Yogi Berra once said, “The future ain’t what it used to be.” Many providers must know exactly what he’s talking about. Technology is changing so quickly that even the most gifted administrator has vertigo.
It’s not just that technology is changing quickly. The demands of it, and from it, are spiraling.
Regulators, consumers, and even business rivals are pushing—as well as pulling—new technologies, as well as a new attitude toward technology, and each new innovation introduces new paradoxes. And the thing is—again to quote Yogi—it’s getting late early.
“In health care, automation in the billing and the medical records area—I’m not sure even the smallest providers can avoid those types of things,” says Mark Eich, a partner at the auditing firm of Clifton, Larson, Allen.
HIPAALong term/post-acute care has been slow on the uptake here, especially as regards health information technology (HIT) and privacy laws that were introduced in the Health Insurance Portability and Accountability Act (HIPAA), Eich says.
“When HIPAA came around in the late ’90s and was a hot topic in 2000, that group probably yawned at the whole thing, in my view. And I’m worried about that industry segment.”

Regulators Leading The Way

It’s clear that policymakers want long term care professionals to adopt new technologies and adopt open attitudes to technology. The Affordable Care Act, for instance, requires states to adopt stringent information technology (IT) requirements for Medicaid enrollment. Forty-seven states already have either submitted or been given approval for plans, according to a recent report from the Kaiser Family Foundation. The feds have promised to pay for 90 percent of upgrade costs for now, but the requirements “require substantial investments in IT infrastructure at a time when state fiscal situations remain constrained,” Kaiser said.
Meanwhile, Medicare is moving quickly to an all-electronic claims system. The government, notoriously, is way behind business in thinking about, and incorporating, new technologies. So any provider that is behind the regulators here at adopting technology may well find itself in deep trouble. (Not that there aren’t opportunities there for the nimble: A New York Times piece found that the move to electronic billing increased Medicare reimbursement to hospitals by more than $1 billion in 2010.)

One of the problems when government leads the way is that small providers can find themselves locked out of new progress, experts say. When the government sets the bar for technology, it automatically gives an advantage to the biggest companies, which, because of their size, set the market and the parameters of new technology. For little operators on the outside looking in, even the best innovations can be swallowed by the procurement officers of big-time companies, experts say.

Ripple Effects

And then there are questions about definitions. Some operators are concerned that, despite the government rhetoric about innovation, they may well find themselves on a tech island.
For instance, many new tech developments allow for remote telemonitoring of patients. The question for some futurists is, at what point does a telemonitoring technology cross over from nursing home care to home care? Since the government reimburses at far different rates for the two categories, this question isn’t moot in any event, they say.
Even those providers that are able to adapt to new government demands still have to think quickly—as well as differently—about the ripple effect of the new technology. For instance, small providers, especially, are increasingly vulnerable to hackers, says Juli Ochs, an engagement director at Clifton, Larson, Allen. “I think long term care is the next victim,” Ochs says of the sector.
For a hacker, getting into a nursing home’s patient records is “a two-fer,” Ochs says. “They can not only get a fraudulent Medicare payment, they can get someone else’s ID.” And since this is a largely elderly and/or largely disabled and/or largely solitary population, the identity fraud can be that much harder to keep up with. The problem is, very few small providers are even aware of how vulnerable they are to hackers, Ochs says.

Illusion Of Safety

“A lot of these rural homes and assisted living centers, they feel they’re immune to the problems in the cities,” Ochs says. “They’re in a small environment; they know everybody who comes through the door. They don’t understand that there can be somebody sitting in a car with a laptop.’”
Just ask the Hospice of North Idaho, which early this year was slapped with a $50,000 fine for violations of patient privacy laws.
In 2010, someone stole a laptop from a hospice employee. The laptop had the records of a mere 441 patients in it, but auditors at the Department of Health and Human Services’ (HHS’) Office of Civil Rights (OCR) weren’t amused.
The fine is the first of its kind. But it won’t be the last, Ochs says.
“When the laptop is stolen, it’s bad enough in itself,” she says. “What’s worse is that they self-report this, then the OCR comes in and looks at them and they get fined because they don’t have policies and procedures in place. If you look at fines from the last year, look at that second sentence in the news release and, over and over again, you’ll see, ‘policies and procedures.’”
In Ochs’ experience, many of these providers’ wounds are self-inflicted.
“When I go in and work on an audit and start talking about HIPAA, I think they can be very cavalier,” Ochs says. “I think they think, ‘No one’s coming to
get us.’”
Nothing could be further from the truth, Ochs says. Last summer, HHS published early results from an audit of health care companies’ privacy compliance. Twenty companies were singled out for inadequate privacy controls. Six of them were small businesses with under $50 million in revenue. They were blasted for having “little to no use of HIT—almost exclusively paper-based workflows.”

Compliance Culture Change

That’s the Washington way of giving providers a whiff of grapeshot, Ochs says. What they want is to change the entire culture of long term care, she says.
“If you Google ‘Office of Civil Rights’ and ‘culture of compliance,’” she says, “you’ll find out that this is what they’ve been barking about all year. Anytime they can put something in the media and slap [providers’] hand really hard, they will.”
IT culture change is easily invoked, but hardly embraced, many experts say. The problem is, that it’s not just government that is pushing and pulling long term care into the 21st century. Consumers are doing it, too.
Technology “really does make people feel less isolated,” says Elaine Eshbaugh, an associate professor of gerontology at the University of Northern Iowa.
“If I go to a nursing home now, I go in and see people in wheelchairs talking on their cell phones,” she says. “I think we’ve been so slow to jump on that.”

Eshbaugh says she’s astounded at how slowly it’s taking nursing homes to offer wireless Internet service. “I think it’s a no-brainer. I don’t think we ask people to leave their homes and move into a place that we are pushing as their new home and not have wireless Internet,” she says.
Everyone in the profession is talking about the so-called “Silver Tsunami” as baby boomers age and move into long term care. Eshbaugh is one of many who say that the boomers, the generation that gave the world Apple and the Internet, simply won’t tolerate 20th century technology in their care environment.
“It would make them much more independent,” she says.
And it also reduces the burden on caretakers, Eshbaugh says.
“My mom was an activity director, and we would always go shopping for things that the residents needed,” she says. “Now those are things that people can order online. A number of older adults use online banking. There are a lot of adults in nursing homes now who will never access the Internet, but I think it’s going to be one of those things that is just considered part of life in the home.”
So why have providers been so reluctant to embrace technology? It’s a mystery to Nina Willingham, senior executive director of Life Care Center of Sarasota and a former president of the Florida Health Care Association.
“I could not begin to answer,” she says. “During my time as president, I visited numerous facilities and districts across the state and talked about culture change initiatives and person-centered care. If we could give them a recipe of how to get there, it would be so nice.”

Accommodating Tastes

Willingham, at least, is willing to try a few new spices. The company has applied to the Centers for Medicare & Medicaid Services for a $25,000 technology grant that would bring new (and more) iPads, iPods, Kindles, and other electronic devices for the residents, she says.
The idea for the grant came out of resident demand, Willingham says. Her activity director came to her one fine morning and said that the residents wanted a bigger recreation room.
The problem was, Life Care’s building dimensions wouldn’t allow for expansion. “When I explained to them we couldn’t do that because of the building, I said to them, ‘Tell me what you want to do?’ We had three focus groups. ‘If you were still at home, what would you do?’”
What came back was a Santa’s list of goodies: shuffleboard, pinball, a bigger television, a poker table (the residents love poker, Willingham says).

The problem wasn’t just the space constraints. Pinball machines, for instance, were difficult to get wheelchairs under.
Technology, though, provides an answer. iPads and the like have apps that would allow residents to play pinball, poker, and even shuffleboard (though the center has “a nice shuffleboard table” anyway).
Kindles and other tablets allow for a nearly limitless electronic library. Seventy-five percent of Willingham’s residents are there on short-term rehabilitation assignments. Most of them are insatiable readers.
“We have a nice library … but with the Kindles, it gives us a whole new opportunity for patient satisfaction and happiness,” she says. “We have a couple of ladies who read all the time. But the books are getting heavy, and the print has to be large. It’s difficult.”
Willingham had already seen the wonder-working power of the gizmos. The center has three Wii systems (they had to buy extras because there was such demand for the games). One of the elderly residents had a particular affinity for one of the games.
“He sat in his wheelchair every day boxing,” Willingham says. “He had the best upper-body strength, and his ADLs [activities of daily living] were great.”

Even if her center doesn’t get the grant, Willingham says she’ll pinch her pennies and buy the electronics piecemeal. “We definitely are moving in the right direction,” she says.

Pays For Itself

If government or consumer demands aren’t enough to push or pull long term care into the tech age, business rivalry certainly will.

A few years ago, Tom Kelly, chief executive officer of Village on the Isle in Venice, Fla., took a look at emerging technology trends and read the writing on the wall.
“I’m older than dirt, so I’ve been around a long time,” he says. But “we really determined that the complexities of the Medicare program alone require that we jump into this process. We as a group said, ‘We’ve got to do something.’”
In 2008, the Village rebuilt its computer system from the ground up (see page 28).The computer remodel was expensive—about $150,000. But “it’s been [very] profitable.” Not only has employee satisfaction improved dramatically, “staff retention has been phenomenal,” Kelly says, but patient care has been so as well.
That doesn’t mean that merely investing in new technology will answer every problem, experts say. In a Provider roundtable reported on in January, Extendicare Chief Information Officer Loren Claypool warned providers against seeing technology “as a field of dreams.”
“If you build it, referrals will not necessarily come,” she said. “It’s not about expecting your fair share, it’s about competition. It’s now cut-throat, full-contact, bare knuckles health care where you compete for patients, employees, referrals, and put others out of business.”

Work Smart And Hard

But just because there is a sense of urgency doesn’t mean that providers can’t be smart in their approach to new technology, Clifton, Larson, Allen’s Ochs says. “New technology” doesn’t have to mean the same thing as “bankruptcy.”
There really are shortcuts to better technology (and a better culture of technology), Ochs says: “I don’t know that I personally would advocate for a whole new IT system,” for instance. “I would argue for a full-time, experienced IT person.”
As another example, many homes could save themselves a lot of tech headaches by just hiring a privacy and compliance officer, Ochs says. “That’s easy to take care of. You create a job description and send it through your board.”
And there are some answers that are even cheaper than that, Ochs says.
“Some of the answers are simple, like just changing your passwords. You’d be surprised how many homes I go into and the staff are still using their starter passwords that they got on the first day.”
Whatever path long term care professionals take toward more robust technology, sitting out simply isn’t an answer, Ochs’ colleague, Mark Eich, says.
“I’m seeing two trends kind of converging on one another,” he says. “One is a tremendous spike on malicious hacking activity. And then on the other side, we’re seeing the increased regulatory scrutiny. You’ve got very troubling trends right there.”