Rule No. 1 in establishing an electronic medical-records system in a long-term-care setting is that "You don't try to have an acute-care system forced into a nursing home," says John Derr, who has developed an easy way to dismiss vendors that think they can ignore this rule.
Derr, director of special programs for the American Health Care Association and National Center for Assisted Living in Washington, says he cuts to the chase with these vendors by asking: "How do you handle MDS?" He is referring to minimum data sets, the ubiquitous CMS forms from which all government payments flow and long-term-care quality indicators are generated.
"They'll say, `What are you talking about? But anyone in long-term care knows exactly what I'm talking about," he says. "So, if they have to ask, I know they can't help."
In many ways, there isn't much difference between acute- and long-term-care information technology needs. In its July 2004 white paper on creating incentives for nationwide adoption of interoperable healthcare IT, Newt Gingrich's Center for Health Transformation noted that "Long-term-care providers recognize that IT adoption would help streamline the annual survey process, promote quality of care and reduce the cost of the program."
That's pretty basic stuff that can apply to almost any care setting, but experts say long-term-care IT has a unique set of needs, challenges and options for future direction. "Most of the concerns are identical to the needs of other care levels," says Peter Kress, vice president and chief information officer for Adult Communities Total Services Retirement-Life Communities. "But there are two considerations that are very important."
More holistic approach
Long-term-care "settings are usually not about primary care. They're more holistic, more interdisciplinary and look less at disease and more on ability or function," Kress says, adding that because of this, "Diagnosis is not our primary organizer."
Also, the clinical information captured is shared by a wide spectrum of caregivers that includes a physician, but the physician is not usually in the lead role and typically only interacts with residents once a month, he says. "The (long-term-care) chart is organized around the needs of a care team who delivers care on a daily basis. In a long-term-care setting, you invert the hierarchy and add a few layers," Kress says.
These layers include instructions for hands-on caregivers who may interact with the nursing-home resident or home-care client on a daily basis and continue on down to physicians and specialists.
Along with the life-and-death issues contained in a do-not-resuscitate order, Kress says the chart's top layer can include basic instructions such as informing a caregiver that the resident likes to have coffee every morning.
These simple instructions can be more important than they appear on the surface, says Nadim Abi-Antoun, director of business systems for the Council for Jewish Elderly, a Chicago-based agency assisting senior citizens in both skilled-nursing and home-care settings.
For example, he says caregivers may think they are doing residents a favor by pushing them to the dining room in wheelchairs, but a physical therapist may consider the walk to the dining room an important part of a patient's exercise regimen. A good chart, he says, can avoid these types of well-intentioned but misguided acts.
Vendors are split on what an EMR in a long-term-care setting should look like and that is a source of frustration, Abi-Antoun says, and vendor options, government requirements and facility needs have yet to be aligned. The result of this misalignment, he says, has been a need to maintain dual electronic and paper records.
Derr, who also works with the Geriatric and Gerontology Advisory Committee for the Veteran Affairs Department, adds that several states still require paper records for their regulators and surveyors to review. He says the AHCA is lobbying the CMS-for whom these state regulators are under contract-to get the local agencies on board electronically.
He says the problem with getting governments to change outdated requirements is that the long-term-care sector is often an afterthought for legislators. In that respect, he says the AHCA worked hard to get skilled-nursing facilities included in recent federal bills promoting healthcare IT.
Derr and the AHCA also worked with the American Health Information Management Association to help to organize a long-term-care health IT summit in Chicago in August. Derr says 130 people attended the event, which generated a lot of creativity and awareness about future direction and current activities.
Getting representatives for all the stakeholders in one room is particularly important, Derr says, so that people become educated about what each group is doing and duplicative efforts are avoided. Implementing any kind of change in long-term care can become a grueling ordeal, Derr says, because of the sector's dependence on government funding and direction.
"Because we're so highly regulated, we're not up to speed in many areas-we're waiting to be told what we can do before we take a step forward," he says.
Kress agrees that the long-term-care sector operates under heavy constraints.
"Government sets the whole billing strategy, so it's hard to do business-model innovation and it's hard to capture the benefits of IT-driven care-even though we'd be a great environment to produce such models," he says. "There are so many ways in which long-term care can serve as a model-but now it's a model in two different worlds: one way ahead and one way behind."
In the one world, the sector's operation is driven by adherence to regulatory controls and the use of antiquated technology, he says. In the other, it is providing interdisciplinary, holistic and person-centered care, which he describes as "not only consumer-centric, but personally empowering."
Several groups attending AHIMA's summit in Chicago presented white papers identifying priorities, obstacles and recommendations for action. Kress, in his role as chairman of the Center for Aging Services Technologies' Electronic Health and Wellness Record Task Force, wrote one of these reports and touts the role of IT as a research and quality-improvement tool.
By integrating research functions into an EMR, Kress wrote that quality of life, overall care, clinical practices and functional assessment can be improved. "Quality organizations should begin to transition their work toward the development of quality indicators and alerts based on real-time capture of clinical and status information," Kress wrote.
Jon White, a physician and a health IT portfolio manager for the federal Agency for Healthcare Research and Quality, says using IT correctly in the long-term-care arena will have big benefits, such as reducing communication breakdowns between providers that expose vulnerable populations to medical errors. "Our long-term-care needs are going to skyrocket and if we set up our information systems in a provider-centric way, they're not going to serve people the way they should," White says.
If the healthcare system does manage to combine long-term care's person-centric focus and acute care's adept use of technology, Derr says the difference would be revolutionary.
"It will change our whole healthcare system and go toward better quality of life and better quality of care," Derr says.
"Long-term care says, `This is a whole human being,' " he says, explaining that using tech- nology with that holistic approach "will move us from a static system based on incidents, to a dynamic system based on trending."
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