Greg Alexander

Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes.

OBJECTIVE There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. METHODS Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures. RESULTS Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups. DISCUSSION Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover. CONCLUSIONS Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology.

Improving Nurse Care Coordination With Technology

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Developing a Comprehensive Electronic Health Record to Enhance Nursing Care Coordination, Use of Technology, and Research

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for thefirst 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents.

Author Affiliations: Sinclair School of Nursing (Drs Rantz, Alexander, Vogelsmeier, Popejoy, Flesner, and Crecelius and Ms Lueckenotte), School of Social Work, College of Human and Environmental Sciences (Dr Galambos), and Curtis W. and Ann H. Long Department of Family and Community Medicine (Dr Koopman), University of Missouri, Columbia; and College of Nursing and Health Sciences, University of Wisconsin–Eau Claire (Dr Zwygart-Stauffacher).

Evaluation of health alerts from an early illness warning system in independent living.

Passive sensor networks were deployed in independent living apartments to monitor older adults in their home environments to detect signs of impending illness and alert clinicians so they can intervene and prevent or delay significant changes in health or functional status. A retrospective qualitative deductive content analysis was undertaken to refine health alerts to improve clinical relevance to clinicians as they use alerts in their normal workflow of routine care delivery to older adults. Clinicians completed written free-text boxes to describe actions taken (or not) as a result of each alert; they also rated the clinical significance (relevance) of each health alert on a scale of 1 to 5. Two samples of the clinician’s written responses to the health alerts were analyzed after alert algorithms had been adjusted based on results of a pilot study using health alerts to enhance clinical decision-making. In the first sample, a total of 663 comments were generated by seven clinicians in response to 385 unique alerts; there are more comments than alerts because more than one clinician rated the same alert. The second sample had a total of 142 comments produced by three clinicians in response to 88 distinct alerts. The overall clinical relevance of the alerts, as judged by the content of the qualitative comments by clinicians for each alert, improved from 33.3% of the alerts in the first sample classified as clinically relevant to 43.2% in the second. The goal is to produce clinically relevant alerts that clinicians find useful in daily practice. The evaluation methods used are described to assist others as they consider building and iteratively refining health alerts to enhance clinical decision making.

Falls, Technology, and Stunt Actors: New Approaches to Fall Detection and Fall Risk Assessment

FALLS are a critical health problem for older adults. One in every 3 people aged 65 or older falls each year, making falls the most common cause of trauma-related injuries and hospitalizations in older adults and the leading cause of death due to injury.1 Falls are often the prelude to rapid functio

Patient-centered care, collaboration, communication, and coordination: a report from AMIA's 2013 Policy Meeting

In alignment with a major shift toward patient-centered care as the model for improving care in our health system, informatics is transforming patient-provider relationships and overall care delivery. AMIAs 2013 Health Policy Invitational was focused on examining existing challenges surrounding full engagement of the patient and crafting a research agenda and policy framework encouraging the use of informatics solutions to achieve this goal. The group tackled this challenge from educational, technical, and research perspectives. Recommendations include the need for consumer education regarding rights to data access, the need for consumers to access their health information in real time, and further research on effective methods to engage patients. This paper summarizes the meeting as well as the research agenda and policy recommendations prioritized among the invited experts and stakeholders.

Better Care, Better Quality: Reducing Avoidable Hospitalizations of Nursing Home Residents.

DOI: 10.1097/NCQ.0000000000000145 33% more per stay than for other Medicare hospitalizations.1 In 2012, the US Department of Health and Human Services provided funding opportunities for organizations to test a series of evidence-based clinical interventions to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions.2 In response to this opportunity, the Sinclair School of Nursing of the University of Missouri developed the Missouri Quality Initiative (MOQI) intervention and received funding under the Patient Protection and Affordable Care Act (Pub L No. 111-148) to implement this intervention.3 The MOQI intervention is a 4year demonstration of a care coordination effort using advanced practice registered nurses (APRNs) in 16 nursing homes in a region of Missouri where the transfer rates were one of the nation’s highest for Medicare readmissions within 30 days of discharge (rates of 16.7%-18.9% for medical discharges).4 The MOQI Intervention Model3 illustrates the key components of the intervention. An APRN guides the intervention delivering care

Integrating advanced practice registered nurses into nursing homes: the Missouri Quality Initiative Experience.

This project is supported by grant number 1E1CMS331080 from the Centers for Medicare and Medicaid (CMS) Innovations Center and MedicareMedicaid Coordination Office. The Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents is focused on improving care and outcomes for Medicare-Medicaid enrollees residing in nursing facilities (http://innovation.cms.gov/initiatives/ rahnfr/). The content is solely the responsibility of the authors and does not represent the official views of CMS.