1. Organizational Structure
Of the PAC and LTC settings visited, there was a fairly even distribution of agencies/facilities that were part of a larger regional or national chain (e.g., Golden Gate National Senior Care [formerly Beverly Living Centers]) and those that were smaller, privately-held. Similarly, some were hospital-based, while others were freestanding. The majority of SNFs and HHAs visited were non-profit.
In general, there was a higher level of HIT adoption in PAC/LTC settings that were owned by other health settings, including being owned by a local hospital; or being part of a local, regional, or national chain. In addition, it was observed that HHAs that were one of the nation's visiting nurse associations also had higher rates of HIT adoption than other HHAs. Agencies/facilities in these categories tended to have purchased, at a minimum, software allowing them to electronically submit claims and remittances, and administrative data to payers (e.g., OASIS, MDS data). This is in contrast to using free software made available by the CMS, such as HAVEN or RAVEN, which tends to be adopted by smaller providers (not visited as part of this study).
The PAC/LTC settings that were involved with other health entities also tended to have additional reporting capabilities built into their system, including accounts payable/receivable, staff scheduling, clinically-relevant alerts (e.g., drug-to-drug interactions, drug-to-food interactions), quality monitoring reports, and in some cases, trending capabilities. These facilities may have had a paper chart, but much of the chart consisted of computer-generated information that was subsequently printed out and placed in the chart.
On the other hand, the group of PAC/LTC settings that were smaller and/or independent tended to have less information technology capabilities and relied fairly exclusively on a paper record/chart. Much of the record was handwritten, and little automation was in place (again, with the exception of meeting regulatory requirements such as OASIS or MDS reporting). The information technology in use was typically to support administrative tasks; the medical record was seen as a separate document altogether.
2. Organizational Impetus to Adopt HIT
As previously described, when selecting the sites, the "hub" delivery system had sophisticated HIT in place, and in some cases, showcased later in the report, some of the PAC/LTC settings did as well. That said, a great deal of variation in HIT adoption by the visited PAC/LTC settings was observed. The majority of NHs/HHAs visited collected information on paper and entered clinical and administrative data (i.e., MDS/OASIS and claims data) into a software specifically designed for those purposes. If additional HIT applications were available, they were add-on modules provided by niche software. Thus, HIE was generally observed to be a traditional process not facilitated through the use of HIT even when the providers had an electronic health information system in place.
When asked what the criteria were for selecting a software vendor and/or software application, costs and ongoing maintenance fees were the most commonly cited. Related training costs also were usually mentioned as a concern. With some notable exceptions (the VNS of New York and Erickson Retirement Communities), interoperability with other settings was not mentioned as a vendor or product selection criterion, and was not necessarily perceived as a necessary or even a desired attribute to an EHR system.
There are multiple reasons that may explain why NHs and HHAs have not made significant investments in and use of more robust EHR systems. In general, both setting types operate with very small margins, and are financially constrained even more now that the Prospective Payment System is in place (CMS, 2007a; National Bureau of Economic Research, 2007).
On more than one occasion the site visitors heard, "if the Federal Government would build and mandate 'it,' then the PAC and LTC market would find a way to make it work." Informants cited the fact that once OASIS/MDS reporting was required to be submitted electronically, NHs and HHAs acquired the necessary equipment to meet that requirement.
HHAs and NHs have a very high rate of staff turnover, averaging close to 50% per year (AHCA, 2003; Seavey, 2004). The costs of implementing an EHR system are high, but the ongoing maintenance and training costs are additional substantial costs that may represent an ongoing additional barrier to adoption. Concerns about the affordability of EHR systems continue to be expressed by NHs despite some anecdotal evidence that some NHs have been able to recover their HIT investment cost through more accurate Medicare SNF claims.
Part of the presumed "cost" is the risk associated with EHR deployments in that they may "fail." This concern was expressed by many of the smaller NHs/HHAs visited. The JHHA (New York SNF) lived this reality--they implemented an EHR system in their SNF only to have to abandon it several years later because it did not meet their needs. The Administrator of the JHHA commented that they are committed to implementing HIT and are currently vetting new software options. This is described in more detail in Appendix C. The decision by the CCHIT to specify certification criteria for NH EHRs could help to minimize NH provider risk in making HIT investment decisions.
At several sites (Briarwood in Indianapolis, St. Joseph's Villa and CareSource in Utah), leaders in the PAC/LTC settings were unfamiliar with the private and public initiatives related to EHR adoption and work being done by RHIOs in their own communities. It was observed that although innovators in these communities are involved in implementing and expanding data exchange efforts, the PAC/LTC settings have either not been invited to participate in the planning or are choosing not to become involved.
As is true with all care settings attempting to implement an EHR system, the disruption of current processes and workflow are great, and the long-term benefits and rewards associated with the adoption of an interoperable EHR system are not always tangible or even imaginable, especially to those expected to use the system. As is the case for other health care settings, NH and HHA providers need "champions," persons who can lead the HIT implementation within their organizations. This person needs to be able to lead by implementing and embracing the changes, understand HIT, and take into account workflow issues inherent in the organization. The champion needs to be able to understand and articulate to others how HIT implementation can alter workflow to increase efficiency and improve care quality.
In some cases, making an EHR investment was not even being considered by key decision-makers' of the organizations that we visited. What is most important to PAC/LTC administrators and staff is the ability to receive legible, timely, complete, and accurate data from the referring health setting. The particular medium used for this information transmission (e.g., phone, fax, hard copy, electronic) was of secondary concern, as was any concern about the cost, time, effort, and opportunity for error involved in re-entering available information stored electronically "somewhere else." Furthermore, several administrators indicated that hospitals (including EDs) and physician offices often are not interested in much of the data collected at SNFs and HHAs. What information is shared often is not trusted, valued, or read by the receiving entity. As previously described, sometimes the information that is being exchanged is not what the receiving organization describes as needed. In addition, liability and fear of litigation were mentioned as reasons why physicians at the receiving hospital or ambulatory setting are skeptical of the information received from PAC/LTC settings, thereby resulting in duplicate testing and procedures to ensure the data they are acting upon are reliable.
The authors note that the literature concerning the organizational benefits of adopting an EHR system, such as worker productivity gains, optimization of billing processes, and other efficiencies is limited and those few studies that report the impact of HIT implementation in hospitals or physician offices have mixed (i.e., positive and negative) results (Booz Allen Hamilton, 2006; Poissant, Pereira, Tamblyn, & Kawasumi, 2005; Sidorov, 2006). Poissant and colleagues conducted a systematic review of the literature on the impact of physician and nurse documentation time in hospital and ambulatory care settings that recently implemented an EHR system. They reviewed findings from studies that used methodologies such as randomized control trials, self-report/survey, as well as time and motion studies. Poissant et al. concluded that increased or decreased documentation times for both nurses and physicians were dependent upon many variables, including the type of computerized system used (i.e., bedside terminals, desktops, PDAs), the length of time since EHR implementation, and the information being documented (e.g., admissions, CPOE functions, etc.). In general, nurses were more likely than physicians to gain time efficiencies by using a computer system to document patient information. However, for separate select tasks, nurse documentation time increased, while physician documentation time decreased.
"HIEcase.pdf" (pdf, 1.68Mb)
"HIEcase-A.pdf" (pdf, 236.81Kb)
"HIEcase-B.pdf" (pdf, 115.31Kb)
"HIEcase-C.pdf" (pdf, 169.18Kb)
"HIEcase-D.pdf" (pdf, 134.56Kb)