My organization, AristaCare Health Services, based in South Plainfield, NJ, owns and operates five skilled nursing facilities in New Jersey and Pennsylvania. We are growing rapidly, anticipating more than doubling in size within the next few months, and have been savvy enough to realize the criticality of bringing state-of-the-art technology to all aspects of operational, clinical, and financial processes.
That said, my mission as CIO here at AristaCare has been to lead the charge to select the EMR/financial system that will best transform our landscape strategically for years to come. In a previous life, I went through a similar experience selecting and implementing an EMR system at a multi-hospital health care system. As most of you know, there is nothing quite like an EMR implementation to keep your blood pressure up and cause you to not sleep right for days on end. It is immensely gratifying when it is live and everyone sees the benefits, but is quite the journey to get the organization to that point.
So here I am again – twice in my life! – implementing a far-reaching clinical and financial technology solution, but this time in skilled nursing facilities instead of acute care hospitals. And, yes, they are very different animals. In common, one has to deal with the notion of order entry (CPOE and non-med order entry), clinical documentation, eMARs, assessments, alerts, etc, etc. Much of what is needed to be tracked in hospital settings also has to be tracked in LTC settings. Meds, tests, assessments – all those things are very real in nursing/sub-acute care settings just as they are in hospitals. So the needs are similar, but IT staffs tend to be much smaller on the LTC side of the spectrum, so often the technology that is available is not fully deployed and many manual paper-based processes continue to coexist with that entity that is called an EMR. While hospitals have EDs and ICUs, nursing homes have a pesky little thing called the MDS, which is the most comprehensive documentation snapshot you possibly imagine and is required on a regular basis for all residents. “MDS” stands for “Minimum Data Set” and is a regulatory requirement, but there is nothing minimum about this data set – rather it should be called the “Mother of all Data Sets”! I have attached one here so you can feast your eyes on the degree of excruciating detailed documentation that is required on an ongoing basis for all residents in a nursing home facility. /Media/BlogMembers/mds20mdsallforms.pdf And our EMRs have to support that, put edits around it, and do all the reporting necessary to surround all this documentation.
Not only is the MDS a regulatory requirement, but it is the driver for reimbursement for Medicare and often other payors as well. Medicare pays based on a model called “RUGs” which calculates a score based on therapy utilization, complexity of assistance with Activities of Daily Living (ADLs), and other extensive services such as IVs which drive up the cost. The RUG is a daily reimbursement rate that is carefully crafted based on the available documentation for the types of services I just mentioned. Miss some documentation, and you wind up costing your organization some major money. So complete and accurate documentation is absolutely critical and ties into the financial piece of the operation even more tightly than in a hospital. Also, because there is some flexibility around exactly when one has to submit an MDS for a patient, data modeling becomes critical to identify the best “look-back period” for documentation to obtain the optimal reimbursement.
Another interesting aspect to this is that clinical workflows – although often seeking the same clinical ends – are very different than in hospitals. Because doctors are not as omnipresent in long-term care settings as they are in hospitals, the electronic ordering process falls more directly on the nursing side of the fence and issues such as how to address alerts that may come up during the ordering process present some interesting challenges. Other workflows are different and job roles and skills are different and thus, in terms of crafting a system that provides the best user experience for all who use it, we can’t lose sight of these differences.
The other kicker is that, in general, hospitals have a default level of technology that typically greatly exceeds those found in LTC facilities. While that is changing, and changing quickly, much time and energy has to be given to infrastructure in long-term care settings to accommodate the greatly-increased demand on networks and the much larger number of people who will be using computers. This is very challenging but, if not done right, can put a project severely at risk.
Just a few things to think about. We are still in our vendor selection process and it is really fun to see the world from this different perspective, but we still have to think of these systems as agents of transformation and not as IT systems, or we will fail in what we are trying to accomplish.