LTC's role in the fed's electronic health record initiative.

Readiness for Change
There is a great need for information tools to be used in the delivery
of health care. Preventable medical errors and treatment variations have
recently gained attention. Clinicians may not know the latest treatment
options, and practices vary across clinicians and regions. Consumers
want to ensure that they have choices in treatment, and when they do,
they want to have the information they need to make decisions about
their care. Concerns about the privacy and security of personal medical
information remain high. Public health monitoring, bioterror
surveillance, research, and quality monitoring require data that depends
on the widespread adoption of HIT [health information technology]. (1)
--excerpt from the report by David J. Brailer, MD, PhD. The Decade of
Health Information Technology

The United States is on the cusp of change in the delivery of healthcare services. On April 27, 2004, President George W. Bush called for the majority of Americans to have interoperable health records within ten years (see sidebar for an explanation of "interoperable"). The first step toward this ambitious goal was to develop a vision and plan. Under the direction of the Department of Health and Human Services (DHHS), National Coordinator for Health Information Technology David J. Brailer, MD, PhD, developed a framework for strategic action (see above).

The Vision

The framework lays out four goals to achieve the President's vision:

1. Introduce information tools into clinical practice.

2. Electronically connect clinicians to other clinicians.

3. Use information tools to personalize care delivery.

4. Advance surveillance and reporting for population health improvement.

This article focuses on the framework's strategies from the point of view of post-acute and long-term care (PA/LTC) providers. All nursing facilities and home care providers already have made investments in information technology (IT) to meet regulatory and payer demands. Managing the current investments and planning for the additional required investments will be key to providers' future success. Each provider must ensure that its vendors or IT staff can evolve to meet the emerging conceptual, technical, and operational requirements that interoperable health records will demand.

The relevant standards are being developed and tested as you read this. New standards will be proposed, and new technologies will compete for inclusion in the developing system. Providers must budget time, money, and other resources to acquire, operate, and maintain the new systems necessary to continue providing care and billing for services. It is essential to understand the full scope of this massive undertaking to guide the strategic plan for each healthcare provider organization. Premature action and/or action without a well-considered and -researched plan may be costly.

The Strategy

Below are excerpts from the framework and my take on what they mean for PA/LTC.

Goal 1 Inform Clinical Practice. Informing clinical practice is fundamental to improving care and making health care delivery more efficient. This goal centers largely around efforts to bring EHRs [electronic health records] directly into clinical practice. This will reduce medical errors and duplicative work, and enable clinicians to focus their efforts more directly on improved patient care. Three strategies for realizing this goal are:

Strategy 1 Incentivize EHR adoption. The transition to safe, more consumer-friendly and regionally integrated care delivery will require shared investments in information tools and changes to current clinical practice.

PA/LTC providers will need to ensure their needs are considered in planning for the shared investments. Inclusion of PA/LTC in creating legislation and regulations is essential. Private foundation grants also may be sources of support for the transition.

Strategy 2 Reduce risk of EHR investment. Clinicians who purchase EHRs and who attempt to change their clinical practices and office operations face a variety of risks that make this decision unduly challenging. Lowcost support systems that reduce risk, failure, and partial use of EHRs are needed.

PA/LTC actually has models for low-cost support systems: the Centers for Medicare & Medicaid Services' (CMS) excellent RAVEN and OASIS systems, supplied at no cost to providers. These or similar products could provide PA/LTC the minimal support needed at a low cost. Steps could be taken to prevent states from mandating requirements that make the use of federally developed systems impossible in some states, as is the current situation with RAVEN. The government and private organizations can reduce risks by moving aggressively in developing and testing standards for data representation and communication to minimize confusion and changes in direction of systems.

Strategy 3 Promote EHR diffusion in rural and underserved areas. Practices and hospitals in rural and other underserved areas lag in EHR adoption. Technology transfer and other support efforts are needed to ensure widespread adoption.

The points I mentioned for Strategy 2 apply here, as well.

Goal 2 Interconnect Clinicians. Interconnecting clinicians will allow information to be portable and to move with consumers from one point of care to another. This will require an interoperable infrastructure to help clinicians get access to critical health care information when their clinical and/or treatment decisions are being made. The three strategies for realizing this goal are:

For PA/LTC facilities to benefit, their clinical systems will have to become interoperable with physician-order systems and hospital systems. The reduction in medical errors will accrue when current orders are available for residents transferred in and new physician orders are available from physicians' order-entry systems. Mutually recognized standards for data representation and communication are the keys to success.

Strategy 1 Foster regional collaborations. Local oversight of health information exchange that reflects the needs and goals of a population should be developed.

Local health information networks can begin to be developed now with cooperation among healthcare organizations in geographic areas, even though the comprehensive standards needed for national adoption still are being developed. The national system will have to be based on evolutions of current standards. The local benefits both to consumers/residents/patients and to providers could be very positive: reduced errors, more timely care, and reduced costs of documentation and claims processing. Local implementation of the Continuity of Care Record (CCR) would make a difference immediately in transferring patients to and from PA/LTC facilities. (2)

Strategy 2 Develop a national health information network. A set of common intercommunication tools such as mobile authentication, Web services architecture, and security technologies are needed to support data movement that is inexpensive and secure. A national health information network that can provide low-cost and secure data movement is needed, along with a public-private oversight or management function to ensure adherence to public policy objectives.

Strategy 3 Coordinate federal health information systems. There is a need for federal health information systems to be interoperable and to exchange data so that federal care delivery, reimbursement, and oversight are more efficient and cost-effective. Federal health information systems will be interoperable and consistent with the national health information network.

Considerable work has been done by the Department of Defense (CHCS I and II) and the Department of Veterans Affairs (DHCP and VistA) with comprehensive systems deployed to more than 500 sites. The agencies are active participants in the standards organizations and freely share their experience with developing clinical support systems. As recognized in the framework, their experience will benefit the national goal and, specifically, PA/LTC.

Goal 3 Personalize Care. Consumercentric information helps individuals manage their own wellness and assists with their personal health care decisions. The ability to personalize care is a critical component of using health care information in a meaningful manner. The three strategies for realizing this goal are:

Strategy 1 Encourage use of Personal Health Records [PHRs]. Consumers are increasingly seeking information about their care as a means of getting better control over their health care experience, and PHRs that provide customized facts and guidance to them are needed.

PA/LTC settings would be great proving grounds for PHRs since residents/clients tend to be recurrent and eventually long term. Communications among the various providers involved in a consumer's care tend to be local in nature, which allows for building on Goal 2's regional collaboration strategy. Issues of proxy for cognitively impaired clients would have to be worked through, but these clients' care could benefit greatly from the PHR.

Strategy 2 Enhance informed consumer choice. Consumers should have the ability to select clinicians and institutions based on what they value and the information to guide their choice, including but not limited to, the quality of care providers deliver.

Strategy 3 Promote use of telehealth systems. The use of telehealth--remote communication technologies--can provide access to health services for consumers and clinicians in rural and underserved areas. Telehealth systems that can support the delivery of health care services when the participants are in different locations are needed.

PA/LTC would also be excellent proving grounds for these technologies. Reducing the burden on residents traveling to physician offices when remote access could adequately serve them will reduce costs and improve care. Emergency care will be better coordinated, and staff will be less likely to err in not contacting physicians on questionable issues.

Goal 4 Improve Population Health. Population health improvement requires the collection of timely, accurate, and detailed clinical information to allow for the evaluation of health care delivery and the reporting of critical findings to public health officials, clinical trials and other research, and feedback to clinicians. Three strategies for realizing this goal are:

Strategy 1 Unify public health surveillance architectures. An interoperable public health surveillance system is needed that will allow exchange of information, consistent with current law, between provider organizations, organizations they contract with, and state and federal agencies.

Strategy 2 Streamline quality and health status monitoring. Many different state and local organizations collect subsets of data for specific purposes and use it in different ways. A streamlined quality-monitoring infrastructure that will allow for a complete look at quality and other issues in real time and at the point of care is needed.

Strategy 3 Accelerate research and dissemination of evidence. Information tools are needed that can accelerate scientific discoveries and their translation into clinically useful products, applications, and knowledge.

Systems already are in use in academic settings that assist clinicians with prescribing. Additional tools will be developed that will bring best practices to PA/LTC, as well as make information available for research to constantly improve practices of other clinicians, such as nurses and therapists. Development and dissemination of best practices will be improved.

Implications for PA/LTC

PA/LTC providers are included as special cases within the framework and have already had significant attention paid to some of their unique needs. A study funded by the DHHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) carried out by the University of Colorado Health Sciences Center examined the current state of use of EHRs in leading-edge nursing facilities. This study found that all of the facilities studied used stand-alone MDS systems, with the EHR based on hospital information systems used by host acute hospital organizations. (3) There is significant opportunity for evolution on the part of nursing facility vendors with new product development.

The nature of many PA/LTC residents will require special accommodations to the framework's consumer-centric goals. Residents with compromised cognitive abilities cannot fully participate in the personal choice aspects of the future system, and proxies will have to be found to ensure all residents' welfare. The same residents stand to gain in improved care when information about their current and past health status is electronically communicated among appropriate providers.

The regulatory instruments used in PA/LTC require special attention: The MDS used in nursing facilities and the OASIS used in home care do not comply with any of the existing proposed standards for data interchange. ASPE and CMS recognize this and are awarding a contract to study the issue.

The national program's major impacts on nursing facilities and home care agencies will be the ability to electronically receive medical orders and results of laboratory and imaging procedures. (4) In addition, receiving or transferring a resident will be improved through electronic interchange of information, resulting in more timely care with less opportunity for incomplete information and missed therapeutic actions. Claims will be more accurate and timely, with no record copying to back up claims. In short, we all will gain from implementing consumer centric and information-rich care.

References

1. Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care: Framework for Strategic Action. Washington, D.C.: Department of Health and Human Services, July 21, 2004. Available at: www.hhs.gov/onchit/framework/hitframework.pdf.

2. Oatway D. Electronic records in long-term care. Nursing Homes/Long Term Care Management 2004;53(9):84, 86-9.

3. Kramer A, Bennett R, Fish R, et al. Case Studies of Electronic Health Records in Post-Acute and Long-Term Care. Washington, D.C.: Department of Health and Human Services, August 18, 2004. Available at: http://aspe.hhs.gov/daltcp/reports/ehrpaltces.htm.

4. National Committee on Vital and Health Statistics. (First Set of Recommendations on E-Prescribing Standards). Letter to Health and Human Services Secretary Tommy G. Thompson. September 2, 2004. Available at: www.ncvhs.hhs.gov/040902lt2.htm.

RELATED ARTICLE: What "interoperable" actually means

The ability to securely exchange clinical, demographic, and financial data that are understood the same way by all users is predicated upon having a method of capturing, storing, and securely transmitting and receiving data. The different users can be using data systems from different vendors on different computer platforms with different user interfaces, but the data's meaning and format are standardized upon transmission to allow use by other systems as if they were entered from within the system.

For example, a nursing facility that may be using a Pentium-based microcomputer network running NetWare with Windows XP workstations, a proprietary software package, and an Oracle database could receive medication orders from a physician using a Palm handheld computer running the Palm operating system and another proprietary software package. The order is entered and formatted on the physician's system and transmitted to the nursing facility's system, where it can be verified and acted on by the facility nurses without having to reenter the order. The nursing facility could forward the order to the supporting pharmacy, which may be running other software on other hardware, but it doesn't matter--the pharmacy can receive and act on the order as if it were entered from within its system, fill the order, and deliver the supply to the nursing facility. The chances of error are decreased, the speed of action increased, and the resident's safety improved. Standardization of data meaning and communications makes interoperability possible.

BY RETA A. UNDERWOOD, ADC

David Oatway was the Department of Defense project officer for the initial clinical requirements phase of the Composite Health Care System (CHCS-I). He worked with HCFA/CMS on the SNF Prospective Payment System and contributed to the development of MDS 2.0. He developed one of the first clinical/MDS systems (CHAMP). He is the cochair of the Healthcare Information and Management Systems Society (HIMSS) Long Term Care Special Interest Group and a member of the American Health Information Management Association and the Health Level Seven (HL7) organization. He was the vice-chair of the American Association of Nurse Assessment Coordinators. The views expressed in this article are the author's and do not necessarily represent the official views of any organization. To comment on this article, please send e-mail to [e-mail]. To order reprints in quantities of 100 or more, call [phone].