The digital disconnect in post-acute care

As the medical director of a nursing home, Kenneth Kubitschek, MD, an internist in Asheville, North Carolina, gets called occasionally about patients he’s never seen. Perhaps a patient has just been transferred in, and he’s asked to sign off on the orders written by the hospitalists.

The problem, he says, is that without an electronic link with the hospital, all the nurse in the skilled nursing facility can do is fax him the orders – without any context for the cases.  

“I’ll go through the medicines and hope that the discharging physicians had it all correct,” he says. “It’s like any pass-off, you have to hope that the person passing the baton is doing a good job.”

The quality of care would improve, he argues, if there were better online communications between hospitals and skilled nursing facilities. 

Most nursing homes and other post-acute-care (PAC) providers, including rehab facilities and home health agencies, are still in the stone age of information technology, experts say. But health care reform is forcing PAC providers to computerize and compelling hospitals to prioritize information exchange with nursing homes and home care agencies.

When physicians are able to access vital data across these care settings much faster than they do now, they will find it easier to care for patients recovering from hospital stays and dealing with complex illnesses, observers say.

“If physicians have improved access to [PAC] data, hopefully they can make better decisions and can provide more efficient care for the patient and can improve transitions and outcomes,” says Mike Seiser, director of the healthcare practice at Chicago-based Huron Consulting Group. “As they move to value-based care and population health, they will need that kind of data.”

Why PAC providers lag

Experts agree that PAC providers trail acute and ambulatory care providers in health IT by a wide margin. 

One reason PAC providers lag is their lack of resources, says Jonathan Baker, FACHE, managing director of the healthcare solutions practice at consulting firm KPMG. He assigns part of the blame to the exclusion of PAC providers from the government’s EHR incentive program, which has deprived these providers of funding to upgrade their health IT systems. 

There are signs of change, however. The Meaningful Use program has provided an incentive for hospitals to send electronic care summaries to skilled nursing facilities and home care agencies. In addition, cooperation with PAC providers can help reduce readmissions, for which the Centers for Medicare & Medicaid Services (CMS) financially penalizes hospitals. And some healthcare systems recognize that post-acute care holds the key to controlling costs under bundled-payment arrangements.  

“In areas like mandatory bundled payment pilots, hospitals are making meaningful attempts to enable bidirectional exchange of data with post-acute facilities,” notes Greg Kuhnen, director of research for Advisory Board., a Washington, D.C.-based consulting firm.

Studies show that most of the variability in cost for bundled procedures stems from post-acute care, notes Kuhnen. Therefore, he says, it makes sense for hospitals in bundled payment arrangements to exert tighter control over what nursing homes are doing. To do that, they need data to make the nursing homes’ activities visible.

In some cases, he adds, PAC facilities owned by or closely affiliated with a healthcare system will piggyback on the health IT infrastructure of that system. That gives nurses in skilled nursing facilities, for instance, the ability to view hospital information online.

Seiser thinks that some healthcare organizations might start to subsidize health IT purchases by PAC providers. He doesn’t believe, however, that the government will cough up any more EHR incentive funds.

Meanwhile, PAC facilities are consolidating into larger entities, and hospitals are acquiring skilled nursing facilities and home care agencies, Seiser points out. As a result, more PAC providers will gain the resources to invest in health IT. At the same time, independent PAC organizations will have to computerize so they can compete for referrals from hospitals.

“If they want to be a good partner as we move toward population health management, they’re going to have to improve their ability to communicate online with hospitals, or they won’t be chosen as a partner,” Seiser says.

EHR vendors expand

As hospital interest in PAC grows, the leading suppliers of acute-care EHRs are also expanding their products into that market, says Kuhnen. Epic, for example, is giving PAC providers some ability to view data and to document in the EHRs of hospitals and ambulatory care clinics. 

Similarly, Healthy Planet, Epic’s population health management software, can be used by home health aides or someone else who would not otherwise have access to a clinical record, he notes. Healthy Planet allows such users to assign tasks to people electronically and to do clinical documentation. A hospital could use that data to trigger an intervention if a patient’s condition  deteriorates.

Baker also sees growing integration between hospital and nursing home systems. “Epic, Cerner and Meditech have the ability to aggregate [acute care] data in the ancillary areas like radiology, lab and pharmacy. When they have an enclosed system with a skilled nursing facility inside it, they can provide those physicians access so they can look up the latest data on the patient.” 

When hospitals and nursing homes are online with each other, and physicians can see what’s happening with their patients, the improved visibility should lead to higher quality and lower cost, Kuhnen says. 

“Reducing length of stay is a clinical win if a patient is ready to move on to a less-acute setting. And we know that post-acute-care facilities have at times held patients longer than necessary. So closer scrutiny of what’s happening in these settings should benefit patients clinically, and there’s a financial incentive to reduce wasteful care.”

Home health agencies’ ability to exchange data with hospitals is rudimentary, Seiser says, but most can send and receive a limited amount of information fairly well.

Some home care agencies have also improved their ability to communicate with physicians, he says. For example, he has seen advanced systems in agencies that allow physicians to view home care data online. But those capabilities are not being widely used. 

Reducing oversight burden

Besides improving quality, the increasing digitization of PAC providers could help reduce the burden of repetitive daily tasks involved in the oversight of post-acute care, such as signing orders and care plans and reviewing patient information. But that relief has not yet arrived for most physicians.

For example, internist Jeffrey Kagan, MD, of Newington, Connecticut, derives 15% of practice revenue from his work in seven nursing homes. Six of them send him orders to sign. The one that doesn’t requires him to pick up them up in person.

Some of the others fax orders to him, some use email, and a couple skilled nursing facilities allow him to go to a website and digitally sign orders there. Home health agencies send orders by fax, snail mail or courier. 

Kagan, a member of the Medical Economics editorial advisory board, would like them all to go online. “It would make my life much easier,” he says.

Kagan also complains about the information overload that he constantly encounters in nursing homes. In the past, he recalls, patients would arrive at a nursing facility with a one-page clinical summary that would include basic data. It would be followed by a two- or three-page discharge summary that included history highlights and physical. 

But nowadays, with hospitals easily able to print out sections of the patient’s EHR or the whole chart, they send the entire H&P, he says.

“For a quick little admission where the patient had a knee replacement, you’ll get 20-25 pages of documentation,” he says.

Specialist model

Kubitschek has some of the same frustrations as Kagan. But Asheville, North Carolina, has much better IT integration between PAC providers and physicians than most of the country. 

One reason is that most of the specialized physicians who staff the 29 local nursing homes belong to a single group owned by Team Health. All the internists and other specialists in the group use the same EHR (Geri-Med), and local primary care doctors can view that record online.

Team Health recently interfaced Geri-Med with PointClickCare, the most commonly used EHR in nursing homes. Now nurses in skilled nursing facilities can enter certain kinds of notes into Geri-Med, says Kubitschek.

This model improves both communications and the quality of care, says Kubitschek, a Medical Economics editorial advisory board member, partly because the geriatric specialists who follow patients in the nursing facility can see them more often than primary care doctors did. 

Also, his access to the specialists’ Geri-Med EHR gives him a birds-eye view of the relevant portions of the patient’s hospital record as well as their nursing home encounter notes. Moreover, his EHR can exchange secure messages with Geri-Med, including attachments of clinical summaries. 

Slow improvement

Physicians should not expect PAC providers to improve their digital capabilities significantly in the near future. 

There’s still a lot of paper in PAC facilities, and document scanning is state-of-the-art in many facilities, Seiser points out. Even skilled nursing facilities and home care agencies with EHRs are not yet exchanging much data electronically with hospitals or ambulatory-care providers.

“The ability to do discrete two-way integration of data is not there yet,” he says. “But the vendors are getting a little better at it, and so are the hospitals. It will continue to ramp up in sophistication.”