U.S. Department of Health and Human Services

Taxonomy of Health Information Technology in Home Health Agencies -- Report C: Review by Representatives from Home Health Agencies and Vendors

University of Colorado, DenverHealth Sciences Center

August 6, 2007

PDF Version (34 PDF pages)

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

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

TABLE OF CONTENTS

I. PURPOSE

II. METHODS

III. RESULTS

IV. DISCUSSION

ATTACHMENT A: DRAFT TAXONOMY OF HIT APPLICATION FEATURES FOR HOME HEALTH AGENCIES

NOTES

LIST OF TABLES

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

TABLE 2: Tally of HHA Responses for EHR Domain Applications

I. PURPOSE

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

II. METHODS

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

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

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

HHA providers: Potential HHA provider representatives were identified through: (a) software vendor recommendations; (b) posted materials from national conferences (e.g., PowerPoint handouts) or authors of journal articles on HIT in home health care; or (c) recommendations from project team members. Eight HHA provider representatives were invited to participate in one of two conference calls that provided information on what was expected of them should they agree to provide us with information. The invited contact persons and affiliated health settings were:

1. Lucille Stufflebeam Eddy Visiting Nurse Association, Troy, NY
2. Dennie McColm Citizens Memorial Home Care, Bolivar, MO
3. Janet Puglisi Professional Home Health Care, Denver, CO
4. Andrea Devoti Neighborhood Health Agencies, Inc., Westchester, PA
5. Thomas Check Visiting Nurse Service of New York, New York, NY
6. Laurie Neander At Home Care, Inc., Oneota, NY
7. April Anthony Encompass Home Health, Dallas, TX
8. John Pipas Visiting Nurse Service of Indiana, Indianapolis, IN

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

III. RESULTS

Five of the HHA providers completed the taxonomy review and submitted feedback on their use of HIT. HHAs indicate they use anywhere between three and eight disparate HIT solutions. Data on use of specific applications were synthesized and findings summarized by taxonomy domain.

Administration: All of the five responding agencies indicate that they use automated systems for the administrative functions. Four of the five noted that for all administrative functions listed in the taxonomy, products are fully implemented and in use by all appropriate staff. One HHA notes that for their application tracking Medicare/nonMedicare claims denials, less than 100% but more than 50% of appropriate staff are using it.

Operations Management: Table 1 summarizes HHA responses for this domain by noting the number of HHAs: (a) owning and using each of the applications; and (b) owning but not using the applications. All five HHAs report using registration applications. Two of the five are using online access for referrals, while two more have the functionality but have not yet implemented it, and one hopes to have this functionality at some future time. Staffing/scheduling and tracking of staff time/attendance are done using electronic technology at all five HHAs. Four HHAs use telephony to allow field care providers to enter limited patient information at the point-of-care (POC). The fifth HHA reports a desire to obtain this functionality at some point in the future. Personnel and workflow management are automated in all five HHAs, and all have the capability of generating user-defined financial management reports. All HHAs are using electronic tracking of medical doctor (MD) signatures on orders, although one reports that state law has prevented them from accepting electronic signatures.

Four of the five HHAs currently have the ability to order patient supplies electronically from the field, while the fifth HHA would like to obtain this functionality at some point in the future. None of the HHAs are using pharmacy management or medications tracking/billing software, which is not unexpected as few HHAs own their own pharmacies. However, two HHAs note that they provide medications directly for hospice patients, and one of the two has some functionality that currently is being redesigned for use in their hospice program. Per Centers for Medicare and Medicaid Services (CMS) requirements, all HHAs electronically enter, check and correct, and transmit OASIS data to the federal repository.

Some sophisticated quality management reports, listed separately on the taxonomy, are available in all five HHAs. One HHA is using an application for electronic incident reports, and four can track adverse events and infection reports. Three are currently generating summary reports of clinical pathway variances, and one HHA has the capability only for their telehealth data, as they are not using electronic clinical pathways for patients without telehealth applications. All five have software that can calculate OASIS outcome data. Two have risk auditing capabilities for areas of concern for surveyors, and all five can generate "dashboard reports" for key quality indicators.

Four of the five HHAs have electronic population health reporting mechanisms, although one HHA notes that their functionality is limited to the reporting of immunizations. All but one HHA has electronic access to clinical guidance, and three HHAs provide that functionality for field clinicians (one only allows a clinical manager access to that application). All HHAs report that they could support de-identified data requests. Three HHAs currently have functionality allowing field clinicians electronic access to policies and procedures, although two of the three have not yet trained staff in its use.

Electronic Health Record: All five responding HHAs are using an electronic health record (EHR) and report full implementation with all appropriate staff. Table 2 provides a tally of responses for each application within this domain. Patient consent and authorizations are captured electronically in four HHAs, while the fifth reports that state regulations prevent them from accepting electronic signatures. All agencies have EHR systems capable of capturing patient assessment and history, and clinical notes for all or a subset of the services they provide (e.g., RN, PT). Four of the HHAs are able to aggregate assessment data to generate summary reports (e.g., discharge summaries), and one has this functionality available but is not using it.

HHAs report only limited or no ability to electronically capture clinical documents from other providers. One reports that they can receive e-mail versions of reports from other providers; another can capture laboratory and radiology data from their own hospital system, but not from other providers. They also note that while some patient history from their own hospital can be received electronically, some of those data must be manually re-entered into the home care EHR. Another HHA has some access to electronic data from wound expert and pharmacy (PharmD) consults. Two of the three HHAs without these information exchange functionalities indicate that they would like the ability to capture these data from other providers electronically.

Problem lists and care planning functionality are in use in all five HHAs, although all do not have, nor are they using, applications for acute problem or discipline-specific plans of care. The use of automated decision-support tools varied considerably across agencies. One setting uses none at all. Four use electronic clinical pathways or standardized care plans and disease management programs, although one of the four reported use by less than 50% of appropriate staff. Two HHAs have electronic alerts for lab draws, but one has not yet implemented it and one has prompts for unusual events (e.g., clinical findings exceeding parameters) and another has prompts for preventative practices (e.g., immunizations). Three HHAs report decision-support functionality for e-prescribing, however, only one reports having e-prescribing functionality (described under the Medications domain). It may be that there was some confusion about e-prescribing, as this functionality is used rarely in home care. Rather, physicians typically call or fax their prescriptions to the pharmacy and the patient or family member is responsible for picking the prescription(s) up. The medications are neither acquired nor distributed by HHA personnel; however HHA staff do review the medication list for side effects, interactions, duplicative drug therapy, etc. Four of the five HHAs have products supporting risk assessment tools and all have results management capabilities. None have alerts for potential noncompliance with specific regulations (e.g., regulatory "tags"), but four have alerts to inconsistencies between OASIS data and plan of care data. Four HHAs have the ability to monitor the effectiveness of care plans electronically. Four are using application features allowing trending of key clinical findings, such as vital signs or laboratory values.

Four responding HHAs have products supporting intra-agency communications via secure messaging for coordination of care and communication between field and office staff, although only two have fully implemented it. Only one is using the functionality that allows for secure messaging with external providers (e.g., physicians). Two have systems that support the electronic exchange of information with patients and caregivers, but are not currently using the technology. Patient education materials that can be printed out and provided to the patient are in use in EHR systems for two HHAs.

All HHA providers have security and privacy applications, such as permissions settings and user authentication. Four HHAs have mechanisms allowing MD or pharmacy review of the home health EHR, although only three report that the applications are fully implemented. Two HHAs are using computerized provider order entry (CPOE) functionality and a third agency has the functionality but has not yet implemented it.

Medications: Typically home health patients self-administer medications. The home health clinician role is to review medication administration and side effects with the patient/family, provide education, determine if the patient/family can obtain and safely self-administer medications, assess the list of medications for adverse reactions and drug interactions, and observe the patient for symptoms of adverse reactions or side effects. Therefore, it is not surprising that only three HHAs report Medication Administration Record (MAR) functionality. All agencies, however, have products supporting medication lists and software for checking medications for potential side effects and adverse reactions, duplicative drug therapy, etc. Only one HHA reports e-prescribing functionality. Again, this is not surprising, as typically physicians send prescriptions directly to a pharmacy and the patient/family obtains the medications. Two HHAs have medication reminder systems for patients included as part of a telemonitoring product and another notes their intention to obtain such functionality.

Telemedicine/telehealth: Due to the potential for cost savings and improved clinical outcomes for home care patients (because of the improved ability of the HHA to monitor the home care patient), there has been great interest in the use of telemedicine applications in home health care. Three HHAs report using telemonitoring applications, while the remaining two hope to acquire this functionality at some point in the future. None of the agencies use electronic tracking systems, intended to monitor patients who may be confused and wander away from a safe environment. Typically, if these types of patients are receiving home care services, their whereabouts will be monitored by their families or caregivers. Wireless personal emergency response systems are in use by two HHAs and another HHA hopes to acquire a system in the future. Two HHAs have in-home messaging devices allowing a two-way dialog between patient and caregivers, one of which provides video and audio capabilities for "virtual visits." The systems in those HHAs provide patient education materials that the patient or caregiver can access on the video monitor. One HHA has a secure e-mail system that allows communication with the patient/family but is not using the application at this time. Another HHA reports that this information exchange functionality is part of their telemonitoring application. Two HHAs have the capability to transmit still images to consulting providers, although one is not currently using it. None of the agencies currently are using still images captured by cellular telephones to document wound status or other clinical findings.

IV. DISCUSSION

All participating HHAs report using all applications listed with the Administration domain. Likewise, many of the operations management functions are automated using a variety of products providing "back office" applications. While HHAs may see costs savings from automating functions not directly related to patient care, the authors believe that the focus of this project should be on applications that may result in more efficient and effective care delivery, particularly those in the EHR and telehealth domains.

Because selected providers were recommended to us from software vendors or identified through materials obtained from industry association materials, (e.g., abstracts or presentations posted for national conferences), all participating HHAs use some type of EHR, although the types of applications in use varied as did the sophistication of the EHR. Feedback indicates that for HHAs, most EHR products offer a basic set of applications including those for recording, storing and retrieving assessment data, problem lists, care plans, visit notes, and medication lists. It appears that most EHRs for home health also include the ability to aggregate data into summary reports, such as discharge summaries, although one respondent notes that they did not have summary reporting functionality. More sophisticated EHRs may contain decision-support tools, reporting tools, and some forms of health information exchange (e.g., a system allowing external providers or patients to access the EHR).

Certain EHR applications for HHAs are typically purchased as part of a basic system (with additional functionality purchased separately in the form of upgrades), which often includes initial set-up, training hours, product support, and regular system upgrades. There is an initial cost outlay, based on user licenses and annual maintenance fees. Thus, it may be difficult to identify the costs and benefits of some of the individual applications within a basic HHA EHR system. While it is likely that some of the costs and benefits may be identified for applications within a basic EHR product, many of them are likely calculated for implementation of the EHR package as a whole (e.g., initial purchase costs, time saved by other members of the care team by reading previous assessments, visit notes, and care plans onscreen from home versus traveling to the office to pick up paper copies). Therefore, we will likely need to focus our efforts during the site visits (Task 6) on evaluating costs and benefits of: (a) a circumscribed set of basic applications common to most HHA EHR products; and/or (b) more sophisticated applications that are purchased as system upgrades or stand-alone modules, or even from a separate vendor. For example, a product supporting the electronic receipt of hospital discharge data, such as e-discharge, may not be bundled with other applications and costs/benefits of that application can be measured directly.

For the site visits (Task 6), the project team is interested in selecting one or more HHAs with a basic EHR in use, including at least the ability to enter, store, retrieve, and view assessment data (including OASIS), clinical notes, medication lists, care plans, and produce summary reports (e.g., discharge summaries). In addition, we would like to select HHAs with some of the more sophisticated EHR applications, particularly those related to decision-support, CPOE, and health information exchange with providers and/or patients. Because the literature contains some anecdotal information that HHAs are reporting direct cost savings by using telemonitoring and telehealth "virtual visits," we recommend visiting at least one HHA using the technology, preferably an HHA that incorporates the clinical data from the telemonitor directly into an EHR. Three of the five HHA providing information on their products meet these criteria and should be considered candidates for site visits.

ATTACHMENT A: DRAFT TAXONOMY OF HIT APPLICATION FEATURES FOR HOME HEALTH AGENCIES

NOTES

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