FHCA 2014 Annual Conference & Trade Show

CE Session #21 – Polished Electronic Health Records Solutions Tuesday, July 8 – 7:00 to 8:30 p.m.

Canary 3 – Operations/Quality Improvement

Upon completion of this presentation, the learner will be able to:

outline the roles of the CIOC and NEC and the impetus for development of the white paper;

differentiate between the current state of EMR in LTPAC and the functionality required for a robust Electronic Health Record; and

articulate one's personal objectives when talking with a vendor/provider in regards to requirements related to EHR in LTPAC.

Seminar Description: This session will review the white paper that was developed by the CIO Consortium and the Nurse Executive Council. This white paper calls attention to the need for an EHR that is patient-centered, comprehensive, intuitive, versatile and becomes a "one and done" product. The EHR should support coordination versus redundancy of patient care across internal and external settings and services. This session will conclude with a call to action for both providers and EHR vendors. Presenter Bio(s): Irene Fleshner, RN, MHSA, FACHE, serves in a part-time capacity as the Senior Vice President for Strategic Nursing Initiatives at Genesis Health Care. Prior to her current role, Irene spent 13 years with Genesis Health Care, most recently as the Senior Vice President for Clinical Operations. Irene speaks nationally on issues related to LTPAC. Donna Megrey is a consultant in the long term care profession. Her prior positions have included Vice President of Clinical Operations for National Health Care Associates and nurse executive with Sun Health Care. Donna has a number of years of LTPAC nursing experience and is a frequent speaker in the field. Renee Reber is the Senior Vice President of Clinical and Regulatory Compliance for Consulate Health Care. She holds responsibility for oversight of 200 plus facilities in 21 states. She is a frequent speaker at long term care conferences on a range of topics. In addition to her 20 years working in LTPAC, Renee spent several years working for a national software vendor.

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POLISHED ELECTRONIC HEALTH RECORDS SOLUTIONS

• Irene Fleshner, RN, MHA, FACHESVP, Strategic Nursing Initiatives, Genesis HealthCarePrincipal, Reno Davis & Associates, Inc.

• Renee Reber, RN, FCDONA, C-Ne SVP, Clinical and Regulatory ComplianceConsulate Health Care

• Donna Megery, RN Long Term Care Nurse Consultant

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SESSION OVERVIEW

• Review white paper developed by the CIO Consortium and the Nurse Executive Council.• The EHR Based Solutions that LTPAC Providers Need Today

• White paper calls attention to need for EHR: • Patient-centered, comprehensive, intuitive, versatile and a

“one and done” product • Support coordination versus redundancy across internal and

external settings and services

• Conclude with a call to action for both providers and EHR vendors

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BACKGROUND

Fun Fact or Quote?

• Who is the NEC?

• Who is the CIO Consortium?

• CIOC/NEC Collaboration on EHR

The EHR Based Solutions that LTPAC Providers Need Today

• CIOC & NEC finalized the whitepaper June 27, 2013

• Technical whitepaper outlines key requirements and capabilities of a LTPAC system needed to support the LTPAC provider today, over the next 5-10 years, and into the future.

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WHITE PAPER TOPICS & GOALS

• Core EHR• Fundamentals still not in place, electronic paper system

• Workflow• Support care delivery processes

• Interoperability• Common language, elements, goals• Transitions of care

• Economics• Operational efficiencies• Incentivize innovation and collaboration

• Call to Action

CHALLENGES

• Regulatory Requirements• HIPAA

• Increasing complexity and acuity of patients

• Explosion of information

• New payment models and provider relationships

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THE GOOD OLD DAYS

EHR - HISTORY

• 1960’s• Lockheed Unveils Clinical Data Management System

• Introduced in El Camino Hospital, Moutain View, CA• Now known as - hospital information system

• Problem-Oriented Medical Record Introduced• Dr. Larry Weed introduced the idea of recording patient

information electronically to generate a record that would allow a 3rd party to verify a diagnosis

• 1970’s• VistA Initiated to Manage Veterans Health Data

• The start of government investments in VistA and clinical IT

• First Electronic Medical Record System Developed• The Regenstreif Institute developed the 1st electronic

medical record.8

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EHR - HISTORY

• 1980’S• VA health Information Software Declared Public

• Available to the public or private sectors• Major hospitals in other countries adopt and modify

VistA’s information driven care model• Dragon System Pioneers Voice Dictation Software

• Early voice recognition prototype• Emergence of Low Cost PC’s Spurs Wide Adoption

• Practice management functions moved computers –billing and scheduling

• Case Mix Programs for Medicaid Reimbursement in Long Term Care

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EHR - HISTORY

• 1990’s• Emergence of the Word Wide Web• Clinitec Sells Software to Convert Paper Records to EHR’s• Allscripts (Eclypsis Corporation) Founded

• EMR, CPOE and Revenue Cycle Management• Health insurance Portability and Accountability Act HIPAA

• Software developers predict HIPAA will force a shift to EHR• Veterans Health Administration Mandates Use of EHR’s• Allscripts Begins Focusing on Healthcare IT

• Launched electronic prescribing solution for physicians• eClinical Works Started by Four Engineers and a Physician

• Ambulatory EHR systems• Data Collection – Long Term Care

• Infections• Incident & Accident

• MDS• First required electronic record with data submission regarding

Medicare & Case-Mix10

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EHR - HISTORY

• 2000’s• Emergence of Web-based Software

• EHR vendors begin to offer remote host options• GE Acquires MedicalLogic and Millbrook

• 31 healthcare IT solutions• President George Bush Promotes Adoption of EHR’s

• Adopt standards for electronically transmitting W-rays, lab results and prescriptions

• CCHIT Certifies Electronic Health Record Systems• VA and Kaiser Permanente Create CONNECT –

• Moves US to national interoperability• HITECH Act Passes

• 2009 stimulus package encourages switch to EHR by providing Medicaid and Medicare rebates 11

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WE’VE COME A LONG WAY BABY

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EHR - TODAY

• 2010’s• Apple iPad Spurs Widespread Use of Tablet

Computers• Physicians start to demand the same simplicity

and convenience in the workplace• ONC-ATCB Certification Program Created

• Meaningful use criteria for adoption of EHR’s• HHS Proposes Accountable Care

• EHR will play a key role in capturing patient data for sharing within the ACO

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EHR - TODAY

• MDS• EHR

• Physician Orders• Progress Notes• H & P• Disciplinary Notes – Nursing, Activities, etc.• Vital Signs & Weights

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WE STILL HAVE A LONG WAYS TO GO

EHR - TOMORROW

• Interoperability/Integration• Greater connectivity• Collaboration among providers• Improve home-based health monitoring• Use of mobile technology• Sharing of data among partnering vendors

• Elimination of redundancy

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HOW DO WE ACHIEVE VISION OF TOMORROW

• Long Term Care CIO Consortium (CIOC) and the Nurse Executive Council (NEC) joined forces to review & evaluate the state of software available to long term care and post acute industry regarding:

• Clinical Data Collection• Clinical Documentation• Electronic Medical Record• Electronic Health Record

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WHITE PAPER EVOLUTION

• Current software offerings do not meet the industry needs

• Develop the whitepaper• Highlighting the issues• Proposing specifics on strategic system offerings

• Encourage software vendors to compare their offerings to the strategies in the whitepaper

• Proposed meeting with CIOC & NEC to formulate and develop improvements to their systems

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SELECTION OF AN EHR

• Conduct a needs assessment• What do you want?• What functionality do you want?• What do you need?

• Review IT infrastructure• Internal • External• Computers• Connectivity• File formats

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EHR & WORKFLOW

• Workflow throughout the day CAN be captured in an electronic record:• Physician Orders• Medication Administration• Notes – Physician, Nurse, Dietary, Activities, SS,

Rehab, etc.• Assessments – Physician, Nurse Dietary, Activities,

SS, Rehab, etc.• Tracking/Trending• Reports

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EHR & WORKFLOW

• Software needs to follow the workflow• The industry does not need to adapt to the software

no matter the setting• SNF• PAC• Home Health• Hospice

HISTORICALLY WE HAVE ADAPTED THE WORKFLOW TO THE TECHNOLOGY.

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A LINE IN THE SAND

• WE WILL NOT STAND FOR IT ANYMORE –• TECHNOLOGY WILL ADAPT TO THE

WORKFLOW

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WHO USES EHR

• CNA• LPN• RN• ARNP• MD• PT• OT• ST• RT• Ect.

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EHR & WORKFLOW

• Workflow & process changes• TAKE ADVANTAGE OF TECJHNOLOGY TO

AID PROCESSES

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EHR & WORKFLOW

• Internal processes can be integrated within the technology (meet the regulation as well as workflow)• Example

• Nursing Assessment – Braden Scale• Every week for 4 weeks then quarterly

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BENEFITS OF EHR

• No more manual tracking• Notification of missing assessment• Who did the assessment• Trending of assessment scores• Etc.

All of this at your fingertips

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BENEFITS OF EHR

• No need to duplicate or have redundancy• Enter information only once • Information is available with only being

entered once• Manual auditing verifications made simple

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EHR & INTEROPERABILITY

• Interoperability• The ability to communicate/share data

with others• Lab• Radiology• Pharmacy• Hospital• ACO’s

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INTEROPERABILITY

How do we communicate:• Send Fax• Receive Fax• Send/Receive via ONC

Direct Project• Direct Provider – Provider

Transfer of Care• Direct Provider – Provider

Shared Care• Provider – Consumer• Health Information

Exchange/Regional Health Information Exchange

• ePrescribing and Medication Management

• Intra-Provider System • Health Information

Exchange – Non-Standards Based

• Health Information Exchange – Hybrid

• Health Information Exchange – Standards based

• Exporting to PHR and/or Resident/Client Portal

• Interface with Hospital/Discharge System

• Interface to Consultant Pharmacy Systems

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THE IDEAL INTEROPERABLE ENVIRONMENT

• Integration of online systems• Secured online systems• Optimized online systems

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LTPAC CHALLENGES

• Rapidly changing regulatory and reimbursement environments• Regulatory Changes

• SFF Program• 5 Star Program

• Reimbursement Changes• RAC’s, MAC’s and ZPIC’s• ACO and Managed Care Model

• This combination equals shrinking access to capital for healthcare IT

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EHR CHALLENGES

• Rapidly changing LTC environment• No longer one type of population in one setting• Now includes diversified workforce at the center

level:Nurses AdmissionsCase Managers Nutrition ServicesDischarge Planners Nurse PractitionerBusiness Office Physician AssistantNurse Navigators Nursing AssistantTherapists Social ServiceActivities Psychological Services

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EHR CHALLENGES

• Rapidly changing LTC environment• Virtual Care Team involvement

Clinical Consultant Physicians Specialists Mobile X-rayPharmacy Community ServicesHome Care Services Acute Care ServicesLaboratory Testing

• ALL of these team members need accessibility and ease to utilize an intuitive EHR that provides effective tools and collaboration

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EHR CHALLENGES

• The EHR and EMR MUST:• Include and have the capability to expand as the

environment changes • Systems that support a secured and easy access to

patient information• Tools for collaboration include secured messaging,

discussions, notes, computer conferencing and telemedicine

• Collaboration and accommodation of an expanded view for the patient’s care team is key to the delivery of quality of care and successful transition to the next care setting

• The capability of integration and transmission of information to different EHR formats of hospitals and other partner systems is CRUCIAL

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THE ENTERPRISE

• What should it look like?• Consolidated model between clinical,

operations, financial, compliance and technology across the continuum

• Consistently and initiatively apply clinical and business protocols, documentation, and practices

• Automation of payer transaction services by gathering pertinent information throughout the enterprise from interdisciplinary partners

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THE ENTERPRISE

• What should it look like?• Facilitate remote monitoring of system use and

business practice delivery, compliance• Provide insightful, consolidated reporting,

analytics, and outcomes at all levels of the organization’s hierarchy

• Feature comprehensive event capture, alert-notification, and management

• Identify the patient across settings and episodes of care

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CONTINUUM

• Our patient population is not stagnant moves from one continuum of care to the other and at times back to the beginning

• Hospital LTPAC Home

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Back to the Beginning of the Continuum

KEY INTEGRATION POINTS

• To ensure clinically safe transfer to and from the LTPAC setting EHR and EMR must have: • Timely access to current patient information• Supports a variety of proprietary and non-

standard integrations with hospital and community-based systems and related health information exchanges (HIEs) or possibly not be chosen by a managed care organizations or ACOs.

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WHAT ARE THE KEY INTEGRATION POINTS FOR COLLABORATIVE

PARTNERS?• Patient Referral

• Referral, response, acceptance• ADT-Patient Profile

• Admission, discharge, transfer• Discharge Summary

• Physician, clinical notes, H&P, problem list, allergies, lab results, medications

• E-Pharmacy • Orders, receipt, reorders, returns

• E-labs, Diagnostics• Orders, results, images

• Payor• Eligibility, benefits, authorization, claims, remittance advice

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BI-DIRECTIONAL EXCHANGE

• The EHR must have the ability to fluctuate • Directionally and bi-directionally within the

network of an organization and the outside continuum

• The exchange must be fluid to allow real time information to be available and transmittable when an event occurs

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THE CUSTOMER --YOU

• The Electronic Health Record (EHR) each LTPAC environment is given the daunting task of choosing and implementing an EHR that includes• “Once and done” approach where information is

recorded should obviate prior processes and downstream redundancies

• Picking the “best of breed” of EHR and EMAR and build interfaces and repositories to integrate and/or aggregate data at the enterprise level.

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THE CUSTOMER --YOU

• The On-site Clinical Care Teams• Clinicians rely on clinical care delivery processes

(workflow) to provide care• The care delivery is a systematic approach called

care-delivery process.• The steps of care process must occur sequentially

if to be successful and effective• Nursing process steps allows the patient to be

cared for in a proven evidence based model i.e., comprehensive nursing assessment

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THE CUSTOMER --YOU

• The importance of systematic care-delivery process is important because it removes the guess work, increases the likelihood of providing the correct and safe care, contributes to improved care quality, customer satisfaction, regulatory compliance, financial performance and reduced legal liability

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THE CUSTOMER –YOUR STAFF

• Similar to the clinical workflow of the EMR training of your staff (customer) is imperative• Train sequentially as their delivery care process

and workflow dictates• Have the EMR work for your staff not for the EMR• Allow for comments and criticisms • Teach at their knowledge level—not everyone is a

smart phone!!!

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THE CUSTOMER –YOUR STAFF

• Use the tools and training sites the EHR has created for you as the trainer and learner

• Develop return demonstration examples to ensure understanding

• Make “How to” binders, help-desk numbers and “super-users” for each shift

• Apply the Train-the-Trainer Model• Correspond frequently with the EHR company regarding

concerns or questions you are having in the field• Learn what the reports are telling you as the consumer does it

make sense• Ensure through your QAPI that the EHR incorporates clinical-

decision support intelligence that assists the interdisciplinary team both within the center and the virtual team

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CONCLUSIONS

• Systems are critical enablers of the quality, process, and innovation

• Achieving positive quality and cost outcomes depend upon these systems.

• Evolving incentives are reconfiguring healthcare delivery for LTPAC• evidence, data, and technology-enabled virtual care

teams, population outcomes, transparency and accountability

• The LTPAC EHR requirements are similar and distinctive from other health care settings.

• “EHR-lite” is already too limiting

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CALL TO ACTION ON COLLABORATION

• LTC Software vendors• work with the Providers and Ancillaries

• Providers• push the software vendors to the best solution

• Ancillary providers• partner with the providers and cooperate your system

development with those of the LTC software vendors• Together we can make this happen

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QUESTIONS?THANK YOU

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REFERENCES

• The Authority on Software Selection; History of Electronic Health Records; Houston Neal, Director of marketing, 1/10/13

• McKnights Long Term Care News, March 2014, Vol. 35, No.3, How to do it: Implementing an EHR System

• eHR or Long Term and Post Acute Care: A Primer on Planning & Vendor Selection 2013, Leading Age Cast Report

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