Navigating the LTC technology landscape:How SNFs are using HIT, POC tools

When it comes to technology, SNFs and their fellow postacute care (PAC) providers are rapidly approaching a crossroads: Find a way to overcome resource gaps to speed adoption efforts, or risk facing new compliance issues down the line as the use of innovative technologies to facilitate data sharing, performance comparison, and patient-centered care across settings and sectors become staples in the modern provision of healthcare.

The increasing precedence of technology is not only reshaping traditional attitudes toward healthcare delivery along the continuum, but could derail providers that don’t keep pace with innovations that fuel new approaches.

“Technology has become a business imperative, frankly,” says Majd Alwan, PhD, senior vice president of technology at LeadingAge, a Washington, D.C.?based trade association for nonprofit aging services providers, and executive director of the organization’s Center for Aging Services Technologies (CAST). “Without the right technologies, you will not be getting in your referrals … either because you do not have the competencies and are ­costing your trading partners money … or because you don’t have the proper documentation and analytics to demonstrate that you have better results than competitors.”

Historic PAC gaps

Although legislators are working to catalyze technology adoption through policy and regulation, PAC providers have historically been passed over for the associated financial incentives (e.g., CMS’ twilighting electronic health record [EHR] incentive programs) in favor of their acute care counterparts.

Until recently, SNFs have also been overlooked in national research on technology adoption. Alwan says the most recent data on usage among nursing home providers across the country is a 2009 research paper whose findings are based on survey results from 2004.

But policymakers aren’t blind to these lapses, says Jennie Harvell, senior policy analyst in the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services (HHS). She explains that while widespread technology adoption initiatives have so far homed in on the acute and primary care spheres, PAC providers are increasingly the targets of federal grants awarded to state- and community-based implementation projects.

“I think [HHS] is aware of … who the EHR incentive programs targeted, and who the EHR incentive programs did not, and so they have made some grant programs available that support technology development and use by long-term and postacute care providers,” she says.

In addition, she explains that CMS reinvigorated national technology research efforts in the sector this year by launching a voluntary survey to analyze if and how PAC providers are using health information technology (HIT) to coordinate care transitions and support their clinical services?an effort that the agency hopes will help it better understand the current benefits and barriers to adoption. The survey will close on April 3.

Mounting incentives

CMS’ recent initiatives aren’t the only moves that suggest an increased push to understand and further flesh out the role technology plays in long-term care.

More legislative evidence includes the PAC-centered Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which sailed through a notoriously fragmented Congress last year and is slated to propel the development of standardized, interoperable assessment data for the sector.

Also in 2014, the Obama administration issued a handful of executive actions that CMS has begun using to recalibrate the star rating system featured on Nursing Home Compare.

The actions also allocated funding from the IMPACT Act to kick-start CMS’ development of an electronic reporting system that will collect nursing homes’ staffing numbers based on payroll data and post this information on Nursing Home Compare. Development is currently underway, and CMS expects to mandate nationwide nursing home reporting through the system by the end of fiscal year 2016.

In addition to setting-specific incentives on the horizon, Alwan says the overarching shift in care priorities illustrated by new payment and care delivery models offers significant indirect motivation for SNFs as well. He points to increasing opportunities for high-performing facilities to reap financial rewards and referrals through bundled payments, participation in accountable care organizations (ACO), and contributions to hospital success in readmission reduction programs.

Major technology landmarks in healthcare

Because of this increasing precedence, the healthcare technology market is awash with tools intended to spur operational efficiency and clinical success.

For example, according to the Office of the National Coordinator for Health Information Technology (ONC), HIT is an umbrella term that encompasses a host of technologies that can facilitate the storage, sharing, and analysis of health data by patients and their providers.

Notable HIT subsets and offshoots include:

• Health information exchange (HIE). As its name suggests, HIE is a process through which patients and their providers securely access and share key medical information in an electronic format.
• EHRs, which proponents say allow for increased organization and accuracy of patient information; better-informed decision-making and data sharing about a patient’s specific needs and conditions; streamlined administrative processes; and easier, more consistent compliance with new regulations.
• Although used in many circles as a synonym for ­EHRs, electronic medical records (EMR) are actually scaled-back versions, according to the ONC. They are also digital iterations of patient charts, but unlike EHRs, they are often only used in their electronic form by a single provider because they are not necessarily interoperable. To share a patient’s EMR with other practices, a provider may need to print out and deliver relevant information by mail.

In addition to the broad collection and data sharing scope of HIT, there are also myriad established, evolving, and emerging technologies on the clinical end of the spectrum, including:

• Point of care (POC) technology, which enables clinicians to electronically collect and measure essential patient information in the field
• Telehealth, which encompasses mobile technology and connectivity devices that support long-distance clinical healthcare, education, and administrative efforts by remotely communicating healthcare data

The long-term care technology landscape

In the SNF arena, providers are using this growing array of dynamic technologies to different extents and with varying degrees of success, according to experts, who peg EHRs and POC as the most prevalent tools.

According to a December 2014 report by CAST and Chicago-based financial services provider Ziegler, 74.7% of the 150 largest nonprofit senior living communities across the country have adopted EMRs and/or EHRs.

Alwan attributes these high implementation rates to the abilities of these technologies to perform federally mandated assessments and feed payment claims?features that he says granted EHRs the first technological foothold in the industry.

But while certain providers have made significant headway in EHR adoption, other HIT facets remain ill-explored in the sector, according to Harvell.

For example, she says few SNFs currently have HIE systems to share discharge summaries with other settings. However, she expects?and hopes?to begin seeing more SNFs turn to such solutions as data sharing continues to gain traction throughout healthcare.

In addition, robust HIT systems can help providers keep track of other essential documentation, such as whether residents have completed advance directives?an increasing focus in the industry, says Elizabeth Babalola, MPH, research analyst at Princeton, New Jersey?based Mathematica Policy Research.

As for the other major technology category in the sector, the CAST and Ziegler report found that 76.6% of surveyed providers have already adopted POC or point of service documentation systems.

Experts say SNFs use POC technologies to monitor crucial care components, such as changes in condition and functional ability, thereby bolstering care planning, service delivery, and resident outcomes.

For example, Babalola points to medication reconciliation as a major focus in the POC realm.

Medication reconciliation is the process of comparing a patient’s new or revised medical orders at critical junctures (e.g., after care transitions or condition changes) to all of the medications that the individual has been taking to avoid triggering dangerous omissions, duplications, dosing errors, or drug interactions. Babalola says this practice is particularly critical for SNFs, whose residents are often on many medications at once, increasing the chances of harmful side effects and interactions. She explains that certain POC technologies can reduce these risks by tracking each patient’s list of prescriptions and alerting providers about any potential complications a new addition could carry.

Alwan says there’s also been an uptick in the adoption of emergency response systems among SNFs, such as bed, chair, and body alarms for residents at risk of falling, as well as devices aimed at managing wandering habits among individuals with dementia.

In addition, he sees the implementation of telehealth picking up speed, particularly among SNFs that have partnered with hospitals (especially through ACOs) to reduce hospitalizations. For example, he says some SNFs and hospitals share real-time video teleconsult services that allow physicians to perform virtual examinations on residents who are exhibiting potentially problematic symptoms?a practice that can circumvent unnecessary readmissions to the hospital.

Barriers to adoption

Despite the strides SNFs have made in certain areas of technology, they still face a host of obstacles that experts say can stall progress during any stage of adoption.

Experts unsurprisingly point to the various costs associated with adoption as some of the biggest barriers to technology usage, such as implementing and maintaining systems over time, converting paper records to electronic files, and training staff to use the new technology, says Babalola.

She adds that in addition to the direct costs associated with using dynamic new technologies, the cost of purchasing the underlying infrastructure to support them can stop some providers before they really get started?a problem she witnessed firsthand during recent research.

Babalola was the lead author of a June 2014 study that examined the baseline level of IT adoption among all 84 licensed nursing homes in Rhode Island between 2009 and 2011?a period just prior to the launch of a statewide initiative to incentivize the purchase and installation of technology in long-term care settings to facilitate the enrollment of residents in the state’s HIE program.

Prior to the launch of the incentive program, Babalola found that a staggering 64% of studied providers lacked computers with Internet access in all clinical areas of their facility, a shortcoming that she says underscores the importance of government backing in this domain.

“Having those funds available for nursing homes is a huge driver if you’re trying to improve technology adoption,” she explains.

Once providers do manage to secure the necessary framework, fair-weather vendors can still prevent them from seeing meaningful results, Babalola adds.

“A lot of vendors will be there for implementation and for setup, but you need someone who’s going to help you maintain the system over time,” she says.

In addition to patchy technical assistance, Alwan says shortfalls in the skill sets of clinical staff (e.g., due to the industry’s steep turnover rates) can also jeopardize the success of a new technology system. He underscores the importance of filling gaps in the competencies of clinicians, CNAs, and other essential frontline workers with ongoing training programs that emphasize innovative ways of thinking about care and methods for delivering it using the facility’s entire arsenal of resources.

The financial and operational barriers that pervade the SNF arena can be further exacerbated by certain provider characteristics, according to Alwan, who says research shows that being small, independent, and/or located in a rural area can impede technology implementation rates.

Getting started

Despite the additional challenges some providers may face when foraying into the technology sphere, Babalola maintains that most can benefit from implementation, particularly of EHRs. However, she points to one significant caveat: providers must act with foresight to achieve success. She underscores the need for providers to have a comprehensive action plan in place at the outset of adoption to fully integrate new systems into daily operations, which she says is the only way to realize the full potential of the investment.

“If [the technology is] not properly incorporated into the workflow of the facility, then you just have a computer there and some fancy software, but you’re not really making any meaningful impact,” she explains.

Consequently, she says plans should detail the specific reasons for adoption (i.e., how the new technology will improve operations, practices, and/or outcomes), articulate concrete methods for reaching these goals, and anticipate additional resources (e.g., underlying infrastructure, technical support, staff training, or adjustments in the scope of job responsibilities) that will be necessary to achieve success.

For SNFs who have already implemented EHRs, ­Alwan recommends expanding their utility of the system beyond its basic functionality.

“If [providers] start with EHRs that are interoperable, that are capable of exchanging information with other providers, participating in health information exchange activities would be the next step,” he says, explaining that providers can use more advanced reporting and analytics features to monitor key operational and clinical considerations, such as hospital readmission rates and number of referral sources.

In addition, Alwan points providers considering adoption of any kind to CAST’s website for access to information on understanding, planning for, choosing, and implementing an array of technologies. Resources include technology-specific materials (e.g., white papers, vendor feature matrices, provider case studies, and interactive selection tools) to aid decision-making in the EHR, telehealth, and medication reconciliation domains, as well as videos that illustrate how different types of technologies can enhance care delivery. This year, Alwan says CAST will add new resources for functional ­assessment and activity monitoring?centered technologies, as well as some to facilitate strategic IT planning.

Leveraging grant programs and outputs

In addition to identifying specific facility needs and creating tailored action plans, experts urge providers to keep an eye toward funding opportunities that can fuel adoption efforts.

Harvell recommends that SNFs find out more about applicable grant programs, which she says often produce inexpensive technology tools that may mitigate financial obstacles. In particular, she points to two recent state-level programs funded by ONC grants that have made promising technology strides:

• In 2011, the ONC awarded more than $ 16 million to 10 states through its HIT Challenge Grant Program, explaining its goal was to “encourage breakthrough innovations for health information exchange that can be leveraged widely to support nationwide health information exchange and interoperability.”

Among the awardees was the Massachusetts Technology Park Corporation, which received two challenge grants totaling more than $ 3.3 million. With its winnings, the organization launched the Improving Massachusetts Post-Acute Care Transfers project (known by the now-familiar acronym IMPACT) to better care transitions by facilitating HIE between acute and postacute care providers, regardless of whether they use EHRs. To initiate this exchange, IMPACT staff developed system architecture called LAND and SEE, which allows providers to electronically create, send, and receive a Universal Transfer Form at a relatively low cost. PAC providers without EMR systems can also use the SEE tool to capture and collect electronic data about their patient populations, Harvell adds.

The awardees are currently piloting and further refining the tools developed through IMPACT in order to share them with other states and support affordable HIE along the continuum.

• Through its Beacon Community Cooperative Agreement Program, ONC awarded an additional $ 250 million over the course of three years to 17 communities across the country that have already made headway in the development of EHRs and other HIE-focused systems to improve cost, quality, and population health, as well as to advance performance ­measurement and other technology initiatives in their localities.

The central Pennsylvania-based Keystone Beacon Community, recipient of more than $ 16 million in grant funding, developed KeyHIE Transform, a tool that parses CMS-required assessments for SNFs (MDS) and home health agencies (OASIS) for clinically relevant points of patient data, and translates this information into an interoperable electronic summary document. The transform tool is particularly useful for enabling interoperable HIE by PAC providers that don’t have EHR systems, Harvell says. She adds that use of the dynamic tool would cost less than $ 1,000 annually for a large SNF.

“It’s very, very, very affordable, and it’s an easy on-ramp to health information exchange for the long-term postacute care provider community,” she says.

Resounding legislative IMPACT

While SNFs’ access to grant opportunities may vary based on their location, Harvell says the phasing in of the IMPACT Act will have sweeping implications for the entire PAC community.

The legislation will first see in the development of standardized, interoperable data items for use on each of the disparate patient assessments that exist across the PAC sphere to promote cross-setting collaboration and care coordination. This stage, coupled with subsequent reporting to providers, the general public, and Congress, will allow CMS and other policymakers to identify gaps and best practices throughout the sector, compare performance between PAC settings, and continue developing new payment models.

In turn, Harvell thinks the legislation’s heavy emphasis on the creation and dissemination of data will inspire vendors to build more dexterous EHRs and will encourage providers to more readily embrace them?especially given the historic influence that CMS’ requirements for providers to electronically submit assessment data to receive payment have had on the development and usage of EHRs.

“The requirements to electronically transmit assessments have served as the backbone for many of these EHR products,” Harvell says, predicting that the IMPACT Act’s call for interoperability will prompt similar progress.

“I think the IMPACT Act has a lot of promise in terms of advancing the type of technology tools that are available and will be used in this sector,” she says.

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