Moving to the next generation of IT: interview with Don Mon, PHD, FHIMSS, vice-president of practice leadership, American Health Information Management Association (AHIMA); and Michelle Dougherty, RHIA, CHP, manager of practice leadership, AHIMA.

It was an open invitation to join the development of 21st century healthcare information technology: This past August, the American Health Information Management Association (AHIMA) sponsored an industry-wide summit for long-term care leaders to get in on the ground floor of creating an electronic health record (EHR). More than 120 providers, vendors, consumers, and association representatives attended. A who's who of long-term care-related associations, some 14 in all, presented white papers offering their own perspectives on the challenges and promises involved. Although long-term care had long occupied its own track at national AHIMA and Healthcare and Information Management Systems Society (HIMSS) conferences, never before had it been singled our from hospitals, physicians, and other acute care providers for such concentrated attention. It was clear that with the federal government declaring an all-out push in the EHR direction and standards-setting bodies in full-swing, influential national IT organizations wanted to make sure that long-term care had a seat at the table. The big question was with so many other concerns on their plates--dwindling reimbursement, increasingly complicated market demands, comprehending the growing array of dedicated long-term care IT products out there--why would long-term care providers care? Could providers reasonably be expected to muster the time and effort needed to achieve the dream of a universally operable EHR? Recently, AHIMA's two spearheads for the long-term care project, Don Mon, PhD, FHIMMS, vice-president of practice leadership, and Michelle Dougherty, RHIA, CHP, manager of practice leadership, addressed these questions and others in an interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: Why the relatively recent focus on long-term care?

Dr. Mon: AHIMA has always had a focus on long-term care, but now we've increased the emphasis. The EHR encompasses health records from womb to tomb and, of course, long-term care and chronic care are a part of that.

Peck: But there's perception that acute care has dominated the discussion thus far and that long-term care is a kind of outlier, with its own requirements.

Dougherty: That's true to a degree. But there's realization that the standards developed have to reflect the unique standards of the field, which is why it's highly important that long-term care gets to the standards-setting table.

Dr. Mon: The perception of acute care dominance is out there, but there is a general openness to the idea, for example, that HL7 standards should incorporate the special perspectives of long-term care. (For definitions of HL7 and other frequently used acronyms, see "EHR Glossary.")

Dougherty: And the same is true of the NCPDP (National Council for Prescription Drug Programs) for e-prescribing. For long-term care, it's a question of getting up to speed on where the standards-setting action is now.

Peck: But with so much else going on in their world right now, why should long-term care providers out in the hinterlands care about this from an operational standpoint?

Dougherty: Even if they're content with the way things are now, they still have to know that change is coming. One thing they will start seeing in their neighborhoods are regional health information organizations (RHIOs) encompassing a wide variety of providers, from hospitals to home care to long-term care. There are as many as 200 of them already throughout the United States. As these grow, long-term care providers will find it difficult to sit on the sideline.

Dr. Mon: That's true, there will be all these providers coming together to share health information to improve safety, quality, and operational efficiency. Their basis of information exchange will be the EHR. And since primary care and inpatient acute care are not collecting the data that will make long-term care's life easier, now is the time for long-term care providers to join in the exercise of developing standards for interoperability and data sharing. This can also make their existing operational task easier because the EHR, when properly constituted, will include the elements they need for their own reporting--the MDS, for example--so that providers need only enter the data once and have them serve many needs. This can happen only if long-term care gets involved in setting the rules of the game right now.

To get started, I'd recommend that facilities participate with local healthcare organizations that have become involved in EHR-related initiatives and continue to encourage their state and national associations to maintain their advocacy efforts on this issue.

Peck: When it comes to IT, though, isn't there a mind-set among many long-term care providers that they have their required software by now, they have their vendors and rely on them to keep them updated, so from the facility standpoint, they're really OK right now?

Dougherty: That's true, having working in long-term care for five years and consulted for ten, I know that is often the mind-set. But if I were an operator, I think I'd realize pretty soon that I have to communicate with hospitals, pharmacies, and physician offices every day, and that we're an integral part of a bigger system.

Peck: What would you say are the biggest obstacles long-term care providers have to overcome in getting up to speed with the EHR?

Dr. Mon: I think it's clear that the technical challenges involved are the least of our worries. The more important issues are organizational mind-set and financial sustainability. If those issues aren't resolved, even if all the technology is worked out, the EHR still won't be adopted and implemented.

The first gestalt in all this, if you will, is organizational willingness to change, to see the EHR as something that will make life better, improve quality, and strengthen market position. The next step is developing an industry-wide view identifying data content that is standard to all levels of healthcare. An example would be a standardized patient transfer form using data that are universal among nursing homes, hospitals, physician offices, etc.

Once these have been developed, the technical work will fall under the general term of intraoperability. This actually encompasses a host of issues. One is the standards for the EHR so that systems will talk with one another. The HL7 work is very important in this regard. Then we have to figure out how the various standards will in fact work together, in a sort of chain. The Standards Harmonization contract that AHIMA is working on addresses just that. Those of us working on this have accepted that all this has to be approached in a general, industry-wide way; there are no more "point solutions."

Peck: Getting back to the individual facility or organization, what are some reasonable first steps it might take?

Dougherty: First the nursing facility has to ask itself, will the hospitals in our area be able to do business with us if they move in this direction? Then they have to evaluate its costs. One way to do this is to look at what might already be in place--e-pharmacy or e-record keeping for the MDS. What will it take to close the gaps between these and the EHR?

Dr. Mon: That is an excellent encapsulation of the first steps. Another is to get business partners to help work on this--other facilities and vendors, too, although the vendors themselves will need some help. It's time to start reaching out. We thought our summit in August was a good step in this direction.

Peck: What sort of time frame are long-term care providers looking at for this?

Dr. Mon: The Bush administration set a ten-year target, and this is all being done in measured steps using contracts with three-year target goals, all coordinated with Dr. David Brailer's Office of the National Coordinator for Health Information Technology. We have the Standards Harmonization contract, and the federal Agency for Healthcare Research and Quality has the contract for reviewing all privacy and security laws and regulations to make sure the EHR doesn't come into conflict with these, and we, again, are the prime contractor for certifying vendor compliance with EHR requirements. In terms of healthcare sectors being focused upon, we are starting with ambulatory care, then acute inpatient, and finally RHIOs, where we envision long-term care providers coming into the picture. It's actually a very logical progression, it's under way, and it's not too soon for long-term care providers to follow their leaders and take an active interest.

For further information, contact Michelle Dougherty, RHIA, CHP, at [phone] or visit www.ahima.org. Further information on the summit, including white papers presented by various long-term care associations, can be found at www.ahima.org/infocenter/whitepapers/ltc.asp. To send your comments to the editors, please e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

RELATED ARTICLE: EHR Glossary

The following are frequently used acronyms and their meanings related to the electronic health record:

AHIC: American Health Information Community, a group appointed to advise the Secretary of Health & Human Services on healthcare IT issues.

ANSI: American National Standards Institute, a body that accredits standards organizations and ensures that standards are developed and approved using appropriate processes.

CCR: Continuity of Care Record, an effort by several healthcare organizations to develop a standardized summary of care record (e.g., a referral form).

HL7: Health Level 7, an organization that develops standards for electronic communication of health information between systems and sets the standards for EHR functionality.

NCPDP: National Council for Prescription Drug Programs, a standards body for pharmacy related processes.

NHIN: National Health Information Network, the concept of a network that shares health information electronically.

ONCHIT: Office of the National Coordinator for health Information Technology, which communicates the federal agenda for healthcare IT and is currently headed by Dr. David Brailer.

PHR: Personal Health Record, the medical record maintained by the consumer/patient.

RHIO/RHIE: Regional Health Information Organization/Exchange, an organization of local providers that comes together to exchange health information electronically.

SDO: Standards Development Organization, a generic term for an organization involved in developing standards.

SNOMED CT: Systemized Nomenclature of Medicine Clinical Terms, a standard healthcare vocabulary that is coded to be computer-readable.