Electronic records in long-term careDavid Oatway
"By computerizing health records, we can avoid dangerous medical
mistakes, reduce costs, and improve care."
President George W. Bush, 2004 State of the Union address
"Ensure that all Americans have secure, private electronic medical
records by the year 2008."
Sen. John Kerry, presidential platform
"... develop a strategic plan to create a comprehensive national
healthcare information infrastructure that encompasses public-sector
and private-sector health information activities, and that includes a
national agenda to guide policymaking, technology investments,
research, and integration with ongoing health care and health care
information technology activities."
Sen. Hillary Rodham Clinton, S. 2003--
Health Information for Quality Improvement Act
"Paper kills.... A paper-based system is an ignorant system."
Newt Gingrich, Center for Health Transformation summit, June 15, 2004
Political and policy leaders of all persuasions concur that current paper-based health and medical records must be replaced with electronic substitutes. While work on the nature of electronic records has been ongoing for many years--HL7, the key standards development group, has been organized since 1987--there is no consensus on what an electronic health record looks like. But we will have one anyway.
What Are Electronic Records?
Any resident information stored in a computer is, in a sense, an electronic record. However, the terms "Continuity of Care Record (CCR)," "Electronic Medical Record (EMR)," and "Electronic Health Record (EHR)" imply additional characteristics and capabilities beyond just storing data in a database (see sidebar for definitions). When the record is limited to a single provider or institution, it can be stored in any convenient format. When the data must be shared with other providers or institutions, standards are necessary for the sender to encode and communicate the record, and for the recipient to decode the record and verify its authenticity. This is an enormously complex undertaking.
What Are the Goals for Electronic Records?
Electronic versions of records can be well safeguarded, shared efficiently, and used to improve care and are more patient-friendly, reducing the redundancy that many patients perceive when asked the same question each time they see a provider. Before widespread adoption can be realized, however, several conditions must be met: The records must be guaranteed to be authentic, unchanged from the time of authentication, and unable to be repudiated by the authenticator. In addition, the records must be available. Moreover, the security requirements of HIPAA are essential minimum standards to ensure that electronic records will be safeguarded, from the technical standpoint. In fact, with adequate system design and maintenance, electronic records will be more secure and available than paper. Also, a lost or destroyed paper record cannot be re-created, while backups permit electronic records to be retrieved.
The HIPAA privacy requirements are essential to gain professional and public trust in the electronic record. Electronic records will be safer from casual access than paper records, and evolving technology will reduce the security burden on providers to authenticate their identity for access.
Sharing records among providers is an other benefit of the electronic record. Sharing records with other providers requires records to meet standards that enable the receiving system to make sense of the record (and to ensure its integrity, authentication, and nonrepudiated status). Standards for records are evolving through groups of providers, academics, and vendors working in structured processes to document, standardize, and promulgate the standards.
Electronic record development will also aid medical research. Many of the difficulties in medical research are a result of privacy issues, inconsistent record keeping, and problems in accessing records. Electronic record systems can be designed to facilitate research while suppressing identifying information, consistent with HIPAA access rules. With electronic records, more attention can be devoted to study design and data interpretation and less to the mechanics of data access.
The most important goal for electronic record development is improvement of healthcare. Once health records can be accessed from anywhere by authorized providers, providers will be better able to offer superior care, since the patient's history and current treatment status will be immediately available.
How Do Nursing Facilities Fit Into the Electronic Record Initiatives?
Nursing facilities will be significant beneficiaries of electronic record development if the unique characteristics and needs of our facilities are considered in the development of record systems. The nature of information needs in nursing facilities differs from those in acute settings: Nursing facilities need extensive histories and descriptive information with a relatively small amount of treatment information and provider communication; acute setting-oriented systems are focused more on diagnosis and treatment and fast, accurate communication of orders and results. Nursing facilities trying to implement acute hospital-oriented systems have encountered limitations because of the larger records and longer lengths of stays at the nursing facility. While most standards work to date has focused on the acute-care and ambulatory environments, the interests of long-term care facilities are represented on associated task forces.
Actually, the new data-management technologies being applied by CMS, IT vendors, and standards organizations have the potential flexibility to accommodate the needs of all providers. Long-term care's MDS 2.0 record was an example of standardization using the technology available at the time it was specified: fixed field position records. For the upcoming MDS 3.0, CMS has committed to using XML technology to make system changes easier for providers to accomplish and maintain, and vendors will do well to make the same commitment. Also, future versions of the MDS will have to meet the promulgated HIPAA data standards, a task made easier by using XML technology.
Once electronic records are accepted in nursing facilities, claims will be easier to compile and backup documentation will be more readily accessible. Wholesale copying of clinical records will be replaced with an electronic transmission.
The CCR is an intermediate step toward electronic records that can have an immediate impact on nursing facilities. A group of clinicians, health information specialists, and information technology personnel under the auspices of the American Society for Testing and Materials (ASTM International) has developed a draft standard of the CCR that will be reviewed and voted on this month (September). Interested professionals can participate by contacting ASTM International (see sidebar). The CCR could be implemented in stages--first on paper and then electronically in local communities. This could facilitate communication between hospitals and nursing facilities during transfers and to other providers involved in the referral.
What Standards Will Nursing Facilities Have to Meet?
Nursing facilities will have to meet all of the HIPAA requirements for electronic records. Some of these are already in place (transactions and code sets, privacy, and security), while others are still under development (electronic signature, record structure). Since all nursing facilities have at least some clinical data in electronic format, the evolution to electronic records may be less difficult for them than for all-paper healthcare organizations.
A Special Case: The Electronic MDS
The MDS systems in most nursing facilities contain all MDSs in an electronic format. However, as the situation stands now, the paper copy is the only version of an MDS that is legal for payment or forensic purposes, since no standard exists to: (1) verify the integrity of the electronic version; (2) ensure that the person attributed to having signed the MDS actually signed it; and (3) ensure that the person signing the record cannot deny that the record is the exact record he signed. It is worth noting that HIPAA requires the Department of Health and Human Services (DHHS) to develop an electronic signature policy, and CMS verified in June that they were close to publishing a proposed standard for this.
What Issues Need to Be Addressed?
Technology has evolved to the point that hardware is not the limiting factor for electronic health records. While additional development will continue to improve speed and capacity, the current environment of new processors and equipment for memory, storage, and communication is an adequate starting point. Further development of voice recognition, portable devices, and authentication methods will serve to enhance the acceptance of electronic records.
Software programs are the major limiting technical factor. Current systems are vendor-unique, with many vendors trying to offer comprehensive solutions in their own ways. For each product, the user interfaces, data structures, and processing flow are closely guarded proprietary property.
Professional acceptance of electronic systems has been problematic for all but the most adventuresome or technologically sophisticated clinicians. Several large systems for computerized physician order entry have failed recently because physicians reject them as too cumbersome to use. New approaches to system interfaces must be explored. Methods to facilitate the drafting of content, signing the content (authenticating), and correcting errors will have to be developed and certified.
Public acceptance also must be considered. Patients are unhappy if they perceive their clinician spending more time at the keyboard than listening to them! Assurances of the privacy of their information will continue to be necessary, as well.
Before facilities can entrust their clinical information to electronic systems, methodology must be developed to certify the trustworthiness of such systems. Questions of liability will have to be addressed--e.g., who is responsible if a resident is harmed by a system failure? Furthermore, the system standards being developed must be implemented by vendors and then certified by an outside agency. Currently, only the HIPAA Transaction and Code Sets standard has a certification mechanism.
Cost will also be a factor. Current budgets in nursing facilities devote less than 2% of operating costs to information technology, while the hospital sector spends about 5%, and other service industries much more. Lawmakers have proposed various approaches to increasing the use of technology and anticipating significant reduction of medical errors and other savings. However, the savings claimed will not necessarily go to the facility making the investment--insurance companies and fiscal agents experience the most financial benefit from some systems. Nursing facilities can expect to benefit from the use of electronic records through increased efficiency, reduced claim rejections, improved documentation, and more informed and coordinated clinical processes. Information technology budgets must be part of the strategic plan for all facilities.
What Can Nursing Facilities Do Now?
Nursing facilities will inevitably become a part of the evolving national system of electronic records. President Bush has appointed a health information technology "czar" (David Brailer, MD, PhD) with the mission of developing a strategic plan to upgrade use of healthcare information technology and announced a deadline of ten years for an all-electronic healthcare system; DHHS confirmed this mission in a report this past July.
Meanwhile, facility managers and information specialists can participate in local initiatives involving information systems, such as collaborations among hospitals, nursing facilities, and physician offices. Interested administrators, clinicians, and information specialists can participate in the Healthcare Information and Management Systems Society (HIMSS) long-term care special interest group (see sidebar) and the technology-oriented committees of their state and national associations. The HL7 and CCR groups welcome participation in their deliberations and the cost is minimal; there is great potential to present the long-term care point of view and ensure that the field's unique needs are met by the evolving standards. Health information management personnel can be also encouraged to participate in the American Health Information Management Association (AHIMA--see sidebar).
When shopping for replacement systems, consider the capabilities, plans, and actual accomplishments of potential vendors. Ensure that the vendors you've considered have the attitude, commitment, knowledge, and resources to evolve in the changing world of electronic systems standards. Budgets for information systems, including hardware, programs, and personnel, should be reviewed (and, yes, probably increased).
Until the political, technical, and professional issues of electronic records are resolved, we will be working in a world of hybrid systems, with paper as the lowest common element, even if the record is required to be transmitted electronically, as is the MDS. Nursing facility managers can prepare for the technology changes to come while harvesting the benefits of today's technology.
Participation in the standard setting, political processes, and the financial planning relevant to IT systems will help ensure that good results are achieved for everyone. The rewards of well-implemented electronic records will benefit residents, staff, facilities, and society.
What follows are working definitions and, except for CCR, are not standardized:
CCR -- Continuity of Care Record--a core data set of the most relevant and timely facts about a patient's healthcare. It is to be prepared by a practitioner at the conclusion of a healthcare encounter in order to enable the next practitioner to readily access such information. It includes a summary of the patient's health status (e.g., problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and care plan recommendations. It also includes identifying information and spells out the purpose of the CCR. (For more information, contact ASTM International via firstname.lastname@example.org.)
HER -- Electronic Health Record--a community-based record of all healthcare information related to an individual. This will likely be a master index with minimum information to identify the person of interest and key data elements, and pointers to repositories of more detailed records of care.
EMR -- Electronic Medical Record--a provider-based record of healthcare received within a provider organization (i.e., physician, clinic, hospital, home care agency, skilled nursing facility, etc.); may be pointed to by an EHR.
AHIMA -- American Health Information Management Association--Professional association representing health information-management professionals who work throughout the healthcare industry. (For more information, visit www.ahima.org.)
HIMSS -- Healthcare Information and Management Systems Society--Membership organization of providers, academics, consultants, and vendors concerned with the management of health information. (For more information, visit www.himss.org.)
HL7 -- Health Level Seven--American National Standards Institute accredited standards-developing organization with the mission "To provide standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of healthcare services. Specifically, to create flexible, cost effective approaches, standards, guidelines, methodologies, and related services for interoperability between healthcare information systems." (For more information, visit www.hl7.org/about.)
David Oatway is a consultant with Chesapeake Applied Technology, Key West, Florida, and cochair of the HIMSS Long Term Care SIG. To comment on this article, please send e-mail to email@example.com.
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