EHRs: Progress or pileup?

The idea of using electronic health records (EHRs) across the continuum of healthcare delivery has been at the forefront of healthcare think-tanks and information technology (IT) groups for at least 20 years. The idea of an overarching health record that follows the person wherever care is sought—a longitudinal health record—has been a valid and beautiful beast, many years in the making. Acute care got the ball rolling at least a decade ago, and today most hospitals use some kind of EHR system. Thanks to government incentives, many hospitals have adopted protocols to exchange health data with each other and, in most cases, physicians with practice rights at those hospitals can access those medical records remotely. But where do long-term care (LTC) providers fit into this mix?

Most non-hospital segments in the life-care chain have not seen such dramatic advancements in EHR use, partially because the low-hanging fruit has always been in acute care—until recently. Now, those in the U.S. healthcare system are realizing that a formidable chunk of Medicare’s dollars are spent within long-term care, including everything from skilled nursing to joint replacement rehab to end-of-life care. 

Yet, it’s no secret that many consider “LTC IT 2014” to be similar to “acute care IT 1999.” So, what’s been the technology delay?


The IT journey within acute care toward the meaningful use of EHRs—including its trial-by-error lessons in successes and mistakes—has provided a decent experience pathway for other care sectors. Yet for many in long-term care, it was seemingly like watching progress from the sidelines while other reaped benefits from EHR adoption.

The person-centered care movement, begun long ago but fired up in national earnest in 2012 by way of several Centers of Medicare & Medicaid Services (CMS) initiatives surrounding readmissions, infection control and transitions of care, has given new depth and breadth to EHR adoption within the LTC field as a way to facilitate data exchange as residents move between stages of care. Yet new hope surfaced in the Office of the National Coordinator for Health IT's (ONC’s) December proposals on its own initiatives, which seemed to open the doors for LTC providers into the incentive fold.


Many LTC providers, eager to reinvent themselves and embrace the opportunities made possible by wireless and remote data capture, are facing technological roadblocks within their own walls—life is far beyond capturing mere data on activities of daily living and fulfilling the MDS records now. For many, their business now depends on these newer technology features—the ability to streamline operations in a wireless way, to gather clinical data from anywhere and to market their new service-faces to their changing communities. Although some LTC providers can upgrade their IT architectures for abilities such as remote resident monitoring, mobile/bedside documentation and enhanced security systems, many other providers face much more difficult choices.

Lutheran Home & Harwood Place, a nonprofit, full-service LTC campus in Wauwatosa, Wis., was ready to embrace new service lines and grow its market position but found its own initiatives stymied by inadequate and outdated technology. “We had a crumbling and accidentally designed IT platform,” recalls Scott McFadden, the organization’s CEO. “Our homegrown payroll system was really hard to audit, and most of our IT systems had been put together piecemeal. Our servers were at the end of their useful life. We had been pennywise and dollar foolish.” Eventually, the organization decided the best option was to scrap the old systems and start over—including rewiring the entire campus and moving servers to cloud-based contracts. “Now we don’t have to deal with hardware issues, and everything is much more efficient,” McFadden says. “We can do things now like a wireless nurse call system, and it really helped with our electronic medical records system.”

Vendors also have struggled over recent years with trying to serve an LTC market that had little official incentive to adopt EHRs. Yet much progress has been made in their acceptance in the daily routines and business of LTC providers, says Doc DeVore, director of clinical informatics and industry relations for AOD Software. “While more providers are moving away from paper, they are beginning to leverage their EHRs to a greater extent, exposing one of the industry’s needs—exchange of clinical information,” he says. “The industry needs a clear and unified strategy with true standards for health information exchange in order for these providers to realize their goals.”

But LTC think tanks have been all over these issues for years, says John Derr, president of JD and Associates Enterprises. “Informatics is so important. [LTC providers] get that in their heads, but it’s still so static instead of being dynamic. Yet you can’t blame them when they’re not being paid that way,” Derr says.

“At the 10,000-foot national level, I think it’s been revealed that LTC is important,” Derr adds. “But I think it hasn’t gotten down to the local community level. I think we’re still being bullied, in a way. [Smaller LTC providers] don’t have big IT departments and may not really understand what’s going on with the driving forces. Too many times the director of nursing ends up being the informatics person, and we need to help them get on board. They’re busy thinking about F-tags, yet if they don’t become part of this bigger IT community, the organization is going to lose business. And I’d really hate to see that happen.”


So far, most LTC providers have not had many structured incentives to adopt EHRs, other than the good business sense of mastering transitions of care to be adept—and therefore valuable—business partners with their local acute care neighbors. Plenty of industry coverage has swirled around “meaningful use” incentives, a program created under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 to give higher reimbursements to providers who adopt EHRs and use them for specific technological and data exchange goals. Stage 1 of the meaningful use program, focused primarily on acute care, has gone rather well—400,000 hospitals now participate in the program, notes the ONC. But Stage 2 has experienced a far bumpier road. Although EHR adoption has increased significantly within the past five years, the use of EHR technology and data exchange “remains low among providers practicing in long-term services and supports, post-acute care and behavioral health settings,” the December ONC proposal states.

In December, ONC officially recognized the crucial issue long-term care and others had complained about since the government’s meaningful use incentives program matured into Stage 2: The incentives for adopting EHRs, under the HITECH Act, were granted primarily to hospitals and physician practices. The ONC’s proposed changes, still under comment, could open the door to long-term care’s long-awaited inclusion in the incentive program.

The progress toward valuable data exchange among EHRs used in acute and LTC environments has come a long way, but not nearly far enough. Standards are still lacking to translate data between MDS systems and EHRs, and between LTC provider EHRs and acute care EHRs.  Simply having the technology to make data electronic doesn’t necessarily make it valuable for exchange, especially if it’s not easily searchable for the data items the recipient needs. And, just because technology allows data to be exchanged between acute care and LTC providers doesn’t mean it results in a timely exchange of the crucial data.

“Much of the interaction with acute and ambulatory systems has not been all that meaningful,” says AOD’s DeVore. “For example, [some clients say] discharge summaries are not received electronically until three or four days after the resident has already arrived. Others say that much of the data received are essentially just an electronic equivalent of a paper chart and takes too much time to find useful information. If ONC is to achieve its Goal 1 to expand HIT adoption, Goal 2 must be accomplished—advance secure, interoperable health information, especially to advance technical standards. The ONC strategy to ‘expand the ONC HIT Certification program to certify products useful for providers across the care continuum’ depends on the strategy to ‘establish technical…standards’ and ‘promote proven practices.’”

None of these issues is new to the Long-Term and Post-Acute Care Health IT Collaborative. Its members produce a detailed work plan each year to determine what goals need to happen next to move LTC’s EHR interoperability and data exchange forward across the entire care continuum. Its most recent work plan, released in June, identified cross-site connectivity as its primary focus for 2015.


Everybody’s already on the wireless and remote resident-monitoring bandwagons, yet few providers have found ways to harness those data for cross-continuum use. The explosion of wireless and wearable technology (see sidebar) has blown open the barn door for providers, who now have a way to see what has always been hidden: A glimpse at what’s going on with a resident’s health when not in front of the doctor or nurse. The ones who can capture those data and find a good way to use them will be winners, many say.

Data analytics is affecting both clinical quality and business strategy, says Coral Lindahl, RN-BC, CLNC, PointClickCare coordinator at Ebenezer Ridges Care Center in Burnsville, Minn. “Some organizations are going to have to recognize that they need nurse informatics. The data analytics you can get right now with cloud-based and virtual servers and EHRs is just invaluable. If you can see where the chronic issues are going to be, you can shift resources, do earlier interventions and save dollars. More importantly, it allows care to become more person-centric.”

So, where are your EHR data, and how are you capturing them? Is your data really about who you are or the census you want to uphold—or who you could become in the future? For LTC providers, doing what you’ve always done for the past 20 years is not a valid solution anymore, Derr says. “The real question is, are you going to be a standby player in these new healthcare models, or are you going to become a real partner? Are you going to sit back and wait for someone to send you a resident referral? What role will you play in this new world?”

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