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September 17, 2007

EMRs: Long-Term Gains in Long-Term Care
By Annie Macios
For The Record
Vol. 19 No. 19 P. 20

Learn about the trials and tribulations of long-term care facilities that have implemented an EMR to improve workflow and bolster patient safety.

Whether small or large, rural or urban, long-term care (LTC) facilities have found varying degrees of difficulty when adopting an electronic medical record (EMR). One thing, however, seems certain: Putting an EMR into place takes more time, energy, and patience than is foreseeable at the project’s outset.

But once in place, the benefits of an EMR abound. From savings in staff time and reductions in medical errors to something as simple as instilling confidence and a sense of pride in caregivers’ performance, using an EMR in an LTC setting is worth the time and effort to implement.

The acute care setting has employed EMRs for many years. Committing to large investments in technology and IT personnel in LTC facilities, however, is sometimes difficult because of funding issues germane to their operation.

Those who have gone through the process of implementing an EMR have experienced varying levels of success. Ultimately, several key elements emerge in the success of any implementation: a strong leadership team, choosing a program appropriate for the facility’s needs, and proper staff support and training. Persistence and a never-say-die attitude also go a long way toward getting an EMR in place.

Going Live
Karrie Ingram, an information systems specialist at Citizens Memorial Healthcare (CMH) in Bolivar, Mo., was hired to lead the team that would implement the EMR in the organization’s long-term care facilities. CMH’s system consists of five freestanding LTC facilities, one residential care facility, a 74-bed hospital, and 16 physician practices.

The endeavor started with a strategic plan and vendor search and involved “as many end users that were interested” in participating. Each entity and department was asked what specifications it needed. “They really did their homework,” says Ingram.

“When we chose our teams, we chose key people from each department,” says Ingram. But she notes that by choosing the right people, it was often difficult to get them out of their area to participate in the planning meetings because they were so vital to everyday operations.

After the hospital’s EMR went live, the LTC implementation began in the spring of 2003. It took six months to create the financial and clinical modules that went live that September. The following February, CMH deployed the full EMR, including computerized physician order entry (CPOE), an electronic medication administration record, and electronic assessments.

“Initially, it was hard for the team to wrap their head around what we were building,” says Ingram. She notes that software is often an empty shell that you build to your own specifications. “Our vendor was very realistic in telling us how many hours and how much manpower it would take to build the system,” she says.

On the day it went live, she says the employees had more fear than resistance, and many were pleasantly surprised with the technology’s capabilities. “People are always nervous the first few days of implementation,” says Ingram. The IT team spent 21 days in each facility on a 24/7 basis to serve as technical support for all shifts.

The EMR has saved time by enabling more than one person to look simultaneously at patient charts. “MDS [minimum data set] coordinators can use the information from the hospitals when performing their five-day lookback period. If a resident has something happen within the last five days during the hospital stay, it can be put in the EMR,” says Ingram. In addition, physicians can access a patient’s chart for urgent issues and obtain information to make a more-informed decision. “We get more documentation and better quality documentation for CNAs [certified nursing assistants],” adds Ingram. In addition, the EMR can “talk” to the billing department and ensure optimal reimbursement.

“Our favorite part is the electronic MAR [medication administration record],” says Ingram. In LTC, medical technicians deliver medicine using a huge cart which previously held a 3- to 4-inch binder with patient medication information. Now, they simply use a laptop, and the CPOE feeds directly into the e-MAR, so there are no transcription errors. Scanning medications has reduced medical errors even more. Using the e-MAR has eliminated the need for reconciling every patient’s order at the end of the month, which previously took three to five days to complete.

Looking to the future, as a large entity with other independent single LTC facilities that could never afford information systems specialists, CMH is looking toward offering these entities the opportunity to piggyback off their system and include them in their network. “As people get to the point where they have to do something, I think this strategy might be a viable option in the future,” says Ingram.

Another Successful Venture
Valley View Center for Nursing Care and Rehabilitation in Goshen, N.Y., has also had success in implementing its EMR. A 520-bed facility employing 600 people, Valley View’s implementation was done in stages, according to Margaret Contro, who served as project director.

In March 2005, the first phase—physician order entry—was deployed using handheld devices and computers for a wireless system. Because everything was documented in real time, physicians could come into a patient’s room with the nurse and use the PDA at bedside to immediately write orders. The results were impressive: a savings of 700 hours per week in staff time. Another benefit was an 84% reduction in medication errors and fewer adverse drug events as pharmacy orders were faxed electronically, thus providing a more complete MAR. Valley View’s program also contains Medicare D formulary, so it shows what’s available and gives a list of therapeutic alternatives. “This has saved the facility money because there is no waiting for pharmacy call backs or issues related to a particular medication not being covered,” says Contro.

Building on that momentum, the electronic medication and treatment administration phase went live in 2006. Bar-coded wristbands ensure resident identification and verification of orders as they are put into the system. “For example, if a nurse is out on a meds pass and a doctor enters a prescription for that patient from a different location, she is alerted and can administer the meds immediately,” says Contro.

There are also medication protocols that reduce transcription errors and improve patient care. In addition, Valley View is integrating its system through a partnership with OmniCare and other pharmacies so physician orders will be electronically sent to the pharmacy filling system. When the bar-coded medication arrives, it is scanned. When the medications are administered, the nurse can scan the blister pack and bar code on the resident’s bracelet, ensuring proper documentation of the medication administration.

The next phase included the addition of electronic MDS, care plans, and progress notes, which keeps care plans and patient notes up-to-date. Should the patient be discharged and later return, their orders and care plans can be put back into place, according to Contro.

Valley View also deployed technology to include rehabilitation documents, a decision that has not only improved the EMR but also increased reimbursement. “It’s important for reimbursement that you provide information on the actual minutes of occupational, speech, and physical therapy that a patient undergoes,” says Contro. With the SigmaCare system, a nurse can place an order for rehab and, as the patient is treated throughout the week, it matches the treatment to the HCPCS codes to keep a running tab as to how many minutes were performed in relation to how many minutes are needed for maximum reimbursement.

In April 2006, Valley View rolled out a system in which CNAs can document care on their PDAs. “Two-hundred and forty nursing assistants were trained on how to document on their PDAs using icon-based screens that are all in real time,” says Contro. This will eliminate end-of-shift documentation. “For them, it’s a huge change in workflow because they document as the day goes on. This is just so fast,” Contro adds.

Teaching how to use the technology and providing ongoing education and support helped users overcome any fears. “Knowledge spread right down the line,” says Contro.

Having patient information available in real time enables the CNAs to provide the most appropriate care. “It’s really important because in a large facility, they may have to float [between units], so now they can see the resident summary before they enter the room,” says Contro. CNAs have immediate information on key issues, such as the resident’s mobility, transfer methods, and how they are toileted, all of which improve delivery of care.

In the future, Contro sees the EMR as something that “is not going to be optional” in LTC facilities. “Many nursing homes have pieces of this technology, but none of it talks to each other,” she adds.

Valley View’s goal is to network with other facilities using the SigmaCare technology. “As more come onboard and are networked, we can share knowledge,” says Contro. By communicating and sharing EMRs, facilities will have access to all those records, enabling the most updated, complete patient information to be available at the time of care, regardless of where someone is seeking treatment.

A Bumpy Road
Unlike at CMH and Valley View, implementing an EMR sometimes requires a longer journey. Renae Spohn, MBA, RHIA, CPHQ, FAHIMA, director of clinical applications, and Monique Lingle, MSW, director of resident services at Evangelical Lutheran Good Samaritan Society (ELGSS) in Sioux Falls, S.D., have been at the job since 1995. Roadblocks such as finding a system that could accommodate their size and needs, setbacks created by Y2K, as well as debating the decision to build or buy the system have prolonged the process. On the positive side, all the hard work has put the pieces into place.

“You must be incredibly tenacious because with the EMR, you can see the improvement in resident care that can occur and the opportunities for staff to improve their work life,” says Lingle.

Prior to beginning its EMR project, ELGSS, the largest not-for-profit in the United States, used Legacy applications, which worked well in processing such items as physician orders, care plans, and MDS information. However, everything was still manually based, and practitioners had to enter the information, print, and file it.

ELGSS explored the business mapping process between the facility’s financial and clinical sides to find the inefficiencies. It showed the biggest breakdown and area for improvement was in communication between the financial and clinical sides, whose reporting systems didn’t “talk” to each other.

“We saw great opportunities for improvement by marrying the two,” says Lingle. With that goal in mind, ELGSS began to look at EMR vendors that could meet those needs.

“What we were asking for didn’t exist,” Lingle recalls. ELGSS received requests for proposals from more than 20 vendors, only to find that its Legacy program already performed much of what the EMR technology was showing at the time. “So we stepped back for a while and took a ground zero approach,” Lingle says.

In 1999, the organization decided to once again move forward with the idea of implementing an EMR. Many companies had solid goals, but, again, the architecture of how to run the program with IT wasn’t there. “As much as you want to believe functionality drives the decision, IT is so vital,” says Lingle. Another challenge was ELGSS’ size. With 240 facilities in 24 states, “it limits us right away because of size and having both rural and urban locations,” says Spohn. Soon after, technology issues related to Y2K consumed much of the organizational energy, and the EMR selection process was put on hold.

A consult with IBM pointed to possible EMR technology for accounts receivables, as well as one piece of clinical—demographics—which was slated to be rolled out across the society. “One thing I learned is that a rollout of technology takes longer and uses more resources than you imagine,” says Lingle. Unfortunately for ELGSS, when the rollout of the accounts receivables was completed and the focus shifted to clinical areas, the society realized the program didn’t work well.

Paving the Way
IBM was consulted again, and this time a clinical leadership team with key players from across the organization was involved. “It’s such a big endeavor. You can’t leave anyone out, and you must draw the right people together,” says Lingle.

Starting from scratch and surveying the latest technology, ELGSS still had to decide whether to build, buy, or wait for the right EMR technology. Currently, it is deciding between building and buying the technology. “It’s not a matter of ‘if’; it’s a matter of ‘when,’” says Spohn about implementing an EMR.

“But the most interesting thing about this entire process is that our vision hasn’t changed,” Spohn continues. “The opportunities for improvement with EMR are undisputed, so that’s what keeps us hopeful.”

In the interim, ELGSS wrote programs to enable its CNAs and activity staff to use mobile documentation. It was so successful that the decision was made to provide five facilities with handheld devices that staff can use to document items such as attendance and the level of participation at directors activities or point-of-care information.

“We are seeing a number of things that are positive with the mobile documentation,” says Lingle, who adds that the plan is to roll out the technology for CNAs systemwide in March 2008.

Road to Success
Despite what may seem like endless setbacks, Spohn and Lingle continue to persevere and remain hopeful that the EMR will soon be in place. “Your infrastructure takes a long time to build and prepare. The last several years have been preparation for the bigger thing. You can see what’s been built in relation to where you are going,” says Lingle.

“A decision is a beginning point because you have gap analysis, contract negotiation, security issues, interfacing issues, and system set-up,” says Spohn. “All of this increases the number of years it can take to implement an EMR that is right for a particular LTC facility.”

— Annie Macios is a freelance medical writer based in Doylestown, Pa.

Information ‘Underload’
While using an electronic medical record (EMR) is an ideal tool for capturing the most up-to-date patient information, the reality is that not every facility uses one. This can present a potential problem when a long-term care resident needs to go to the emergency department (ED) or transfer to an out-of-network facility.

The medication administration record (MAR) is a critical document that serves as a legal record of the drugs administered by a healthcare professional to a patient. At times, a patient’s MAR may arrive at the ED incomplete, possibly excluding vital information, such as the most recent dose of medications. This prohibits doctors from performing optimal care in a timely fashion.

According to respondents to a posting at the blog gruntdoc.com, there are certain elements that a MAR should include for physicians to begin immediate treatment. Many in the online discussion group are alarmed by what they see as a growing trend in which this information is omitted.

Medical personnel suggest that ideally a patient should be admitted with the patient’s do not resuscitate (DNR) status, healthcare proxy, emergency contact, preferred medical doctor, medications, medication allergy information, and baseline mental status. In addition, many facilities have policies in place to send copies of medications, DNR/do not intubate forms, and a brief statement of vital signs and last administered medications—particularly narcotics and per requested needs—when a resident is sent to the ED.

— AM