U.S. Department of Health and Human Services

Survey Questions for EHR Adoption and Use in Nursing Homes: Final Report

Andrew Kramer, MD, Meg Kaehny, MSPH, Angela Richard, MS, RN, and Karis May

University of Colorado, DenverDivision of Health Care Policy and Research

January 5, 2010

PDF Version: http://aspe.hhs.gov/daltcp/reports/2010/EHRques.pdf (197 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. INTRODUCTION

II. BACKGROUND ON HIT USE IN NURSING HOMES

III. METHODS

A. Literature Review

B. Technical Expert Panel

IV. CORE SURVEY: CONTENT AND ADMINISTRATION RECOMMENDATIONS

A. Core Survey Content and Rationale

B. Facility Characteristics Data

C. Alignment of Core Survey with Existing National Surveys

D. Recommended Administration Methods

V. EXPANDED SURVEY

A. Expanded Survey Content

B. Administration Recommendations for Expanded Survey

VI. PILOT TESTING

REFERENCES

APPENDICES

APPENDIX A: Literature Review and Synthesis: Existing Surveys on Health Information Technology

APPENDIX B: Technical Expert Panel Review Materials and Meeting Notes

APPENDIX C: Core Survey on Use of Health Information Technology in Nursing Homes

APPENDIX D: Expanded Survey on Use of Health Information Technology in Nursing Homes

NOTES

I. INTRODUCTION

Despite the potential of health information technology (HIT) to improve quality and efficiency of care in nursing homes and the national priority placed on adoption of HIT, information on HIT adoption in the nursing home setting is relatively scarce, and the reported estimates of nursing home HIT adoption are inconsistent. For example, estimates of nursing home adoption of electronic health record (EHR) or electronic medical record (EMR) adoption range from 18 percent to 47 percent and estimates of computerized or electronic provider order entry in nursing homes range from 16 percent to 48 percent (Richard, Kaehny, May, and Kramer, 2008). While most estimates suggest that HIT adoption rates are relatively low in nursing homes, in terms of use of non-administrative HIT applications, surveys have used varying definitions of HIT/EHR (or no definitions at all). The lack of consistent, well-defined terminology makes the accuracy of national adoption estimates difficult to ascertain (Robert Wood Johnson Foundation, 2006). Although the Office of the National Coordinator (ONC) for Health Information Technology released “consensus definitions” of EHR and EMR in April 2008 (National Alliance for Health Information Technology, 2008), the estimates referenced in this report resulted from surveys that used varying definitions of EHR or EMR and therefore do not necessarily reflect EHR or EMR use as defined by the ONC consensus definitions.

Although the National Nursing Home Survey (NNHS) sponsored by the National Center for Health Statistics (NCHS) has established a valuable starting point with its current item addressing nursing home HIT use, the single dichotomous item is limited in its breadth and precision. In addition, some current surveys designed to assess nursing home HIT/EHR adoption (e.g., a California HealthCare Foundation study on long-term care provider readiness; a Minnesota Department of Health/Stratis Health survey on use and intended use of EHRs among Minnesota nursing homes), are state-specific and may not be generalizable to the national nursing home community. More detailed and specific tools for assessing HIT adoption in hospitals and physician offices exist, but these are not directly applicable to nursing homes because of the unique care and HIT requirements in long-term care.

Policymakers need reliable and valid data on HIT adoption rates for nursing homes to assess movement toward the goal of promoting EHR adoption and inform decisions about the policy actions needed to accelerate adoption. To meet these needs, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (HHS) funded the University of Colorado Denver (UCD) to develop two survey instruments. The first instrument was to be a relatively narrow set of "core" survey questions, for possible administration with the NNHS or other surveys, designed to assess and track HIT adoption rates over time and to obtain information on perceived barriers and benefits associated with HIT use. The second instrument was intended to be a more comprehensive, expanded survey containing both the core questions and follow-up questions designed to obtain additional detail on electronic functions that are actively in use in nursing homes.

As described in this report, the project was aimed at developing a core survey that has the sensitivity to capture change over time in nursing homes’ level of automation and, whether fielded in conjunction with the NNHS or through other means, will provide a valuable snapshot of nursing home HIT use while establishing a baseline from which to track future growth. The project also was aimed at producing an expanded survey useful for gathering greater detail on automated functions that are actively in use at nursing homes. The expanded survey may be of particular utility for entities (e.g., provider associations, corporations, individual nursing homes) seeking a comprehensive and rich picture of HIT use in targeted nursing home(s) and/or detailed information on the use of particular functionalities (e.g., e-prescribing).

Additional background information on the potential benefits and use of HIT in nursing homes is provided in Section II of this report. Section III describes the literature review and technical expert panel (TEP) work conducted under this project that shaped the development of the core and expanded surveys presented in this report. Section IV and Section V present detailed information on the content of and administration recommendations for the core survey and the expanded survey, respectively. Section VI discusses recommendations for pilot testing the surveys.

Although the core and expanded surveys were designed to gauge HIT use in nursing homes, with modest wording changes (e.g., replacing references to “facility” with “organization” or “care setting”; replacing references to the MDS with “regulatory assessments”), the surveys also may be useful in other care settings in the long-term and post-acute care supports and services spectrum, or even cross-care settings.

II. BACKGROUND ON HIT USE IN NURSING HOMES

HIT refers to an array of computer applications for health care, ranging from those used by administrators (e.g., census management, billing), managers (e.g., staffing and scheduling modules), direct care providers (e.g., EHRs) and in some cases, patients (e.g., personal health records) (UCD, 2007). An EHR is defined by the Healthcare Information and Management Systems Society (HIMSS) as a “longitudinal electronic record of patient health information generated by one or more encounters in any health care setting…including patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports” (HIMSS, 2007a). The Institute of Medicine (IOM) specifies that an EHR includes: (1) longitudinal collection of electronic health data for and about persons; (2) immediate access to health data pertaining to an individual by authorized users; (3) provision of knowledge and decision support to enhance quality, safety, and efficiency of patient care; and (4) support of efficient processes for healthcare delivery (IOM, 2003). Consensus definitions released by the ONC in April 2008 define an EMR as “an electronic record of health-related information regarding an individual that conforms to nationally adopted interoperability standards and implementation specifications, and that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization”. EHR is defined the same way with the exception of being “created, gathered, managed, and consulted by authorized clinicians and staff across more than one health care organization”.

EHRs have the potential to improve quality, patient safety (particularly related to medication errors), and patient satisfaction and to decrease costs and inefficiencies by making current patient information and clinical decision making tools instantly accessible to clinicians in an easily-readable format (Booz Allen Hamilton, 2006; Shekelle, Morton, and Keeler, 2006; Bates and Gawande, 2003; Kaushal, Shojania, and Bates, 2003; Bates, 2002). By minimizing the number of times that patient care information is manually re-entered into a health record, potential transcription errors and redundant procedures can be avoided (Coleman, May, Bennett, Dorr, and Harvell, 2007). A recent study of perceived costs and benefits of HIT in nursing homes and home health agencies found four primary categories of perceived benefits: (1) anywhere and anytime access to the clinical record, including access by more than one simultaneous user; (2) greater efficiency in meeting administrative and federal requirements in long-term care, including shorter billing cycles and fewer claims denials, and improved documentation of compliance with Conditions of Participation; (3) improved quality management through reports, alerts, and decision support tools; and (4) health information exchange technology to enhance care coordination and data accuracy across providers (Kramer, Richard, Epstein, Winn, and May, 2009).

The implementation of interoperable HIT has become a national priority. IOM has recommended that “the U.S. health care system make a commitment to the development of a health information infrastructure by the year 2010” (IOM, 2003). In April 2004, President Bush set a goal that most Americans have an EHR by 2014, and signed Executive Order 13335, establishing the Position of the National Health Information Technology Coordinator. The American Recovery and Reinvestment Act of 2009 provided $2 billion for implementing and/or evaluating HIT as part of a platform to improve health care quality, including the coordination of care, patient safety, and efficiency of care; and made available approximately $17 billion in Medicare and Medicaid payment incentives to eligible professionals and acute care hospitals for their meaningful use of certified EHRs.

The IOM identified the EHR-System (EHR-S) functions and timeframes over which these functions could be introduced for particular health care settings, including nursing homes (IOM, 2003). In late 2006, the Certification Commission for Healthcare Information Technology (CCHIT) was petitioned by long-term care stakeholder groups to include nursing homes in the development of certification criteria for EHR products. In the summer of 2009, CCHIT began its work to identify the EHR certification criteria for skilled nursing facilities, nursing facilities, home health agencies, long-term care hospitals, and inpatient rehabilitation facilities. CCHIT expects to begin certifying EHRs for Long-Term/Post-Acute Care providers in the summer of 2010. CCHIT is leveraging the Long-Term Care-Nursing Home EHR-System Functional Profile (the LTC-NH EHR-S Functional Profile) that was passed by Health Level 7 (HL7) as a Draft Standard for Trial Use in December 2008/January 2009. The LTC-NH EHR-S Functional Profile was developed by a workgroup of long-term care industry stakeholders, including representatives from the American Association of Homes and Services for the Aging, the American Health Care Association (AHCA), and the National Association for the Support of Long Term Care; along with representatives from organizations involved in standards development, including the American Health Information Management Association, HL7, and the National Council on Prescription Drug Programs, and with the support of ASPE within HHS.

III. METHODS

A. Literature Review

An extensive literature review was conducted to provide foundational understanding for the construction of new data items to measure HIT adoption in nursing homes. The literature review included nine surveys for nursing homes and other long-term care settings (e.g., assisted living facilities) pertaining to current HIT adoption and barriers to adoption, including the NNHS, a California HealthCare Foundation study on provider readiness, and a Minnesota Department of Health/Stratis Health survey on use and intended use of EHRs. Fifteen surveys on HIT adoption and use developed for other care settings including hospitals, ambulatory care, and home health agencies were identified and included in the review. These included the National Ambulatory Medical Care Survey, the National Home Health and Hospice Survey, surveys conducted by the Healthcare Financial Management Association, American Hospital Association, the Leapfrog Group, and others. The literature review report can be accessed on the ASPE Website at http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm and in Appendix A.

The literature review validated existing perceptions about the limitations of existing surveys for measuring HIT adoption. Although numerous survey instruments have been fielded to assess HIT use in various provider settings, the lack of consistent definitions, terminology, item construction, sampling frames, respondents, and measurement approaches render it difficult to accurately gauge current HIT adoption. The literature review, however, provided useful information that supported decisions about the content and design of the questions for a new survey. For example, the taxonomy of HIT applications available for use in nursing homes (UCD, 2007) provided extensive information on the administrative, operational, and clinical functions that could be supported by HIT applications. The nursing home HIT taxonomy can be accessed on the ASPE Website at http://aspe.hhs.gov/daltcp/reports/2007/Taxonomy-NH.htm; and http://aspe.hhs.gov/daltcp/reports/2007/Taxonomy-SDO.htm.

In addition, selected surveys supplied information on content and wording elements that were helpful. For example, a question on barriers to HIT adoption used in the national physician survey developed under an ONC contract (RTI International, 2006) provided the foundation for the design of similar data items for the core and expanded surveys. The use of six “personas” that delineate a range of levels of HIT usage in a survey by AHCA and the National Center for Assisted Living, and described in their white paper, “A Snap-Shot of the Use of Health Information Technology in Long Term Care” (2006), provided a useful conceptualization of levels of HIT usage. A Stratis Health survey of Minnesota nursing homes (Stratis Health, 2008) assessed software/technology use for a selection of key nursing home functions. The survey’s inclusion of explicit descriptions of the work functions provided an example of an effort to enhance accuracy of HIT use estimates.

B. Technical Expert Panel

A group of individuals with expertise in nursing home administrative and clinical management, information technology (particularly applications for nursing homes), long-term care health policy, and survey development and administration was recruited to serve on a TEP for the project. (A list of TEP members can be found in Appendix B.1.) The role of the TEP was to provide feedback to guide survey item development and refinement. TEP activities included review and comment on several iterations of draft data items, along with recommendations for future efforts to field the survey. A TEP meeting was held in Washington, D.C. on September 24-25, 2008.

An initial set of survey data items was drafted and sent to TEP members for review prior to the September 2008 meeting. TEP members were requested to complete the draft core survey questions as if they were a nursing home provider, then give feedback on: (a) clarity of wording and suggestions for rewording; and (b) ability for a survey respondent to accurately characterize a facility’s level of automation given the response options provided for each function in the early draft of Question 1. TEP members also rated all of the items in the draft core survey on a scale of 1-3 for clarity, importance to the survey, and the likelihood that the question would have response variability. (Appendix B.2 contains the review materials used to obtain TEP feedback on the draft questions prior to the in-person TEP meeting.)

Project team members compiled and summarized TEP input prior to the September 2008 meeting. A summary of the pre-meeting feedback and ratings (contained in Appendix B.3) was provided to TEP members during the meeting to guide the discussion. During the course of the meeting, TEP members offered extensive suggestions for survey item reconceptualization and rewording. (Notes from the TEP meeting are contained in Appendix B.4.) These suggestions became the basis for the first revision to the survey items. The revised draft survey questions were sent electronically to the TEP members in spring 2009, to obtain review and suggestions for additional refinements. Project staff incorporated TEP comments from the spring 2009 e-mail review to create the current iteration of the draft survey questions. The TEP also had the opportunity to review the survey items included in this draft final report prior to finalization of the surveys at the end of this project.

IV. CORE SURVEY: CONTENT AND ADMINISTRATION RECOMMENDATIONS

A. Core Survey Content and Rationale

The core survey (contained in Appendix C) contains nine questions, several of which include multiple sub items. The nine questions address the following topics:

1. Current level of automation and plans for additional automation for 21 clinical functions/applications;
2. Automated clinical decision support for 9 functions/applications;
3. Health information exchange capabilities for 13 functions/applications;
4. Automated systems to capture and query information relevant to health care quality;
5. Automated summary reports;
6. Telehealth;
7. Telemonitoring;
8. Perceived barriers to HIT adoption and use; and
9. Perceived benefits of HIT.

With the goal of limiting respondent burden and streamlining survey administration, efforts were made from the outset to limit the number of questions included on the core survey. It remains important to achieve a balance between obtaining key information and restricting the time commitment of respondents. The rationale for inclusion of the questions in the current version of the core survey is discussed below. The opinions and feedback of TEP members played a major role in decisions on survey content.

1. Current Level of Automation and Plans for Additional Automation (Question 1)

A key purpose of the survey is to gauge and track the current level of use of automated systems in nursing homes. Question 1 assesses level of use for 21 functions/applications, using the following three-point scale:

a -- Paper Only (no automation) b -- Combination Paper/Electronic c -- Fully Electronic, with Point of Care

The three response options are designed to facilitate clear and simple characterization of facilities’ automation level by respondents. Early in the survey development efforts, the question included five response options that represented more detailed gradations of automation at facilities. While this approach would allow more precise characterization of facility automation levels and greater sensitivity to change over time, it also brought greater complexity to the question. The complexity could have affected the consistency of interpretation by respondents and therefore survey reliability and accuracy of results, as well as increased respondent burden. The decision was made to somewhat reduce the sensitivity of the question in order to increase its simplicity and clarity; the use of three response options is less burdensome and should promote greater respondent accuracy while retaining sufficient sensitivity to monitor change over time.

Given the intent to administer the core survey questions routinely over ongoing time intervals, the survey will provide the ability to track changes and trends as the proportion of respondents that choose levels a, b, or c for the Question 1 sub items will move over time. Trends can be monitored nationally or at regional or local levels (e.g., city, county), or even within corporations or individual facilities.

Identifying functions/applications to include in the core survey posed a critical decision point in the developmental process. Question 1 and other core survey questions deliberately specify individual functions and applications, rather than referring to an EHR or EMR. These terms were excluded as they are associated with a wide range of interpretation despite various efforts to establish standard definitions. The focus on specific functions/applications also allows the survey to obtain valuable information on electronic features in use at nursing homes regardless of the function’s place in a larger electronic system or health record. The list of functions/applications, which has undergone multiple iterations throughout the developmental process, includes those that are frequently-performed and/or are integral clinical and operational functions for which software applications are known to be available and in use at some nursing facilities. The list casts a wide net, offering the capacity to elicit information from facilities that use any HIT applications rather than only those with relatively sophisticated or widespread HIT use. The question design facilitates quick and straightforward response for each function/application.

Table 1 lists the functions/applications included in core survey Question 1.

TABLE 1: Functions/Applications Included in Core Survey Question 1 on Level of Automation
Resident (Patient) Demographics b Advance Directives b Medical History Clinical Notes: Attending MD a,b Clinical Notes: Licensed Nurse a,b Clinical Notes: CNA observ., notes a,b Clinical Notes: Other Disciplines (social services, therapy, dietary, others) a,b Problem List b Allergy List b Medication Administration Record a Treatment Administration Record a MDS Assessment/RAPS a,b	Assessments Other than MDS a,b Care Plan a,b Task List Medication Order Entry by Physician or Other Authorized Personnel a Other Order Entry by Physician or Other Authorized Personnel a,b Results Viewing--Labs a,b Results Viewing--Radiology a,b Results Viewing--Diagnostic Tests Other than Radiology or Labs a,b Results Viewing--Consults
Indicates functions/applications also addressed in core survey Question 2. Indicates functions/applications also included in core survey Question 3.

Many of the functions/ applications from the list in Table 1 also are addressed in core survey Question 2 (automated clinical decision support) and/or Question 3 (health information exchange capabilities). Those functions/applications that are also addressed in Questions 2 and/or 3 are designated by the footnotes in Table 1. Questions 2 and 3 are described below.

2. Automated Clinical Decision Support and Health Information Exchange Capabilities (Questions 2 and 3)

Automated clinical decision support functions/applications and health information exchange capabilities are specifically designed to improve patient care delivery and safety by minimizing the risk of medical and transcription error, in addition to improving efficiency for care providers. These applications are particularly relevant to national policy goals of increasing HIT adoption rates to improve patient care quality and safety.

Automated decision support functions may be developed for various direct clinical functions, such as clinical assessments (e.g., prompts to remind care providers to assess immunization status; red flags for vital signs exceeding pre-established parameters); medication orders; medication administration record; and lab orders/results. Likewise, health information exchange capabilities may be available for several types of data, such as admission/transfer/discharge referral data; consults; lab orders/results; radiology images/results; and medication orders. Because these two types of capabilities affect a variety of clinical functions, these survey questions are designed to capture the type of clinical decision support and information exchange capabilities that the nursing home is using.

3. Automated Systems to Capture and Query Information Relevant to Health Care Quality and Automated Summary Reports (Questions 4 and 5)

Many nursing homes indicate that the use of report functions for quality management is one of the most valuable benefits of HIT (Kramer, Richard, Epstein, Winn, and May, 2009). These nursing home-level reports may be generated from data entered into an EHR and in some cases may be combined with information entered in administrative systems (e.g., reports of all residents who have received influenza vaccines; occupancy reports; or “dashboard” reports). Automated summary reports (e.g., discharge summary) pull information from the EHR for specific residents. Because both the quality management report and automated summary report functions may include a variety of reports, these questions are designed to capture the types of reports the nursing home is using.

4. Telehealth and Telemonitoring (Questions 6 and 7)

Telehealth is defined in the core survey as the use of electronic communication and information technologies to allow direct interaction between providers and patients in different locations. Examples include wound consultation by a physician at an offsite location using audiovisual equipment to perform a clinical assessment, and interpretation of a real-time EKG reading by an offsite physician. Although telehealth is not currently in widespread use across nursing homes, the availability and use of telehealth applications is expected to grow over time. Inclusion in the survey provides a unique opportunity to track the growth of telehealth use in nursing homes over time.

5. Perceived Barriers to HIT Adoption and Use (Question 8)

In light of the current national push toward interoperable HIT and the continued relatively slow pace of growth of HIT adoption and use in nursing homes, it is valuable to obtain information from nursing home respondents regarding issues they find or found to be barriers to their purchase and/or use of HIT. This information can guide policymakers in identifying factors that contribute to slow adoption rates and make informed decisions about the policy actions needed to accelerate adoption.

6. Perceived Benefits of HIT (Question 9)

This question is included to obtain information relevant to research on the costs and benefits associated with implementing HIT. The question allows comparison of perceptions among facilities at various levels of automation (as indicated in core survey Question 1) to determine whether perceptions are associated with varying degrees of HIT use. For example, nursing homes that use no automation may perceive greater, lesser, or different benefits of HIT than those facilities that actively utilize HIT applications in support of their clinical work. Data from this question also could be analyzed to determine whether a particular presentation of HIT use is associated with the perception of particular benefits (e.g., if facilities that use a certain number of automated applications or particular applications, as indicated by responses to Question 1, tend to identify certain benefits; if facilities with full health information exchange capabilities, as indicated in responses to Question 3, perceive certain benefits compared to others).

B. Facility Characteristics Data

Five questions obtaining information on facility characteristics also are included on the core survey. The questions (other than the facility location question) are adapted from the NNHS Facility Questionnaire (NNHS FQ), with some wording modifications. The question topics, and affiliated NNHS question number for each, are: (a) facility location/state; (b) size/number of beds (NNHS FQ22); (c) chain affiliation (NNHS FQ5); (d) facility type (NNHS FQ8); and (e) ownership (NNHS FQ21).

The facility characteristics items are included on the core survey to ensure that this information is collected if the core survey is used as a stand-alone survey. If the core survey is fielded with the NNHS, the facility characteristic items should be eliminated, as the same information is collected through the NNHS.

C. Alignment of Core Survey with Existing National Surveys

Alignment of the core survey questions with existing national surveys was a consideration throughout the project, although it was agreed at the September 2008 TEP meeting that the development of effective questions for the specific purpose and setting addressed in this project must take precedence over alignment efforts. The current core survey questions are aligned with other surveys to the extent that a subset of the results--particularly related to a provider’s level of electronic capabilities for various clinical work functions--could be compared with findings from NCHS surveys fielded in other provider settings (e.g., the National Home Health and Hospice Survey, the National Ambulatory Care Survey) and other existing surveys. This capacity for “cross-walking” can support interest in assessing HIT adoption across provider settings. The question on perceived barriers (Question 8) in the iteration that was discussed at the September 2008 TEP meeting was a modified version of a question on barriers included in the national physician survey developed under an ONC contract (RTI International, 2006). This question has since evolved into a condensed version using conceptual headings instead of listing individual barriers, as recommended at the TEP meeting in the interest of reducing respondent burden.

D. Recommended Administration Methods

The core survey questions could be administered as a stand-alone survey and also could be included in the fielding of the NNHS. The questions can enhance the HIT/EHR-related data item currently collected by the NNHS by gathering more specific information on the adoption of specified applications. A key advantage of fielding the core survey with the NNHS is the opportunity to utilize a pre-established data collection methodology to administer the survey to a large, representative group of nursing homes, resulting in findings that could be generalized to the nursing home industry. In addition, as the survey is fielded with nursing homes on a regular basis, it would be possible to track HIT adoption rates more closely over time. Data gathered from the core survey questions also could be considered along with other survey data to address other issues important for national health policy (e.g., whether there is a difference in rates of rehospitalization in nursing homes that use HIT applications versus those that do not).

If administered with the NNHS, it may be most effective to include the core survey questions with the NNHS Staffing Questionnaire, as suggested by NCHS staff, rather than administering the questions by computer-assisted personal interview as is done for the NNHS FQ. The Staffing Questionnaire is mailed or e-mailed to nursing home administrators and is self-administered (by hard copy) by the administrators or designated staff. NCHS staff subsequently review the completed hard copy of the Staffing Questionnaire and follow up with respondents during an onsite visit to clarify responses (e.g., reasons for missing data, confirming atypical responses). The simple design of the core survey questions facilitates straightforward pen and paper completion and would fit effectively with the Staffing Questionnaire data collection protocol. Administering the core survey with the Staffing Questionnaire also may garner the benefits of improved data quality resulting from the follow-up by NCHS staff and a strong response rate due to respondents knowing that there will be follow up by NCHS staff during the facility visit. As noted, the core survey’s design allows straightforward pen and paper completion and does not necessitate in-person administration or the conduct of an onsite follow-up visit; the core survey could easily and effectively be implemented independently of the NNHS by mail (or Web application) and without any onsite data collection or data confirmation visits.

Given that the next anticipated NNHS administration is in 2010 or later, waiting to administer the core survey with the NNHS would mean that national data from the survey would not be available for several years (allowing time for data analysis). With the current national emphasis on HIT, administration of the core survey as soon as feasible should be considered to establish a baseline. While the data collection interval does not need to be too frequent, it would seem that administration at least every two years would be important and informative. Within organizations adopting HIT systems, the survey could be used more frequently to track adoption.

V. EXPANDED SURVEY

A. Expanded Survey Content

The expanded survey includes both the core survey questions and follow-up questions designed to supplement the core survey questions. The expanded survey, formatted for pen and paper administration, can be found in Appendix D. (Recommended administration via an electronic, Web-based format is discussed in Section V.B.) The expanded survey includes the same set of five questions on facility characteristics as is included on the core survey, as described in Section IV.B of this report.

The expanded survey is designed to obtain greater detail in targeted areas where nursing homes are using HIT. The survey is a valuable tool for a variety of uses on a national, regional, or local level. It is useful for obtaining a comprehensive, detailed look at HIT implementation, whether targeting a particular region, corporation, or even individual building(s). The expanded survey also can be used to gather information on use of particular functionalities. Using the example of e-prescribing, the expanded survey can shed light not only on the pervasiveness of “paperless” medication ordering, or e-prescribing, but also collect more detailed information such as the most commonly used electronic data capture methods for e-prescribing; type and timing of decision support tools used; use of national standards for data exchange; and entities with which electronic data are exchanged.

The expanded survey includes follow-up questions related to Questions 1, 2, and 3 of the core survey, which address level of automation; automated clinical decision support; and health information exchange capabilities. Follow-up questions are answered only when triggered by particular responses to the core survey questions. For example:

• If a respondent answering Question 1 on the core survey selected level c (fully electronic, with point of care) to describe their facility’s level of automation for its medication order entry (see core survey Question 1, sub item 1.16), when completing the expanded survey questions, the respondent would then answer a series of follow-up questions related to the facility’s electronic medication order entry application (e.g., is the authoritative record paper or electronic; is the electronic system housed at the facility or hosted by a third party; how does electronic documentation/data capture occur).

• Expanded survey questions triggered by responses to core survey Question 2 on automated clinical decision support obtain more detailed information on such topics as the type of automated decision support tools (e.g., data quality checks/illogical data alerts; reminders for scheduled events; lab results management).

• Expanded survey questions associated with core survey Question 3 on health information exchange capabilities address such topics as the form/structure of information shared (i.e., non-structured; proprietary structure negotiated with vendors for system-to-system sharing; national standards-based data exchange) and the type of entities with which the facility exchanges electronic data (e.g., hospitals; pharmacies; home health agencies).

B. Administration Recommendations for Expanded Survey

The expanded survey is recommended for administration via an electronic, ideally Web-based, application to constrain respondent burden in terms of number of pages, time commitment, and perceived complexity. Respondents using the Web application would see only the specific follow-up questions that are triggered by their core survey responses, thus substantially reducing the average number of follow-up questions per respondent. Although a respondent using pen and paper administration of the expanded survey would be asked to respond only to the same triggered follow-up questions as a Web respondent, the pen and paper respondent would need to follow skip patterns on a hard copy document and flip through multiple pages, likely resulting in greater time commitment and greater perceived burden of effort. Although pen and paper administration is an option for the expanded survey, electronic administration simplifies and facilitates completion and likely would increase response rates. A Web format also would likely result in lower administration costs, eliminating several costs associated with pen and paper administration (e.g., copying/mailing, tracking, data entry). For nursing homes where Web-based administration is not feasible, the current formatting of the expanded survey (in Appendix D) facilitates pen and paper completion.

Facility administrators (or their delegates), in combination with facility Information Systems officers if available are the recommended respondents for the expanded survey. The expanded survey could be fielded by various long-term care industry stakeholder groups (e.g., national provider associations or their state affiliates; corporations; even individual buildings) seeking an in-depth understanding of the use of HIT applications among targeted nursing homes. It was noted at the September 2008 TEP meeting that AHCA has a foundation that might consider fielding such a survey, particularly if additional support could be obtained (e.g., through The Commonwealth Fund). While surveys administered by provider groups or other long-term care stakeholders tend to have lower response rates than those fielded by the NCHS and may be subject to respondent bias (i.e., nursing homes who are members of the provider group may adopt HIT/EHR at higher rates than the industry as a whole), this information could be very valuable in assisting industry stakeholders in assessing specific patterns of use of HIT in nursing homes.

VI. PILOT TESTING

The surveys presented in this report are the result of rigorous developmental activities that integrate the expertise and experience of HIT, measure development, and long-term care experts represented on the project’s TEP. Before widespread administration, we recommend a pilot test of the survey questions and administration methods. Pilot testing with a small sample of nursing home respondents will provide the opportunity to examine and improve the clarity of wording for question stems and response options, refine administration methods, and assess respondent burden. The core survey questions should be tested as a stand-alone, self-administered pen and paper survey to simulate administration methods that would be used if fielded with the NNHS.

The expanded survey ideally would be first pilot tested as a pen and paper survey, refined, and then tested after conversion to an electronic format. The electronic, Web-based format likely would facilitate completion for respondents as skip patterns would be triggered electronically, allowing respondents to view only the follow-up questions relevant to their core question responses.

The surveys also may be conducive to other methods of administration (e.g., telephone or in-person interviews, or possible newly developed methods). However, pilot testing of the surveys using any intended methods should occur prior to full-scale administration using those methods.

REFERENCES

American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL). (2006). A Snap-Shot of the Use of Health Information Technology in Long Term Care. http://www.amda.com/news/othernews/2007/ahca_hit_longtermcarewhitepage1206.pdf [On-line].

American Health Information Management Association (AHIMA). (2007a). 2007 Long Term Care (LTC) Health Information Technology (HIT) Summit working document. (Unpublished Document)

American Health Information Management Association (AHIMA). (2007b). HL7 LTC-Nursing Home EHR-S Functional Profile and Letter of Invitation. (Unpublished Document)

Bates, D.W. (2002). The quality case for information technology in healthcare. BMC Medical Informatics & Decision Making. 2:7.

Bates, D.W. & Gawande, A.A. (2003). Improving safety with information technology. New England Journal of Medicine. 348(25):2526-34.

Booz Allen Hamilton. (2006). Evaluation Design of the Business Case of Health Technology in Long-Term Care: Final Report. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, ASPE, HHS. http://aspe.hhs.gov/daltcp/reports/2006/BCfinal.htm [On-line].

Coleman, E.A., May, K., Bennett, R.E., Dorr, D., & Harvell, J. (2007). Report on Health Information Exchange in Post-Acute and Long-Term Care. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, ASPE, HHS. http://aspe.hhs.gov/daltcp/reports/2007/HIErpt.htm [On-line].

HIMSS (2007a). HIMSS Electronic Health Record. http://www.himss.org/ASP/topics_ehr.asp [On-line].

Institute of Medicine (IOM) Committee on Data Standards for Patient Safety. (2003). Key Capabilities of an Electronic Health Record System: Letter Report. Washington, DC: National Academies Press.

Kaushal, R., Shojania, K.G., & Bates, D.W. (2003). Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review. Archives of Internal Medicine. 163(12):1409-16.

Kramer, A., Richard, A.A., Epstein, A., Winn, D., May, K. (2009). Understanding the Costs and Benefits of Health Information Technology in Nursing Homes and Home Health Agencies: Case Study Findings. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, ASPE, HHS. http://aspe.hhs.gov/daltcp/reports/2009/HITcsf.htm [On-line].

Middleton, B., Hammond, W.E., Brennan, P.F., & Cooper, G.F. (2005). Accelerating U.S. EHR adoption: How to get there from here. Recommendations based on the 2004 ACMI retreat. Journal of the American Medical Informatics Association. 12(1):13-9.

National Alliance for Health Information Technology Report to the Office of the National Coordinator (ONC) for Health Information Technology. (2008). Defining Key Health Information Technology Terms. http://healthit.hhs.gov/defining_key_hit_terms [On-line].

Poon, E., Jha, A., Christino, M., Honour, M., Fernandopulle, R., Middleton, B., et al. (2006). Assessing the level of healthcare information technology adoption in the United States: A snapshot. BMC Medical Informatics and Decision Making. 6:1.

Richard, A., Kaehny, M., May, K., & Kramer, A. (2008). Literature review and synthesis: Existing surveys on health information technology. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, ASPE, HHS. http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm [On-line].

Robert Wood Johnson Foundation. (2006). Health Information Technology in the United States: The Information Base for Progress. With the George Washington University School of Public Health and Health Services and the Institute for Health Policy at Massachusetts General Hospital. http://www.rwjf.org/files/publications/other/EHRReport0609.pdf [On-line].

RTI International with George Washington University and Massachusetts General Hospital on behalf of National Coordinator for Health Information Technology. (2006). Supporting statement prepared for the Office of Management and Budget (Unpublished Document).

Shekelle, P., Morton, S., & Keeler, E. (2006). Costs and Benefits of Health Information Technology. Evidence Report/Technology Assessment No. 132. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication 06-E006.

Stratis Health. (2008). Minnesota Nursing Home Health Information Technology Survey: Survey Results. Submitted to the Minnesota Department of Health, Minnesota e-Health Initiative. Minnesota: Stratis Health.

University of Colorado, Division of Health Care Policy and Research. (2007). Taxonomy of Health Information Technology in Nursing Homes -- Report B: Review by Representatives from Nursing Homes and Vendors. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, ASPE, HHS. http://aspe.hhs.gov/daltcp/reports/2007/Taxonomy-NH.htm [On-line].

APPENDIX A. LITERATURE REVIEW AND SYNTHESIS

An extensive review of the literature was conducted early in the project to provide foundational and contextual understanding for the construction of new survey questions to measure health information technology adoption in nursing homes. The literature review, entitled, Existing Surveys on Health Information Technology, Including Surveys on Health Information Technology in Nursing Homes and Home Health, is contained in this appendix and also can be accessed on the Office of the Assistant Secretary for Planning and Evaluation Website at http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm.

APPENDIX B. TECHNICAL EXPERT PANEL MATERIALS

Technical expert panel (TEP) members provided three rounds of feedback on survey development during the project. The initial round included review and ratings of draft survey items by e-mail in late summer 2008. Feedback from the pre-meeting review was compiled and used to help direct the two-day TEP meeting held in Washington, DC in September 2008. The discussion and recommendations from the TEP meeting significantly shaped the survey content and approach. After project team members revised the survey questions based on the TEP meeting recommendations, TEP members reviewed and provided feedback on the revised survey in spring 2009 via e-mail.

This appendix contains the following materials related to the fall 2008 TEP activities that helped guide development of the core and drill-down survey questions and administration recommendations (materials for the spring 2009 review are not included as the review did not involve ratings or structured questions).

B.1: List of TEP members

B.2: Materials used to obtain TEP feedback prior to the September 2008 meeting, including the following:

• Review instructions letter
• Core survey to complete
• Core survey ratings sheet

B.3: Compilation of the ratings and feedback received from the pre-meeting review

• Compiled ratings
• Comments from TEP members

B.4: Notes summarizing September 2008 TEP meeting discussion and recommendations

Survey Questions for EHR Adoption and Use in Nursing Homes

Technical Expert Panel Members

Anita Bercovitz, PhD National Center for Health Statistics Centers for Disease Control and Prevention Hyattsville, MD

Dan Cobb Health MEDX Ozark, MO

Michelle Dougherty, RHIA, CHP American Health Information Management Association Mahtomedi, MN

Yael Harris, PhD Office of the National Coordinator for Health Information Technology Washington, DC

Mary Jane Koren, MD Frail Elders Program The Commonwealth Fund Washington, DC

Peter Kress American Adults Retirement Communities and Retirement Resorts Retirement Life Support Services Amber, PA

William Kubat, MS The Evangelical Lutheran Good Samaritan Society Sioux Falls, SD

Nathan Lake, RN, BSN American HealthTech Jackson, MS

Barbara Manard, PhD American Association for Homes and Services for the Aging Washington, DC

William Marton, PhD Office of the Assistant Secretary for Planning and Evaluation Washington, DC

Frank McKinney Achieve Healthcare Technologies Eden Prairie, MN

Todd Smith American Health Care Association Washington, DC

Russell Williams SNF Technologies, LLC Atlanta, GA

University of Colorado DenverDivision of Health Care Policy and Research13611 East Colfax Avenue, Suite 100Aurora, CO 80045-5701Phone: 303-724-2400Fax: 303-724-2530

September 5, 2008

Dear __________:

We appreciate your willingness to participate in the TEP meeting on September 24 and 25 in Washington, DC, for the project to develop survey questions related to health information technology in nursing homes. This letter provides project background, a description of the attachments, and instructions to complete two documents: a rating form for the draft core survey and the draft core survey itself. We ask that you return them to our office by September 17th. We will use your consolidated responses to these ratings as a basis for the meeting. Please let us know if you have any questions regarding these ratings.

Background

The Office of the Assistant Secretary for Planning and Evaluation (ASPE), through a contract with the University of Colorado Denver Division of Health Care Policy and Research (HCPR), is developing survey questions to measure the adoption, barriers, and use of electronic health records (EHRs) and health information technology (HIT) in nursing homes. Survey questions are composed of 1) a set of core questions that could potentially be added to the National Nursing Home Survey (NNHS) periodically fielded by the National Center for Health Statistics; and 2) an expanded set of survey questions that could be used by public and private sector entities interested in measuring issues related to EHR/HIT in nursing homes.

Core survey questions will focus on the level of automation used to support several key work functions (e.g., clinical notes, medication administration, provider orders), as well as identifying barriers and incentives that may influence HIT adoption. It is anticipated that this set of 10-12 questions may be fielded with the NNHS. Questions could be provided (electronically or surface mail) along with the staffing questionnaire portion of the NNHS to the nursing home administrator or delegated individual prior to the telephone interview. During the telephone interview, the interviewer would request that the NH respondent refer to the list of questions and provide verbal responses, which would be data entered along with other NNHS responses.

The expanded survey is intended for administration via an electronic (Web) format and could be fielded by long-term care stakeholder groups. We anticipate that survey respondents will be Nursing Home Information Systems officers or delegated individuals. Respondents will first respond to care survey questions. The response for each core question will trigger follow-up questions designed to provide additional information about specific functionalities. For example, if the respondent indicated that a specific HIT application has health information exchange (HIE) capabilities, a follow-up questions will inquire whether the application incorporates HIE for semantic or messaging standards.

Attachments

There are six attachments to this document.

1. Meeting Agenda
2. Core Survey--includes an instruction sheet and then five sections of questions
3. Rating from for the core survey
4. Branch on Drill-Down Questions for Expanded Survey
5. List of Other Related Questions on HIT Adoption from Selected Surveys
6. Literature review

The second and third documents, the core survey and rating form for the core survey, are electronic documents in Microsoft Word, which you can save and then fill out. Instructions are provided in this letter and with the core survey. Once you have completed them, please send them back in a reply e-mail to angela.richard@uchsc.edu. The other documents are for you to review prior to the meeting. As you can see from the agenda, the first day will be spent on the core survey using consolidated information that you provided to us related to the core survey. The second day will be devoted to the expanded survey.

Instructions

Core Survey: Please complete the core survey questions as if you were a nursing home administrator (or person delegated by the administrator) completing the survey. If possible, use your knowledge of the HIT applications in use at a particular nursing home, with which you are very familiar.

Rating Form: Please rate each question on a three-point Likert scale for the following three criteria:

1. Clarity of wording--“1” represents “not clear enough to complete,” and “3” represents “as clear as it needs to be.” Please provide specific rewording suggestions if you think they are required.

2. Importance for the survey--“1” represents “do not include in survey,” and “3” represents “definitely include in survey.”

3. Likely response variability--“1” represents “likely to vary only minimally across nursing homes,” and “3” represents “substantial variability is likely.”

In addition to completing the evaluation of the core questions, please review the branch or drill-down questions for scope, clarity, and relevance. We will be obtaining your feedback on these items during the meeting. We also plan to discuss the feasibility of the current plans for fielding the survey. We look forward to your input and the subsequent discussion. Call if you have questions (303-724-2500). We look forward to seeing you in Washington and thanks again.

Sincerely,

/S/Andrew Kramer, MDPrincipal Investigator

/S/Angela Richard, MS, RNProject Director

Survey on Use of Health Information Technology and Barriers and Incentives to Use in Nursing Homes

Core Survey¹

INSTRUCTIONS

Survey Sections

Section 1: MDS Automation Section 2: Electronic Capability of Clinical Work Functions Section 3: Surveillance Data Transmission Section 4: Barriers to HIT Adoption and Use Section 5: Incentives for HIT Adoption and Use

Survey Instructions by Section

Section 1: Indicate how you enter, store, and transmit MDS data based on the five questions.

Section 2: Questions 2.1-2.14 ask you to rate your facility’s level of electronic capability for 14 functions. Please select the response option that best reflects the system used at your facility for each function based on the highest level of automation currently used--not just installed or available, but actually used--even if not used system-wide (e.g., used only on one unit or by particular provider types, or other by some individuals).

For each function, please choose one of five response options that represent increasing levels of electronic capability, from none (i.e., paper system) to an integrated electronic system that supports information exchange within and outside of your facility (and health network, if relevant). Each level is named to indicate the additional capacity gained by the level, as shown below.

Level a: Paper System Level b: Electronic Storage and Access within Facility/Health Network Level c: Point of Care Data Input Level d: Integrated Systems within Facility/Health Network Level e: Electronic Information Exchange with Outside Providers or Contractors

To clarify each level, a description is provided on the following five dimensions in the table above the questions:

• Information input
• Information storage
• Information access within facility/health network
• Internal system integration within facility/health network
• Information exchange with outside providers or contractors

Please use the table as a reference when responding. The table highlights the progressive/cumulative nature of information management. The addition of electronic capacity from one level to the next is highlighted by the use of italics and by the level name. For example, the change from Level a to Level b is characterized by additional electronic capacity with regard to three dimensions: information input, storage, and access (in italics). Level b is named “Electronic Storage and Access” to reflect this added capacity.

Section 3: Answer the two questions related to surveillance data transmissions.

Section 4: For each factor listed, please indicate how much of a barrier it was or currently is to purchasing and using electronic systems for clinical work functions in your facility.

Section 5: Please rate the impact that each of the possible policy changes would have on your decision to adopt health information technology, or your perception of their impact on adoption among nursing homes generally. Also indicate whether the impact was/is positive or negative.

Section 1: MDS Automation

1.1  How does your facility collect MDS data?

_____ a - MDS data are collected using paper form and data entered at a central location (e.g., by a data entry clerk) _____ b - MDS data are entered into an electronic system at point of care

1.2  How does your facility store MDS data?

_____ a - MDS data are not stored electronically, hard copies only are maintained _____ b - MDS data are stored electronically in a database separate from the medical record _____ c - MDS data are stored electronically within an electronic medical record

1.3  Are MDS data transmitted electronically to entities other than those required by CMS?

_____ a - No _____ b - Yes, to physicians _____ c - Yes, to other providers when residents are transferred _____ d - Yes, to a third party that audits them _____ e - Yes, to other entities (specify): _________________________

1.4  Does the information exchange application incorporate any messaging or semantics standards? Mark all that apply.

_____ a - Only text is exchanged _____ b - Health Level 7 (HL7) (specify): _________________________ _____ c - Laboratory Logical Observation Identifier Name Codes (LOINC) _____ d - SNOMED CT _____ e - National Council on Prescription Drug Programs (NCPDP) _____ f - Institute of Electrical and Electronics Engineers 1073 (IEEEE 1073) _____ g - Digital Imaging Communications in Medicine (DICOM) _____ h - Other (specify): _________________________

1.5  Are fields on electronic MDS forms populated from other electronic applications?

_____ a - No _____ b - Yes

Section 2: Electronic Capability of Clinical Work Functions: Using Levels a-e as described below, rate your facility’s level of electronic capability for each of the functions listed in 2.1-2.14.

Dimension	Level a:Paper System	Level b:Electronic Storage and Access within Facility/Network	Level c:Point of Care Data Input	Level d:Integrated Systems (Facility/Health Network)	Level e:Electronic Information Exchange (External)
Information Input	Clinical and clerical staff handwrite or type notes, use hard copy forms	Clerical and/or clinical staff enter handwritten or typed information electronically at central workstation -- no point of care data input	Clinical staff enter information electronically at point of care (when relevant) -- using kiosk, laptop, PDA, bar code reader	Clinical staff enter information electronically at point of care (when relevant) -- using kiosk, laptop, PDA, bar code reader	Clinical staff enter information electronically at point of care (when relevant) -- using kiosk, laptop, PDA, bar code reader
Storage	Information stored in hard copy only	Information stored electronically	Information stored electronically	Information stored electronically	Information stored electronically
Access	All staff receive information by hard copy	“Anywhere/ anytime” electronic access for authorized staff (onsite, remote)	“Anywhere/ anytime” electronic access for authorized staff (onsite, remote)	“Anywhere/ anytime” electronic access for authorized staff (onsite, remote)	“Anywhere/ anytime” electronic access for authorized staff (onsite, remote)
Internal System Integration	No electronic system	Not integrated with other clinical or administrative record components or software systems within the facility	Not integrated with other clinical or administrative record components or software systems within the facility	Integrated electronic functions within facility information exchange (e.g., medication orders populate MAR) accomplished by a) single software product that includes multiple functions or b) interfaces built between unique products or systems	Integrated electronic functions within facility. Information exchange (e.g., medication orders populate MAR) accomplished by a) single software product that includes multiple functions or b) interfaces built between unique products or systems
Information Exchange (External)	Hard copy information exchange with outside providers and contractors (e.g., unaffiliated physician group, hospital, pharmacy), including fax, e-mail, mail	Hard copy information exchange with outside providers and contractors, including fax, e-mail, mail	Hard copy information exchange with outside providers and contractors, including fax, e-mail, mail	Hard copy information exchange with outside providers and contractors, including fax, e-mail, mail	Electronic information exchange with outside providers, contractors with or without use of standards. One-way or two-way information transmission between facility and external systems. Ex: Hospital data populates or can be pulled in to facility health record, facility order entry system transmits and/or receives data to/from pharmacy order/distribution system

Level		a	b	c	d	e
2.1	Resident Demographic Data
2.2	Problem Lists (list of conditions [potentially] affecting resident physical or psychosocial status and requiring facility evaluation)
2.3	Assessment/Care Planning (other than MDS)
2.4	Dietary Management (e.g., special diets, meal tickets, etc.)
2.5	Resident Activities Management
2.6	Clinical Notes (except CNA notes)
2.7	Medication Administration Record (MAR)
2.8	CNA Charting and Workflow (e.g., electronic task lists by resident)
2.9	Decision Support Tools, Alerts, Reminders (e.g., flags for drug interactions, preventive screening reminders)
2.10	Provider Orders - Medications
2.11	Provider Orders -- Other than Meds
2.12	Lab Results
2.13	Radiology Results
2.14	Resident Summary Reports (e.g., discharge summaries)

Section 3: Surveillance Data Transmission

3.1  Do you use an electronic system for transmitting information on notifiable diseases to meet public health reporting requirements?

_____ a - No _____ b - Yes

3.2  If no to 3.1, are you unable to transmit information electronically due to your system capabilities or due to the capabilities of the receiving end/county Health Department?

_____ a - Facility capabilities _____ b - Recipient capabilities

Section 4: Barriers to HIT Adoption and Use: For each factor listed, please indicate how much of a barrier it was or currently is to purchasing and using electronic systems for clinical work functions in your facility.

		Not a barrier0	Minimum barrier1	Moderate barrier2	Major barrier3
Financial Barriers
4.1	The amount of capital needed to acquire and implement
4.2	Uncertainty about the return on investment (ROI)
Organizational Barriers
4.3	Resistance from facility staff
4.4	Lack of IT personnel/expertise within organization
4.5	Capacity to select, contract, install, and implement a software/technology system
4.6	Capacity to train staff
4.7	Concern about loss of productivity during transition to the new system(s)
4.8	Difficulty transitioning historic information into new systems or maintaining historic information in paper record and new information in electronic record during transition period (or indefinitely if no plans to transition historic information)
Legal or Regulatory Barriers
4.9	Concerns about inappropriate disclosure of protected health information (i.e., breaches of resident confidentiality)
4.10	Concerns about the ability to keep resident data private and secure (including illegal record tampering or “hacking”)
4.11	Concerns about the legality of accepting an EHR that is donated from a hospital
4.12	Concerns about legal liability if residents have more access to information in their medical records
4.13	State regulations preventing acceptance of electronic signatures
State of the Technology
4.14	Finding a system that meets the needs of users in your facility
4.15	Concerns that the system will become obsolete (e.g., due to concerns about vendor ability to upgrade and/or support products on an ongoing basis)
4.16	Software incompatibilities with established system (e.g., administrative software products)
4.17	Hardware incompatibilities
4.18	Difficulty obtaining or maintaining wireless access (e.g., if located in rural area)

Section 5: Incentives for HIT Adoption and Use: Please rate the impact that each of the possible policy changes listed below would have on your decision to adopt health information technology, or your perception of their impact on adoption among nursing homes generally. Also indicate whether the impact was/is positive or negative.

		No impact0	Minor impact1	Moderate impact2	Major impact3	Pos.  +	Neg.  -
5.1	Removal of legal or regulatory barriers (e.g., regulatory changes recognizing and accepting electronic signatures)
5.2	Certification identifying EHRs meeting published standards
5.3	Subsidies for the purchase of an EHR or other electronic functions such as e-prescribing (e.g., tax credits, low interest loans, grants)
5.4	Additional payments (i.e., reimbursement) for the use of an EHR or other electronic functions such as e-prescribing
5.5	Lower liability insurance premiums for facilities using EHRs
5.6	Use of technology to support quality improvement as a Pay for Performance incentive
5.7	Use of technology to support inclusion of NHs as part of an HIT demonstration program
5.8	Other (specify):

Thank you for participating.

ASPE/University of Colorado NH HIT Core Survey -- 9/2008

Survey on Use of Health Information Technology and Barriers and Incentives to Use in Nursing Homes

Core Survey Rating Sheet¹

		Clarity1, 2, or 3	Importance for Survey1, 2, or 3	Likely Respond Variability1, 2, 3	Comments
1.	MDS Automation
1.1	How does your facility collect MDS data? Mark all that apply.
1.2	How does your facility store MDS data?
1.3	Are MDS data transmitted electronically to entities other than those required by CMS?
1.4	Does the information exchange application incorporate any messaging or semantics standards? Mark all that apply.
1.5	Are fields on electronic MDS forms populated from other electronic applications?
2.	Electronic Capability of Clinical Work Functions
2.1	Resident Demographic Data
2.2	Problem Lists (list of conditions [potentially] affecting resident physical or psychosocial status and requiring facility evaluation)
2.3	Assessment/Care Planning (other than MDS)
2.4	Dietary Management (e.g., special diets, meal tickets, etc.)
2.5	Resident Activities Management
2.6	Clinical Notes (exc. CNA)
2.7	Medication Administration Record (MAR)
2.8	CNA Charting and Workflow (e.g., electronic task lists by resident)
2.9	Decision Support Tools, Alerts, Reminders (e.g., flags for drug interactions, preventive screening reminders)
2.10	Provider Orders - Medications
2.11	Provider Orders -- Other than Meds
2.12	Lab Results
2.13	Radiology Results
2.14	Resident Summary Reports (e.g., discharge summaries)
3.	Surveillance Data Transmission
3.1	Do you use an electronic system for transmitting information on notifiable diseases to meet public health reporting requirements?
3.2	If no to 3.1, are you unable to transmit information electronically due to your system capabilities or due to the capabilities of the receiving end/county Health Department?
4.	Barriers to HIT Adoption and Use
4.1	The amount of capital needed to acquire and implement
4.2	Uncertainty about the return on investment (ROI)
4.3	Resistance from facility staff
4.4	Lack of IT personal/expertise within organization
4.5	Capacity to select, contract, install and implement a software/technology system
4.6	Capacity to train staff
4.7	Concern about loss of productivity during transition to the new system(s)
4.8	Difficulty transitioning historic information into new systems or maintaining historic information in paper record and new information in electronic record during transition period for indefinitely if no plans to transition historic information
4.9	Concerns about inappropriate disclosure of protected health information (i.e., breaches of resident confidentiality)
4.10	Concerns about the ability to keep resident data provide and secure (including illegal record tampering or “hacking”)
4.11	Concerns about the legality of accepting an EHR that is donated from a hospital
4.12	Concerns about legal liability if residents have more access to information in their medical records
4.13	State regulations preventing acceptance of electronic signature
4.14	Finding a system that meets the needs of users in your facility
4.15	Concerns that the system will become obsolete (e.g., due to concerns about vendor ability to upgrade and/or support products on an ongoing basis)
4.16	Software incompatibilities with established systems (e.g., administrative software products)
4.17	Hardware incompatibilities
4.18	Difficulty obtaining or maintaining wireless access (e.g., if located in rural area)
5.	Incentives for HIT Adoption and Use
5.1	Removal of legal or regulatory barriers (e.g., regulatory changes recognizing and accepting electronic signatures)
5.2	Certification identifying EHRs meeting published standards
5.3	Subsidies for the purchase of an EHR or other electronic functions such as 3-prescribing (e.g., tax credits, low interest loans, grants)
5.4	Additional payments (i.e., reimbursement) for the use of an EHR or other electronic functions such as e-prescribing
5.5	Lower liability insurance premiums for facilities using EHRs
5.6	Use of technology to support quality improvement as a Pay for Performance incentive
5.7	Use of technology to support inclusion of NHs as part of an HIT demonstration program
5.8	Other (specify):

ASPE/University of Colorado NH HIT Survey

FINAL VERSION 093008

CORE SURVEY RATINGS

1 MDS	DC	PK	BK	FM	RW	MD	TS	N	a	b	c	d	e	f	g	h	NR
1.1	b	b	a	b	b	b	a	7	28.6%	71.4%	---	---	---	---	---	---	0
1.2	c	c	b	c	bc	c	b	7	0.0%	42.9%	71.4%	---	---	---	---	---	0
1.3	d	a	d	d	de	a	a	7	42.9%	0.0%	0.0%	57.1%	14.3%	---	---	---	0
1.4	a	a	ab	a	a	h	a	7	85.7%	14.3%	0.0%	0.0%	0.0%	0.0%	0.0%	14.3%	0
1.5	b	b	b	b	b	b	a	7	14.3%	85.7%	0.0%	---	---	---	---	---	0

2 Capability	DC	PK	BK	FM	RW	MD	TS	N	a	b	c	d	e	NR
2.1	e	d	b	e	bcd	c	b	7	0.0%	42.9%	28.6%	28.6%	28.6%	0
2.2	b	c	a	d	bcd	c	b	7	14.3%	42.9%	42.9%	28.6%	0.0%	0
2.3	c	c	ab	de	bcd	c	a	7	28.6%	28.6%	57.1%	28.6%	14.3%	0
2.4	a	c	a	de	bcd	c	a	7	42.9%	14.3%	42.9%	28.6%	14.3%	0
2.5	c	c	c	b	bcd	c	a	7	14.3%	14.3%	71.4%	14.3%	0.0%	0
2.6	c	c	a	d	bcd	c	b	7	14.3%	28.6%	57.1%	28.6%	0.0%	0
2.7	c	a	a	b	bcd	c	a	7	42.9%	28.6%	42.9%	14.3%	0.0%	0
2.8	c	d	c	d	bcd	c	a	7	14.3%	14.3%	57.1%	42.9%	0.0%	0
2.9	c	c	a	d	bcd	c	a	7	28.6%	14.3%	57.1%	28.6%	0.0%	0
2.10	c	b	b	e	bcd	c	a	7	14.3%	42.9%	42.9%	14.3%	14.3%	0
2.11	c	a	b	d	bcd	c	a	7	42.9%	28.6%	42.9%	14.3%	0.0%	0
2.12	a	a	a	b	bcd	c	a	7	57.1%	28.6%	28.6%	14.3%	0.0%	0
2.13	a	a	a	b	bcd	c	a	7	57.1%	28.6%	28.6%	14.3%	0.0%	0
2.14	c	c	a	b	bcd	c	a	7	28.6%	28.6%	57.1%	14.3%	0.0%	0

3 Surveil.	DC	PK	BK	FM	RW	MD	TS	N	a	b	NR
3.1	a	b	a	a	a	a	a	7	85.7%	14.3%	0
3.2	a	ab	ab	a	ab	a	a	7	100.0%	42.9%	0

4 Barriers	DC	PK	BK	FM	RW	MD	TS	N	Pct 0	Pct 1	Pct 2	Pct 3	NR
4.1	3	3	3	2	3	2	NR	6	0.0%	0.0%	33.3%	66.7%	1
4.2	3	3	3	1	3	2	NR	6	0.0%	16.7%	16.7%	66.7%	1
4.3	2	1	2	1	3	1	NR	6	0.0%	50.0%	33.3%	16.7%	1
4.4	2	0	2	1	3	2	NR	6	16.7%	16.7%	50.0%	16.7%	1
4.5	2	1	2	1	3	2	NR	6	0.0%	33.3%	50.0%	16.7%	1
4.6	2	1	3	1	3	2	NR	6	0.0%	33.3%	33.3%	33.3%	1
4.7	2	1	2	1	3	2	NR	6	0.0%	33.3%	50.0%	16.7%	1
4.8	1	1	1	1	23	2	NR	6	0.0%	66.7%	33.3%	16.7%	1
4.9	1	0	1	0	3	1	NR	6	33.3%	50.0%	0.0%	16.7%	1
4.10	1	0	3	0	3	1	NR	6	33.3%	33.3%	0.0%	33.3%	1
4.11	0	0	1	1	3	0	NR	6	50.0%	33.3%	0.0%	16.7%	1
4.12	1	1	0	0	3	0	NR	6	50.0%	33.3%	0.0%	16.7%	1
4.13	1	1	2	0	0	2	NR	6	33.3%	33.3%	33.3%	0.0%	1
4.14	2	2	3	2	3	2	NR	6	0.0%	0.0%	66.7%	33.3%	1
4.15	1	2	1	0	3	1	NR	6	16.7%	50.0%	16.7%	16.7%	1
4.16	1	1	3	0	3	1	NR	6	16.7%	50.0%	0.0%	33.3%	1
4.17	1	0	1	0	3	1	NR	6	33.3%	50.0%	0.0%	16.7%	1
4.18	1	0	3	1	3	0	NR	6	33.3%	33.3%	0.0%	33.3%	1

5 Incent.	DC	PK	BK	FM	RW	MD	TS	N	Pct 0	Pct 1	Pct 2	Pct 3	NR	Pos	Neg	NR
5.1	1+	1+	3+	2+	3+	2+	NR	6	0.0%	33.3%	33.3%	33.3%	6	100.0%	0.0%	2
5.2	2+	2+	3+	1+	3+	2+	NR	6	0.0%	16.7%	33.3%	50.0%	6	100.0%	0.0%	2
5.3	3+	1+	3+	1+	3+	3+	NR	6	0.0%	50.0%	0.0%	50.0%	6	100.0%	0.0%	2
5.4	2+	3+	3+	1+	3+	3+	NR	6	0.0%	16.7%	16.7%	66.7%	6	100.0%	0.0%	2
5.5	1+	3+	3+	1+	3+	2+	NR	6	0.0%	33.3%	16.7%	50.0%	6	100.0%	0.0%	2
5.6	2+	3+	3+	2+	3+	3+	NR	6	0.0%	0.0%	33.3%	66.7%	6	100.0%	0.0%	2
5.7	1+	1+	3+	0+	3+	2+	NR	6	16.7%	33.3%	16.7%	33.3%	6	100.0%	0.0%	2
5.8	NR	NR	3+	NR	NR	NR	NR	1	0.0%	0.0%	0.0%	100.0%	6	100.0%	0.0%	6

NR = No Response 09/30/08

Survey on Use of Health Information Technology and Barriers and Incentives to Use in Nursing Homes

TEP Meeting

September 24-25, 2008

PARTICIPANT'S COMMENTS REGARDING SURVEY QUESTIONS

1.  MDS AUTOMATION

1.1.  How does your facility collect MDS data?

Dan Cobb (DC): Some data may be collected electronically, some on paper. Perhaps change to “mark all that apply” or add a third hybrid option. Or, the “b” option could say that “some data” entered at point of care (POC).

Yael Harris (YH): Suggest b is broken into two--data collected electronically sometimes (e.g., by CNAs) but not by others (e.g., therapist) and another option that ALL MDS data is collected electronically. Might want to acknowledge that small subset of homes do not transmit any of their data electronically

Nathan Lake (NL): There are more than 2 ways to do this. In fact, most facilities probably do both a and b in some combination.

Peter Kress (PK): MDS is a summary so each section sources information separately.

Frank McKinney (FM): The phrase “point of care” could be clarified here and where used elsewhere in the survey, e.g., would entry at a kiosk in the hallway suffice. Also, how should this be answered if the majority, but not all info is entered at point of care?

Michelle Dougherty (MD): The word point of care is confusing. Many who assess and complete the MDS are not doing it at the “point of care”. Reword--“assessors complete directly in the EHR” or something similar.

1.2.  How does your facility store MDS data?

DC: Similar issues to above. Some may store MDS electronically, while still printing hard copy and placing in the chart. It would be useful to know how many facilities store electronically, but also still print hard copy for the chart.

NL: I don’t know if most people would know if b or c is true. This also assumes they have an electronic medical record (EMR) and that is doubtful depending on how they define that term.

Bill Kubat (BK): Need a choice of electronic and hard copy.

MD: Is a even a probable answer with electronic submission requirements? When would an MDS be stored in a separate data base--would this be a stand-alone MDS module like RAVEN?

Barbara Manard (BM): On all of these questions, are you sure enough that you have covered all the possible options so you don’t need a “other” response?

1.3.  Are MDS data transmitted electronically to entities other than those required by CMS?

DC: Are multiples allowed?

PK: Consumer should be added. Not sure how significant it is that MDS specifically is transmitted. More interested in summary documents which could incorporate MDS.

MD: What about electronic submission to corporate offices?

BM: What do you mean by “transmitted electronically”? Does an e-mail count?

1.4.  Does the information exchange application incorporate any messaging or semantics standards?

DC: I believe most providers will not understand “information exchange application”. Also SNOMED should be spelled out or briefly explained. Finally the CDA, CCR, CCD should be added as a single option.

YH: Add “don’t know” as category.

NL: I am not sure how aware facility people are aware of this.

BK: Administrators won’t know.

PK: Detailed terminology knowledge won’t be available to those filing out form. MDS Context makes this particularly unclear. Perhaps better would be “textual” vs. “structure” vs. “standards-based”.

MD: A response of “I don’t know" is needed make sure that people do not just guess and decrease the accuracy. Although the question is clear, I think this will be a very difficult questions to answer--messaging and semantic interoperability is understood by a fairly small group. Consider rewording or delete.

1.5.  Are fields on electronic MDS forms populated from other electronic applications?

DC: “Other electronic applications” may be confusing--from external sources or internal?

BK: Clarify whether talking about demographic or clinical assessments.

NL: All major vendors that I am aware of make this possible. The better question might be whether the facility makes use of this. Also, all software allow a “pull forward” functionality from the previous MDS. This is something that many facilities do not allow.

PK: Different for different segments, options include paper sourced, electronically sources but keyed, electronically sourced automatically integrated.

MD: Will users understand other electronic applications? Consider “populated from information within the EHR/clinical system”.

2.  ELECTRONIC CAPABILITY OF CLINICAL WORK FUNCTIONS

2.1.  Resident Demographic Data

DC: As a general comment there will be gray areas. A provider may not have point of care, but may exchange information integrated systems (d) and External exchange (e) doesn’t necessarily guarantee point of care input.

YH: Find table very cumbersome. Can this be an appendix to the survey or a look up table if administered electronically?

NL: All software does this. I would rather see this entire section worded so that we can determine who has this functionality AND who actually uses it.

PK: In general, column d is problematic, wide variability of approach and result.

FM: Throughout this section, it wasn’t entirely clear where data entry at the point of care applies. This one seems less likely to involve point of care entry than others. It would be useful to provide more direction on this point to the reader. Another comment about the section in general: rising above level c requires point of care entry…that means that a facility with an integrated system (the level d differentiator) but not POC will be lumped in with level b facilities--and the survey will not reflect its additional capability. Likewise re the level b requirement for remote access…if a facility’s system isn’t Web-based can it get above level a? Lastly, does use of a tablet computer running a standard desktop app count for POC, or is it expected that there would be a more specialized application/module (e.g., touch screen w/no stylus needed).

BM: I found all of the questions in this section very confusing and pretty much impossible to answer, unless I am really willing to study the instructions. I would not count on people being willing to do that. My suggestion would be to go for greater simplicity, recognizing that you will have less precision. You need a simpler definition of the various “levels”.

2.2.  Problem Lists (list of conditions [potentially] affecting resident physical or psychosocial status and requiring facility evaluation)

NL: The term “problem list” is open to interpretation. Does this mean automatically generated lists based upon some facility input (e.g., diagnosis or risk assessments)?

FM: See above. I included the identification of new problems as a point of care event.

2.3.  Assessment/Care Planning (other than MDS)

BK: Two different questions.

PK: Confusing as assessment and care planning are typically separate steps in process, also and relationship to MDS is not always clear.

FM: See above. I didn’t see the care conference as a point of care opportunity, but did see that for tracking the follow-through on approaches.

MD: Consider separating assessments from care plans.

2.4.  Dietary/Management (e.g., special diets, meal tickets, etc.)

PK: Clarify between data collection, nutritional assessment, and service delivery.

FM: See above. Assumed that planning was not POC, but tracking intake and response is.

2.5.  Resident Activities Management

FM: As for Dietary Mgmt above. Point of care w/b relevant to tracking activity.

2.6.  Clinical Notes (exc. CNA)

NL: Why exclude CNA? This application is one that varies the most in functionality. Some are no more than just a text field. Others offer substantially more features.

MD: Consider clarifying--progress notes, weekly/monthly summary notes, etc. if all are included in this clinical notes category.

2.7.  Medication Administration Record (MAR)

DC: Add Treatment Administration (TAR)

NL: What about CPOE and electronic prescribing?

BK: And TAR (treatment administration).

PK: Distinguish between MAR and medication bar coding?

FM: Would interpret that level e requires use of an eMar.

MD: Does this also include TARs?

2.8.  CNA Charting and Workflow (e.g., electronic task lists by resident)

BK: Two different questions--also communication tools would be important here.

PK: Observation vs. task.

MD: Are workflow and charting always a combined application? May want to ask the question separately.

2.9.  Decision Support Tools, Alerts, Reminders (e.g., flags for drug interactions, preventive screening reminders)

YH: Ask to describe or select from drop down list.

PK: What does it mean to “data enter” alerts/reminders? Not sure the matrix works for this question.

MD: Does this mean the ability to enter med orders into the EMR, to the pharmacy or to the physician--only one of these or all three?

2.10.  Provider Orders--Medications

NL: Does this mean orders entered directly by the prescriber, or a system of documenting orders as entered by the nurse?

BK: Import to ask if physician can enter orders from home or office with acceptable electronic signature.

PK: Do we need to distinguish e-prescribing?

2.11.  Provider Orders--Other than Meds

YH: Might want to break out lab ordering.

NL: Same comment as above.

MD: Does this mean the ability to enter med orders into the EMR, to the pharmacy or to the physician--only one of these or all three?

2.12.  Lab Results

NL: Anything about receiving lab results electronically?

PK: How to answer self service Web access, vs. message based integration?

FM: Electronic lab communication isn’t very common, but I believe that the ability to upload faxed/PDF’d results is more frequently available (and better than nothing). Since the infrastructure for electronic labs, radiology isn’t widely available, would it be useful to track the lesser upload capability?

MD: Please clarify--would one answer the question the same if they received results from the lab on a separate system which wasn’t integrated into the EMR?

2.13.  Radiology Results

NL: Same comment as above.

FM: See above re. electronic labs.

MD: Please clarify--would one answer the questions the same if they received results from the lap on a separate system (or electronically--i.e., e-mail) which wasn’t integrated into the EMR?

2.14.  Resident Summary Reports (e.g., discharge summaries)

NL: Same comment as above.

MD: Very vague--are you talking about a discharge transfer form, consult form, the discharge summary (i.e., recap of stay).

PK: Matrix is difficult. Interesting aspects are how much of summary report is assembled by system. Is annotation manual, or keyed, and how is summary transmitted.

3.  SURVEILLANCE DATA TRANSMISSION

3.1.  Do you use an electronic system for transmitting information on notifiable diseases to meet public health reporting requirements?

YH: Clarify that this is NOT e-mail.

NL: I would really like to know if this capability is part of their core suite of applications, or a stand-alone non-integrated product.

PK: Should distinguish between Web self service reporting and message based integration.

BM: Need to give some “for examples.”

3.2.  If no to 3.1, are you unable to transmit information electronically due to your system capabilities or due to the capabilities of the receiving end/county Health Department?

DC: They may not know. Or, unable due to both?

YH: May need any other category.

MD: What about both answers being a possibility--include a box for both.

BM: What is the answer is “neither”--I have the capability and so does the HD, but we just don’t do it.

4.  BARRIERS TO HIT ADOPTIONG AND USE

4.1.  The amount of capital needed to acquire and implement

BM: I am rating all of these clear and important because they are clear and easy to fill out, hence useful to know, relative to the ease of complaint.

4.2.  Uncertainty about the return on investment (ROI)

4.3.  Resistance from facility staff

DC: Another factor to add: “Lack of support from board or executive management”.

BK: Should be asking about a change management methodology and whether staff have basic keyboarding skills--use e-mails, etc.

4.4.  Lack of IT personnel/expertise within organization

BK: Two separate questions.

MD: Would this be for both installation and ongoing management?

4.5.  Capability to select, contract, install, and implement a software/technology system

BK: Multiple questions. Should be more than one question.

MD: Should a separate question be asked about the use of agency/pool/ temp staff and the ability to train for the intricacies of the EMR?

4.6.  Capacity to train staff

BK: Capacity to backfill for staff being trained and to assist with workflow changes after initial implementation. Should be more than one question.

MD: Used EHR in this statement--EMR had been used in other parts of the survey.

4.7.  Concern about loss of productivity during transition to the new systems

4.8.  Difficulty transitioning historic information into new systems or maintaining historic information in paper record and new information in electronic record during transition period (or indefinitely if no plans to transition historic information)

BK: No value to this question.

NL: Too complex. Might be better as multiple items.

PK: Mixes multiple issues, data conversion vs. hybrid record are fundamentally different and, at times coincident problems.

4.9.  Concerns about inappropriate disclosure of protected health information (i.e., breaches of resident confidentiality)

DC: Mention HIPAA?

BK: Capacity to identify adequate security strategies.

PK: I don’t perceive a clear distinction between 4.9 and 4.10.

4.10.  Concerns about the ability to keep resident data private and secure (including illegal record tampering or “hacking”)

DC: Mention HIPPA?

YH: This g and 4.9 could be consolidated into single privacy question.

4.11.  Concerns about the legality of accepting an EHR that is donated from a hospital

NL: I would bet most have not even considered this possibility.

BK: Concern about meeting e-discovery requirements and electronic health exchange information as secondary information--keep or get rid of/lack of retention guidelines for secondary info transferred from another organization.

PK: Not sure how applicable this really is.

MD: Whether records are paper or electronic shouldn’t change what a resident has access to in their medical record. Perhaps this should be concern with the ability to provide electronic access.

4.12.  Concerns about legal liability if residents have more access to information in their medical records

BK: Residents wouldn’t have more access than they do now--can access entire chart in hard copy if needed.

PK: hmmm.

4.13.  State regulations preventing acceptance of electronic signatures

YH: This will not be a barrier in just a few years.

BK: Lack of federal standards for electronic signatures--so states do not have different requirements.

PK: Excuse only.

4.14.  Finding a system that meets the needs of users in your facility

BK: Multi-state centers have to meet data collection requirements because of another state regulation the organization practices in.

4.15.  Concerns that the system will become obsolete (e.g., due to concerns about vendor ability to upgrade and/or support products on an ongoing basis)

4.16.  Software incompatibilities with established systems (e.g., administrative software products)

BK: Additional question might be--Lack of interface engine to easily build interfaces as well as lack of mobile Web-based learning software availability (other than for iPhones).

PK: Perhaps reword to something like “challenges of integrating disparate systems”.

4.17.  Hardware incompatibilities

BK: Ability to afford replacement of hardware periodically.

PK: Reword to “cost of acquiring/replacing hardware”?

MD: Where would you place concerns with having enough hardware in the facility adequately maintain an EMR?

4.18.  Difficulty obtaining or maintaining wireless access (e.g., if located in rural areas)

DC: Another factor “Concerns about system availability and reliability”.

BK: Additional item might be bandwidth limitation and network costs. Need additional clarification.

FM: Is this referring to simply Internet access or to wireless networking inside the facility? Being a rural facility would impact Internet access but not wireless networking (e.g., for POC devices), I’d suggest having one question about Internet availability and a separate question about cost/complexity of establishing a wireless network.

5.  INCENTIVES FOR HIT ADOPTION AND USE

5.1.  Removal of legal or regulatory barriers (e.g., regulatory changes recognizing and accepting electronic signatures)

BK: Standard format for health information exchange and recognition or legal ownership and responsibilities for secondary information receive from another organization as miscellaneous information.

PK: Too generic. Generally I think the pos/neg indicators are redundant as the questions are phrased to equate size of impact to the positive.

FM: Could break out different areas of regulation, electronic signatures in general, pharmacy board regulations, state NH regs, etc.

BM: I don’t think people can give meaningful answers to these questions as written because it all depends on the details of the policy changes--for example, “payments” depends on “how much”; my guess is that people will answer anyway, assuming the details are to their liking, but I’d suggest rethinking how to address this section.

5.2.  Certification identifying EHRs meeting published standards

YH: Need better language. Many will not know what certification is/means.

BK: Standards for certification need to advance in depth--having a function and doing it according to an efficient workflow are two different things!

MD: May want to clarify--external agency validates and certifies EHR product and adherence to published standards.

5.3.  Subsidies for the purchase of an EHR or other electronic functions such as e-prescribing (e.g., tax credits, low interest loans, grants)

PK: First use of e-prescribing, so suggest lack of clarify regarding components being evaluated.

5.4.  Additional payments (i.e., reimbursement) for the use of an EHR or other electronic functions such as e-prescribing

5.5.  Lower liability insurance premiums for facilities using EHRs

5.6.  Use of technology to support quality improvement as a pay for performance incentive

NL: This is worded differently than the rest of the items in this section. Not sure what it means.

5.7.  Use of technology to support inclusion of NHs as part of an HIT demonstration program

NL: Same comment as above.

FM: This question isn’t clear to me. Would the incentive be free or reduced-cost access to technology due to a grant or subsidy?

5.8.  Other (specify)

DC: Another factor: “Readily available objective business cases and returns on investments”.

NL: There is nothing about electronic communication (Health Level 7 for demographics, e-prescribing, etc.).

BK: Incentives to implement a Content Management System with document imaging to be paperless and to assist with workflow design and improvements. Defined federal standard for cut, copy and past functions in EHR. Define requirements for printing an entire EHR for the legal system.

Additional comments:

YH: Found the format of the survey to be difficult to navigate. Will this survey be electronic or paper based? If it is paper based, I suggest that the table for section 2 be a separate document that they can reference as they work through the questions. I also recommend that we ask if they have an EHR (we can then map that response to the functionalities that they claim they have) and whether it is Certification Commission for Healthcare Information Technology (CCHIT) certified. Another thing knowing is the size of the facility, if they are affiliated with a hospital, if they are for profit or not for profit, and their location, how long have they been doing each of these functionalities. And for those who don’t have an EHR, do they plan on buying one in the next 6-12 months? In the next 2-5 years? We are adding two questions to the NAMC survey going forward that might be valuable to add to the survey:

(Note that the language will be changed to EHR in the final survey.)

I think we need to recognize that providers may not know which standards they are using so it is probably more practical to ask them if they are using products that are CCHIT certified rather than whether they are using LOINC, SNOMED, etc. Finally, I think it would be great to ask them about their plans to purchase/upgrade in the future. (I believe I mentioned this in my e-mail below but wanted to re-emphasize the point.)

Survey Questions for EHR Adoption and Use in Nursing Homes

Notes from Technical Expert Panel (TEP) Meeting

Office of the Assistant Secretary for Planning and Evaluation (ASPE)Humphrey Building Health Policy Conference Room 443F, Washington, DCSeptember 24-25, 2008

Meeting Participants

Anita Bercovitz, PhD National Center for Health Statistics Centers for Disease Control and Prevention Hyattsville, MD

Dan Cobb Health MEDX Ozark, MO

Michelle Dougherty, RHIA, CHP American Health Information Management Association Mahtomedi, MN

Yael Harris, PhD Office of the National Coordinator for Health Information Technology Washington, DC

Mary Jane Koren, MD Frail Elders Program The Commonwealth Fund Washington, DC

Peter Kress American Adults Retirement Communities and Retirement Resorts Retirement Life Support Services Amber, PA

William Kubat, MS The Evangelical Lutheran Good Samaritan Society Sioux Falls, SD

Nathan Lake, RN, BSN American HealthTech Jackson, MS

Barbara Manard, PhD American Association for Homes and Services for the Aging Washington, DC

William Marton, PhD Office of the Assistant Secretary for Planning and Evaluation Washington, DC

Frank McKinney Achieve Healthcare Technologies Eden Prairie, MN

Todd Smith American Health Care Association Washington, DC

Russell Williams SNF Technologies, LLC Atlanta, GA

Project Officer

Jennie Harvell Office of the Assistant Secretary for Planning and Evaluation Washington, DC

University of Colorado Denver

Andrew Kramer, MD Principal Investigator

Angela Richard, MS, RN Project Director

Survey Questions for EHR Adoption and Use in Nursing Home

Technical Expert Panel (TEP) Meeting

September 24-25, 2008

Agenda

September 24, 2008--Core Survey
8:00 a.m.	Continental Breakfast
8:30 a.m.	Welcome and Introductions
9:00 a.m.	Overview of Project Background and Goals
9:30 a.m.	TEP Member General Comments on Draft Core and Expanded Survey Questions, Including Alignment with Existing Surveys
10:30 a.m.	Break
10:45 a.m.	Summary of TEP Feedback: Proposal Fielding of Core and Expanded Surveys
11:15 a.m.	Discussion--Core Survey Section 2 (Clinical Work Functions)
12:15 p.m.	Lunch (catered)
1:00 p.m.	Discussion--Core Survey Sections 1 (MDS) and 3 (Public Health Reporting)
2:00 p.m.	Discussion--Core Survey Section 4 (Barriers)
2:30 p.m.	Break
2:45 p.m.	Discussion--Core Survey Section 5 (Incentives)
3:30 p.m.	Discussion--Facility Characteristics
4:00 p.m.	Additional Discussion of Fielding Issues and Wrap-Up Comments
4:30 p.m.	Adjourn
September 25, 2008--Expanded Survey
8:00 a.m.	Continental Breakfast
8:30 a.m.	Overview of Expanded Survey and Break-out Groups to Discuss Assigned Subsets of Survey Questions
10:15 a.m.	Break
10:30 a.m.	Discussion of Break-out Group Input on Expanded Survey Questions
11:30 a.m.	Discussion of Time Frames and Next Steps and Wrap-up Comments
12:00 p.m.	Adjourn

Meeting Summary

Overview and TEP Member Initial Comments

Jennie Harvell and Andy Kramer opened the meeting with a brief overview of the policy background for funding the project and overall project goals. A summary of the draft survey design and potential fielding applications were discussed.

The articulated goals for the meeting were to obtain feedback on:

• Draft survey items alignment with existing surveys
• Proposed survey fielding in collaboration with the NNHS and other private sector surveys, needed facility data, and needed next steps to pursue prior to fielding
• Potential core item refinements (work functions and response scale)
• Potential expanded item refinements

Prior the meeting, TEP members had been provided with the draft survey items and asked to: (a) complete the items based on knowledge of a particular nursing home system (if possible); and (b) to rate the items in terms of clarity, importance and potential response variability. After the start of the TEP meeting, each TEP member was given the opportunity to provide general comments on the draft survey. Key points from the initial comments are listed below.

• Responses to the overall survey approach were generally positive.

• A point was made that historical motivation to adopt HIT applications may be predictive of future HIT adoption efforts.

• There were some concerns about the complexity of questions (particularly question #2 on the core survey) and consistent use of terms.

• There were some concerns about the ability of the potential respondents to answer all questions. Some questions may be more appropriate for a clinical expert to answer while others may require administrative input.

• There were concerns about the length of the expanded survey and potential burden to nursing homes.

• Very few people would be able to answer the question on specific standards (an expanded survey question).

• Another study funded by the Commonwealth Foundation is conducting a market scan of HIT applications available to nursing homes and identifying barriers to adoption. Their work may help inform this project.

• The current wording of the barriers section has a negative tone. However, the concept is important for many audiences, including vendors and policymakers.

• The current questions may not work for more than one fielding method, such as in-person data collection effort (i.e., NNHS) and an on-line survey.

• Comments were mixed on the need to align the survey with existing surveys addressing HIT adoption in other provider settings. From a policy setting, it is important to track adoption rates across settings. However, if this approach is judged to be superior to those used in existing surveys, it should be used.

• Text fields for comments should be allowed.

• The current scale for the clinical functions (question #2 on the core survey) may not adequately distinguish levels of adoption. For example, it does not really indicate if systems are fully implemented vs. partially implemented.

• Some of the clinical function areas are too broad (e.g., assessment and care planning).

• The surveys do not include any infrastructure questions, such as securities and records management.

• The survey approach should take a futuristic viewpoint. The industry is rapidly changing, roles and definitions are changing, software solutions are rapidly changing. A maturation model of HIT adoption may be a better approach.

• There should be a heavier emphasis on aligning with the industry developments such as the Long-Term Care-Nursing Home EHR-System Functional Profile.

Discussion of Core Survey

Peter Kress raised the possibility of assessing general functions vs. specific “tracer” functions (e.g., would a wound assessment be a tracer for assessments in general?). The group voted to retain the focus on general functions for the core survey and to address specifics on the expanded questions.

A comment was made that our list contained both clinical functions and data sets (e.g., problem lists). Other surveys similarly list both as “functions”. Dietary management and resident activity management are separate modules and should be dropped from the core list of functions.

A new scale was proposed for level of automation:

Level A: Paper Level B: Combination paper and electronic Level C: Point of Service electronic

For each application, a question on decision support (y/n) will be asked (see further discussion of this topic in the discussion of the expanded survey below).

The following key areas for the core survey were identified:

1. Functions/applications
   • Resident Demographics
   • Advance Directives
   • Clinical Notes: Attending medical doctor (MD)
   • Clinical Notes: registered nurse
   • Clinical Notes: certified nurse assistant (CNA) observations and notes
   • Problem List
   • Allergy List
   • Medication Administration
   • Treatment Administration
   • MDS Assessment
   • Non-MDS Assessment
   • Care Plan
   • Task List (e.g., CNA workflow)
2. Results Viewing
   • Labs
   • Xrays
   • Consults
3. Order Entry
   • Med Order Entry--Nurse
   • Med Order Entry--Prescriber
   • Other Order Entry--Nurse
   • Other Order Entry--Prescriber
4. Telehealth/Telemonitoring
   • Telehealth (One question: Do you incorporate? y/n)
   • Telemonitoring (One question: Do you incorporate? y/n)

An information exchange scale was created/added for a key set of functionalities (identified below).

For each function, mark all that apply:

Level A: Information sharing across applications (enter data once, access as appropriate) Level B: Receives data from external organization Level C: Sends data to external organization N/A: None of the above

Each of the following areas should be rated on the information exchange scale:

• Demographics
• Notes and observations
• Assessments
• Lists: problems, allergies, meds
• Med orders/e-prescribing
• Ancillary orders (Xrays, labs, DME, therapies, etc.)
• Lab orders and results
• Other ancillary results (e.g., Xrays, labs)
• Summary reports (discharge, transfer, consults)
• Advance directives
• Public health reporting (e.g., tuberculosis, etc.)

In addition, a few areas for single questions for the core survey were identified:

1. Quality Management Reports (see draft expanded survey, item CDT-3 for response options).
2. Summary Reports (transfer, discharge, etc.).

Discussion of Expanded Survey (drill-down questions)

1. For function/application, if respondent marks levels of automation b and c described on page A-123 of these notes, drill-down:
   1. Is authoritative record paper or electronic? (y/n)
   2. If electronic, does facility maintain a hard copy? (y/n)
   3. If maintain hard copy, why? (a) for surveyors; (b) state regulations; (c) concerns that system will crash; (d) attorney advice; (e) for business continuity.
   4. Is electronic system housed at facility or hosted by a third party (e.g., vendor)?
   5. Do you have wireless capability (for level of automation c only)?
   6. Does the same person who generates clinical note or observation also transcribe it into the computer?
   7. How are data captured? (a) desktop; (b) kiosk; (c) laptop on med card; (d) PDA; (e) voice-activated device; (f) sensors.
   8. What is the ratio of devices/appropriate staff (e.g., one kiosk for every three CNAs)?
   9. If not doing point of service, why not? (list reasons, mark all that apply)--relevant for response option “b”.
   10. Do clinicians (e.g., MD, etc.) work remotely?
   11. Does the same person who generates the order also enter the information into the computer?
2. Decision Support question (answered for each function), if response is “yes”, drill-down:
   1. Is decision support function: (a) created by facility; (b) standardized library or vendor-created; or (c) a combination?
   2. Which decision support tools are used? (a) data quality (e.g., out-of-range data alerts); (b) alerts triggered by an entry; (c) workflow--system guides next steps; (d) reminders for scheduled events (these can be categorized from our list from the draft set of expanded questions).
   3. What is the timing of decision support? (a) real-time--when delivering services [preventive]; (b) near time; (c) end of shift; (d) weekly, etc. [Some discussion of the need for b-d vs. a dichotomous response for “real-time” and “later”.]
3. Information Exchange questions to be asked for the smaller group of key functions, as discussed previously, if response is d, e, or f, drill-down:
   1. What is the form/structure of information shared? (a) non-structured (text, images); (b) proprietary structure negotiated with vendors for system-to-system data sharing; (c) national standards-based data exchange.
   2. With whom do you exchange information? (a) within organization only; (b) external systems.
   3. If information is exchanged with external systems, which ones? (mark all that apply) (a) hospitals; (b) pharmacies; (c) home health agencies; (d) MD offices; (e) labs; (f) radiology clinics; (g) personal health records; (h) information exchange networks (Health Information Organizations); (i) other nursing homes.
4. Barriers--For each function/application that respondent indicates is an “a” or “b” level of automation (see page A-123 of these meeting notes):
   1. Do you intend to implement additional automated capabilities to support this function? (a) no; (b) yes, within 1-3 months; (c) yes, within next 12 months; (d) yes, within 13-36 months.
   2. There could be a general question on barriers, using the headers on our question (also adopted from the hospital survey question on barriers); financial, organizational, legal/regulatory, state of the technology.

On the question of incentives/benefits to HIT adoption, Mary Jane Koren remarked that the Degenholtz work has found that benefits fall into three categories: control (e.g., management oversight), efficiency, and empowerment (especially of CNAs). In addition to these, financial benefits should be addressed.

Survey Administration

There are challenges with fielding the survey along with the NNHS. These include cost, infrequency of administration (next anticipated survey is 2010 at earliest; time is needed to analyze the data). There is no money current in the ASPE budget to support this as an add-on.

It will be necessary to use a Web-based approach if the survey is fielded by the private sector. It is unlikely that the American Association of Homes and Services for the Aging would field the survey. American Health Care Association (AHCA) has a foundation that would consider fielding such a survey, particularly if additional support could be obtained (e.g., Commonwealth).

There is an “Advancing Excellence” initiative, which is funded by Commonwealth, although CMS (through the Quality Improvement Organization) hosts a Website. This avenue should be investigated.

Barbara Manard noted that there is a private enterprise tracking adoption of hospital and ambulatory care HIT. The group recently published an article in Health Affairs, and they maintain a Website. She will try to get more information.

Barbara also noted that industry stakeholders need to try to push for funding to field the NNHS soon, because it has not been fielded for four years.

Next Steps

• Refine instrument based on meeting input and send to TEP for another round of feedback.

• Provide paper and pencil version to potential funders.

• Convert core and drill-down questions (longer survey) to a Web format?

APPENDIX C. CORE SURVEY QUESTIONS

This appendix contains the core survey questions from the Survey of Use of Health Information Technology (HIT) in Nursing Homes. The objective of the core survey questions is to track the use of automated health information systems in nursing homes over time and identify perceived barriers and benefits associated with implementation and use of such systems. The core survey questions are designed for use as a stand-alone survey or as part of the expanded survey (see Appendix D), which obtains additional information through follow-up questions that are triggered by responses to selected core survey questions.

Survey on Use of Health Information Technology (HIT) in Nursing Homes

CORE SURVEY (December 2009)¹

Core Survey Objective: To track the use of electronic/computerized (also referred to as automated) health information systems in nursing homes over time and identify perceived barriers and benefits associated with implementation and use of such systems.

1.  Level of Automation and Plans for Additional Automation: For each function listed below, please:

• Mark a, b, or c to indicate the level of automation (or computerization) currently in use at your facility - not just installed or available, but actually used - even if not facility-wide;

AND

• Mark Yes or No to indicate whether your facility plans to expand current automated capabilities for each function.

Function/Application		Level of Automation			Plans to Expand Automation Capabilities
		aPaper Only (no automation)	bCombination Paper/ Electronic	cFully Electronic, with Point of Care1	Yes	No
1.1	Resident (Patient) Demographics
1.2	Advance Directives
1.3	Medical History
1.4	Clinical Notes: Attending MD
1.5	Clinical Notes: Licensed Nurse
1.6	Clinical Notes: CNA Observations and Notes
1.7	Clinical Notes: Other Disciplines (social services, therapy, dietary, others)
1.8	Problem List (resident diagnoses, conditions, and limitations requiring facility evaluation, treatment, and monitoring)
1.9	Allergy List
1.10	Medication Administration Record (MAR)
1.11	Treatment Administration Record (TAR)
1.12	MDS Assessment/RAPs
1.13	Assessments Other than MDS
1.14	Care Plan
1.15	Task List (e.g., CNA workflow)
Order Entry by Physician or Other Authorized Personnel
1.16	Medication Order Entry
1.17	Other Order Entry
Results Viewing
1.18	Labs
1.19	Radiology (e.g., x-rays)
1.20	Diagnostic Tests Other than Radiology or Labs (e.g., lung function, stress tests)
1.21	Consults
Point of care data entry refers to an electronic/computerized system that allows the nurse, physician, aide, or other provider to enter information into an electronic record during or immediately after visits with residents. Point of care data entry involves use of equipment such as a computer laptop, handheld device (e.g., PDA), kiosk, or bar code reader to record information, rather than pen and paper notes.

2.  Automated Clinical Decision Support: For each function listed below, Mark Yes or No to indicate whether automated clinical decision support is used. Examples include computerized alerts triggered when unexpected or problematic information is entered (e.g., out-of-range date of birth; prescription for a drug with potential contraindications for a particular resident) or reminders for scheduled events (e.g., lab draws, immunizations).

Function/Application		Automated Clinical Decision Support
		Yes	No
2.1	Clinical Notes and Observations (by any or all clinical staff)
2.2	Medication Administration Record (MAR)
2.3	Treatment Administration Record (TAR)
2.4	Assessment (MDS and others)
2.5	Care Plan
2.6	Med Orders/E-Prescribing
2.7	Lab Orders and Results
2.8	Radiology Orders and Results
2.9	Diagnostic Test Orders and Results Other than Radiology and Labs

3.  Health Information Exchange Capabilities: For each work function listed in items 3.1-3.14, select the option that represents the highest level of electronic information exchange and integration capabilities used by your facility. Exclude e-mail and fax.

a - Within Facility Electronic Information Sharing: Computer software programs within my facility allow patient information sharing among two or more databases after entering information only once. No electronic information sharing outside of my facility.

b - Within Corporation/Affiliated Organization Electronic Information Sharing: Computer software programs within my facility allow patient information sharing with other organizations in the same network or system (e.g., corporate headquarters or other facilities in corporation; hospital in same health delivery system). No electronic information sharing with non-affiliated providers or organizations.

c - Electronic Information Sharing with Non-Affiliated Organizations: My facilitys computer system exchanges (sends and/or receives) electronic patient information with one or more non-affiliated providers or organizations.

d - None

Function/Application		aWithin Facility Electronic Information Sharing	bWithin Corporation/ Affiliated Organization Electronic Information Sharing	cSend and/or Receive and Integrate Electronic Information with Non-Affiliated Provider	None
3.1	Resident (Patient) Demographics
3.2	Advance Directives
3.3	Resident Medical History
3.4	Clinical Notes and Observations
3.5	Lists: Problems, Allergies, Meds
3.6	MDS Assessments
3.7	Non-MDS Assessments
3.8	Care Plans
3.9	Summary Reports (discharge, transfer, consults)
3.10	Lab Orders and Results
3.11	Radiology Orders and Results
3.12	Diagnostic Test Orders and Results Other than Radiology and Labs
3.13	Med Orders / E-Prescribing
3.14	Public Health Reporting (e.g., tuberculosis)

4.  Electronic Systems to Capture and Query Information Relevant to Health Care Quality: Which of the following electronic systems or reports does your facility use to capture and query information relevant to health care quality? Mark all that apply.

a - No electronic systems used for quality management and reporting activities b - Incident reporting c - Tracking adverse occurrences (e.g., falls, medication errors, infections) d - Calculation of outcomes from MDS or other assessment data (e.g., hospitalization) e - Risk audits for quality areas of concern for surveyors (e.g., pressure ulcers) f - "Dashboard Reports" or composite reports that present data on several key quality indicators (e.g., hospitalizations, medications or treatments due/past due but not given, infections and falls) g - Occupancy rates and trends h - Other (please specify): _________________________

5.  Electronic Summary Reports: Which of the following electronic summary reports do you use? Mark all that apply.

a - No electronic summary reports used b - Transfer c - Discharge d - Consults e - Other (please specify): _________________________

6.  Telehealth: Does your facility use telehealth capabilities? Telehealth is defined as the use of electronic communication and information technologies to allow direct interaction between providers and patients in different locations (e.g., wound consultation by a physician at an offsite location using audiovisual equipment; interpretation of a real-time EKG reading by an offsite physician).

a - No b - Yes

7.  Telemonitoring

a.  Does your facility use telemonitoring capabilities (e.g., sensors to monitor resident wandering, sleep patterns; enuresis monitoring)?

a - No b - Yes

b.  Is information obtained through telemonitoring electronically incorporated into other electronic health records of programs at your facility?

a - No b - Yes

8.  Perceived Barriers to HIT Adoption and Use: Indicate which factors below you perceive to be a major barrier, minor barrier, or not a barrier to purchasing and/or using electronic system(s) for clinical work functions at your facility.

BARRIER		Major Barrier	Minor Barrier	Not a Barrier
a -	Financial Barriers (e.g., needed capital, uncertain return on investment)
b -	Organizational Barriers (e.g., staff resistance, lack of IT personnel, concern about loss of productivity during transition, transitioning historic information, capacity to train staff on new system)
c -	Legal or Regulatory Barriers (e.g., concern about confidentiality breaches, state regulations regarding electronic signatures)
d -	State of Technology (e.g., finding a system that meets facility needs, concerns that system will become obsolete, software or hardware incompatibilities with established systems, difficulty with wireless access)

Comments: If you believe one or more specific functions (e.g., e-prescribing, MAR) are particularly affected by specific barriers, please comment on this:

9.  Perceived Benefits of HIT: Indicate which factors listed below you perceive to be a major benefit, minor benefit, or not a benefit associated with electronic systems used in support of clinical work functions.

BENEFIT		Major Benefit	Minor Benefit	Not a Benefit
a -	Anywhere/anytime access to clinical data (i.e., by multiple users, from multiple locations)
b -	Management oversight/control
c -	Quality monitoring
d -	Enhanced efficiency
e -	Staff empowerment and/or staff satisfaction
f -	Attractive job feature when recruiting new staff
g -	Faster and more accurate billing with integrated data systems (e.g., computer programs that can “talk to each other” by allowing information entered in one screen to fill in more than one database or program)
h -	Improved regulatory compliance
i -	Ability to electronically exchange data with other providers or organizations (e.g., hospital, MD offices, labs, pharmacy)
j -	Cost savings
k -	Resident safety (e.g., reduced medical errors)
l -	Improved care planning
m -	Improved communication within facility (e.g., among staff between shifts)

Comments: If you believe one or more particular functions (e.g., order entry, e-prescribing, MAR) bring about specific benefits, please comment on this:

10.  Facility Characteristics

10.1  In which state is your facility located? State: __________

10.2  How many beds are currently available for residents? Include all beds set up and staffed for use whether or not they are in use by residents at the present time.

Number of beds: __________

10.3  Is this facility part of a chain?

a - No b - Yes

10.4  How would you describe this facility? Mark all that apply.

a - Independent b - Nursing home or unit within a CCRC or retirement center c - Hospital-based skilled nursing facility d - Part of an integrated delivery system e - Other (specify): _________________________

10.5  Which one of the following categories best describes the ownership of this facility?

a - For profit b - Private nonprofit c - City/county government d - Department of Veteran Affairs e - Other federal agency f - Other (specify): _________________________

ASPE/University of Colorado NH HIT Core Survey -- Revised Draft 12/09

APPENDIX D. EXPANDED SURVEY

This appendix contains the expanded Survey of Use of Health Information Technology (HIT) in Nursing Homes, formatted for pen and paper administration. The expanded survey includes both the core survey questions and the follow-up questions triggered by responses to selected core survey questions. The expanded survey is recommended for administration through an electronic, Web-based format, which would significantly reduce respondent time commitment and burden as only follow-up questions that are relevant to the respondent would appear on the computer screen.

Survey on Use of Health Information Technology (HIT) in Nursing Homes

EXPANDED SURVEY (December 2009)¹

Question 1.  Level of Automation and Plans for Additional Automation:

For each Function/Application listed in Questions 1.1 – 1.21, please:

• Mark Yes or No to indicate whether your facility Plans to Expand Current Automated Capabilities for the function/application; AND
• Mark a, b, or c to indicate the Level of Automation (or computerization) currently in use at your facility - not just installed or available, but actually used - even if not facility-wide.
  • If you mark response a, then skip Follow-Up Questions and go to next page.
  • If you mark responses b or c, then answer Follow-Up Questions.

*Note: Point of care is defined as an electronic/computerized system that allows the nurse, physician, aide, or other provider to enter information into an electronic record during or immediately after visits with residents. Point of care data entry involves use of equipment such as a computer laptop, handheld device (e.g., PDA), kiosk, or bar code reader to record information, rather than pen and paper notes.

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.1	Resident (Patient) Demographics

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper/Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation.

1.1a.  Do you have wireless capability for this function?

a - No b - Yes

1.1b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.1c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.1f b - Electronic

1.1d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.1f b - Yes

1.1e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify):____________________________

1.1f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.1g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.1h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this methodc - Staff resistance to the idead - No time for traininge - No technical support staff to support ongoing usef - Other (specify):______________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.2	Advance Directives

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.2a.  Do you have wireless capability for this function?

a - No b - Yes

1.2b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.2c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.2f b - Electronic

1.2d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.2f b - Yes

1.2e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyorsb - Required by the statec - As a back-up in case system crashesd - Based on advice of an attorneye - For business continuity purposesf - Other (specify):____________________________

1.2f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facilityb - Hosted offsite by a vendor

1.2g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.2h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.3	Medical History

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.3a.  Do you have wireless capability for this function?

a - No b - Yes

1.3b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.3c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.3f b - Electronic

1.3d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.3f b - Yes

1.3e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.3f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.3g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Direct data transferred from a monitoring device or sensor h - Other (specify): _________________________

1.3h.  Does the same person who generates the information (clinical note, observation, history) also enter it into the computer?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.3i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.4	Clinical Notes: Attending MD

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.4a.  Do you have wireless capability for this function?

a - No b - Yes

1.4b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.4c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.4f b - Electronic

1.4d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.4f b - Yes

1.4e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.4f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.4g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Direct data transferred from a monitoring device or sensor h - Other (specify): _________________________

1.4h.  Does the same person who generates the information (clinical note, observation, history) also enter it into the computer?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.4i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.5	Clinical Notes: Licensed Nurse

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.5a.  Do you have wireless capability for this function?

a - No b - Yes

1.5b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.5c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.5f b - Electronic

1.5d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.f b - Yes

1.5e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.5f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.5g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Direct data transferred from a monitoring device or sensor h - Other (specify): _________________________

1.5h.  Does the same person who generates the information (clinical note, observation, history) also enter it into the computer?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.5i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.6	Clinical Notes: CNA Observations and Notes

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.6a.  Do you have wireless capability for this function?

a - No b - Yes

1.6b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.6c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.6f b - Electronic

1.6d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.6f b - Yes

1.6e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.6f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.6g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Direct data transferred from a monitoring device or sensor h - Other (specify): _________________________

1.6h.  Does the same person who generates the information (clinical note, observation, history) also enter it into the computer?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.6i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.7	Clinical Notes: Other Disciplines (social services, therapy, dietary, others)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.7a.  Do you have wireless capability for this function?

a - No b - Yes

1.7b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.7c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.7f b - Electronic

1.7d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.7f b - Yes

1.7e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.7f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.7g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Direct data transferred from a monitoring device or sensor h - Other (specify): _________________________

1.7h.  Does the same person who generates the information (clinical note, observation, history) also enter it into the computer?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.7i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.8	Problem List (resident diagnoses, conditions, and limitations requiring facility evaluation, treatment, and monitoring

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.8a.  Do you have wireless capability for this function?

a - No b - Yes

1.8b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.8c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.8f b - Electronic

1.8d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.8f b - Yes

1.8e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.8f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.8g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.8h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.9	Allergy List

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.9a.  Do you have wireless capability for this function?

a - No b - Yes

1.9b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.9c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.9f b - Electronic

1.9d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.9f b - Yes

1.9e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.9f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.9g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.9h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.10	Medication Administration Record (MAR)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.10a.  Do you have wireless capability for this function?

a - No b - Yes

1.10b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.10c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.10f b - Electronic

1.10d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.10f b - Yes

1.10e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.10f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.10g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.10h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.11	Treatment Administration Record (TAR)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.11a.  Do you have wireless capability for this function?

a - No b - Yes

1.11b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.11c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.11f b - Electronic

1.11d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.11f b - Yes

1.11e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.11f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.11g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.11h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.12	MDS Assessment/RAPs

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.12a.  Do you have wireless capability for this function?

a - No b - Yes

1.12b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.12c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.12f b - Electronic

1.12d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.12f b - Yes

1.12e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.12f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.12g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.12h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.13	Assessments other than MDS

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.13a.  Do you have wireless capability for this function?

a - No b - Yes

1.13b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.13c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.13f b - Electronic

1.13d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.13f b - Yes

1.13e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.13f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.13g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.13h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.14	Care Plan

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.14a.  Do you have wireless capability for this function?

a - No b - Yes

1.14b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.14c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.14f b - Electronic

1.14d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.14f b - Yes

1.14e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.14f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.14g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.14h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.15	Task List (e.g., CNA workflow)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.15a.  Do you have wireless capability for this function?

a - No b - Yes

1.15b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.15c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.15f b - Electronic

1.15d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.15f b - Yes

1.15e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.15f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.15g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Other (specify): _________________________

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.15h.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.16	Medication Order Entry

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.16a.  Do you have wireless capability for this function?

a - No b - Yes

1.16b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.16c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.16f b - Electronic

1.16d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.16f b - Yes

1.16e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.16f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.16g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Provider enters orders from a remote location via Web interface or other remote access to facility system h - Other (specify): _________________________

1.16h.  Does the prescribing clinician directly enter the order into the electronic system?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.16i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.17	Other Order Entry

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.17a.  Do you have wireless capability for this function?

a - No b - Yes

1.17b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.17c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.17f b - Electronic

1.17d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.17f b - Yes

1.17e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.17f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

1.17g.  How does electronic documentation/data capture occur? Mark all that apply.

a - Desktop computer in a central location (e.g., nursing station) – No point of care data capture b - Desktop computer located at bedside c - Laptop (e.g., on med cart) d - PDA or other hand-held devices e - Kiosks located outside resident rooms f - Voice-activated dictaphones for later transcription g - Provider enters orders from a remote location via Web interface or other remote access to facility system h - Other (specify): _________________________

1.17h.  Does the prescribing clinician directly enter the order into the electronic system?

a - No b - Yes

Respond to the following if selected option b for Level of Automation (skip to next page if selected option c)

1.17i.  If you are not using point of care data capture, why not? Mark all that apply.

a - Budget restrictions b - Concern about staff capabilities to effectively use this method c - Staff resistance to the idea d - No time for training e - No technical support staff to support ongoing use f - Other (specify): _________________________

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.18	Results Viewing -- Labs

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.18a.  Do you have wireless capability for this function?

a - No b - Yes

1.18b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.18c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.18f b - Electronic

1.18d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.18f b - Yes

1.18e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.18f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.19	Results Viewing -- Radiology (e.g., x-rays)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.19a.  Do you have wireless capability for this function?

a - No b - Yes

1.19b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.19c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.19f b - Electronic

1.19d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.19f b - Yes

1.19e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.19f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.20	Results Viewing – Diagnostic Tests other than Radiology or Labs (e.g., lung function, stress tests)

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.20a.  Do you have wireless capability for this function?

a - No b - Yes

1.20b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.20c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.20f b - Electronic

1.20d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.20f b - Yes

1.20e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.20f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

Level of Automation -- Function/Application		Plans to Expand Automation Capabilities
		Yes	No
1.21	Results Viewing -- Consults

a - Paper Only (no automation) èGO TO NEXT PAGE b - Combination Paper / Electronic c - Fully Electronic, with Point of Care

FOLLOW-UP QUESTIONS: Respond to the following if selected option b or c for Level of Automation

1.21a.  Do you have wireless capability for this function?

a - No b - Yes

1.21b.  Is the electronic application/function certified either as a stand-alone application or as part of a certified electronic health record or system?

a - No, not certified b - Yes, certified

1.21c.  Is the authoritative record (i.e., official, legal record) paper or electronic?

a - Paper Go to 1.21f b - Electronic

1.21d.  Although the authoritative record is electronic, does the facility still maintain a hard copy?

a - No Go to 1.21f b - Yes

1.21e.  Why is a hard copy record maintained? Mark all that apply.

a - For surveyors b - Required by the state c - As a back-up in case system crashes d - Based on advice of an attorney e - For business continuity purposes f - Other (specify): _________________________

1.21f.  Is the electronic system housed at the facility or hosted by a third party?

a - Housed at the facility b - Hosted offsite by a vendor

Question 2.  Automated Clinical Decision Support: For each Function/Application listed in items 2.1 – 2.9, Mark Yes or No to indicate whether automated clinical decision support is used. Examples include computerized alerts triggered when unexpected or problematic information is entered (e.g., out-of-range date of birth; prescription for a drug with potential contraindications for a particular resident) or reminders for scheduled events (e.g., lab draws, immunizations). Answer Follow-up questions as indicated.

Automated Clinical Decision Support -- Function/Application
2.1	Clinical Notes and Observations (by any or all clinical staff)

a - No èGO TO Question 2.2 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.1a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.1b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.1c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.2	Medication Administration Record (MAR)

a - No èGO TO Question 2.3 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.2a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.2b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.2c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.3	Treatment Administration Record (TAR)

a - No èGO TO Question 2.4 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.3a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.3b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.3c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.4	Assessment (MDS and others)

a - No èGO TO Question 2.5 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.4a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.4b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.4c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.5	Care Plan

a - No èGO TO Question 2.6 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.5a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.5b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.5c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.6	Med Orders/E-Prescribing

a - No èGO TO Question 2.7 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.6a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.6b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.6c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.7	Lab Orders and Results

a - No èGO TO Question 2.8 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.7a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.7b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.7c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.8	Radiology Orders and Results

a - No èGO TO Question 2.9 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.8a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.8b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.8c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Automated Clinical Decision Support -- Function/Application
2.9	Diagnostic Test Orders and Results other than Radiology and Labs

a - No èGO TO Question 3 b - Yes, automated clinical decision support is used

FOLLOW-UP QUESTIONS: Respond to the following if selected Yes for Automated Clinical Decision Support

2.9a.  Which of the following automated decision support tools does your facility use for this function? Mark all that apply.

a - Data quality checks/illogical data alerts (e.g., out-of-range date of birth) b - Clinical alerts triggered by an entry (e.g., alert for low heart rate prior to giving digoxin, outlier lab values, drug-to-drug interactions) c - Workflow/guide to next steps (e.g., disease-specific medical treatment protocols; clinical pathways/standardized care plans; disease management programs) d - Reminders for scheduled events (e.g., lab draws, immunizations) e - Lab results management f - Alerts for SOM/F-tag compliance g - Other (specify): _________________________

2.9b.  How were the underlying data parameters/algorithms for this functions decision support mechanism created? Mark all that apply.

a - Created entirely by facility staff b - Created entirely by an outside entity (e.g., vendor developed, standardized library) c - Combination – the facility modified/customized a standard set created by an outside entity

2.9c.  What is the timing of decision support alerts and guidance for this function?

a - Real time – when using the electronic system b - Near time c - End of shift d - Weekly e - Monthly f - Other (specify): _________________________

Question 3.  Health Information Exchange Capabilities: For each work function listed in items 3.1 - 3.14, select the option that represents the highest level of electronic information exchange and integration capabilities used by your facility. Exclude e-mail and fax.

a - Within Facility Electronic Information Sharing: Computer software programs within my facility allow patient information sharing among two or more databases after entering information only once. No electronic information sharing outside of my facility. b - Within Corporation/Affiliated Organization Electronic Information Sharing: Computer software programs within my facility allow patient information sharing with other organizations in the same network or system (e.g., corporate headquarters or other facilities in corporation; hospital in same health delivery system). No electronic information sharing with non-affiliated providers or organizations. c - Electronic Information Sharing with Non-Affiliated Organizations: My facilitys computer system exchanges (sends and/or receives) electronic patient information with one more non-affiliated providers or organizations. d - None

Health Information Exchange Capabilities -- Function/Application
3.1	Resident (Patient) Demographics

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.1c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.1b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.1a d - None èGO TO QUESTION 3.2

FOLLOW-UP QUESTIONS

3.1a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.1b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.1c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.2	Advanced Directives

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.2c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.2b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.2a d - None èGO TO QUESTION 3.3

FOLLOW-UP QUESTIONS

3.2a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.2b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.2c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.3	Resident Medical History

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.3c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.3b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.3a d - None èGO TO QUESTION 3.4

FOLLOW-UP QUESTIONS

3.3a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.3b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.3c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.4	Clinical Notes and Observations

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.4c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.4b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.4a d - None èGO TO QUESTION 3.5

FOLLOW-UP QUESTIONS

3.4a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.4b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.4c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.5	Lists: Problems, Allergies, Meds

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.5c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.5b b - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.5a b - None èGO TO QUESTION 3.6

FOLLOW-UP QUESTIONS

3.5a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.5b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.5c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.6	MDS Assessments

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.6c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.6b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.6a d - None èGO TO QUESTION 3.7

FOLLOW-UP QUESTIONS

3.6a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.6b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.6c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.7	Non-MDS Assessments

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.7c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.7b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.7a d - None èGO TO QUESTION 3.8

FOLLOW-UP QUESTIONS

3.7a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.7b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.7c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.8	Care Plans

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.8c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.8b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.8a d - None èGO TO QUESTION 3.9

FOLLOW-UP QUESTIONS

3.8a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.8b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Hospitals b - Pharmacies c - Home health agencies d - Physician offices e - Labs f - Radiology clinics g - Personal health records h - Information exchange networks (Health Information Organizations) i - Other nursing homes j - Corporate office k - Other (specify): _________________________

3.8c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.9	Summary Reports (discharge, transfer, consults)

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.9c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.9b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.9a d - None èGO TO QUESTION 3.10

FOLLOW-UP QUESTIONS

3.9a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.9b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Home health agencies b - Physician offices c - Labs d - Radiology clinics e - Personal health records f - Information exchange networks (Health Information Organizations) g - Other nursing homes h - Corporate office i - Other (specify): _________________________

3.9c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.10	Lab Orders and Results

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.10c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.10b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.10a d - None èGO TO QUESTION 3.11

FOLLOW-UP QUESTIONS

3.10a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.10b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Home health agencies b - Physician offices c - Labs d - Radiology clinics e - Personal health records f - Information exchange networks (Health Information Organizations) g - Other nursing homes h - Corporate office i - Other (specify): _________________________

3.10c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.11	Radiology Orders and Results

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.11c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.11b b - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.11a b - None èGO TO QUESTION 3.12

FOLLOW-UP QUESTIONS

3.11a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.11b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Home health agencies b - Physician offices c - Labs d - Radiology clinics e - Personal health records f - Information exchange networks (Health Information Organizations) g - Other nursing homes h - Corporate office i - Other (specify): _________________________

3.11c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.12	Diagnostic Test Orders and Results other than Radiology and Labs

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.12c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.12b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.12a d - None èGO TO QUESTION 3.13

FOLLOW-UP QUESTIONS

3.12a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.12b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Home health agencies b - Physician offices c - Labs d - Radiology clinics e - Personal health records f - Information exchange networks (Health Information Organizations) g - Other nursing homes h - Corporate office i - Other (specify): _________________________

3.12c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.13	Med Orders/E-Prescribing

a - Within Facility Electronic Information Sharing  èGO TO QUESTION 3.13c b - Within Corporation/Affiliated Organization Electronic Information Sharing èGO TO QUESTION 3.13b c - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.13a d - None èGO TO QUESTION 3.14

FOLLOW-UP QUESTIONS

3.13a.  Which of the following represents your facilitys electronic information exchange with non-affiliated organizations?

a - Send information to non-affiliated facilities b - Receive and integrate information from non-affiliated facilities c - Both send and receive information

3.13b.  With which of the following entities does your facility exchange these electronic data? Mark all that apply.

a - Home health agencies b - Physician offices c - Labs d - Radiology clinics e - Personal health records f - Information exchange networks (Health Information Organizations) g - Other nursing homes h - Corporate office i - Other (specify): _________________________

3.13c.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

Health Information Exchange Capabilities -- Function/Application
3.14	Public Health Reporting (e.g., tuberculosis)

a - NA Within Facility Electronic Information Sharing  b - NA Within Corporation/Affiliated Organization Electronic Information Sharing  b - Send and/or Receive and Integrate Electronic Information from Non-affiliated Providers èGO TO QUESTION 3.14a b - None èGO TO QUESTION 4

FOLLOW-UP QUESTIONS

3.14a.  Does the information exchange incorporate national health information exchange standards?

a - No b - Yes

4.  Electronic Systems to Capture and Query Information Relevant to Health Care Quality: Which of the following electronic systems or reports does your facility use to capture and query information relevant to health care quality? Mark all that apply.

a - No electronic systems used for quality management and reporting activities b - Incident reporting c - Tracking adverse occurrences (e.g., falls, medication errors, infections) d - Calculation of outcomes from MDS or other assessment data (e.g., hospitalization) e - Risk audits for quality areas of concern for surveyors (e.g., pressure ulcers) f - "Dashboard Reports" or composite reports that present data on several key quality indicators (e.g., hospitalizations, medications or treatments due/past due but not given, infections and falls) g - Occupancy rates and trends h - Other (specify): _________________________

5.  Electronic Summary Reports: Which of the following electronic summary reports do you use? Mark all that apply.

a - No electronic summary reports used b - Transfer c - Discharge d - Consults e - Other (specify): _________________________

6.  Telehealth: Does your facility use telehealth capabilities? Telehealth is defined as the use of electronic communication and information technologies to allow direct interaction between providers and patients in different locations (e.g., wound consultation by a physician at an offsite location using audiovisual equipment; interpretation of a real-time EKG reading by an offsite physician).

a - No b - Yes

7.  Telemonitoring

a.  Does your facility use telemonitoring capabilities (e.g., sensors to monitor resident wandering, sleep patterns; enuresis monitoring)?

a - No b - Yes

b.  Is information obtained through telemonitoring electronically incorporated into other electronic health records of programs at your facility?

a - No b - Yes

8.  Perceived Barriers to HIT Adoption and Use: Indicate which factors below you perceive to be a major barrier, minor barrier, or not a barrier to purchasing and/or using electronic system(s) for clinical work functions at your facility.

BARRIER		Major  Barrier	Minor  Barrier	Not a  Barrier
a -	Financial Barriers (e.g., needed capital, uncertain return on investment)
b -	Organizational Barriers (e.g., staff resistance, lack of IT personnel, concern about loss of productivity during transition, transitioning historic information, capacity to train staff on new system)
c -	Legal or Regulatory Barriers (e.g., concern about confidentiality breaches, state regulations regarding electronic signatures)
d -	State of Technology (e.g., finding a system that meets facility needs, concerns that system will become obsolete, software or hardware incompatibilities with established systems, difficulty with wireless access)

Comments: If you believe one or more specific functions (e.g., e-prescribing, MAR) are particularly affected by specific barriers, please comment on this:

9.  Perceived Benefits of HIT: Indicate which factors listed below you perceive to be a major benefit, minor benefit, or not a benefit associated with electronic systems used in support of clinical work functions.

BENEFIT		Major  Barrier	Minor  Barrier	Not a  Barrier
a -	Anywhere/anytime access to clinical data (i.e., by multiple users, from multiple locations)
b -	Management oversight/control
c -	Quality monitoring
d -	Enhanced efficiency
e -	Staff empowerment and/or staff satisfaction
f -	Attractive job feature when recruiting new staff
g -	Faster and more accurate billing with integrated data systems (e.g., computer programs that can “talk to each other” by allowing information entered in one screen to fill in more than one database or program)
h -	Improved regulatory compliance
i -	Ability to electronically exchange data with other providers or organizations (e.g., hospital, MD offices, labs, pharmacy)
j -	Cost savings
k -	Resident safety (e.g., reduced medical errors)
l -	Improved care planning
m -	Improved communication within facility (e.g., among staff between shifts)

Comments: If you believe one or more particular functions (e.g., order entry, e-prescribing, MAR) bring about specific benefits, please comment on this:

10.  Facility Characteristics

10.1  In which state is your facility located? State: __________

10.2  How many beds are currently available for residents? Include all beds set up and staffed for use whether or not they are in use by residents at the present time.

Number of beds: __________

10.3  Is this facility part of a chain?

a - No b - Yes

10.4  How would you describe this facility? Mark all that apply.

a - Independent b - Nursing home or unit within a CCRC or retirement center c - Hospital-based skilled nursing facility d - Part of an integrated delivery system e - Other (specify): _________________________

10.5  Which one of the following categories best describes the ownership of this facility?

a - For profit b - Private nonprofit c - City/county government d - Department of Veteran Affairs e - Other federal agency f - Other (specify): _________________________

ASPE/University of Colorado NH HIT Expanded Survey -- Revised Draft 12/09

NOTES

1. This is a recreation of the questions asked on the survey. See the PDF at http://aspe.hhs.gov/daltcp/reports/2010/EHRques-A2.pdf for a scanned version of the form itself.

---

REPORTS AVAILABLE

Literature Review and Synthesis: Existing Surveys on Health Information Technology, Including Surveys on Health Information Technology in Nursing Homes and Home Health

Executive Summary   http://aspe.hhs.gov/daltcp/reports/2009/HITlitreves.htm

Full HTML Version   http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.htm

Full PDF Version   http://aspe.hhs.gov/daltcp/reports/2009/HITlitrev.pdf

Survey Questions for EHR Adoption and Use in Nursing Homes: Final Report

Full HTML Version   http://aspe.hhs.gov/daltcp/reports/2010/EHRques.htm

Full PDF Version   http://aspe.hhs.gov/daltcp/reports/2010/EHRques.pdf

---

To obtain a printed copy of this report, send the full report title and your mailing information to:

U.S. Department of Health and Human ServicesOffice of Disability, Aging and Long-Term Care PolicyRoom 424E, H.H. Humphrey Building200 Independence Avenue, S.W.Washington, D.C. 20201FAX:  202-401-7733Email:  webmaster.DALTCP@hhs.gov

---

RETURN TO:

Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home [http://aspe.hhs.gov/_/office_specific/daltcp.cfm]Assistant Secretary for Planning and Evaluation (ASPE) Home [http://aspe.hhs.gov]U.S. Department of Health and Human Services Home [http://www.hhs.gov]