The National Imperative to Improve Nursing Home Quality Honoring Our Commitment to Residents, Families, and Staff (2022) / Chapter Skim
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9 Health Information Technology
9 Health Information Technology
Pages 453-494
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. Moreover, a nursing home resident's stay tends to be extended rather 1 Although the terms "electronic health record" (EHR)
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This chapter of the report explores the role of HIT systems in nursing home settings, beginning with a brief background on the introduction and use of HIT in nursing homes. The discussion then turns to an examination of how HIT aligns with and supports the components of the committee's conceptual model for high-quality nursing home care.
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As discussed in Chapter 4 and explored further below, the MDS was designed for three key purposes: to collect data to describe each resident's condition and create individualized resident care plans, generate quality indicators to evaluate nursing homes and guide improvement efforts, and serve a reimbursement role. Notably, MDS data are also used to develop publicly reported quality measures (Rahman and Applebaum, 2009)
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. The 21st Century Cures Act of 20166 contains several provisions designed to accelerate the effective use of HIT to promote interoperability, or the seamless and secure access, exchange, and use of electronic health information, to sup port better access to health care information for all stakeholders, including nursing homes (ONC, 2021a)
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A lack of interoperability, or the inability to electronically share health information between different HITs such as hospital and nursing home EHRs, is a key barrier to the full and effective use of EHRs. Only a small share of the 600 nursing homes surveyed in the study referenced above indicated that they were able to perform the key functions associated with the benefits of interoperability, namely sending, receiving, searching, and integrating patients' electronic health information across care settings.
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The implementation of HIT in nursing homes, if done well, holds the potential to yield benefits for nursing home residents, their families, and the people who care for them. Effective use of HIT can improve the quality of care and quality of life of nursing home residents, reduce medical errors, increase the efficiency of nursing home staff, provide the data needed to drive quality improvement and quality assurance efforts, and increase person-centered care.
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. HIT and Quality Improvement Given its capacity to facilitate communication between health care providers and advance patient safety across all health care settings, including nursing homes, HIT is viewed as an effective tool for improving the quality of care.
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. HIT is also associated with improved communication and the documentation of risk assessments for falls, a key area of patient safety in nursing homes (discussed in Chapter 6)
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. Another example of the ways in which the effective use of EHRs can advance patient safety in nursing homes is in the area of medication management.
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This is particularly important when patient information is shared between nursing homes and hospitals during transitions of care because nursing homes often collect very specific and unique types of clinical data related to patient outcomes, while hospitals may not. Moreover, nursing home residents have very specific care needs related to chronic health conditions and care management.
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. Advance Care Planning As discussed, the care plan is instrumental in the delivery of personcentered care to nursing home residents.
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. Many nursing homes, however, only have computers located at central nursing stations and not close to residents' rooms.
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. Research on nursing home responses to performance-based accountability measures, including the adoption of quality improvement changes, indicates that the strongest correlation between quality improvement changes was the implementation of EHRs and other HIT, such as clinical decision-support tools, to help frontline staff improve care delivery (Shetty et al., 2020)
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While HIE is necessary, it is, in and of itself, not sufficient for interoperability.9 Among the approximately two-thirds of nursing homes that had EHRs in 2017, less than 20 percent were capable of integrating patient health information from other health care organizations (Henry et al., 2018)
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and a nearly 60 percent decrease in potentially avoidable hospitalizations. HIE facilitated staff access to detailed resident health information, enabling staff members to monitor patient progress more effectively and to identify signs of possible problems, which helped to reduce avoidable hospitalizations (Ingber et al., 2017; Rantz et al., 2017a)
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. CHALLENGES OF HIT ADOPTION AND USE IN NURSING HOMES The adoption, implementation, and effective use of EHRs in nursing home settings face significant challenges.
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. If incentives are offered to high-performing nursing homes to encourage the adoption of quality improvement strategies involving EHRs, these funds might potentially serve to offset the costs of EHR implementation.
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. HIT that is designed well and takes into account the human factor is thought to build upon organizational capacity by enabling nursing home staff to better identify resident care needs, to track and manage care delivery processes, and to access needed information for making decisions about care delivery (Alexander, 2015; Alexander and Staggers, 2009)
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. Interoperability The ability of nursing homes to share patient data about residents as they transition from the hospital to post-acute care settings is critical to the health care professionals who are responsible for care coordination and post-acute care.
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Lower rates of HIT adoption in nursing homes in rural areas, in contrast, might lead to greater disparities in care delivery, leaving rural nursing home residents increasingly vulnerable to poor outcomes. One analysis, for example, found that 60 percent of resident care systems in rural nursing homes are not at all able to interface with external entities' computerized systems, including those found in clinics, clinical laboratories, hospitals, and other nursing homes, reducing those nursing homes' capacity for health data sharing (Powell et al., 2021)
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. HIT AND THE COVID-19 PANDEMIC Nursing homes used health information technology during the OVID-19 pandemic in a number of ways, including to enhance the surC veillance of outbreaks and the responses to those outbreaks.17 The Centers for Disease Control and Prevention (CDC)
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. In many ways, nursing homes represent ideal settings for the use of telehealth services.
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The use of telehealth as a viable modality for health care delivery accelerated dramatically after March 2020, when CMS, under a public health emergency waiver, removed existing barriers to telehealth services.18 This policy change, which enabled nursing homes and other health care providers to be reimbursed for telehealth visits at the same rate as a TABLE 9-1 Potential Benefits and Challenges Associated with Telehealth Use in Nursing Homes Potential benefits of adopting telehealth Potential challenges to adopting telehealth Enable residents to avoid exposure to Greater difficulty building the resident– infectious disease, and to avoid the stress provider relationship associated with transportation to and from Variability in implementation, use, and appointments outside of a facility integration of different software/platforms/ Improve access to care/providers devices used for telehealth visits Improve efficiency for clinicians (e.g., less Lack of available, integrated, and time spent traveling to nursing homes) interoperable data Improve communication between nursing Delays in follow-up care of nursing home home staff and providers residents Provide opportunities for early intervention Increased burden for nursing home staff Provide opportunities to include family in care of the resident Reduce hospital readmissions SOURCE: Powell and Alexander, 2021.
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Regulations had previously limited the reimbursement for telehealth services to rural nursing homes as originating sites of care. In addition, CMS developed a telehealth toolkit to provide guidance to health care facilities in the use of telehealth19 (CMS, 2020; Gillespie et al., 2020)
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. HIT to Counter Social Isolation The restrictions imposed by nursing homes in response to the C OVID-19 pandemic intensified feelings of social isolation and loneliness among nursing home residents who were unable to see friends and family members for long periods of time.
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BOX 9-3 Resident and Family Member Perspective "One of the great tragedies of the present era is the proliferation of this option [nursing homes] as more people live longer and are separated from their families.
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For example, radar and other sensing devices are able to • Assist in detecting falls by nursing home residents, • Provide automatic alerting mechanisms with early notifications sent to nursing home staff when a resident is alone in a room (Su et al., 2018)
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Effective use of HIT can improve the quality of care and quality of life of nursing home residents, reduce medical errors, increase the efficiency of nursing home staff, and provide the data needed to drive quality improvement and quality assurance efforts, and increase person-centered care. While there are a number of barriers to successfully implementing EHRs and other HIT systems in nursing homes, research has identified potential approaches to addressing those barriers.
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• HIT implementation in nursing homes, if done well, has the poten tial to yield far-reaching benefits for nursing home residents, their families, and the people who care for them. • Nursing homes have not had the financial support granted to other health care providers, given their ineligibility to participate in the federal EHR incentive program.
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2014. A state wide assessment of electronic health record adoption and health information exchange among nursing homes.
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nursing homes. Journal of the American Medical Informatics Association 28(2)
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nursing homes. Computers, Informatics, Nursing 35(8)
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2020. Long-term care nursing homes tele health and telemedicine tool kit.
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2021. Adoption of electronic health records by practices of nursing home providers and wi-fi availability in nursing homes.
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1986. Improving the quality of care in nursing homes.
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2018. Advance care planning documentation in electronic health records: Current challenges and recommendations for change.
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2017. Electronic health records in long-term care: Staff perspectives.
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2019a. What are the differences between electronic medical records, electronic health records, and personal health records?
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in nursing homes. Journal of the American Medical Directors Association 11(7)
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2013. Health information technology in nursing homes: Why and how?
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2008. Caregivers' acceptance of electronic documentation in nursing homes.
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2016. Health information technologies: Which nursing homes adopted them?
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