Care transitions between settings are a well-known cause of medical errors. A key component of transition is information exchange, especially in long-term care (LTC). However, LTC is behind other settings in adoption of health information technologies (HIT). In this article, we provide some brief background information about care transitions in LTC and concerns related to technology. We describe a pilot project using HIT and secure messaging in LTC to facilitate electronic information exchange during care transitions. Five LTC facilities were included, all located within Oklahoma and serviced by the same regional health system. The study duration was 20 months. Both inpatient readmission and return emergency department (ED) visit rates were lower than baseline following implementation. We provide discussion of positive outcomes, lessons learned, and limitations. Finally, we offer implications for practice and research for implementation of HIT and information exchange across care settings that may contribute to reduction in readmission rates in acute care and ED settings.
Key Words: care coordination, care transition, health information technology, long-term care, information exchange, readmission, secure messaging
Care transitions between two or more settings are a well-known cause of medical errors... Care transitions between two or more settings are a well-known cause of medical errors, and may often result in harm to patients. This is particularly true for elderly patients, who are not only more likely to be transferred between multiple facilities but are also more likely to have comorbid conditions, take multiple medications, and see several providers (Hwang & Morrison, 2007; Kessler, Williams, Moustoukas, & Pappas, 2013; The Joint Commission, 2012; Roberts, McKay, & Shaffer, 2008). Thus, the importance of information exchange cannot be understated. This is especially so in long-term care (LTC), which not only serves the elderly population, but is also a setting where access to relevant clinical information is an important key to maintaining continuity of care (Halasyamani et al., 2006; Kessler et al., 2013; Murtaugh & Litke, 2002).
Long-term care facilities often lag behind other healthcare facilities in the adoption of health information technologies... Long-term care facilities often lag behind other healthcare facilities in the adoption of health information technologies (HIT), increasing the difficulty of electronic information exchange to facilitate care transitions (Caffrey & Park-Lee, 2013; Poon et al., 2006). Common barriers to adoption of technology include: lack of experience managing/leveraging HIT; high employee turnover rates; limited funding; and lack of software designed for unique LTC needs (Mohamoud, Byrne, & Samarth, 2009). Recent evidence of poor information exchange includes a report from the United States Department of Health and Human Services indicating that LTC facilities commonly admit and care for patients with incomplete information regarding their medical status, even though over one third of all Medicare patients discharged from acute care are discharged or return to LTC facilities (Byrne & Dougherty, 2013). There is a clear need to improve information exchange in LTC to avoid poor outcomes such as early readmissions to acute care facilities (i.e., less than 30 days).
In addition to clinical implications associated with lack of information exchange, there are also financial implications, especially related to the readmission rate. Under new reimbursement policies, the Centers for Medicare and Medicaid Services (CMS) is focusing on the quality of care delivered by hospitals, a key indicator of which is hospital readmissions. Hospitals are now accountable for readmissions as CMS enforces financial penalties for facilities with high readmission rates within 30 days of discharge (Rosenthal, 2007). The cost of readmissions among Medicare patients alone stands at $26 billion annually, more than $17 billion of which could have been avoided (Dartmouth Atlas Project, 2013). The potential of poor clinical outcomes and steep financial implications has quickly led to reducing readmission rates as an area of increased focus in acute care.
There is a clear need to improve information exchange in LTC to avoid poor outcomes such as early readmissions to acute care facilities. In this article, we will provide brief background information about care transitions in LTC and concerns related to technology. We will then describe a pilot project using HIT and secure messaging in LTC to facilitate electronic information exchange during care transitions. Five LTC facilities were included, all located within Oklahoma and serviced by the same regional health system. The study duration was 20 months. Both inpatient readmission and return emergency department (ED) visit rates were lower than baseline following implementation. We will provide discussion of positive outcomes, lessons learned, and limitations. Finally, we will offer implications for practice and research for implementation of HIT and information exchange across care settings that may contribute to reduction in readmission rates in acute care and ED settings.
Background
Overall effectiveness and utility of electronic health records (EHRs) remains mixed (Hillestad et al., 2005); however, some recent research has suggested that utilization of HIT such as electronic health records (EHR) and secure messaging may play an important role to coordinate safe and effective care transitions (MacTaggart & Thorpe, 2013; Resnick, Manard, Stone, & Alwan, 2009). ...well over 90% of LTC facilities already use HIT for billing purposes, [but] fewer than 50% use HIT for medical records, laboratory, medication administration, or daily care. While past research has indicated that well over 90% of LTC facilities already use HIT for billing purposes, fewer than 50% use HIT for medical records, laboratory, medication administration, or daily care (MacTaggart et al., 2013).
In 2010, the American Medical Directors Association (AMDA) issued a policy brief on improving care transitions between LTC facilities and hospitals (AMDA, 2010). The brief highlighted the importance of communication between care settings, calling out the potential of EHRs as a way to increase the flow of information. Access to an EHR would provide a way for those currently providing direct care to a resident to obtain records that may not otherwise be available at the time of transfer. Such records could include pending test results, final lab results, or cultures, all of which may help provide appropriate care.
The potential for HIT to improve information exchange has also garnered federal attention. For example, the Office of the National Coordinator for Health Information Technology recently introduced the Health Information Exchange Challenge Grant Program. (HealthIT.gov, 2013, Mertz & Russell, 2013) The program was designed to foster innovative solutions to support nationwide health information exchange and interoperability in five key areas, one of which is improvement in long-term and post-acute care transitions.
Using HIT in Long Term Care: A Pilot Project
Although some research has highlighted the benefits of HIT (e.g., EHRs) within the acute care setting, the role of HIT in LTC settings, particularly during care transitions, remains less clear. As part of the Office of the National Coordinator for Health Information Technology Challenge Grant Program, we developed an objective to use HIT in LTC facilities to facilitate electronic information exchange between LTC and acute care facilities (e.g., hospitals) during care transitions. The next section of the article describes our pilot project and results.
Methods
Sample. A convenience sample of five LTC facilities was selected for inclusion in the pilot study. All facilities were located in one geographically defined area within the state of Oklahoma and serviced by a multi-campus regional health system.
Facility Characteristics. The five participating facilities varied in bed size, ranging from 69 to 136 available beds, and had from 53 to 130 residents; none were at capacity. All were for-profit organizations; participated in Medicare and Medicaid; and were considered skilled nursing facilities. All facilities had a ratio of 10 residents to 1 aide; 1 charge nurse per shift; a designated director of nursing; and at least 1 advanced practice registered nurse practitioner and medical director per facility. Two facilities were owned by a corporation, two were included in a broader partnership, and one was individually owned. No facility was a continuing care retirement community and all provided resident, but not family, councils.
The exchange transmits clinical data using an international standard for communication of electronic health information and structured clinical documents. All facilities also had existing transfer patterns with local acute care facilities, as well as access to a statewide health information exchange (HIE) known as Coordinated Care Oklahoma (CCO). CCO is a health information organization based in Oklahoma that serves seven different health systems, including 45 hospitals and 2,700 providers. Over 275 facilities contribute data into this exchange, resulting in over 4 million records across five states. The CCO Health Information Exchange allows flexibility for connecting with all existing certified EHR systems. The exchange transmits clinical data using an international standard for communication of electronic health information (health level 7, HL7) and structured clinical documents. These unique features allow CCO to connect with LTC facilities, helping providers coordinate care after discharge from acute care settings.
Health Information Technology. Each of the five participating facilities implemented an electronic clinical documentation tool (CDT). The CDT used in the study is a lightweight-hosted electronic point-of-care documentation tool that is wall mounted outside of a resident’s room. This location provides easy access for caregivers to record changes in patient status as well as any required daily documentation (e.g., activities of daily living). Clinical information recorded from each facility’s CDT could also be sent to the state’s HIE, allowing access to information by local acute care facilities. In addition, LTC facilities were also able to access the state HIE, allowing them to receive a similar flow of information from acute care facilities if desired.
Clinical Documents. We utilized two standardized documents to record changes in resident status; both were used across all participating LTC facilities. First, an SBAR (Situation/Background/Assessment/Recommendation) document was used to record any initial changes in resident status (see Figure 1). The SBAR document provided a way to inform clinicians of relevant clinical information and encourage preventive and early engagement to avoid transfer to an acute care facility. Second, we used a universal transfer form (UTF) in the event a resident required a transfer. The UTF provided a more comprehensive account of a patient’s condition for the receiving facility (see Figure 2). The same SBAR and UTF documents were utilized across the five LTC facilities to allow for consistent communication between care settings.
Figure 1. Situation, Background, Assessment, Recommendation (SBAR) Document
Figure 2. Universal Transfer Form (UTF)
Secure Messaging. To exchange clinical documents and communicate relevant clinical information, facilities used a secure messaging system via Cerner Direct. Developed as a secure, Health Insurance Portability and Accountability Act (HIPAA)-compliant messaging system, Cerner Direct was designed specifically for the exchange of personal health information. Cerner Direct was used to transmit the SBAR as well as UTFs to the receiving facility.
An alert... immediately notified the charge nurse of a change in resident status. Procedure. Initial changes in resident status were first noted by caregivers at the point of care via the CDT located directly outside the resident room. An alert, based on specific ranges and alerts programmed into the CDT, then immediately notified the charge nurse of a change in resident status. Specifically, we programmed alerts to determine if the resident was at risk in areas such as dehydration, blood sugar levels, temperature, behavior, pain, intake, bowel movement, congestive heart failure, urinary tract infection, and lower respiratory tract infection. If changes recorded in the CDT confirmed a risk for any of the above factors, an automated alert was sent to the charge nurse, who would then complete an SBAR document. The resident’s designated physician reviewed completed SBAR documents.
Following the physician review, there were two possible courses of action: engage in preventive treatment at the facility or transfer the resident to a nearby hospital. If the physician decided to transfer the resident, a UTF document was completed just prior to the transfer. The UTF document was sent, along with any corresponding SBAR documents, via Cerner Direct to the receiving hospital. All clinical information was also communicated through the state HIE. Together, through secure messaging and the state HIE, we were able to ensure that receiving facilities had access to all relevant clinical information for residents who were transferred from any participating LTC facility.
Data Collection. Readmissions data for participating sites were collected through chart abstraction. Data collection included the number of residents that had been transferred to a hospital; hospital names; transfer result (inpatient admission or ED visit only); whether or not the transfer occurred within 30 days of a previous transfer, and if so, the result of the prior transfer (e.g., inpatient admission, ED visit only). The study duration was 20 months, from April 2012 to December 2013.
... through secure messaging and the state HIE, we were able to ensure that receiving facilities had access to all relevant clinical information for residents who were transferred from any participating LTC facility. To establish a baseline, we collected data for the five LTC facilities for the 6-month time frame prior to study initiation (October 2011 to March 2012). Baseline data included information regarding how frequently facilities used clinical documents during transfers prior to study initiation, and prior readmission and ED return rates. However, data were not available between April 2012 and December 2012 as all five facilities were in the process of implementing various HIT components and aggregate data were not available.
Each LTC facility included a core team comprised of a project leader, clinical leader, training coordinator, two compliance leaders, and an individual responsible to manage data metrics. All core team members were trained on various elements of the HIT and HIE. During training activities for the pilot study, we also included feedback sessions from case managers at acute care facilities, including those in the ED.
Statistical Methods. Once data collection was complete, statistical analyses were provided by the Oklahoma Foundation for Medical Quality. In January 2013, all five facilities deployed the CDT; had access to Cerner Direct; and could access and exchange information on the state HIE. Thus, data on readmissions and ED visits were collected monthly from January 2013 until study completion in December 2013. To account for changes in workflow and varying implementation dates within the first 6 months of our pilot, we focused analyses on data collected during the final 6 months of the study (July 2013 to December 2013). To maintain confidentiality, given the small number of participating facilities, we considered only on aggregate data for hospital readmission rates and return rates for ED visits across all of the five LTC facilities. Readmission and return rates to ED were calculated as follows:
Readmission to acute care facility within 30 days:
| Total # of inpatient admissions within 30 days of a previous inpatient discharge |
| Total # of patient transfers from LTC to inpatient hospital admission |
Return rate to ED within 30 days of a previous ED visit:
| Total # of ED visits within 30 days of a previous ED visit |
| Total # of patient transfers from LTC to ED
|
Upon completion of the data collection phase, data were sent to the Oklahoma Foundation for Medical Quality for analyses. Following data analyses, a separate dataset including only de-identified aggregate data was provided to the project team for interpretation. At no time was the project team able to link any of the five LTC facilities with any information protected under HIPAA. Given this use of de-identified data only, institutional review board approval was exempted, deemed inapplicable under Health and Human Services 45 CFR 46.101 (a) (4).
Results
Overall, there was a steady increase in utilization of completed UTF documents when residents were transferred and admitted to the hospital. Adoption. All facilities implemented the CDT and had access to Cerner Direct. Overall, there was a steady increase in utilization of completed UTF documents when residents were transferred and admitted to the hospital (see Figure 3). Among transfers resulting in an ED visit only (i.e., no inpatient admission), there were no greater than four of these transfers per month for all months with the exception of one. UTFs were completed for at least half of all transfers, regardless of inpatient admission.
Facilities also demonstrated a steady increase in utilization of SBAR documents. The ratio of completed SBAR documents steadily increased in relation to the number of overall transfers (inpatient admissions and ED-only visits) recorded over the course of the study (see Figure 4). Over 80% of all chief complaints prior to transfer were due to fever, urinary tract infection, altered mental status, and respiratory distress. Our results also indicated the vast majority of clinical information was communicated via Cerner Direct. In fact, of the 71 care transitions that took place during the last six months of the pilot, 59 were communicated via Cerner Direct (83%), suggesting a high adoption rate among participating facilities.
Figure 3. Percentage of Inpatient Admissions with Completed Universal Transfer Form
Figure 4. Ratio of Completed SBAR Documents In Relation To Total Number of Transfers
30-Day Readmissions. Results indicated that hospital 30-day readmission rates generally decreased over the course of our pilot (see Figure 5). Of the 48 residents who were transferred for any reason and admitted to an inpatient facility during the last six months of the study, only six had been previously admitted (12.5%). In comparison, baseline data indicated that 33.6% of residents who were transferred and admitted had been previously discharged from an acute care facility within 30 days. In this regard, our findings suggested that 30-day hospital readmission rates gradually decreased following study initiation.
Figure 5. 30-Day Readmission Rates
Return ED Visits. Similar trends were noted among residents and ED visits (see Figure 6). At baseline, 85.3% of residents who were transferred to the ED, but not admitted, had returned to the ED within 30 days. Following implementation, data from the last six months of the study indicated that among the 56 residents who were transferred to the ED for any reason, only eight had visited the ED within the last 30 days (14.3%). Furthermore, over the course of the entire 12-month study, a total of 241 residents were transferred to the ED and not admitted; among those, only 34 had visited the ED within the past 30 days (14.1%). Considering the total number of residents transferred to the ED, the proportion of those who had previously visited the ED within 30 days decreased following implementation.
Figure 6. Total Return Emergency Department Visits
Discussion
Positive Outcomes
There is a clear shift in the United States healthcare system toward a more patient-centric and value-based approach. As part of this shift, provider use of HIT plays a key role to facilitate information exchange and maintain continuity of care across settings (Resnick et al., 2009). Given changes in reimbursement related to quality of care (as measured by reduced readmissions), now more than ever we have a critical need for safe and efficient information exchange. This is perhaps nowhere more evident than in LTC, where the ability to electronically record and exchange health information has traditionally been limited (MacTaggart et al., 2013).
Our goal was to pilot the use of HIT between LTC and acute care facilities to expedite electronic information exchange during transitions of care and determine any potential positive impact on hospital readmissions. We included five different LTC facilities, all of which implemented the same electronic CDT. We also used a secure, HIPAA-compliant, messaging system in addition to the local HIE to communicate via standardized clinical documents during care transitions.
...through safe and secure information exchange combining HIT and secure messaging, acute care facilities experienced a reduction in readmission rates within 30 days among discharged LTC residents. Our findings indicated that through safe and secure information exchange combining HIT and secure messaging, acute care facilities experienced a reduction in readmission rates within 30 days among discharged LTC residents. Overall, there was an average decrease, from 33.6% at baseline to 12.5% post implementation. These findings highlight the potential of HIT and electronic information exchange to help maintain continuity of care and potentially reduce resource utilization and costly fines by avoiding hospital readmission.
We also observed a reduction in ED return visits among LTC residents. The proportion of residents in our pilot study transferred to the ED who had a preceding ED visit within 30 days had declined. Considering that prior research (Hwang et al., 2007; McCloskey, 2011; Terrell et al., 2005) that has suggested the information gap between LTC and the ED not only puts patients at risk, but is also a significant source of resource utilization, our positive findings suggest that the appropriate use of HIT may help close that gap.
While our pilot focused on readmissions, our work also emphasizes the broader issue regarding the importance of communication across care settings, especially in the population of elderly LTC residents who may be more likely to receive care in multiple venues. According to a recent report from the Office of the National Coordinator for Health Information Exchange (Mertz & Russell, 2013), patients with a change in condition in nursing facilities were previously managed via telephonic support or facsimile (fax) by an off-site medical provider. For example, in the event of a transfer to the ED, individuals would likely be accompanied by available paper documentation, and then handed to emergency medical technicians for delivery to the ED. Not surprisingly, individuals from nursing facilities appeared in EDs with limited documentation about cryptic symptoms. Subsequently they were often admitted. Our pilot highlights the potential impact of quality electronic information exchange to help ensure that residents are transferred with relevant clinical information in a consistent manner. Instead of telephonic support or faxing information, our pilot demonstrated how efficient electronic information exchange may help to have a positive impact on readmission rates.
Lessons Learned
In addition to the successes of our pilot study, we also experienced unique barriers in the adoption of HIT. Mohamoud et al. (2009) noted common barriers related to utilization of HIT in LTC (e.g., lack of experience, high employee turnover, limited funding and appropriate software options), but our experience has suggested that the biggest barrier of all may be the necessary cultural change. For example, many of our facilities had a very minimal technological footprint, often even lacking adequate computers for basic clinical and operational functions. Thus, HIT implementation to help facilitate electronic information exchange, let alone access the state HIE, may have required considerable change. However, in lieu of these changes, our facilities were able to successfully implement and utilize HIT for information exchange in less than one year, despite facing many barriers that often hinder similar facilities.
Minimizing the burden of additional training and maximizing the ability to recognize benefits to care may have been a key factor in the success of our project. One reason for our success may be the fact that we selected HIT that required little if any previous training or computer skills. Considering that most LTC facilities do not have a support team or resources dedicated to information technology, having intuitive, easy-to-use tools is critical for technology adoption. Minimizing the burden of additional training and maximizing the ability to recognize benefits to care may have been a key factor in the success of our project. This is likely true from the perspective of both implementation in the pilot and plans for long-term adoption of the process.
Limitations
There were several limitations in our pilot study. Perhaps the most important was the small sample size of only five LTC facilities, all within a short distance from a large metropolitan acute care center. As a result, many of our facilities had transfer patterns already in place prior to study initiation. Thus these facilities may not have accurately reflected the challenges faced by other facilities lacking a pre-existing relationship with a receiving facility. Since we utilized a small, convenience sample, conducting a focus group regarding HIT adoption may have strengthened our ability to identify barriers and facilitators of HIT in participating facilities. However, while we did receive periodic feedback about ways to improve exchange of clinical information from case managers at acute care facilities, a more comprehensive focus group with all stakeholders likely could have been even more beneficial.
Second, our statistical analyses were descriptive only. More robust statistical analyses would have allowed determination of potential correlations regarding the relationship between HIT and reduction in readmission rates. Although all facilities shared similar characteristics (e.g., staffing ratios and nursing practice), we were unable to account for patient mix. For example, since we did not look at differences across individual facilities, we were unable to distinguish whether or not specific facility characteristics (e.g. size, patient mix) impacted transfer and readmission rates.
We also only looked at chief complaints for initial transfer and did not examine whether chief complains were associated with an existing condition or new condition. More detailed clinical information around initial transfer and admission may have helped to identify clinical circumstances in which readmission is more likely to occur. Given these limitations, our findings cannot be generalized to the broader population or be used to make any causal inferences.
Implications for Practice and Research
The findings from our pilot study suggest some valuable practice implications. Facilities should consider HIT solutions that are intuitive and easy to use. First, given the lack of IT support resources at most LTC facilities, we found that implementation of HIT is most likely to succeed if the technology in question requires little or no previous training. High turnover rates among caregivers in LTC (especially among nursing assistants) is another important consideration related to time and training requirements. Facilities should consider HIT solutions that are intuitive and easy to use.
Second, to increase adoption of HIT resources, caregivers need convenient access. Convenient access to HIT resources not only helps in capturing relevant clinical information early and often, it also may help to increase the collection of accurate data. In a traditional paper-based system, we have noted that caregivers frequently document ADLs at the end of a shift, often committing information to memory. This very likely increases the chance for human error. We mounted HIT resources directly outside of resident rooms to allow caregivers to document information immediately after evaluating a resident. Easy access to electronic documentation encourages caregivers to accurately chart early signs and symptoms that can then be immediately forwarded via an alert to appropriate personnel for early intervention, if necessary.
... to increase adoption of HIT resources, caregivers need convenient access. While our pilot provided insight about issues surrounding electronic information exchange, several questions for future research emerged. For instance, it remains unknown whether our findings would be replicable after controlling for size of facility, length of stay, and/or clinical circumstances such as patient mix, all of which are likely to impact transfer and readmission rates. In addition, we do not know whether or not a similar approach to information exchange during care transition would yield the same results with other care settings (e.g., rehabilitation, urgent care, smaller community hospitals). We also focused our pilot study on readmissions, however improved information exchange between care settings may also have a positive impact on other outcomes such as hospital length of stay, healthcare utilization (e.g. cost), and clinical outcomes (e.g. infection rates, mental status).
Conclusion
Our pilot focused on the use of HIT to maintain continuity during care transitions to ensure that receiving facilities have relevant clinical information to provide the highest quality, appropriate care. Introducing such technology is especially important within LTC facilities, where electronic information exchange has been historically poor and residents are often transferred without adequate clinical information, increasing risk of poor clinical outcomes (e.g., readmission) and subsequent financial consequences. Our findings from this early pilot study suggested that consistent information exchange through combining HIT and secure messaging may contribute to the reduction in readmission rates in both acute care and ED settings.
Acknowledgements
The authors would like to thank the Office of the National Coordinator for Health Information Technology for their financial support in conducting the pilot study as well as Jonathan Kolarik MBA, BSN, BS, RN, CIA, Claudia Wright, and Wato Nsa, PhD, MD from the Oklahoma Foundation for Medical Quality for their valuable insight regarding analysis of the pilot data.
Authors
Brian Yeaman, MD
Email: dryeaman@nrh-ok.com
Dr. Yeaman has over ten years of informatics experience in helping organizations transform its capture, integration and delivery of clinical data, information and knowledge. Dr. Yeaman is a nationally renowned expert in Health Information Exchange and Health IT. He has guided some of the largest healthcare companies and assisted in bringing new solutions to the healthcare market. To further the health information exchange reach, he created and led an initiative to combine contract and private physicians to develop a shared services model selection of single electronic health record to represent the Norman community and to develop one of the first continuity of care models in the United States. Dr. Yeaman completed his residency at Tufts University. He works as a primary care physician, is Chief Medical Informatics Officer at Norman Regional Health System, and is board certified in Family Medicine.
Kelly J. Ko; PhD
Email: kelly.ko@cerner.com
Dr. Ko is a Research Scientist with Cerner Corporation. Since joining Cerner, Dr. Ko has worked with pharmaceutical companies, health plans, and provider groups with a focus on outcomes research. Prior to joining Cerner, he received funding and had worked on multiple research projects in the social and behavioral sciences. Dr. Ko has published and presented research on a wide range of topics and therapeutic areas such oncology, chronic disease management, benefit design, and leveraging electronic health records for secondary research.
Rodolfo Alvarez del Castillo, MD
Email: radcastillo@yeamanandassociates.com
Dr Rodolfo Alvarez del Castillo MD is a physician trained in Mexico at the Autonomous University of Guadalajara (UAG) with a two-year experience on the clinical practice and a four-year experience on Health Information Technology. He has been involved in HIE implementation and diffusion for Acute Care and Long Term Care organizations in the state of Oklahoma since 2009. He actively participates as a Physician Advisor for the ONC Oklahoma Challenge Grant, bringing valuable clinical knowledge that significantly improves workflow processes for LTCPAC settings. Dr Rodolfo is equally fluent in English and Spanish and has played a key role in promoting full adoption of Health Information Technology within organizations that have a significant number of Hispanic workers. He proudly serves as the Director of LTC for Yeaman and Associates.
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