U.S. Department of Health and Human Services

Case Studies of Electronic Health Records in Post-Acute and Long-Term Care

Executive Summary

Andrew Kramer, MD, Rachael Bennett, MA, Ronald Fish, MBA, C.T. Lin, MD, Natasha Floersch, BA, Karin Conway, RN, MBA, Eric Coleman, MD, MPH
University of Colorado Health Sciences Center

Jennie Harvell, MEd
U.S. Department of Health and Human Services

Mark Tuttle, FACMI
Apelon

August 18, 2004

This report was prepared under contracts #HHS-233-02-0070 and #HHS-100-03-0028 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy and the University of Colorado Health Sciences Center. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

Project Objectives

The following study, entitled "Electronic Health Records in Post-Acute and Long-Term Care," was sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), United States Department of Health and Human Services (USDHHS). The objective of the project was to evaluate the status of interoperable electronic health records (EHRs) that extend into post-acute care (PAC) and long-term care (LTC) settings, and are capable of health information exchange with other care settings such as acute care hospitals, physician offices, pharmacies, or other PAC/LTC providers. This report summarizes case studies of four leading-edge sites, and reviews the findings and recommendations of a technical expert panel.

Context

Since 2001, the Department of Health and Human Services (HHS) has been actively promoting the development and use of electronic health records. In 2001, the National Committee for Vital and Health Statistics recommended a strategy to encourage efficient and secure exchange of health information through a common electronic health record (EHR) and through a National Health Information Infrastructure (NHII).² Recognizing that the NHII will require standards for (at least) messaging, terminology, and documents, other public and private initiatives also have contributed to this effort, including: (1) the Federal Government's acquisition of a license to freely distribute to healthcare entities in the United States the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT); (2) the Consolidated Health Informatics (CHI) initiative to review and endorse vocabulary and messaging standards for use in the federal healthcare enterprise; and (3) the Health Level 7 (HL7) effort to specify standards and a functional model for EHRs. More recently, establishment of a national health information system has become a major national priority backed by an Executive Order to create a national health information technology coordinator within HHS.¹ Thus, substantial momentum exists for rapid development and deployment of standardized EHRs that facilitate the exchange of health information when and where needed, across all healthcare settings.

One strategy for the exchange of information across the healthcare spectrum includes the use of Local Health Information Infrastructures (LHIIs) for the electronic exchange of patient-level health information among multiple providers in a community. Through the use of LHIIs, data could be shared and re-used without replication. However, development of most EHRs and the few LHIIs that exist in the U.S. today primarily has focused on acute hospitals and ambulatory care settings, with almost no attention to or implementation in nursing homes, home health agencies, and inpatient rehabilitation facilities (i.e., PAC and LTC). In total, these PAC/LTC settings include more than 26,000 Medicare-certified providers that treat more than one-half of Americans during the course of their lifetimes.^{3, 4, 5, 6, 7} Further, literature and surveys show that interoperable EHRs are not well developed in these settings.

From a patient care perspective, PAC and LTC have unique issues and requirements. First, transitions to and from these settings are a major source of medical errors in relation to medication administration, advanced care directives, allergies, and delivery of essential services. Second, the typical geographic separation of PAC/LTC providers from hospitals, diagnostic services, and physician offices creates communication barriers that contribute to medical errors. Third, persons treated in PAC/LTC settings suffer from impairments in physical, cognitive, and social functioning, as well as multiple chronic diseases, rendering them vulnerable to various threats to patient safety and quality. Fourth, PAC/LTC is provided by interdisciplinary teams with substantial family/informal caregiver involvement. Finally, government-mandated standardized assessments (i.e., MDS, OASIS, and IRF-PAI) exist in PAC/LTC settings and require information that is not comparable across settings and may not be clinically relevant, codeable with standardized, interoperable vocabularies, or readily able to interface with each patient's EHR. The use of standardized EHRs has potential to reduce many preventable errors, enhance the communication of needed information among providers, and provide needed tools to enhance and support more effective management of service delivery. Implementing standardized vocabularies adopted through the CHI initiative in future revisions to federally-required patient assessment forms would facilitate the exchange of information across settings.

Benefits of Leading-Edge PAC/LTC Systems

Four leading-edge sites were chosen for their implementation of interoperable EHRs in PAC/LTC and other parts of the healthcare continuum. Each of these sites was visited for two to three days using a structured site visit protocol. The four sites included a VA Medical Center (Bay Pines), North Mississippi Health Services, PeaceHealth, and Deaconess Billings Clinic. Each site had been established for at least 35 years, and each was a pioneer in the development of EHRs through strong local leadership and an organizational and cultural commitment to enhancing quality of care and increasing efficiencies. All four of the health systems visited were composed of an urban referral medical center in a medium-sized city and the surrounding environment, with outreach into rural areas and sometimes smaller communities and hospitals. The visited sites "owned" most of the providers and employed most of the physicians in their systems, but were branching into relationships with previously unaffiliated providers. Because the selected health systems are pioneers in the field and are "early adopters" of EHR systems used to exchange information across the continuum of care, the systems were deployed before widespread agreement existed regarding the use of standards for terminology and messaging. Nevertheless, these four sites represent the most advanced EHRs that have and use the capability for interoperable information exchange across the healthcare delivery spectrum, including PAC and LTC.

At each of the selected sites, clinicians reported that the most highly valued function of the EHR in PAC/LTC settings was the provision of care transition information from the previous provider, (predominantly an acute care hospital) and from pharmacists and physicians. All four of the visited sites exchanged health information among their owned providers, with reported benefits in terms of patient safety, quality of care, and efficiency. The information was available in real time and followed the same medical record architecture as provided in the hospital, without abstraction of core content most relevant to PAC/LTC. Nevertheless, the information was useful in evaluating patients for admission from geographically removed settings, which frequently is required by PAC/LTC providers, and to initiate care, enhancing continuity.

Medication management is a major function in PAC/LTC settings because of the large number of medications received by these patients and the high proportion of medical errors that are related to medication prescribing and administration. Medication list management upon admission to PAC/LTC -- ensuring that the appropriate medications are prescribed -- is complex. It requires the reconciliation of lists from before a hospital stay and during an acute care stay with any new discharge medications. Although only the VA had a single medication list (and only for prescriptions filled at VA pharmacies), all sites were moving toward a single medication list and a system for reconciliation. Sites also had systems for tracking medication administration in PAC/LTC settings. More expensive technologies reportedly were difficult to support under current Medicare PAC and Medicaid payment rates, but were used in the VA (e.g., bar coding). However, lower cost solutions, including unit dosing or multiple day packaging and an automated medication administration record, were in place at all sites. Drug alert systems also were used to review dosages, drug interactions, and sometimes necessary laboratory data.

At some sites, systems for electronic physician/geriatric nurse practitioner orders and progress notes from all PAC/LTC providers were structured partially and were part of the EHR. Where orders were entered electronically in IRF units or nursing homes, staff reported a reduction in ordering time and error rates, and these systematized processes were received favorably. Where nursing progress notes were fully electronic, considerable reduction in documentation time was noted and clarity of documentation for shift changes was enhanced. Despite limited structure for progress notes (except for vital signs) in the sites where an EHR was used, both RNs and CNAs endorsed the potential of EHRs for care management and documentation of nursing care activities in PAC/LTC settings. At some sites, physical and occupational therapists also utilized the system for progress notes, leading to better communication among different disciplines treating the same patient. Thus, even relatively rudimentary systems in terms of structure and standardization demonstrated some of the potential benefits of interoperable EHRs for PAC/LTC.

Limitations of Leading-Edge Systems

The same characteristics that enabled these sites to become leaders in interoperable EHR systems -- local control and strong leadership -- also are limitations to further development. Through the local clinical, organizational, and information technology culture, each system has flourished, but in a unique manner that is not replicable. With the exception of the VA, no economies of scale exist because each system had to develop its own applications. The VA is part of a larger national network, but individual sites customize components and lack interoperability with other VA Medical Centers (VAMCs) and non-VA health systems. Thus, the ability to "go it alone," and the success of this method, now places these state-of-the-art health systems in the difficult position of needing to retool and adapt to enable wider connectivity.

In no area is this more apparent than in the lack of standards for messaging, vocabularies, and documents. As reflected in the President's Executive Order, and in various public and private initiatives, the use of healthcare information technology standards is an essential part of an infrastructure that ensures the availability of real-time clinical information to support clinical decision making, reduce errors, and promote efficiencies. For the most part, each of the four sites will face challenges as it conforms its "homegrown" clinical content with CHI-endorsed standards and works to ensure its information technology infrastructure interoperates with the national health information technology infrastructure. As an example, these health systems will be challenged when there is agreement on core clinical content that should be transmitted at times of patient transfers from hospitals to PAC/LTC settings, the standardization of that clinical content, and the use of a standardized clinical document architecture for the efficient communication of this information across settings. Standards development is only in the early stages, and the PAC/LTC systems that were visited did not use standardized terminologies, messaging standards, or documents for the electronic recording and exchange of any information. In fact, standardization was not high on the agenda at most sites because each was functioning adequately within the confines of the EHR system.

Lack of standards contributes to another limitation: difficulty in extending electronic health information systems into provider settings that are not owned and operated by the site or its employees. Although all sites were experimenting with business affiliations that addressed technological, legal, privacy, and communication issues, no sites had been able to overcome the barriers to being interoperable with unaffiliated PAC/LTC providers using staff who were not employees of the larger system. Although these barriers existed with extension into all unaffiliated providers, linkages with PAC/LTC facilities generally lagged behind physician offices and other hospitals for several possible reasons. Health enterprises that include PAC/LTC facilities still are focused on improving EHR functions in the acute care operations, where greater value and return on investment are anticipated. As PAC/LTC settings utilize EHR technology to a greater extent, interoperability will become more essential so that external parties can use and contribute to the record.

A final limitation to interoperability that also could be improved by standards development is the integration between the EHR maintained in the various PAC/LTC sites and the government-mandated data sets: MDS, OASIS, and IRF-PAI. In every case, the information systems for the mandated data set were completely distinct from the EHR. None of the sites was able to import information from the comprehensive clinical assessments contained in the EHR and populate mandated data sets. In most cases, the process for completing the mandated data sets was separate from the process used to maintain the EHR. Thus, the lack of integration between mandated assessments and the clinical information recorded in the EHR was a major impediment to integrated care delivery. Further, the EHR was dominated by orders and assessments written by the physician and/or nurse practitioner, and by nursing and therapy reports of medical care issues such as medications, vital signs, and treatments. However, linkage of mandated data sets and the EHR requires standardized content and messaging not only for the EHR, but also for the federally mandated data sets. Furthermore, enhancing the clinical utility of content in the mandated data sets will be necessary to avoid the documentation burden of two distinct sets of information for PAC/LTC patients.

Recommended Next Steps

Following completion of the draft report, a technical expert panel (TEP) was convened on April 14, 2004, to recommend next steps in research relating to EHR in PAC and LTC settings (see Appendix E for panel membership). Several major themes emerged from this discussion that, when taken together, suggest a strategy for further research.

A major barrier to widespread implementation of EHRs in PAC/LTC seemed to be the inability of these health settings to recognize the potential for interoperable EHRs to benefit patient care, efficiency, and clinicians. Thus, demonstration, dissemination, and education regarding these benefits relative to the associated costs were considered imperative if providers and vendors were going to invest more heavily in EHRs for PAC and LTC. Consideration is needed of options to promote the value of and return on investment for using interoperable EHRs in PAC/LTC, particularly for those PAC/LTC providers that are unaffiliated (i.e., not owned or managed by) larger health systems. Absent implementation of complete and interoperable EHRs across the health continuum, including PAC/LTC providers, quality, safety, and continuity of care will be comprised. Panel members recognized that the visited sites had the most advanced IT infrastructure in PAC/LTC, but argued that further investment at the federal level should be in the development and implementation of EHR functions that could be translated to sites beyond these legacy systems. These leading sites in PAC/LTC could serve as laboratories for further development to rapidly deploy and test EHR functions.

The panel fully supported and endorsed the use of health information technology standards in any future federal research and policy activities directed toward specifying clinical content and the use of EHRs in PAC and LTC settings. The most efficient and cost-effective way to extend systems to sites that are not owned and providers that are not employees of a health system is through the use of standardized vocabularies, messaging formats, and document architecture. In addition, work is needed to enhance the clinical content in federally mandated data sets to avoid the documentation burden of two distinct sets of information for PAC/LTC patients -- documentation needed in the course of providing care and documentation to meet federal reporting requirements. In addition, the expert panel concluded that, given the limited state of EHR implementation in PAC and LTC, the development of a single needed application (rather than a comprehensive EHR system) would be the most effective strategy for increasing the awareness of and demand for EHRs by PAC and LTC providers. The expert panel recommended the Federal Government follow a "design-build" strategy and invest in the development of a needed cutting-edge technology that could be demonstrated rapidly in at least a couple of PAC/LTC sites. The technical experts recommended developing a standards-based, electronic transfer document that would meet the business and clinical needs of PAC and LTC providers to receive timely information when a patient is to be admitted into these settings. The approach should allow rapid deployment of an application that could be supported in environments that use standardized EHRs, as well as those that do not have this technology.

Such an approach would take advantage of available content, messaging, and document architecture standards; identify gaps in these standards; and allow for future refinements to the application as additional standards become available. The approach would support the design of the best possible initial electronic transfer document based on what is presently known, and allow the electronic document to be engineered, implemented, and refined in practice. Through a series of iterations, the content and application would be refined, and the impact on continuity and quality of care and costs would be evaluated. An advantage of this approach is that a prototype would be available in a short timeframe (preferably within a year) for widespread implementation. The expert panel recommended engineering, implementing, and refining the application at a VA Medical Center and in a private-sector health provider.

In summary, as a result of the expert panel discussion and information learned as a result of the literature review and site visits activities conducted as part of this study, the following activities are recommended:

1. Ensure the content of federally-required patient assessments instruments data sets is information that would otherwise be routinely collected in the course of providing care and integrate health information technology standards into the development and modification of federally mandated data sets. This would facilitate the linkage of required data sets with standardized EHRs and reduce the administrative burden for PAC/LTC providers by supporting and maximizing the re-use of information collected and entered into a standardized EHR for the completion of administrative data requirements.

2. Work to fill the gaps in the disability content in existing standardized, codeable terminologies. Previous research has found gaps in the physical and cognitive disability content of standardized vocabularies and terminologies. Terms and concepts regarding the disability status of individuals' residing in nursing homes are critically important in this setting.

3. Engineer, implement, refine, and disseminate to the public, the specifications for an electronic care transfer document that would embed, using health information technology standards, the clinical content needed at times of transfers from acute care hospitals to nursing homes and develop a method for the timely exchange of this information in environments with or without interoperable EHRs. Development of an electronic, standardized transfer document would permit the timely exchange of information from acute care systems with EHRs to nursing homes with or without EHRs. In addition, such a transfer document could serve as a template for EHRs for nursing homes.

4. Examine the costs and benefits to nursing home patients, providers, the health system, and payers of implementing interoperable electronic medication management and administration systems in nursing homes and develop options for promoting the use of these systems. Given the high proportion of medical errors that are related to medications, the large number of medications taken by persons in PAC/LTC, and the relatively advanced state of terminology standards for medications, electronic medication management and administration systems are a high and immediately viable priority for development in the PAC/LTC EHR.

REFERENCES

1. Executive Order 13335. (2004) Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator. Federal Register, Part VII, 69(84):24059-24061.

2. National Committee on Vital and Health Statistics. (2001) A Strategy for Building the National Health Information Infrastructure. 1-51.

3. Reuben D, Schnelle JF, Buchanan JL, Kington RS, Zellman GL, Farley DO, et al. (1999) Primary Care of Long-Stay Nursing Home Residents: Approaches of Three Health Maintenance Organizations. J Am Geriatr Soc; 47:131-138.

4. Kemper P, Murtaugh C. (1991) Lifetime Use of Nursing Home Care. N Engl J Med, 324:595-600.

5. Centers for Medicare & Medicaid Services (CMS). (2003) CMS Health Care Industry Market Update: Home Health. 7. Centers for Medicare & Medicaid Services.

6. CMS/OIS/HCIS. (2003) Medicare Home Health Utilization by State, Calendar Year 2000. 8. Centers for Medicare & Medicaid Services.

7. American Rehabilitation Providers Association. (2003) Off the Record: Legislative and Regulatory Updates for AMRPA Members. 11. Washington, DC: American Rehabilitation Providers Association.