LeadingAge Magazine · July/August 2013 • Volume 03 • Number 04

Long-Term Care and Interoperable EHRs: A Strategic Match

July 01, 2013 | by Gene Mitchell

Aging-services providers are adopting electronic health records and learning to partner, via health information exchanges, with acute-care and physician practices. Here’s a look at what some providers are doing.

At the recent Long Term and Post-Acute Care Health IT Summit in Baltimore, MD, an impressive variety of speakers from the worlds of health care, long-term care, government, industry and academia succeeded in offering a collective snapshot of the state of health information technology in 2013. The many sides of the subject were covered—from the technical details of data collection and sharing, to the policy/political changes that drive regulation and reimbursement systems, to the changes in business models and collaborations across the continuum of health care it enables.

It’s clear that long term and post-acute care (LTPAC) providers face big change in the next few years, as the demographics of aging, increasing incidence of chronic diseases, workforce challenges and uncertainty about how well government-driven changes to the health and services for the aged will work.

If a theme could be generalized from most of the presentations at the LTPAC conference, it’s that we’re in a time of “challenges and opportunities.” At the same time, an ability to keep an eye on long-term goals is a necessity for providers, remaining flexible in the short term, as they work through the introduction of new technologies and procedures in a process that may develop by fits and starts.

That flexibility was highlighted by the conference’s keynote speaker, Doug Fridsma, M.D., who is the chief science officer and director of the Office of Science and Technology in the Office of the National Coordinator for Health IT.

Fridsma noted that this year featured an important milestone: “50% EHR adoption was achieved this year, with 85 percent possible by 2015.” He was referring to a U.S. Department of Health & Human Services announcement that “Half of all doctors and other eligible providers have received Medicare or Medicaid incentive payments for adopting or meaningfully using electronic health records (EHRs).” The adoption rate for hospitals stands at about 80%. The adoption rate for long-term care providers, however, is much lower.

Noting that a national HIT infrastructure needs to be built in incremental steps, Fridsma says, “Don’t let the perfect be the enemy of the good.” He also noted that efforts to bring the benefits of health IT to the nation’s health care system should never try to shoehorn everyone into the same tool. “This is not a one-size-fits-all approach.” Finally, he noted that “The key is, when part of the system doesn’t work well, we can remove it and implement something better. Modularity and substitutability is important. We are not trying to create one giant interface for everyone.”

For long-term care providers, left out of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program’s “meaningful use” incentives, pursuit of greater capabilities for data exchange and adoption of EHRs is nonetheless worthwhile. In an article on that subject on the LeadingAge Center for Aging Services Technologies (CAST) website, CAST Executive Director Majd Alwan says, “While (LTPAC providers) don’t have access to the Meaningful Use incentives, they can make their physician partners and hospital partners more meaningful users of electronic health records.”

(See this issue’s Vision column, “Technology as a Strategic Initiative,” for Alwan’s take on how LeadingAge members can use technology to strategically position themselves to thrive in years to come.)

That kind of inter-provider cooperation will be a must in a future where collaboration between different parts of the continuum will be necessary to hold down costs and improve outcomes for seniors who are served by physician practices, hospitals and long-term and post-acute care providers.

An issue brief from the Office of the National Coordinator for Health Information Technology echoes Alwan’s point: “Although [long-term, post-acute care] providers are not eligible providers in the EHR Incentive Program … the ability for [these] providers and facilities to send and receive information with eligible providers and to electronically exchange standardized data bidirectionally between care settings is paramount to the continuity and quality of patient-centered care.”

At the June Health IT conference, which CAST co-sponsors and helps to organize, attendees not only gained a lot of new information, they were treated to an update on the next release of the CAST Electronic Health Records Selection Tool. First launched last summer, the tool is designed to help aging-services providers sort through all of the available EHR products to find the ones that will best meet their needs. An update of the tool is scheduled to launch in August, cataloguing more than 200 major functionalities in 36 EHR products, up from 22 in the 2012 release.

Along with the updated tool, a new white paper, “EHR for Long-Term and Post-Acute Care: A Primer on Planning and Vendor Selection,” is now available for download, as is a selection matrix that catalogs more than 200 major functionalities in EHRs. Careful review of the white paper is the recommended first step for providers wanting to begin the selection process, as it outlines the planning and assessment of EHR products, and includes sections on decision support systems, interoperability standards and health information exchange capabilities.

Alongside the tool and selection criteria available for providers, advice from peers can help lend perspective and concrete examples to organizations wanting to adopt EHRs. Last year, the launch of the CAST EHR Selection Tool was accompanied by a series of case studies of providers’ experiences in implementing EHRs or other forms of health information exchange. A new batch of case studies will be released later in July, downloadable at the CAST website.

In anticipation of the new round of case studies, we talked to several of the providers involved in them for their perspectives on a complicated process, and advice for other providers.

Brian Yeaman, M.D., has a better understanding than most of the crossroads where health care, long-term care, EHRs and health information exchanges (HIEs) meet. He’s a family medicine practitioner and the chief medical information officer of the Norman Regional Health System (NRHS) in Norman, OK. He’s also been instrumental in the development of health information exchanges (HIEs) in the state. He administers both SMRTNet, a publicly-owned network of three HIEs within Oklahoma, and OPHX (Oklahoma Physician’s Health Exchange). OPHX helps individual medical practices share some patient data to streamline treatment and improve record keeping.

With funds from a challenge grant awarded by the Office of the National Coordinator for Health Information Technology (ONC), NRHS is working with five nursing homes, SMRTNet and the Cerner Corporation to demonstrate the infrastructure necessary to allow hospitals and nursing homes to share information and improve care transitions.

Cerner’s CareTracker clinical documentation tool was chosen as the starter EHR module for the five nursing homes.

“All five were primarily paper-based to begin with,” says Yeaman, “and the selection of CareTracker was built around three factors: First, it had to be lightweight—nothing with a six-to-twelve month install period. Second, we truly needed something web-based, hosted centrally, allowing it to interface with the HIE. Third, we needed to have [a package with] a very simple training session for the end user. The heart of what’s made this project successful so far is that we’re empowering the medical assistant and getting maximum value from those resources.”

The software analyzes data entered by users, looking always for changes in resident conditions. Data indicating a resident at risk for health problems generate alerts to caregivers and management staff. A SBAR (Situation/Background/Assessment/Recommendation) document is created when a problem is found, and sent to providers using the “Direct” messaging tool, which Yeaman describes as “HIPAA-compliant e-mail.” A universal transfer form is also created, allowing the HIE to facilitate the transfer of data.


“We took providers from documenting on paper to 96 percent real-time [electronic] documentation, which means alerts can fire in real time, directors of nursing can look at dashboards in real time, and attention to changes can happen earlier, before things get bad enough to require hospitalization,” Yeaman says.

At the Long-Term and Post-Acute Care Health IT Summit in Baltimore, Yeaman listed some encouraging outcomes: an overall reduction of 40% in hospital readmissions over the five skilled nursing communities (one of them saw a 50% reduction); a 70% reduction in emergency room visits to NRHS by those providers; a 98% compliance rate with daily assessments, and dramatic improvements in the five nursing homes’ ratings in the Oklahoma state Focus on Excellence program.

Yeaman was very surprised by the 40% improvement in hospital readmissions. “I predicted a 10 percent improvement and thought I was being cautiously optimistic.”

Of the five nursing homes, the lowest reduction in readmissions was 15 percent. “That [home] was already well-run, and had a low rate to begin with,” he adds. The home that hit 50% had more room for improvement, and not only saw a $50,000-plus increase in Medicaid reimbursement, it also raised its Five-Star rating from one to four.

“I didn’t anticipate these types of numbers, Yeaman says, “and when they came out in the first three months, I thought, ‘That’s nice, it won’t last.’ But it got better in the second measurement at six months. It shows what a systematic approach to care delivery methodologies can do.”

Maria Joseph Continuing Care Community, Danville, PA, found itself in a familiar position for many providers: eager to find ways to share resident data electronically but lacking a true “electronic health record” package (i.e., an electronic record that meets interoperability standards and can be used by more than one organization). Fortunately, Maria Joseph’s long-standing relationship with Geisinger Health System, which serves more than 2.6 million people in central and northeastern Pennsylvania, is just what Maria Joseph needed to get its feet wet in electronic data transfer.

When Geisinger received a $16 million award from the Office of the National Coordinator of Health IT to help hospitals, nursing homes, physician practices and home health agencies better coordinate patient care and share data, it asked Maria Joseph to participate. Another crucial player in the project is Keystone Health Information Exchange (KeyHIE), one of the nation’s oldest and largest HIEs.

Thus began a several-step process. Maria Joseph’s Emmanuel Center for Nursing & Rehabilitation, as one of the first skilled nursing centers to participate in the project, wanted a way to “map” its MDS 3.0 data from its NTT DATA NetSolutions software to continuity of care documents (CCDs) held by KeyHIE. NTT DATA was able to develop an interface that allowed MDS data to be transmitted in a “HL7” (Health Level Seven) message to KeyHIE. The next step was development of software, “MDS-to-CCD Transformer,” by a company named Caradigm, to then transfer the transmitted data into KeyHIE’s CCDs.

The success of the project demonstrates that nursing homes—many of which do not yet have true EHRs—can still do secure and inexpensive data transfer. As the Maria Joseph case study notes, almost all providers have electronic MDS data.

“We are moving forward this summer into having nurses’ notes and documentation be electronic,” says Thomas Conlin, Maria Joseph’s chief operations officer. “We’re also working with our pharmacy and rehab company so their information can be part of it too.”

Conlin says the organization’s close working relationships with Geisinger has gotten even stronger in the last couple of years: “They have teams of nurses and doctors coming into our nursing home and looking at quality indicators. We’re not only working with [Geisinger] on the EHR, but also moving forward with them on a CMS demonstration project on bundling.”

As Conlin sees it, these closer working relationships, along with the sharing of data and streamlining of transitions, requires a new way of looking at what have traditionally been seen as separate spheres.

“It’s no longer the care of the nursing home, the hospital, the home health [agency] … it’s one continuum of care process now. The whole idea of the hospitals being penalized for readmissions [under the Affordable Care Act’s Hospital Readmission Reduction Program (HRRP)] is a reflection of the care in the nursing home.”

Cross Keys Village – The Brethren Home Community, New Oxford, PA, has used the Answers on Demand system for nearly a decade for back office functions and various other purposes, but April 2012 marked a turning point, when Cross Keys began using AOD’s electronic health records. Changes in resident health and behavior are now documented easily, and Cross Keys can more easily design care plans for residents. The system creates “workflows” that include necessary forms, and the completion of the forms creates chains of related tasks to be completed. The system also allows multiple caregivers—e.g., dietitians, speech therapists and nurses—to view the same notes on a resident. A fall, for instance, generates a workflow and appropriate staff are notified immediately. Busy staff in nursing neighborhoods are kept up-to-date without the time and hassle of multiple phone calls.

“Anecdotally, we know the workflows in the past were labor-intensive, required a lot of phone calls, and there were gaps we know existed,” says Karl Brummer, senior executive vice president. “We have not attempted to quantify it at this point, but anecdotally, we are confident this is an improvement. There is security knowing that a list of things to be done is generated and has to be checked off.”

Lisa Weyant, Cross Keys’ IT clinical coordinator, adds that use of the system is a great benefit to new employees, as it helps them better understand how work is organized.

Brummer says the early days of implementation created some difficulty for staff that were uncomfortable with technology. Careful “walking-through” the system has increased comfort. Ultimately, notes Weyant, only one or two staff (out of more than 125) left their jobs as a result.

One-on-one training has gone a long way, and Brummer applauds a spontaneous trend that has helped bring staff up to speed: “It’s cool to see [how] team members are helping each other through the system. To me that’s a sign of success. I see that more and more through the facility, [staff] rallying around to help each other.”

The next challenge—interoperability with hospital systems—lies down the road, according to Brummer. Data exchange, he says, “to be frank is still in the conversation stages.” At this point, transfers still rely on printed patient information accompanying residents when going to the hospital.

“Nurses didn’t get into the profession to be tied to a computer all day.”

Those are the words—and the motivation—of Donna Conner, director of clinical information systems for Aloha Nursing Rehab Centre (ANRC), Kaneohe, HI. As is noted in the CAST case study focusing on Aloha, the 140-bed nursing home was an early adopter of QAPI (Quality Assurance and Performance Improvement), a framework developed by CMS for implementation in nursing homes. Read about the five elements of QAPI on the CMS website.

One QAPI-related goal ANRC focused on was the reduction of hospital readmissions. ANRC decided its 30-day readmission rate, 26.6% in 2011, needed to drop to 15% or less. Using a mix of American HealthTech outcomes reporting and INTERACT tools with the right training, the provider drove down its readmission rate to 9.5% by the fourth quarter of 2012. Since then, Conner says, the rate has gone back up a little, to 13 percent in May, but adds that Aloha serves higher-acuity residents than most homes.

A long-time user of American HealthTech systems, ANRC ramped up its use in 2012.

“Before October [2012] we were using MDS and all the accounting software was in place,” says Conner. “We were already using the electronic medication administration record. But the information management for the clinical side was not in place.” Now, Conner says, the CNAs chart on kiosks in the hallways. The system has a simple interface that benefits users that are not “computer-comfortable.” Aloha is using the outcomes reporting tool and analytics functions, and charting electronically. In May, Aloha added a pharmacy interface using Corepoint and has plans to interface with its rehab contractor’s software, with its dietary department’s dedicated software and hopes to integrate therapeutic recreation charting as well.

“The point is to cut down the time our nurses spend playing with paperwork instead of doing care,” says Conner. She adds that the plan is to have all these new capabilities in place by the end of the year, so that 2014 time and resources can devoted to handling the switch to ICD-10.

“The low-hanging fruit of what we’ve been able to do in our project doesn’t break the bank and it works,” says Yeaman. “The solution can be lightweight, and easy to implement. EHRs position a provider to hit those metrics that will be extremely important to your [organization], and to aligning yourself strategically with hospitals, because today’s Medicare revenues are under great pressure on those 30-day readmissions. Most health systems are looking at ways to create a preferred list of providers. This is [a] way to position yourself strategically at a low cost, stay competitive and increase your market share.”

The newest round of case studies, which include the providers above and more, will be available later this July on the CAST website. LeadingAge magazine will continue to cover the stories of members implementing EHRs and partnering with health systems and regional health information organizations to make interoperability the norm.