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The current state of EMRs in LTC settings

February 1, 2008
by STEVE PACICCO
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Exploring the health information technology link in improving patient care and outcomes

Long-term care (LTC) requires hands-on support and care from frontline workers—the human element in caring for a frail, aged population. While the important role of these frontline workers will never be replaced by technology, the application of health information technology (HIT) increasingly is helping caregivers provide quality care and deliver positive outcomes. As providers take a more expansive view of HIT beyond automated charting and the elimination of paperwork, they are beginning to see HIT and, more specifically, electronic medical records (EMRs) as tools to summarize trends in a patient's care, improve provider decision making, decrease errors, monitor the application of evidence-based disease protocols and, ultimately, improve quality and safety. The goal is to improve patient and disease management, not just records management.

The interesting dichotomy in the adoption of HIT for LTC settings is that efforts across the entire healthcare spectrum to install HIT systems cite improved quality as a primary reason for moving forward. Yet long-term care, which has had a decade-long industry-wide commitment to quality, has made significant achievements without adopting HIT. Increasingly, however, there is a belief among healthcare experts that further leaps in LTC quality and efficiency may only be achieved through HIT solutions.

Clinical and Operational Benefits

A 2005 study by Rainu Kaushal, MD, MPH, and colleagues from Brigham and Women's Hospital in Boston, entitled “Functional Gaps in Attaining a National Health Information Network,” estimated that the adoption of EMRs in skilled nursing facilities (SNFs) is only about 1%, which significantly lags behind hospitals’ 18% penetration rate. Yet a case can and should be made that it is nursing homes that can benefit more from the implementation of EMRs and it is they that should be the early adopters. Unlike hospitals that typically focus on unique episodes of care for people of all ages, nursing home residents are typically older and frail, and 50% of residents stay at least one year and 21% remain for five years. The extended stays, coupled with the realization that the average SNF resident receives six to seven medications per day to address multiple chronic conditions, suggest that an EMR will better prevent harmful drug interactions, track assessments, and monitor clinical outcomes than current methods.

Operationally, an EMR that also tracks billings and reimbursements can improve and streamline regulatory compliance, reduce and eliminate paperwork redundancies, improve charge capture, and reduce time spent charting. The opportunity to marry operational improvements in back-office functions with evidence-based protocols for caregiving presents a wonderful opportunity to dramatically improve how SNFs function. By improving efficiencies in paperwork and increasing knowledge about the resident's condition, EMRs free frontline caregivers to do what they have been trained to do and what they want to do: provide care.

EMRs Developed Exclusively for LTC Settings

Providers investigating the implementation of EMRs should retain one fundamental but obvious consideration that is often overlooked: LTC settings are very different from hospitals and physicians’ offices. The staffing ratios, different care management assessments and systems, staff training, and regulatory and reimbursement requirements of LTC facilities are all substantially different. An EMR developed for an acute or ambulatory care setting will have very different functionality from one developed for LTC settings and may not be adequately converted to LTC use. When exploring HIT and EMR systems, consider those developed exclusively for the clinical and operational needs of LTC settings.

Because LTC is by and large low tech, custodial care, paper, and manual functions have dominated the careers of most clinicians. Introducing HIT will replace entrenched care techniques and require planning and sensitivity to manage the culture change. Creating employee buy-in and shared learning among all levels of clinicians and administrators on each shift will facilitate EMR adoption and maximize its value. The following steps have been shown to help achieve these goals:

  • Perform a facility-wide workflow assessment to understand the needs, policies, and procedures from the perspective of the nurses, physicians, certified nursing assistants (CNAs), and administrators before implementation.

  • Create an on-site training center that provides hands-on experience with equipment and competency testing.

  • Establish a group of dedicated, highly trained “super-users” comprising facility administrators and department managers who will be able to support and train other users beyond the initial and periodic vendor-supplied training.

  • Undertake an internal marketing and change-management campaign to get employees excited about the change.

Point-of-Care Entry and Data Synchronization

To maximize the benefits of an EMR, the system must collect and dispense information at the point of care (POC). Failure to do so requires the continued use of paper records until information can be entered at a fixed computer station, negating efficiencies and increasing the potential for error. The availability and lower costs of rugged laptops, tablet computers, and handheld portable digital assistants (PDAs) support the mobile nature of clinical staff, and they can be sterilized for infection control purposes.

Instantaneous software response time is necessary to encourage adoption and utilization by clinicians. A slow system or one that does not have the most recent data will result in decreased utilization and the eventual failure of the EMR. Moreover, the system must automatically synchronize to:

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