Almost 40% of Medicare patients discharged from the hospital require "post-acute care" services. Almost 80% of these services are provided either in a skilled nursing facility (SNF) or in the home by home health caregivers (HHC). Newer, innovative models of health care delivery such as the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACO) emphasize managing illness across the full continuum of care and focus particularly on integrated "post acute care" to reduce costly hospital readmissions. The role of the EMR in this space is largely unexplored territory. As recently as 2007, only 28% of more than 10,000 HHC were using an EMR. As adoption increases, we need to look beyond simply improved documentation and billing to how best to leverage the technology to improve patient outcomes in a value based world.
A study completed in 2014 assessed the impact of an EHR implementation in a HHC practice with approximately 1200 patient visits per month. While the EMR improved the time to completion of documentation and submission of billing, no significant change in clinical outcomes was found. The authors found several "barriers" to EMR adoption including:
- Frequent hardware problems and lack of field support.
- Need for better intial and ongoing training of caregivers.
- Decreased caregiver efficiency because of a mismatch of the EMR to clincial workflows. The latter finding is particularly notable and speaks to the need to involve caregivers - usually nurses - in the selection and development of HHC EMR.
A more recent study compared health care utilization and quality in the patient-centered medical home (PCMH) model versus usual care with or without an EMR. EMR users ordered more lab tests and xrays but no significant difference in quality was found. The authors concluded that the EMR as a static respository of data was not sufficient to transform clinical care and improve patient outcomes. Integration of clinical workflows with decision support and guidance in the EMR is a critical component.
3 Steps to Building the Best HHC EMR
1) Involve the Nursing Caregivers
98% of nurses working in the inpatient setting report no involvement in EMR design or selection. Not surprisingly perhaps, 90% report the EMR has adversely affected their relationship with the patients they care for and 67% report using "workarounds" to grapple with the user-unfriendly EMR. I have previously written about physician burnout. Nurses are burning out too! Home health care nurses should be involved in ensuring that the EMR captures necessary documentation and embeds realistic clinical workflows. Clinically experienced frontline users can best describe what works in the remarkably diverse settings home care nurses confront.
2) Integrate clinical workflows and guidance
If the EMR is really going to improve patient outcomes, it must be more than a data repository used primarily for billing purposes. Well conceived clinical protocols with user friendly interfaces in the EMR are a must if the focus is really on improving patient care and the caregiver experience.
3) Link with outcomes measurement
First rate post acute care is crucial to providing value along the full continuum of patient care. Linking EMR clinical workflows with patient-centered outcomes is critical to improving processes of care and demonstrating value. Reducing hospital readmission rates and ER visits are important measures of a successful homecare program. In addition, patient centered outcomes focussing on function and quality of life should be captured. Home health caregivers can best assess their patients' individual goals.
Providing value-based care mandates attention to the complete continuum of care. High quality post acute and chronic disease management are critical to achieving the best patient outcomes. Enhancing the EMR in the HHC setting will play an important role moving forward.
As always, I welcome your thoughts and comments.