The federal EHR incentive payment program established in 2009 has helped boost EHR adoption to nearly 81% of hospitals and 59% of physicians and other eligible professionals while spending almost $15.9 billion. But Congress, in establishing the program, excluded nursing homes, other long-term care facilities, assisted living and other residential care providers.
The studied facilities included corporate-owned assisted-living facilities as well as noninstitutional settings such as personal-care homes, adult-care homes, board-care homes, and adult foster-care homes, which typically are mom-and-pop operations that do not provide medical care or have medical professionals on staff. Even larger assisted-living facilities generally provide limited medical care. In addition, these facilities typically do not receive payment from Medicare, Medicaid, or private insurers, with most residents paying the costs out of pocket.
David Kyllo, executive director of the National Center for Assisted Living, representing 3,300 assisted-living providers. Kyllo said the NCHS study was the most comprehensive look at the industry in its history. Although somewhat dated now, the 2010 data on relatively low levels of EHR adoption by assisted-living providers was unsurprising, he said.
The cost of the EHR systems is a barrier for assisted-living organizations. Also, depending on state regulations, which vary widely, some assisted-living sites are limited in what they can and cannot track. “For some licensure categories in some states, by virtue of their license, they can't track certain types of healthcare information because of their scope of practice,” Kyllo said.
Those assisted-living communities that are linked to a healthcare system, “where the hospital and long-term care are all tied together, they'd certainly be the earliest adopters,” Kyllo said. But EHR use is growing within the assisted-living community, he said, driven by healthcare payment reform and the advent of accountable care organizations.
The lack of EHR connectedness of these facilities could present a challenge for hospital systems that work with patients living in these residential care settings. “All providers are going to have to track hospital readmissions, because of the changes in Medicare,” and penalties for 30-day hospital readmissions, Kyllo said. “The 30 days is regardless of where the discharge occurs to. The count applies if they go home or to a skilled nursing facility or go to assisted living. The predominant population we all care for is the Medicare population, so it becomes a factor for us, too.”
Even among those residential care communities reporting an EHR, the quality and functionality of the systems that were being used was called into question by the survey results, which asked participants which of 16 EHR functions they used.
For example, of those organizations that used an EHR, only 72% of the systems listed a resident's medications, 70% had a list of medication allergies, 53% kept clinical notes, 45% had problem lists, 43% warned of drug interactions and 42% took electronic orders.
Systems with interoperability were even scarcer. Just 40% of the EHR systems used by respondents to the survey could communicate with any other provider, only 23% could link with a pharmacy and just 17% could exchange information with other physicians.
NCHS researcher Christine Caffrey is a co-author of the data brief on EHR use in residential care, the first of its kind by the agency, and other reports about the national survey, which included on-site interviews with operators and residents.
“About 2,300 facilities that ended up participating,” Caffrey said. “It ranged from those small ma-and-pa ones, to the big ones with 100 or more beds.” The minimum size of state-regulated facilities surveyed was four beds.
According to the NCHS, these residential care communities serve 733,000 people, more than half of whom are age 85 and older, providing them a place to live and be cared for, including help with bathing 72%, dressing 52% and eating 22%. The median length of stay is 22 months. Nearly three-fourths of residents have at least two common chronic medical conditions, with high blood pressure (57%) and Alzheimer's and other forms of dementia (42%) being the most frequent. Nearly a quarter (24%) of residents has been hospitalized within the past 12 months.
During a webinar last month, Dr. Farzad Mostashari, head of the Office of the National Coordinator for Health Information Technology at HHS, said he wanted to set up a voluntary testing and certification program for health information technology systems designed for use by these other care providers not covered by the EHR incentive program. Mostashari also released a 14-page guidance (PDF) on the “Principles and Strategy for Accelerating Health Information Exchange.”
Last week, the federally chartered Health Information Technology Policy Committee was asked to make recommendations to ONC about a proposed voluntary EHR certification program “that would improve interoperability across a greater number of care settings,” said ONC spokesman Peter Ashkenaz. The recommendations are to address EHRs used in long-term, post-acute care and behavioral health, he said.
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