U.S. Department of Health and Human Services

Taxonomy of Health Information Technology in Nursing Homes -- Report B: Review by Representatives from Nursing Homes and Vendors

University of Colorado, DenverHealth Sciences Center

August 6, 2007

PDF Version (35 PDF pages)

This report was prepared under contract #HHS-100-03-0028 between U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of Colorado. 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.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

TABLE OF CONTENTS

I. PURPOSE

II. METHODS

III. RESULTS

IV. DISCUSSION

ATTACHMENT A: DRAFT TAXONOMY OF HIT APPLICATION FEATURES FOR NURSING HOMES

NOTES

LIST OF TABLES

TABLE 1: Tally of NH Responses for Operations Management Domain Applications

TABLE 2: Tally of NH Responses for Electronic Health Record Domain Applications

I. PURPOSE

This is the second report in a series that is describing the findings from stakeholders. The background on the taxonomy development is described in more detail in Report A and it is the expectation of the authors that these reports would be read as a set. A select group of nursing home (NH) providers was invited to provide feedback on the draft taxonomy and information on which applications are currently in use (or planned for future implementation) and the extent to which they are used. This report provides a summary of the findings from this review.

II. METHODS

Taxonomy Adaptations: Based on comments received from representatives from standards development organizations (SDOs) (see Report A), the taxonomy was revised. It was then disseminated to home health and NH health information technology (HIT) vendors for their review and comments. The taxonomy was modified to reflect the vendor comments and revisions. The next step was to further modify the taxonomy to capture what HIT applications/features were being used in NHs and for them to identify the extent of use. This version became known as the "nursing home provider taxonomy" and can be found in Attachment A. Columns noting related standards and other "frequently packaged with" applications that existed in earlier versions of the taxonomy (for SDOs and vendors) were replaced with the following columns to allow the providers to specify for each application:

1. the name of the supporting product;
2. the name(s) of other products supporting interfacing applications;
3. current or planned usage;
4. types of employees using the application; and
5. the extent to which the product had been implemented in the NH.

Scales were developed for two of the columns. For current/planned usage (#3 above) the scale ranged from "1-We have this application and are currently using it," to "5-We do not have this application and have no desire to obtain it." For the extent of application implementation (#5 above), the scale ranged from "1-The application is fully implemented and all applicable staff are using it," to "5-This application has been purchased but we do not plan to use it at this time." As mentioned previously, a copy of the adapted taxonomy and answer key containing the scales can be found in Attachment A.

NH providers: Potential representatives from NHs were identified through software vendor recommendations or based on previous contacts and relationships with project staff and/or the ASPE project officer. In selecting the nine NH provider representatives, we attempted to include a variety of ownership (profit vs. nonprofit), geographical locations, and vendor products. The following NH providers were invited to participate in one of two conference calls that provided information on what was expected of them should they agree to provide us with information about their health care setting:

1. Kena Dubberly Garrison Geriatric Care Center, Lubbock, TX
2. Russell J. Williams AG Rhodes Homes, Atlanta, GA
3. Gary Kelso Mission Health Services Hillside Rehabilitation Center, Huntsville, UT
4. Bill Krantz Benedictine, Cambridge, MN
5. Mark Pavlovich Sava SeniorCare, Atlanta, GA
6. Bill Kubat Lutheran Good Samaritan, Sioux Falls, SD
7. Terri Martell Home Quality Management, Palm Beach Gardens, FL
8. Sunni Herman Gurwin Jewish Geriatric Center, Commack, NY
9. Daniel H. Wilt Erickson Communities, Baltimore, MD

Providers participated in conference calls according to their preferred date and time. During the calls, the purpose of the project and the draft taxonomy were reviewed. Participants were asked to complete the columns in the adapted taxonomy and submit their input within one to two weeks.

III. RESULTS

Five of the NH providers submitted feedback on their use of HIT. NH providers listed from one to 24 unique products in use by facility staff. In the case of a NH providing conflicting information on an application (e.g., stating they have a product they are using to support the application and also stating that they plan to purchase the application within the next 12-24 months), we interpreted the finding to mean that the NH provider did have the functionality in question. Data on use of specific applications were synthesized and findings summarized by taxonomy domain.

Administration: Four of the five responding NH providers indicate that they are currently using automated systems for most of the functions listed under the administration domain. However, only one NH reports the use of software for contracts management and only three are using applications to track claims denials. Interestingly, one NH reports that they do not use an automated payroll feature; the same NH uses a single HIT product.

Operations Management: Table 1 summarizes the data from the five respondents for the applications in this domain, tallying the number of providers reporting that: (a) they own and use a product that supports the application; or (b) that they own a product supporting the application but are not currently using it. Only two operations management applications are in use by all five facilities: registration and MDS data management (i.e., software for data entry, editing, and transmission to data repositories). None of the NH providers use software for electronic receipt of referral data (e.g., e-Discharge or E-CIN), and only two facilities have systems for assigning patient acuity and for staffing and scheduling. Four of the five use an automated staff time/attendance system, and three use personnel management systems (e.g., tracks hire dates, in-service attendance, credentials/licenses). Consistent with the number of providers reporting use of administrative functions, four are able to generate financial management reports. Two use workflow management systems and another has some functionality but is not currently using it. Two facilities have products supporting facilities/materials management, three have systems for dietary management, and four have pharmacy management tools. However, none of the facilities are tracking/managing medications for billing using an automated system.

Four of the five nursing facilities report some automated quality management tools, and all four are able to generate risk audit reports, "dashboard" reports of key quality indicators, and reports of occupancy rates ant trends. Two or three providers note the functionality to produce other types of quality reports. However, only two have the functionality to electronically report population health data and notify public health agencies for reportable conditions (e.g., tuberculosis). Electronic access to clinical guidance is available at two NH providers, although another site reports that they have the functionality but are not currently using it. Only one facility can provide de-identified health data and one allows care providers access to an online policy and procedure database.

Electronic Health Record: Given the methods used for identifying the NH provider participants (described in the Methods section above), we anticipated that all participating facilities would be using an electronic health record (EHR). However, only four of the five report using an EHR. One reports some EHR functionalities (e.g., the ability to electronically produce summary reports), but not an electronic record that allowed the capture and reporting of assessment data or visit notes. For each application within the domain of the EHR, Table 2 provides a summary of the provider data.

Four NH providers report having an EHR that allows them to maintain the health record, record the initial and follow-up patient assessments, record and produce clinical notes for some or all of the disciplines listed, and produce summary reports. One multi-facility provider notes that two of its five facilities are beginning to implement some EHR functionality for clinical notes using a home-grown system. Only two providers report having the functionality to capture patient consent/authorizations and directives within the EHR. The ability to electronically receive external clinical documents is in use at two facilities (three for laboratory data) and one facility has the functionality but currently is not using it. Three NH providers note having the EHR applications to generate problem lists and plans of care, while another notes that they have the software for these functions but currently are not using it.

Some type of decision-support software is in use by three providers. A fourth has some of the functionality but has not yet trained its staff. All three report having some form of electronic risk assessment tools (e.g., falls risk), and two are using electronic clinical pathways and/or disease management programs. One has functionality for automated alerts for laboratory draws, while another reports some limited functionality whereby staff could access stored dates in some of the provider's facilities (although this was not classified as an automatic alert). Two of the providers note they have functionality for automated prompts for unusual events (e.g., medication errors) and decision-support for e-prescribing. Automated prompts for preventive practice are in use at only one provider site. Two of the respondents note that they have results management tools. No provider reports that it uses alerts for F-tag compliance (survey deficiency tags).

Care plan monitoring software has been implemented by three NH providers and two have functionality for trending clinical data (e.g., vital signs). An additional provider has the functionality but has not yet trained the staff. Two respondents note that they have secure electronic messaging between: (a) staff within the facility; and (b) staff external to the facility (e.g., physician, pharmacy). None report the use of systems for electronic health information exchange with patients and families, although one noted the functionality was present but not yet in use. Patient education materials that can be accessed by clinical staff and printed for use in patient teaching were available electronically in only one facility. All four providers using EHRs have security features, such as the ability to set permissions and authenticate users. Two have systems allowing physicians and pharmacists to access the EHR. Computerized provider order entry (CPOE) is in use by three of the providers, while another has not yet implemented the functionality even though they have purchased it.

Medications: While only two of the NH providers use automated Medication Administration Records (MARs) (one with barcode technology to enter medications), three have the ability to record and product medication lists electronically. Three respondents report having applications for checking medication lists for side effects, potential adverse events, and other alerts. Four facilities report that they own products that support e-prescribing, but only two currently are using those products.

Telemedicine/telehealth: None of the responding NH providers reported use of any of the applications within this domain.

IV. DISCUSSION

All participating NHs report using many or all applications listed with the Administration domain. Fewer of the Operations Management functions are automated. It is surprising that only two had automated activities such as staffing/scheduling or workflow management, as it is common to see short-term return on investment when automating some management functions. However, while many of the functions under the administration and operations management domain can be associated with cost savings and are intended to make NH facility operations more effective, most are not directly related to patient care. The exception is the Operations Management functions related to quality management activities. Providers using these reporting functions may initiate quality improvement efforts that can directly impact the way care is provided. It may be useful as part of Task 6 (the site visits) to visit one facility using several of these reporting functions to identify costs saved by automatic generation of the reports (e.g., we anticipate that significant time savings would be realized by not hand-tallying reports) and benefits in terms of improved ability to monitor quality of care and clinical outcomes.

Because selected providers were recommended to us from software vendors or identified through previous contacts by project staff and the task order manager, it was not surprising that all but one provider are using an EHR. However, the systems used and functionality varied considerably across the providers. The one provider not using an EHR had some limited functionality related to health data. It appears as though clinical assessment data, clinical notes, and summary reports are components of all the EHRs. While we will likely visit one or more NHs with fully implemented EHR systems, if those applications are considered part of a basic EHR system (i.e., a bundled "package" of applications purchased from a single vendor), it may be difficult to identify the costs and benefits of some of the individual applications. It may be necessary instead to identify a set of applications common to most/all NH EHR products and evaluate costs and benefits for that basic set of applications together.

The ability to electronically receive clinical data from external providers (including referral data), decision-support tools, and health information exchange tools were not in use by most of the respondents. Likewise, only two providers reported using e-prescribing functions. Because these applications may be purchased as system upgrades or stand-alone modules, it may be easier to identify specific costs and benefits. When evaluating costs and benefits of some of these more sophisticated applications, it may be useful to visit some facilities using the applications and others who are not. It may be possible that we would be able to identify both anticipated costs/benefits (from NHs who do not use these more sophisticated features but are interested in acquiring them) and realized costs/benefits from those NHs currently using the applications.

For the site visits, we may want to consider one or more NHs that has implemented a basic EHR, which would include at least the ability to enter, store, retrieve, and view assessment data (including MDS), clinical notes, and produce summary reports. In addition, we could include one or more NHs with some of the more sophisticated EHR applications, particularly those related to decision-support, CPOE, and health information exchange with providers and/or patients, and one or more not using those functions but considering purchasing products to support the applications. As alluded to above, and given the government and industry's interest in and focus on e-prescribing, we likely should visit one or more NHs that use e-prescribing. We may consider visiting one NH using sophisticated quality management reporting functions. All but one of the five NH providers providing information on their products meet these criteria and could be considered candidates for site visits.

ATTACHMENT A: DRAFT TAXONOMY OF HIT APPLICATION FEATURES FOR NURSING HOMES

NOTES

1. EHR Systems are defined in the HL7 EHR FM DSTU as: (1) a longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of the individual or health care provided to an individual; (2) immediate electronic access to person and population-level information by authorized, and only authorized, users; (3) provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and (4) support of efficient processes for health care delivery. HIMMS defines an EHR as a "computer-based longitudinal records of patient health information generated by one or more encounters in any care delivery setting." The EHR is intended primarily for use by health care providers. For the purposes of this taxonomy, we consider that an EHR is an integrated record containing information crossing provider settings and is compliant with (or is becoming compliant with) existing interoperability standards. We consider EMRs to be a subset of EHRs and are used and maintained by a single provider setting.