EHR Interoperability With Long-Term Care Providers Wanted, but Who Will Pay?

CMS has urged skilled nursing facilities (SNFs) and home care agencies to acquire electronic health record systems that are capable of exchanging data with hospitals and other health care providers, but it hasn't explained where these long-term and post-acute-care (LTPAC) providers will get the money to implement these health IT systems. LTPAC providers are ineligible to participate in the federal EHR incentive program.

CMS has proposed raising payments to SNFs by 1.4% in fiscal year 2016, but that is barely enough to cover inflation. Beginning in FY 2018, CMS plans to apply the same value-based payment system to SNFs that it already is using with hospitals and physicians. Many of those providers, however, have more advanced health IT systems to help them make that transition.

It's unlikely that the government will provide additional incentives to LTPAC providers or that it will launch a new program to bring SNFs into the EHR world, according to Catherine DesRoches, a senior fellow at Mathematica Policy Research. Yet bringing these providers in, she said, "is going to be very important in realizing this idea of the interoperable [electronic health information] system."

More than 15,000 SNFs care for about 1.4 million people at any given time. About half of the people discharged from the hospital are transferred to SNFs or to rehab units, which are often attached to the nursing homes. Many of these patients are readmitted to hospitals because of complications or exacerbations of their conditions.

"SNF patients are medically fragile, and getting information from one provider to another is critically important," DesRoches said.

Most nursing homes have electronic information systems, which they use for documentation, internal communication and data submission required by CMS. Some of these systems are "robust EHRs," said John Derr, president of JD Associates & Enterprises, a former nursing home executive and a member of the Health IT Standards Committee. But these EHRs are designed differently from the certified EHRs used by hospitals and physicians, and none of the leading LTPAC EHR vendors are related to the major suppliers of certified EHRs.

Current State of Data Exchange

This is not to say, however, that it is impossible to exchange data between nursing homes and hospitals or physician practices. The top LTPAC EHRs can generate structured care summaries -- known as continuity of care documents (CCDs) or consolidated clinical document architecture documents (CCDAs) -- that meaningful use-eligible providers must exchange in transitions of care. The late Certification Commission for Health IT certified a few LTPAC vendors for their ability to generate CCDs, among other things, and other LTPAC EHR companies have obtained modular certification from government-approved certification bodies, Derr noted.

In a recent American Hospital Association survey, 38% of hospitals said that they sent structured care summaries to LTPAC providers, including SNFs. But Julia Adler-Milstein, an assistant professor at the University of Michigan, questioned how much information is really being exchanged.

"That's some basic level of connectivity, but whether that means [the care summaries] are arriving in a way that's useful is unclear," she said. "It's not the case that 38% of hospitals have really good connectivity with long-term care providers."

The same survey found that only 16% of hospitals received CCDs or CCDAs from LTPAC providers. That could indicate that SNFs and home health agencies are less capable than hospitals of generating and transmitting summaries. But Derr said hospitals "just haven't created the mechanism" to receive these documents from LTPAC providers.

As for why more hospitals haven't sent CCDs to SNFs, DesRoches noted that "only one partner is required" for a data exchange that counts toward the meaningful use requirement, and that partner doesn't have to be a SNF.

Of course, hospitals and SNFs need a method to exchange CCDs with each other. One such mechanism is a health information exchange. The research from Adler-Milstein and her colleagues shows that 51% of HIEs receive data from "long-term-care providers" and that 40% of them send data to these providers. That's good news, but HIEs are still few in number and limited in geographical reach. Moreover, Derr said the cost of interfacing with an HIE can be too high for many SNFs.

The other major transmission method is Direct secure messaging, which can connect providers without the use of an HIE. Most health information service providers (HISPs) that supply Direct connectivity are focusing on hospitals and physician practices. But Inofile, a Boise, Idaho-based company, offers a clinical document exchange platform called Kno2 that, in partnership with Surescripts, provides LTPAC providers with Direct addresses and HISP services, Derr noted.  Inofile charges a monthly subscription fee that ranges from $19.99 for single providers to lower per-user rates for higher numbers of providers.

Where Do We Go From Here?

EHR vendors want LTPAC providers to upgrade their systems to the latest version, according to Derr. "A lot of them are still on the licensed model, instead of the [monthly subscription] model, and they wait for CMS to tell them [they have to do it]," he said.

So far, the agency has not made interoperability mandatory. However, Derr said, "They're strongly encouraging the providers, and once you get into value-based pricing, the providers need interoperable systems." Consequently, he added, "I think we're at a touch point."

DesRoches is less optimistic. "These SNFs are generally are not operating on big margins, so it's got to be a pretty strong business case. These systems are expensive and costly to maintain," she said.

One strong motivation for the implementation of interoperable EHRs, she said, is for hospitals to steer referrals to nursing homes that are able to exchange data with them. "If a hospital knows that they can meet their own meaningful use metrics by sending patients to a particular SNF, it could make the SNF look better to the hospital and possibly to the patients and their families. They could say, 'We have seamless communication with your doctors and your hospital.' So it could give them a competitive edge."

Nathan McCarthy, a senior manager at ECG Management Consultants, said he has seen hospitals do this with local nursing homes. In response, some SNFs are stepping up their health IT investments, he noted.

In addition, DesRoches suggested that hospitals could exchange data with the SNFs they own, and they could also extend their EHRs to SNFs as part of an accountable care organization infrastructure.

However, a hospital EHR does not necessarily include the data elements that SNFs need to provide good care, such as a patient's mental acuity and whether they have pressure ulcers.

"A hospital EHR can provide lab results, images and imaging reports, but a SNF needs a template that they can use to record more subtle changes in a patient's condition," DesRoches said. "Most EHRs are not designed to capture that kind of nuanced information."

The LTPAC Health IT Collaborative, representing most associations in the sector, recently completed a report for the Office of the National Coordinator for Health IT. The key finding of the report: "More financial and technical assistance support is needed to advance the use of interoperable health IT and HIE" in LTPAC.

Specifically, the report recommended that ONC:

• Consider grants and loans for providers, especially small and rural facilities;
• Emphasize person-centric longitudinal care, which would be advanced by data exchange; and
• Target EHR functionality "unique to LTPAC and important for service delivery payment."

Finally, the collaborative said, payers, physicians, hospitals and "new payment models," such as ACOs, should absorb some of the transition of care costs for electronic exchange with LTPAC providers.

Will the private-sector step up to the plate? That's unknown, but one thing is clear: For the new payment models to achieve improved outcomes at lower cost, they will have to establish electronic connections with SNFs, home health agencies and other providers that are not included in the meaningful use program.