morton also believes in the use of “a carrot approach instead of penalty,” and a quality measure program could be that approach.

One example is to incentivize by creating or changing some of the current quality measures that are imposed on nursing facilities; the facilities would be given more credit on a quality measure if they exchange EHRs.

Most experts agree that vendors are already on the right digital trail and that choosing the right vendor will make the difference in easily achieving interoperability. Field agrees, noting “more and more vendors are working together to complete that interoperability work on behalf of providers.”

Ultimately, experts agree that providers need to accept that the world is moving toward interoperability, and that they will need to adapt to the digital environment.

“Providers need to view implementing the right technology solutions as an expected and routine business expense, not as an optional budget line item,” says Janine Savage, VP of product management, PointRight.

“It’s the cost of doing business in our healthcare world today. And they need to move from adoption to engagement to get even greater value from their investment.”

Boyle says providers need to focus on doing what is right for their residents, which means embracing federal guidelines. View it as “an opportunity to further enhance the care LTCPAC residents and patients are receiving,” he says.

“The only way to do that is to work with technology partners who are focused on the big picture, that are well connected, and most importantly, that are making the investments necessary to help make the future successful.”