Tech Tactics for the Long-Term

With growing emphasis on postacute care, leaders are looking for solutions that enhance information exchange and patient safety.

This article first appeared in the January/February 2016 issue of HealthLeaders magazine.

Technology is driving a new wave of care coordination into long-term postacute care and home settings to enable improved outcomes at lower cost.

In July 2015, the Centers for Medicare & Medicaid Services published a proposed rule that incorporates encouragement for LTPAC facilities to adopt electronic health records, even though the meaningful use incentive payment program provided zero dollars for purchasing EHRs.

Many LTPACs are still using paper records at this point.

Despite such industry challenges, Dallas-based Tenet Healthcare—a for-profit organization that operates 87 general acute care hospitals, 20 short-stay surgical hospitals, and more than 425 outpatient centers in the United States—is already leveraging technology to speed care coordination between its facilities and LTPACs. From February to October 2014, Tenet's health information service provider (HISP) connected 350 LTPAC providers with 75 Tenet hospitals in 23 states, says Carol George, Tenet director of clinical integration.

Specifically, each LTPAC became incorporated into an online directory available to Tenet care managers from within Tenet's EHR software.

Using the Direct secure messaging protocol required in meaningful use stage 2–certified software, Tenet case managers have since sent thousands of care coordination messages to LTPACs, George says.

Prior to this initiative, such LTPACs had to receive these messages via phone or fax. "They didn't have what I would call the catcher's mitt," says Liz Johnson, chief information officer for acute care hospitals and applied clinical informatics at Tenet. "They didn't have a way for us to send something to a secure box that was managed by someone who had had their ID proofed. We made a decision as a company that the best thing we could do, given that there was no incentive on their side, was to begin to orchestrate Direct mailboxes for those entities."

Using Direct secure messaging is "much easier than printing from a chart and faxing things over," George says. "And if you get a busy signal on a fax machine, you've got to wait. It seemed so normal in healthcare for years."

Johnson explains, "What we hope is, by getting more complete information to the place of care, that the patients would be able to move in a more orchestrated or orderly fashion, and therefore their care wouldn't [for instance] repeat meds," Johnson says.

George says that in the past year, five large LTPAC providers have rolled out their own Direct HISP connections, further smoothing the flow of information.

Tenet has not yet studied the effect of this process improvement on overall outcomes, Johnson says. "We're always working diligently, like I said, to get the patients where they need to be."

Leveraging tablets, speech
One way some postacute care facilities are becoming more efficient with technology—and achieving some of the same cost-control objectives as acute care facilities—is to leverage EHRs based on tablets that enable a quicker learning curve for nurses and speech recognition to speed order entry.

Landmark Hospitals, a 282-bed, seven-hospital, long-term acute care (LTAC) system originating in Cape Girardeau, Missouri, in 2006, has since opened or acquired facilities in Missouri, Utah, and Georgia, and opened its seventh hospital in July 2015 in Naples, Florida. The company was formed to establish regional hospital referral centers for medically complex patients in need of intensive postacute care.

Joseph Morris joined Landmark eight years ago as consulting chief information officer. Nearly four years ago, the company decided to build its own EHR software to serve the needs that were different than those of a conventional hospital, Morris says. Partnering with Nuance, Landmark made the EHR voice-enabled and focused on running on tablets, although it also developed a desktop version, and recently added an electronic medication administration record to its ChartPad voice-driven EHR.

The goal by the end of 2015 was to complete the feature set, starting a separate company, Technomad, which is offering ChartPad to other long-term care facilities. "We divested our entire IT department to Technomad, which sells its services back to Landmark," says Morris, who also serves as CIO for Technomad.

"One of the main reasons we decided to build our own EHR was we don't qualify for meaningful use dollars," Morris says. "But we had to make it easy for our physicians as well. Physicians don't like point-and-click. They don't like the large EHR systems. When they come to our hospitals, they're glad we have ChartPad, and we allow them to dictate freely as they'd been doing before.

"If you look at the other EHRs, every lab that you have, every radiology result that you have, is going to populate your progress note every day," Morris says. "With our note, we just carry over from day to day. We only carry over the pertinent information that they need. And we allow physicians to make changes with their voice, changes that go right into the note." The Nuance SpeechAnywhere technology in use does not require the kind of training that an earlier Nuance technology, Dragon Medical, required, Morris says.

To facilitate care coordination with mainstream hospitals, the ChartPad EHR also generates meaningful use standard structured data, including ICD-10, RxNorm, and allergies,
he says.

"I don't think, nationwide, that people are aware of what long-term acute care facilities can do," says Adry Oliveira, RN, director of nursing at Landmark Hospital of Salt Lake City, which is based in nearby Murray, Utah, and has been open for two years. "We do chest tubes, bronchoscopies, arterial line monitoring, central venous pressure monitoring, and basically anything an acute care ICU can do. We have a respiratory therapist here 24 hours a day, and they are all intubation-certified. Our charge nurses place PICC lines. Our doctors will do central lines. A patient who is critically ill can be taken care of in a hospital like this."

ChartPad helps Landmark with efficiency, which is helpful considering that it gets a smaller reimbursement for taking care of a postacute patient than an acute hospital would get. "I can have an agency nurse come in, and she will learn ChartPad within an hour," Oliveira says. Even visiting physicians from Intermountain Healthcare—one of the area hospitals which discharges ICU patients to Landmark—use ChartPad while rounding at Landmark, and "they're happy with it," she says.

"All my audits can be done in a shorter time than it was before, because I can pull out the fall risk assessments, pain assessment, and reassessment. I can look at every single patient within minutes, and review the care provided by all departments."

Feeling the technology benefit
PointClickCare, an EHR built specifically for long-term care facilities, has helped LTPACs detect drug-to-drug interactions and out-of-range dosages and allergies, but interoperability issues with acute care remain, says Coral Lindahl, RN, nurse informaticist and PointClickCare coordinator at Ebenezer, the senior service division of Fairview Health Services, a Minneapolis-based system that operates six hospitals and medical centers, more than 40 primary care clinics, and more than 67 independent living, assisted living, memory care, and nursing home facilities.

"When I started out in nursing, we had a book that was probably 4 or 5 feet thick that we had to keep on our med carts and [use to] look up these drugs, and we had to know it all," Lindahl says. "Now the system does it for us."

Recently, Ebenezer moved to the latest version of the cloud-based EHR, and is now able to have providers view lab results online, instead of having them faxed from the lab, Lindahl says.

At this point, Fairview and Ebenezer still lack a common provider directory. "There was an organization here in Minnesota that was the state health information organization, but they don't exist anymore," Lindahl says. "It was going to be their responsibility to maintain that repository of information, so everybody's kind of scrambling in Minnesota, trying to get back on track. Right now, unfortunately, it would be me calling providers up and saying, 'Can you give me your Direct message address?'

"We've got a lot of organizations that will say, 'We're interoperable. We'll share health records.' Everybody talks the talk, but nobody moves. I think there's a lot of competing priorities."

One bright spot: Completion in 2014 of an 18-month project conducted by Stratis Health, which serves as the Medicare quality improvement organization for Minnesota, that facilitated health information exchange and medication reconciliation between 10 skilled nursing facilities and their three admitting hospitals.

Home health agency cites technology's role in growth
One fast-growing residential home health agency is leveraging technology but without the benefit of any integration with electronic health records from area hospitals or healthcare systems.

Residential Home Health, based in Troy, Michigan, is an independent provider of in-home home care and hospice services. The agency works with approximately 100 hospitals annually, 200 nursing homes, and 3,000–4,000 physicians, caring for about 3,500 home care patients and 300 hospice patients, performing about 400,000 home visits annually, generally paid for by Medicare, says company president David Curtis.

Ten years ago, Curtis and some partners bought the company and were able to sell it in 2015 to Graham Holdings, a NYSE-listed diversified conglomerate with $3.5 billion in operating revenue in 2014.

"We've grown from 48 employees and $5 million in revenue to about 900 employees and around $100 million in revenue in 2015, all in home care and hospice," Curtis says.

Tech tools of the company are Homecare Homebase, an EHR designed for home healthcare; the Medtronic's Cardiocom telehealth platform, which monitors more than 300 patients around the clock; and Salesforce.com, a customer relationship management platform adapted by Residential Home Health to manage care workflow.

"We need not just point-of-care documentation, but we need good workflow management, really good operational reporting and analytics, and dashboards, so the people know how we're tracking relative to our goals," Curtis says. "And we need email, secure email, which triggers communication of events as they happen, to people who need to know. So good technology is vital for us to stay connected, particularly given the decentralized operating model."

Residential Home Health boosts its referrals from physicians by providing them with a mobile app for iOS or Android that gives those physicians visibility into how their patients' home care is progressing, Curtis says.

"We don't have any data we get directly from a hospital EHR, and we've been doing it for 15 years," Curtis says. "Epic, which is a market leader, runs a very closed system and, in my opinion, they're not open to integration with third parties. And hospitals are doing all they can just to manage their systems, let alone plug in other people.

"Plus, generally speaking, hospitals work with dozens, maybe hundreds of home health providers, who all use different EHRs, so there's no easy way to plug into all the potential postacute partners, so they don't."

Instead, Residential Home Health relies on Extended Care Information Network, hospital care management and discharge planning software acquired by Allscripts in 2008. "I get a 30-page PDF that I've got to comb through and transpose into our EMR," Curtis says.

"Our sales team, when they get a referral, they know, quickly, and if something happens with one of those patients, whether it's an acute event, a rehospitalization, or a successful discharge, they know."

The net result: more informed and productive clinics, hospitals and physicians, and close to 2,000 new patient referrals a month for Residential Home Health, Curtis says.

As long-term care becomes more important to the overall success of acute care, finding partners such as Residential Home Health, aided by technology, will be increasingly important to the success of healthcare overall, Curtis says. Despite many competitors, he plans to expand beyond Michigan and Illinois into other states, he says.