As health information technology (HIT) has become more prevalent in long term care settings across the country, administrators and clinicians have access to more information than ever before. However, they now face the challenge of sorting through the vast volumes of data available to them and determining how to use them to enhance quality.
As Sarah Crane, MD, medical director at a Mayo Clinic facility, says, “There is so much data that it’s challenging to make it customer-specific. It’s like trying to swallow an elephant. We need to figure out how to make the elephant smaller and easier to digest.”
From Collection To Analysis
Many senior and long term care communities have evolved from data collection to full-fledged data analysis. They are targeting specific information to collect and analyze, and they are using it to identify trends, track outcomes, implement quality improvement initiatives, and recognize and celebrate successes. 
When the first Presidential Order to establish person-centric integrated electronic health records (EHRs) came out in 2004, health care facilities started thinking about how they would access, pay for, implement, and use this technology. Over the subsequent years, various government officials have urged health care facilities across settings to embrace technology, and various programs began establishing financial incentives for HIT and EHR adoption. The Office of the National Coordinator for Health Information Technology estimated that the health care system will save $140 billion annually if HIT is adopted on a widespread basis.
Facilities that have embraced technology and used it to track and manage quality have powerful stories to share, and none would go back to the days before technology was part of their daily lives and their efforts to maximize outcomes. “We have come a long way,” says Carol Carder, manager of medical records at Levindale Hebrew Geriatric Center and Hospital in Baltimore. “We started out with electronic medical records. Now everyone does their portion of the MDS [minimum data set] on computer. We try to keep everything electronic and not print the chart out and hand-enter data.”
The move to electronic data makes it easier for organizations to track quality. Mary Norman, MD, regional medical director for Erickson Living in Dallas, says, “It’s an incredible way to care for patients.” The physician notes are custom made for senior patients and trigger questions relating to outcomes. For example, patients are asked about falls. If the person reports experiencing a fall recently, the notes trigger additional questions about home environment evaluations, blood pressure, medications associated with falls, physical therapy history, use of assistive devices, and so on.
“The physician notes move you through a checklist and encourage you to think of everything you can do to reduce patient risk,” she says. The notes are particularly designed for the senior outpatient population and used when patients come in for each visit. It includes prompts for the physician that address conditions and issues common for seniors, and the information becomes part of the patient record. Norman says, “Each time the patient comes in, the physician can view the notes from the individual’s last visit.”
She loves the system. “At the touch of a button, I can graph weight and blood pressure for the last few months or years. I can show the patients right there how—for example—their blood pressure came down as they lost weight. It’s a great teaching tool and a way to empower patients.”
Norman and her medical group use these data to track outcomes. “Every year, we target issues for improvement in the coming year—important quality markers for Medicare,” she says. “To date, our ‘quality scoreboard’ has looked at issues such as influenza and bone health.” This year, the group is focusing on memory and dementia. To this end, Erickson Living will track and analyze data related to functional status, cognitive levels, and depression. “Part of the record template is designed to pull these data,” says Norman.

Getting Results In Real Time

In addition to tracking quality issues over time, the electronic system enables Norman and her team to address quality at the drop of a hat. For example, she says, “If I have a patient who says she wants to stop taking calcium, in two minutes I can pull up her profile and see the results of bone-density testing, what medications she is taking, and whether she is at risk for falling. As a result, I can help the patient in the moment with this decision.”
The amount of data available through the electronic record can be daunting, so Norman suggests “choosing your issues and goals carefully. Really focus on something and measure it. You need to narrow down where you set quality goals and how you will invest your time. Once we meet goals, we rotate onto other issues.” The system is working for Norman, her team, and their patients. “We’ve seen dramatic improvements in areas such as ER [emergency room] visits and hospital stays,” she adds.
Determining what reports to pull for quality purposes is key, Crane agrees. For example, she was involved in a project focusing on managing heart failure. By electronically flagging the charts of heart failure patients, Crane can check weights and other information at will in real time. “Before, we were depending on other people to determine what information they should communicate to us. The electronic system removes the middle person. Now we can identify problems and correct them quickly,” she says.
The ability to identify issues and problems quickly is key to quality improvement. As Gary Kelso, president of Mission Health Services in Huntsville, Utah, says, “You have things happening every day that affect the quality of your elders’ lives, but you don’t know what you don’t know. With HIT, you can stay on top of what is taking place. I can see issues every day and can jump on them. I get knowledge instantaneously.” As a result, he adds, “All of our surveys have improved dramatically. We have created an environment where surveys are easy.”

Quality Data Increase Buy-In

As organizations increasingly see the link between data analysis and quality, more clinicians are embracing HIT. “There’s a book that talks about the difference between ‘digital natives’ and ‘digital immigrants;’ that is, those who grew up with technology and those who had to learn it later in life. Many digital immigrants didn’t want to change, and we saw some older physicians retire rather that adopt technology,” says Norman. “Those that stayed are starting to see the benefits and are embracing it. They like getting information instantly and being able to look up something on the spot. It’s easier to provide better care.”
Kelso notes that even clinicians who initially oppose HIT come to embrace it. “There were a couple of times I got frustrated and said to our clinical directors, ‘If we can’t do this right, we’ll go back to paper.’ And they were adamant that they didn’t want that. They realize that technology is 100 times better than paper, and they don’t want to go back to the old ways,” he says. When organizations get past the cost and hassle of introducing technology, Kelso says, they see what it can do to improve quality. He concludes, “For me, it’s a no brainer.”
HIT And Care Transitions
An obvious quality improvement role for HIT involves improving care transitions. For example, Cynthia Morton, executive director of the Virginia-based National Association for the Support of Long Term Care, observes that HIT can help prevent hospitalizations due to medication errors. “When providers have EHRs for residents, they can view the medication list and see all the meds prescribed by different physicians. The paper record doesn’t follow patients as readily,” she says. “With technology, you can set up a sophisticated pharmaceutical review to prevent problems from happening. You can work with the consultant pharmacist to run these reports and identify various medications or issues you want to track.”
Organizations such as the Center for Medicare Innovations are ramping up the idea of increasing quality by reducing hospitalizations and transfers. As Morton says, “Providers that have not taken steps to use technology and be interoperative will have to catch up on the learning curve. They will hear more and more that this is a national priority designed to reduce costs, improve quality, and maximize efficiencies by reducing hospitalizations and improving communication between care settings. Consumers will demand this, too.”
Technologies to improve transitions are promising, but Morton notes that there still are some issues to address. “Hospitals and nursing facilities have to accept and agree to the same standards so that information can easily flow back and forth. The two settings have to work on interoperability,” she says.

The Power Of Portals

One way to enable users to focus on specific data is to create portals. These are websites or computer-based entry points that offer various services and resources, such as e-mail, bulletin boards, and information and education. For example, Mayo created portals for physicians and providers. Crane explains, “The physician can log on and see a patient’s record and only that patient’s record. A provider portal enables a broader snapshot of what is happening in the facility—beyond individual patient information. The goal is to get the information people need when they need it.”
Norman talks about her organization’s patient portal. “Patients can access portions of their charts—allergies, meds, diagnoses, advance directives. They can view this information and then print it out. At the same time, family members across the country can have a password and access data from anywhere.
So, for instance, a daughter in California can review the lab results for her mother on the East Coast.” The patient portal also enables seniors to set appointments and communicate with their physicians. “This is the way of the future,” says Norman.

Data Analysis As Marketing Tool

“People know they are providing good care, and they want to do what is best for their patients but they find themselves short on reimbursement,” Kelso says. “They may not realize what they are leaving on the table. As we got more into HIT, our case-mix scores started to improve. By capturing our acuity, our Medicare rates went up substantially. And if you get paid for what you do, the odds are that you can provide better quality,” he says.
Kelso utilizes a program in Utah designed to give providers incentive to invest in technology and quality. The program identifies those who embrace culture change and those who invest in HIT systems that create change and provides them with financial incentives. “By doing this, we encourage people to embrace technology. It doesn’t pay for everything, but it helps.”
Norman and her team are compensated based on quality goals and are paid according to their performance on various quality markers (such as immunization rates). Each year, the community sets a different theme. This year the focus is on falls, so the markers are things such as asking about falls, discussing physical therapy for patients with gait problems, and bone-density testing. “We advertise this to patients and celebrate reaching milestones during town hall meetings,” Norman says. “We educate patients about what we’re doing and what our quality standards are. We’re all in this together.”

Studies Say…

While there currently is a dearth of research about the impact of HIT on long term care quality, there likely will be more in the years ahead. And these are likely to show a significant relationship between quality improvement and the use of EHRs and other technology in nursing facilities and other long term care settings.
To date, studies are validating anecdotal knowledge. For example, one study of small- and medium-sized physician practices, reported by A.S. O’Malley et al. in the Dec. 29, 2009, issue of the Journal of General Internal Medicine, found that electronic medical records (EMRs) systems can help coordinate patient care. However, the authors said, interoperability issues make it difficult to share information between settings.
“We are advocating for interoperability standards so that the information that populates personal health records [EMRs] can be shared to populate EHRs, especially when patients are being transferred between settings,” says Morton. Interoperability likely will continue to be a priority for the health care HIT industry, and this is an issue that purchasers of EHR systems should address with their vendors, she says.

Paper-Driven Data Still Have Power

While technology makes data tracking and analysis for quality purposes easier, even those facilities without EHRs or other HIT can use data to make a difference. As Norman says, “I came from a system that didn’t have EHRs but was very interested in quality. We had a flow sheet that included a wide variety of data and information. And we were able to use this to track issues and improve quality.
“The basic thing is that what is measured gets improved. You have to have a system and processes in place to measure outcomes so that you can improve them. If we don’t measure something on our quality dashboard, it probably isn’t going to change.”
The dashboard—what many call their monthly reports—is key for any facility but is especially useful when HIT is used, says Kelso. Norman agrees. She says, “You can’t run a car without the information on the dashboard—speed, mileage, temperature gauge, etc. And you need your facility’s dashboard to help you gauge what is happening with individual patients and the facility as a whole.” Kelso says his dashboard provides all the key indicators—everything from a labor report to case mix and MDS scores. “It’s a one-stop shop of data where I can find anything I need. For example, I can review quality survey reports in preparation for a federal survey.”
The dashboard gives staff trending information for a community and lets them track specific issues such as falls. “We have 600 reports built into the system. For me, a successful HIT system allows you access to this kind of information,” Kelso says. These reports include data regarding missed medications, risk assessments, activities of daily living, falls, fractures, wound care, bowel and bladder, and much more. Kelso admits that his is a very robust system, and others might not have such extensive capabilities.
How does Kelso decide what reports to access? He starts with information from director of nursing reports that identify issues or problems. For instance, if a pharmacy was late in its delivery of medications, he can drill down to find out exactly what happened and what impact it had on medication administration. He is automatically notified about common issues of global importance such as falls.
The beauty of the system, he says, is its flexibility. He is able to view information as broadly or narrowly as necessary. He can see what is happening in the entire facility, view broad data on a subset of patients—such as those with diabetes or those who have had a recent fall—look at what is happening in one area such as incidents or medication errors, or examine data for a single patient.

Keep It Person-Centered

Nonetheless, combining high-tech and high-touch also can have a positive impact. As Kelso says, “You can embrace technology that seems to be high-tech and embrace quality care that is low-tech in a way that builds relationships and becomes relationship-centered.
He adds, “We are totally paperless right now. We have created technology that allows us to implement innovations such as not having a nurses’ station. We are eliminating these and creating congregation centers instead. Nurses are working on laptops or kiosks in the hallway. They can collect data in the same amount of time that it took them before—and less in some cases.”
While the high-tech approach to data management increases efficiency, eliminating the nurses’ stations creates a more person-centered environment.
While data analysis without technology is possible, Kelso stresses the value of technology in quality improvement.
“With HIT, you can run trending reports on issues such as medication errors or weight loss. It’s very important to be able to see if falls have increased or decreased 10 percent and be able to identify the reasons,” he says. “We are approaching care more holistically, and these HIT tools give us the capacity to do this.”