Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes.

BACKGROUND: Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs. OBJECTIVE: Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR. METHODS: The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes. RESULTS: Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes. DISCUSSION: Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation.

Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site.

OBJECTIVE: Provide evidence-based advise to "Program of All-inclusive Care for the Elderly" (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes. METHODS: Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians' usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members. RESULTS: Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR. CONCLUSION: This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.

Cost analysis of telehomecare.

The demand for home health care has skyrocketed in recent years. The aging population and the push for more efficient delivery of hospital services have fueled this growing demand. However, health care financing reforms have constrained the industry's growth. Home health agencies struggle to deliver high-quality services while staying within the financial limitations imposed by reimbursement changes. Telehomecare is one way to provide cost-effective care in the current environment. Personal computers and video equipment can transmit data over ordinary telephone lines and allow home health providers to monitor patients and provide care at a much lower cost than earlier technologies that required wider bandwidth telephone lines and more complex equipment. But can telehomecare yield cost-savings for home health agencies? This article addresses the costs associated with a telehomecare intervention in a large, urban, home health agency. The purpose of the study was two-fold: (1) to test the effects of telehomecare on clinical outcomes, and (2) to estimate the financial costs associated with providing telehomecare services. Our results show that, while telehomecare imposes additional expenses for care delivery, it contributes substantial savings without compromising quality. Additionally, we found that the financial benefit increases exponentially as the duration of the patient care episode increases.

Informatics application provides instant research to practice benefits.

A web-based research information system was designed to enable our research team to efficiently measure health related quality of life among frail older adults in a variety of health care settings (home care, nursing homes, assisted living, PACE). The structure, process, and outcome data is collected using laptop computers and downloaded to a SQL database. Unique features of this project are the ability to transfer research to practice by instantly sharing individual and aggregate results with the clinicians caring for these elders and directly impacting the quality of their care. Clinicians can also dial in to the database to access standard queries or receive customized reports about the patients in their facilities. This paper will describe the development and implementation of the information system. The conference presentation will include a demonstration and examples of research to practice benefits.

Application of the Omaha System in acute care.

Although effective as a standardized language for documentation in community and public health settings, the Omaha System has not been evaluated in acute care settings. The purpose of this study was to evaluate the utility of the Omaha System to code the terms used by nurses when documenting hospital care. The nursing documentation in 30 hospital records was content analyzed for signs and symptoms, patient problems, and nursing interventions, then coded into the categories of the Omaha System. Degree of match was evaluated using concept match scores, and utility was determined using empirical, operational, and pragmatic criteria. Study findings suggest several strengths (i.e., high reliability, coded 97% of the problems, easy to use) and some limitations (lack of mutual exclusivity among terms, lack of semantic clarity, the need for three new problems). This study has important implications in demonstrating the utility of the Omaha System for possible expansion into acute care to standardize communication between the hospital setting and home care.

Patient problems and advanced practice nurse interventions during transitional care.

This study is a secondary analysis of patient records written by advanced practice nurses (APNs) as they provided discharge planning and 4 weeks of home follow-up to elderly patients hospitalized with common medical and surgical conditions. The purposes of this study were to examine the problems experienced by elders who were hospitalized and discharged to home, the interventions used by APNs as they cared for these patients, and the linkages between patient problems and APN interventions. Care logs written by the APNs to document the patient problems and nursing interventions were content analyzed and coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. The results provided a description of the 10 most frequent problems experienced by the patients linked with the APN's interventions. The study provides a description of the nature and complexity of patient problems as they transition from hospital to home and increases our understanding of the contribution of APNs to the care of elders.

Patient problems and nurse interventions during acute care and discharge planning.

Standardization and computerization of medical documentation has provided a method to describe patient care by naming and linking patients' needs with nursing interventions. This study used a standardized nursing classification system to describe the types and frequency of problems experienced by elders hospitalized and discharged to home and the interventions used by staff nurses and advanced practice nurses (APNs) as they provided acute care and discharge planning for these cardiac patients. The patients' hospital records and the APN logs were content analyzed and then coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. Patients experienced an average of 8.6 problems that required a total of 7,000 interventions in all four Omaha System intervention categories. The results provided a description of the most frequent problems experienced by the patients linked with the most common nursing interventions. The nature, complexity, and prevalence of patient problems and the importance of communication across settings are evident. In addition, the study findings increase understanding of the contribution of nurses to the care of hospitalized elders as they make the transition from hospital to home.

Vulnerable links in the home care referral process.

This article identifies some of the vulnerable links in the discharge referral process and discusses areas where home care providers might intervene to improve the process.

How telehomecare affects patients.

The emergence of telemedicine as an acceptable mode of health care delivery creates opportunities and challenges for home care providers. As part of strategic planning and deployment of a telemedicine project, agencies must ask questions, such as, is this technology suitable for elderly clients? Can patients with multiple, chronic conditions benefit? Are caregivers willing to take on the responsibility of additional equipment in the home? Agencies must consider these and other issues when planning and evaluating a telemedicine project.

The barriers and benefits of nursing information systems.

Nursing informatics is a growing field with many opportunities for nursing involvement. Because nurses are involved increasingly in the design, installation, and use of nursing information systems (NIS) it is important that they are aware of the barriers to and benefits of nursing information systems. This article describes the evolution of nursing information systems and the design goals for current systems. The lack of a unified nursing language and individual and organizational factors such as characteristics of the nurse, the unit, the administrative philosophy, and workload issues are discussed as barriers to NIS development. Increased nurse involvement, education, research, and recognition of the benefits of computerization are suggested to overcome the barriers. A review of the literature provides the reader with evidence of improved efficiency, patient safety and satisfaction, and ability to measure quality as benefits of NIS. Areas for further research are identified: outcomes measurement using NIS, decision support and expert systems, point-of-care documentation, interagency and interdisciplinary communication, and further work on individual and organizational factors.

Nursing intervention classification systems.

PURPOSE: To analyze the features, development, and research of the Omaha System, the Iowa Nursing Intervention Classification, and the Home Health Care Classification and provide a critical review of the unique components of each. ORGANIZING FRAMEWORK: Five elements: achievement of original purpose, language used, ease of computerizing format, clinical utility, and linkage of the Nursing Minimum Data set (NMDS) nursing care elements. CONCLUSIONS: Further testing and development of nursing classification systems should be done to determine the general value of nursing classification, the extent to which the original goals and purposes of classification are met, and to identify the unique features and contributions of each system. Further testing is important to determine the strengths, weaknesses, and applicability of the various systems for capturing the elements of the NMDS for different care settings, care givers, and patient populations. IMPLICATIONS: Nursing classification may eventually lead to naming and describing the work of nurses. Research findings will continue to provide information leading to a unified nursing language system that describes the practice of nursing in local, regional, national, and international health-care data sets used for research, clinical, education, policy, and administrative purposes.