Part two of a two-part series (Access part one here):
No healthcare information technology systems for long-term care have been tested or certified by the federally supported Certification Commission for Healthcare Information Technology, but that may likely change in a couple of years, according to CCHIT Chairman Mark Leavitt. "It's very much on the radar," Leavitt says. Both ambulatory and inpatient hospital systems are being tested now, with plans to add certification programs for child health, cardiovascular medicine and emergency medicine by July 2008. In discussions toward developing the commission's road map for the future, "long-term care came up very strongly as an area of great need," Leavitt says.
Larry Wolf, the senior consulting application/data architect for skilled-nursing chain Kindred Healthcare, says his company began computerizing operations 15 years ago. Kindred, which operates 250 skilled-nursing facilities nationwide, runs all its software applications and its main data repository from centralized IT operations at the company's home base in Louisville, Ky. It began with reporting of the minimum data sets required for Medicare and Medicaid reimbursements, Wolf says, adding, "We have extended that to provide other support tools," including care planning, tracking meals and diet preferences. The company also has boosted the bandwidth of communication infrastructure in its facilities and increased the number of PCs, but Wolf concedes Kindred may be behind some other providers in day-to-day data capture by front-line workers such as certified nurse assistants.
"We'd rather take one small step in all 250 buildings than take one giant leap in two or three of them," Wolf says. "The downside of scale is that everything we do is times 250. So we need to take small steps.
"Certainly 2009 is way too soon for us to have a fully functional" electronic medical record, he says. "We certainly will have expanded use of our care plans and CNA data capture, but not physician order entry."
Geoffrey Bunza is a founder and vice president of engineering and operations for Vigilan, of Wilsonville, Ore., a 5-year-old company that manages 10 assisted-living facilities in Oregon and provides management services to two others. The clinical and business computer system that Vigilan developed and sells to other assisted-living providers guides staff on keeping schedules for which residents might need help bathing and require assistance getting dressed, keeps records for periodic assessments required by most states and does billing as well as internal cost allocation.
"This is barely 20 years old as an industry," Bunza said. "It's still trying to find its way. There are virtually no federal regs on assisted living. They're all state regs and we have 50 states and 50 regs.
The systems for assisted living are different than those in nursing homes or skilled-care facilities," he said. "It's not a skilled-care nursing software modified for this industry," Bunza said. "People like things simple. The software winds up being a little simpler to use, because it is designed for this industry. If you look at skilled care vs. community-based care, the skill set of the average worker in this industry is much lower than in skilled care, so you can deduce things from that. You have to design the systems to be incredibly easy to use. It's a challenge.
"When I first got involved in this industry five years ago, the big hue and cry was from people trying to find out what their census was in their buildings," he said. "You'd think that would not be hard, but you'd go to talk to people and they'd say, 'I manage 10 buildings across multiple states and I have a hard time figuring out what my census is.' A lot of these people didn't know what it cost to maintain a person in a building. Each one has a different care plan. A lot of them don't know. In fact, today, most of them don't know. If you ask the general question of what it costs to serve one of your residents, they take the total costs and divide it by the number of residents, but it doesn't tell you what it costs to serve John Doe. There might be one that needs a lot of services. What's the trend for Jane Doe? Some of these facilities have 100% turnover in personnel, so asking a caregiver a longitudinal analysis and preparing a trend line for their care, they haven't a clue. If they know what's going on day-by-day, that's a radical change for them. Some of them wouldn't know except by month-to-month, or a lot of them, week-by-week, so technology can give them a lot of leverage that they might not otherwise have."
Facilities do acuity-based care billing, Bunza said, but "a lot of people will do it by levels, which is the traditional way. But even when you run it by level, you really should know how much it costs an individual. That way you'll know you have them at the right level, or whether they should be in skilled care. You can do that with our system and before you couldn't do that."
Thomas "Mike" Walters is a registered nurse and the program director of construction and medical services for the Oklahoma Department of Veterans Affairs, a state agency that receives partial funding from the federal Veterans Affairs Department. It operates seven nursing homes with a total of just over 1,400 beds. Because its residents receive most of their hospital care from federal VA facilities, the Oklahoma agency contracted with Hewlett-Packard Co. and Medsphere Systems Corp. to install the Computerized Patient Record System, a key element of the VA's VistA clinical computing system, in all of its nursing homes.
The project cost about $7.2 million initially, Walters says, a price that included software installation and training, necessary hardware and infrastructure improvements, plus some software modifications to adapt the inpatient hospital system to long-term care.
Walters is a fan of VistA for long-term care.
"It greatly reduces paperwork," he says. "People who are not computer literate have some difficulty getting used to the system, but I'm a one-handed typist and I get along just fine."
Within the seven-facility Oklahoma department, the electronic record system is completely interoperable. Residents can be moved from one home to another and their records follow them. For discharges to private hospitals and the federal VA, however, Oklahoma pulls up and prints out what Walters calls the "911 record," a paper-based discharge summary that includes demographic information, labs, medication history and the reason for the transfer. "It's done in a matter of minutes," Walters says. The physician at the receiving hospital "has everything at his fingertips."
Full, direct electronic access to the federal VA and transmission between the state and federal VA still is not possible for the Oklahoma agency, even though both operate on the same VistA system. At issue is the Health Insurance Portability and Accountability Act of 1996 and other bureaucratic rules, not technological problems, Walters says. "We're working with them. We have some limited access they've granted us. That's our ultimate goal, to be able to communicate electronically with the federal VA."
A new path
The current crop of commercial IT systems targeting the long-term-care market needs improvement on clinical data capture and reporting, according to physician Robert Kane, who serves as director of both the Center on Aging and the Minnesota Geriatric Education Center at the University of Minnesota. What Kane has in mind is a form of computerized decision-support system that he calls the "clinical glide path" to care.
"Basically, what you want is a proactive system," he says. "They're being developed, but they are not yet available. In long-term care, we measure success by slowing the rate of decline. If you had a patient with chronic heart failure, you might want to weigh them on a daily basis, and if they gained more than X number of pounds in Y number of days it would trigger an alert. You could intervene when you had some reason to believe theyre not doing as well as expected. You also can use that information to show staffs in nursing homes with appropriate feedback when their care is making a difference. Morale is important."