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

Nursing Homes, Nov, 2004 by David Oatway

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.