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The CMS Nursing Home Compare Five Star Update

Nursing Home Compare Five Star Rating

Since the Nursing Home Compare Five Star rating program was first launched in 2008, providers have approached it with a mix of trepidation, envy and awe. Using a set of complex statistical models, CMS awards between one and five stars to every nursing facility, with the goal of helping consumers make more informed and better care decisions. Unfortunately, its reliability is somewhat suspect, as most providers experience fluctuation in their star rating. According to a five-year analysis prepared by Abt Associates, only 3% of providers had the same star rating over the entire period, although 28% ended up with the same rating as when the program started. Almost 40% moved up or down one star over the five year period, while 20% moved two stars. Recently, CMS announced changes to the quality measure content and scoring methodology, costing about 8% of nursing facilities their five-star rating and creating unhappiness in the provider ranks:

LeadingAge Supports Transparency, But Still Finds Flaws in the CMS 5-Star Nursing Home Rating System
New Government Rating System Forces Nearly 1 in 3 Skilled Nursing Centers to Lose Coveted Quality Star
CMS’s confusing kick in the teeth

To understand what happened, first we need to understand how the score is calculated. You can read the CMS Technical Users Guide, or just follow along:

Health Inspections Five Star Rating

The health inspection rating is calculated from the number, severity and scope of deficiencies in the past 3 annual surveys, along with deficiencies from the last 36 months of complaint surveys. There is an aging component, as well, so that more recent surveys are weighted more than older ones. CMS then stratifies the star rating so that the lower 20% of nursing homes in each state receive one star, the middle 70% receive between 2 and 4 stars, and only the top 10% receive 5 stars. The actual state-by-state distribution looks like this:

Nursing Home Compare Five Star Rating

Staffing Five Star Rating

The staffing rating is based on reported staffing during the more recent annual survey, and looks at RN staffing and total nursing personnel (licensed nurses and nurse aides) adjusted by case-mix based on the RUG-III group. The star rating is determined according to the grid below:

Star ratings based on nurse staffing

And the state-by-state distribution looks like this:

Nursing Home Compare Staffing Star Rating

Alaska is excluded from the chart above. Why? Because 100% of Alaskan facilities received five stars for staffing.

Quality Measures Five Star Rating

The quality measure star rating is based on how the facility performs during the previous 3 quarters (9 months) on 11 of the 18 quality measures currently calculated by CMS:

Long-Stay Residents:
• Percent of residents whose need for help with activities of daily living has increased
• Percent of high risk residents with pressure ulcers (sores)
• Percent of residents who have/had a catheter inserted and left in their bladder*
• Percent of residents who were physically restrained
• Percent of residents with a urinary tract infection
• Percent of residents who self-report moderate to severe pain*
• Percent of residents experiencing one or more falls with major injury
• Percent of residents who received an antipsychotic medication

Short-stay residents:
• Percent of residents with pressure ulcers (sores) that are new or worsened*
• Percent of residents who self-report moderate to severe pain
• Percent of residents who newly received an antipsychotic medication

* Risk adjusted

The scoring methodology is somewhat complex, but essentially point values are assigned for each measure based on the nursing home’s performance compared to other nursing homes in the same state. Each quality measure is given equal weight, so the individual scores are simply summed. The total score is then applied to a scale to determine the star rating.

The current star distribution for quality measures, by state, looks like this:

five_star_QM

Overall Five Star Rating

With the complicated math behind, calculating the overall star score is easy. Begin with the health inspection rating. Next, add one star if the staffing rating is a four or five stars *and* the staffing rating is higher than the health inspection rating. Subtract one star if the staffing rating is one star. Finally, add one star if the quality measure rating is five stars,  or subtract one star if the QM rating is one star.

Special note: If a facility has a one star health inspection rating, its maximum overall rating is limited to two stars. Also, if the facility is in the Special Focus Program, its overall star rating cannot be more than three stars.

Why was the Recent Rebasing Done and Why are Providers Unhappy?

Since the fundamental methodology is intended to stratify facilities relatively evenly, but the actual scoring is based on a known point system, a gradual drift towards higher star ratings occurred over the past five years. Part of this is probably due to overall care improvements, and part of this is probably due to providers gaming (or at least selectively improving) parts of the system.

There is also a slight issue of state imbalance. Consider the District of Columbia:

five_star_DC

 

More than 50% of DC facilities hold a five star rating. Does this mean that DC providers provide phenomenal care? Perhaps, though it’s unlikely they provide significantly better care overall than providers in many other states. So how did so many providers get this coveted rating? As you can see above, the majority of DC providers received either four or five stars for staffing and five stars for QMs, which would lead to either one or two stars added to the health inspection rating. This points to a core problem with the five star system: CMS selectively stratifies measures by state, attempting to account for differences in state Medicaid policy and surveyor quirks, but this ends up causing some parts of the measure to reflect best-in-a-state results and others to reflect best-in-the-country results. Since the methodology isn’t standardized, it creates a real problem when comparing the five star rating of facilities located in different states.

What Does This Mean for Providers

CMS has clearly stated that it will continue to update measures and rebase scoring to promote continual improvement in nursing homes. While providers are understandably frustrated, this is simply the reality of healthcare today. Complaining about being ‘kicked in the teeth’ only furthers the perception that the nursing home field is behind the times. Instead, providers should see this as an opportunity to excel, not only in Nursing Home Compare rankings, but in service and care as well.

Understanding the methodology behind the five star rating system, as well as the state-level distribution, is a crucial first step to responding to this recent change. It should be clear that the health inspection score is the biggest driver of the overall score, and to reach a five star rating, a provider must be at or below the state average for survey deficiencies. Thus, it is critical, now more than ever, to build effective systems that embed quality processes into daily work. Customer service is also key, as most complaint surveys begin from unhappy residents or family members. Second, staffing hour cutoffs make it easy to compare current staffing metrics to the star rating system. For some facilities, adding slightly more staffing hours is an easy way to improve the star rating. Third, since quality measures are equally weighted, facilities can determine what measures are close to a higher point cut-off and work to improve those specific measures.

 

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Building a Culture of Continuous Improvement with an Idea-Driven Approach

Ideas are the fuel of innovation, but many senior housing communities and long-term care operators struggle to engage their front-line employees in idea generation. This is both unfortunate and short-sighted. As Alan Robinson and Dean Schroeder note in their book, The Idea-Driven Organization, a steady stream of ideas can lead to competitive advantage, better service and higher quality—three things that aging services providers, now more than ever, must maximize. For nursing homes, an idea-driven culture is a crucial component to any successful QAPI program. For other providers, rapid growth and development is squeezing margins and increasing calls for enhanced regulation around quality and service.

 

Ideas are crucial to performance and quality improvement in long-term care

Generating Ideas

Generating ideas isn’t hard and it doesn’t have to cost a lot money. In fact, more employees will offer them for free. Why? Humans love to make things easier—it’s hardwired into our biology. In a typical workplace, however, rules, bureaucracy, and hierarchies all work to hamper employee engagement and reduce the flow of new ideas. An employee with too many ideas is often ostracized or, worse, accused of being trouble and offered the door. Other employees learn that it’s better to be quiet and keep ideas to themselves.

To break this cycle, build a culture where ideas are welcomed. Reward employees for sharing ideas. Create safe spaces when employees’ voices aren’t overshadowed by louder colleagues or discounted by management. (The nominal group technique can help with this!) Make it easy by ensuring that management spends time with front-line staff in their own work areas. When there, leaders should probe employees, ask questions and encourage contrarian views. Include idea generation and testing in job descriptions and performance evaluations to reinforce its value and importance.

Some organizations try suggestion boxes to solicit ideas. These rarely work; ideas becomes disconnected from their source, and are pre-judged to be undoable, or forgotten about in an ever-growing mountain of executive to-dos.  Instead of closed (or locked!) boxes, try open boards, instead, where ideas and follow-ups are shared openly. Open boards are also useful for aligning ideas with strategic priorities and organizational goals; list specific topics with known barriers or challenges on the board to help harness the wisdom of staff. Technology tools can be useful, too, such as idea management software and enterprise social networking tools.

Generating ideas in a nursing facility or assisted living is a team process

Managing Ideas

Generating an idea is only the first step. Once an organization starts to truly encourage an idea culture, it’s important to have a system to manage them. Countless idea programs fall into quick disuse as employees learn that the systems are of little value in enacting change.

Idea management takes energy and resources, but it shouldn’t be complicated or hidden from view. Track ideas openly, and allow for feedback, evolution and improvement. Many organizations limit the flow of ideas due to a lack of perceived bandwidth to accomplish goals. Instead of parking ideas or telling staff that there isn’t time to work on something, look for ways to enable and empower staff members themselves. While prioritization of ideas is important, of course, but don’t get trapped into creating so formal a system as to require every action be approved by three levels of management. Decentralization is key to an idea-driven culture. The vast majority of ideas should be tried and tested by front-line staff and supervisors, who are then supported in sharing both successes and failures.

There are many examples of organizations that have successfully done this, such as Ritz Carlton permitting any employee to spend up to $2,000 to make a guest happy. (Compare this to some nursing homes where staff struggle to have enough pens and thermometers.) Brasilata, described in The Idea-Driven Organization, authorizes front-line supervisors to spend up to 100 reals and managers up to 5,000 reals implementing an idea.

However the system is designed, the most crucial point is to not let ideas linger. Static action plans, known issue lists, and problem trackers that are not acted upon serve to stifle innovation and reassure staff members that the organization cares little about their ideas.

Here again, managing ideas through a visual board or an open, collaborative software system enables open lines of communication, frank discussions of challenges and impediments and innovative problem solving approaches.

Kaizen Idea board showing quality improvement ideas

Ideas Lead to Success

Lean organizations thrive on a constant, substantial flow of ideas. By building a culture that not only allows, but actively supports, idea generation, and then managing the flow in an efficient and transparent manner, companies can accelerate their improvement practices and develop a more robust and agile organization. When combined with a fervent improvement mindset, these organizations can far outshine their competitors.

Have more time? Listen to a wonderful podcost with Dr. Dean Shroeder & Dr. Alan G Robinson, authors of the Ideas Driven Organization, and visit their website, Idea Driven.

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EHR Implementation Guide: Part Two – Implementation and Optimization

Build and Implementation

Build

Depending on the system and vendor, the build phase can take anywhere from weeks to months. During the process, you may find yourself discovering better ways to accomplish a process halfway through the build. Don’t be afraid to rebuild modules when this occurs—a little extra time spent now can save considerable time over and over again down the road. It’s a good idea to talk with colleagues who have already implemented the system to learn from their challenges and experience.

Data Governance

As part of the build phase, spend time to develop a data governance structure. This entails a written plan of who is accountable for information integrity and security, processes for managing data quality, and auditing systems for HIPAA compliance, security, and accuracy. The structure should involve oversight from the corporate or board-level.

Training

Vendors typically recommend a slew of webinar-based training modules for all staff. The idea is to gather a group of staff and watch someone demonstrate the EHR functions step by step. Not only is this training style time-consuming and expensive, it is ineffective at building proficiency in users. Why is proficiency important to think about? Research has shown that adults learn much better when concepts are tied to the work they are expected to do. In the case of EHRs, the goal should be to have proficient users– in other words, that staff are able to use the application effectively to do their job– as opposed to knowing a complex set of modules and screens.

By listening to and/ or watching a remote user walk through screens and screens of capabilities, staff are likely to retain very little once the training is completed. Instead, training should be developed and deployed around workflow and roles, using a well-designed simulation environment that closely matches the new system. In other words, staff members should have access to a computer and be able to complete the step by step activities at the same time as the trainer. The savings in reduced training time and increased proficiency from this approach alone can make retaining an external, experienced EHR consulting firm cost-effective.

Go-Live

Go-Live is the big day to switch the new EHR system on. If you have invested the time and resources in your journey so far, Go-Live should be simply another step in the process. Make sure you have extra staff available to ease the transition. Management staff should also spend time in crucial operational areas to demonstrate commitment and provide support as needed.

Implementation Project Closure/ Transfer to Optimization Structure

The optimization phase of an EHR project should be built long before go-live day. After the implementation phase ends, usually 90 days or so after go-live, return to the established goals for the system and compare to the results achieved so far. Begin implementing a long-term strategy to understand how the EHR is integrating into workflows and make adjusts to the system when necessary. In addition, consider the following tips:

  • Develop strong training programs that can be consistently provided to new staff. A reliance on web-based training modules leads to poor proficiency and increased variation in usage and data entry, as does training provided solely as part of a traditional floor orientation program. Instead, take the time to develop (and keep updated) a training program that includes simulation, facility-specific guides, and leadership oversight to ensure continuity of information and practices.
  • Commit to one place for data. Many organizations are loathe to give up their trusted Excel-based census tracking worksheets and paper-based incident tracking systems. Resist the urge to keep data in different places. To fully capitalize on the business intelligence and analytic features of EHRs, you need to have all the data in one place to properly guide future decision-making. Data analytics is quickly reshaping all of healthcare. For LTPAC providers, this means you must have accurate data on rehab outcomes, rehospitalization statistics, and efficiency of operations. If your EHR solution is a barrier, press your vendor for added functionality. Chances are good they either have a solution from another provider, or, more likely, other providers are struggling with and clamoring for the same solution.
  • Ask staff probing questions. It’s not enough to ask, “Is everything okay?” At one organization where I served as administrator, I discovered months after implementation that some of our med aides were not following the proper procedures to chart their med pass. In researching why the staff had not mentioned the deviation before, I discovered that they had never been able to follow the process as described, but quickly found a workaround that seemed to work. When I would ask if everything was okay in the months after go-live, naturally and honestly they answered, “Sure!” Ask staff directly if things are working as expected. Ask regularly if staff are finding different ways to accomplish tasks. Encourage your superusers to report common questions and issues so you can examine whether there are organization-wide trends.

It’s also crucial to note, you must approach problems with usage of the EHR with a “just” mindset. This means if staff are not following established protocols, it’s crucial to understand why in a way that doesn’t place blame on individuals when the problems are system-induced. (And in our experience, virtually all problems with EHR usage are system-induced.)

  • Stay curious. EHRs vendors are quick to promise their system will do everything under the sun. It won’t, trust us. EHRs currently on the market are clunky adaptations of LTPAC operations. For some processes, you will ask how to do something and receive an answer of either the EHR can’t do that, or it can, but requires a complex set of steps. Push your vendor to simplify steps and improve workflows. What EHR vendors lack in user experience design and functionality, they more than make up in attention to customer needs. So be vocal about what you need and what you’d like to see. Remember Robert Kennedy: “Some [people] see things as they are and ask why—I dream things that never were, and ask why not?” Ask why not. Often.
  • If something doesn’t work, don’t give up on it. This part is a little shocking to us, but we find many organizations that, after struggling to adopt a certain feature or workflow, simply decide an EHR can’t support this part of their business and drop it. One time, we worked with a client that had paid for the billing/ finance module of an EHR, but had completely abandoned it in favor of staying with Quickbooks because they weren’t able to get the system to bill correctly for their independent residents. Resist the temptation. If a billing module doesn’t support your CCRC model, talk openly with your vendor about what you are trying to accomplish. Take a look at your internal process, as well, and be open to reconceptualization of your processes. While current EHRs are clunky, they are hardly impotent. Don’t give up on such a big investment.
  • Be open to—brace yourself—replacing your shiny new EHR. Most vendors work hard to ensure client satisfaction, but if you find yourself with a vendor who refuses to work with your struggles and challenges, go back to your shortlist and reexamine other vendors. The cost to replace a system is truly less than continuing to use a beast that doesn’t actually improve your operations and ability to care for your residents.

Final Thoughts

Current EHR systems on the market are valuable tools to manage data more effectively and streamline some of the labor-intensive parts of LTPAC operations. At the same time, they are not perfect solutions, and unfortunately reflect too much history as revenue cycle agents and not enough experience in day-to-day operations. Most systems are just now integrating workflow engines into the design, and it will be years before useful workflow and clinical decision support tools are available.  Worse, all complete EHR systems currently on the market suffer from a deep bias of paper-centric thinking, which hampers the ability of much of the healthcare industry to leverage technology in the same way that other industries have done (think Apple, Amazon, Google, and Netflix). This means that we likely will see tremendous innovation moving forward, and some of the giants today will struggle or fall away in the near future. Staying on top of technology solutions, rather than clinging tight to a trusted vendor, will require LTPAC organizations to think differently than they have in the past and embrace change much more quickly and tentatively.

EHR Implementation Guide: Part One – Project Management and Vendor Selection

 

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

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EHR Implementation Guide: Part One – Project Management and Vendor Selection

Choosing an EHR is a significant investment in time, resources, and staff goodwill. Therefore, it is crucial to conduct a thorough readiness assessment, consider vendor options carefully, and commit the resources necessary through full use and adoption of the software. For nursing homes and comprehensive care communities, the vendor landscape is wide. Several large solutions offer consolidated billing, MDS, care plan, MAR/ TAR, and resident care solutions. For assisted living, memory care, and senior housing, vendors have responded with a range of options from basic care tracking tools to integrated family/ provider engagement platforms.

This guide will help prepare you for an implementation by describing basic project management concepts, offering an overview of EHR options, and detailing how to construct an outcome-oriented training plan.

 

Project Management Basics

Choosing a project manager and sponsor

Selecting a person to manage an EHR project is crucial to success. The project manager should be organized, an effective communicator, and familiar with the care setting, resident requirements, and staff capabilities. Most important of all, the project manager must have sufficient free time to manage the project effectively, respond to challenges and problems quickly, and support implementation with on-the-ground support at critical junctures.

Equally important is choosing the right project sponsor who “authorizes” the project. This person must have sufficient decision-making ability and availability to support the project, remove roadblocks, and make critical decisions in a timely manner.

Picking the project team

The project team should include, at a minimum:

  • Representatives from administration
  • Clinical leaders
  • Clinical users
  • IT staff
  • Ancillary department staff (dining, environmental services, social services, marketing, etc.)
  • Resident representatives

Project team members should be collaborative thinkers, team players, and committed to the organization’s goals and mission.

Scoping the project

A careful project scoping process is essential to accurately forecast budget needs and time requirements. Will the project include IT infrastructure upgrades? Workflow analysis consulting? Conversion of paper records? What positions and resources will become permanent and what will be solely project-based?

Managing the project process

A successful project requires ongoing attention, oversight and adjustment. Organizations will want to consider postponing other strategic initiatives during the implementation process to focus on the work ahead. When adjustments are needed, the project team should act swiftly to avoid losing momentum and support.

Organization Review and Goals

To begin, you need to adequately define your current state (assess IT infrastructure, map workflows, measure staff engagement and readiness, quantify funding sources). The following websites have some great free resources for beginning this process:

Stratis Health (a QIO based in MN): http://www.stratishealth.org/expertise/healthit/nursinghomes/

LeadingAge CAST EHR Selection Tool: http://www.leadingage.org/ehr/search.aspx

You should also explicitly define goals for the EHR system: What do you want it to do? What areas of performance do you expect to improve? Be specific and measurable in selecting goals. Vendors typically focus on operational efficiencies and revenue generation, but your organization may have alternate goals to consider, such as improved customer service, better resident outcomes, and more satisfied staff.

EHR Vendor Considerations and Hardware

Hosted vs. Local Installation

Most EHRs offer a hosted version of their service (either through purchase or as a Software as a Services (SaaS) option, and some allow for software to be installed locally. Each option has advantages and challenges:

Hosted Solutions:
  • Vendor managed storage, reliability, upgrades and security reduces infrastructure and capital needs. Most vendors offer uptime guarantees and automatic upgrades to the latest version. In addition, vendors typically conduct ongoing, comprehensive security and penetration testing, meaning, somewhat counterintuitively, the data is typically more secure than with local installations.
  • Usually offered on a monthly contract or service charge basis, which can lower initial deployment costs substantially.
  • The ownership of data varies, and it’s important to clarify at the onset. When a vendor owns the data, migrating to another solution in the future can prove to be an expensive proposition.
  • Usage of the software is dependent on internet access, and reliability at the community site, thus, is crucial. Most organizations are not able to afford redundant solutions or direct internet pipelines, which can lead to some risk of downtown. Many EHRs have ways to mitigate the risks and challenges of internet disruption, such as local backups for time sensitive items like resident face sheets and MARs.
Local Installations:
  • Software is oftentimes more customizable for a particular organization’s needs.
  • Though it requires a higher up-front investment, purchased solutions may be less expensive over time, especially for organizations with already expansive IT capabilities.
  • Less reliance on internet connectivity, which may be crucial for locations with intermittent or unreliable access to the internet.
  • In addition to software, hardware investments and ongoing IT staff costs may be significant.

Hardware

After assessing your current IT infrastructure, you’ll want to decide what hardware you will need to acquire. Desktops are the cheapest solution and require minimal oversight and maintance, but they are less flexible and can contribute to institutional practices. Laptops are slightly more expensive, but offer greater flexibility and mobility. Tablets are easy to use and very mobile, but lack a keyboard for data entry and must be protected from theft and accidental damage. As the price of laptops and tablets continues to drop, more and more providers are opting in this direction.

Wireless internet is essential for most EHR deployments. While some facilities opt for home and office-grade equipment, it is well worth the investment to purchase healthcare-rated devices. Overlapping deployment of wireless radios is crucial, and it is recommended to maintain a signal strength of -70 dBm in all care locations.

Platform/ Browser Dependence

Some EHR solutions are dependent on Microsoft Windows and/ or Internet Explorer. Additionally, EHR vendors are beginning to develop mobile applications, which may be only available on either iOS (Apple) or Android platforms. In general, dependence on a particular platform or browser is not recommended, though many otherwise good LTPAC EHR vendors are designed in such a fashion, which can raise the cost of hardware, particularly if using mobile or tablet technology. Software that is only capable of running on a desktop environment is not recommended, as the technology is quickly being surpassed by tablet technology with lower costs and more person-centered design options.

Reporting Features

EHRs capture a tremendous amount of data. Using this data in a meaningful way, however, is a very different proposition. It’s important to review report generation capabilities of EHR systems thoroughly, as there is significant variation among vendors. Specifically, you want to understand:

How does reporting work in the EHR? What reports are standard? How are options controlled? What export formats are available?

What options are available for customized report writing? Can the data be segmented and can multiple data fields be included in report writing?

Person-Centered Practices and Assisted Living Environments

Most EHRs were initially designed as revenue cycle management platforms. Accordingly, the software and databases are well-attuned to catching and reporting MDS data at the expense of resident outcomes. As you explore vendors, consider how the user experience allows (or hinders) access to the data that is important in day-to-day operations. Are nurses able to easily manage resident health issues? Are care plan templates designed to allow for flexibility in display and reporting to suit different user needs (e.g., LN vs. CNA vs. family member)? Are point of care portals intuitive and easy to use?

On this note, if your community has an assisted living component, carefully examine any AL-specific modules. Does it reflect your needs and workflows? Does the system focus on the whole resident rather than just the medical record and ADL capture? Most EHR vendors took SNF modules and repackaged them for ALFs, which has led to unnecessary medicalization of these community-based-care environments.

Vendor Contracts and Post-Selection

We’ve seen countless organizations trust vendors to ensure a smooth transition only to struggle as customization takes longer than expected, costs run over budget, and the final product offers less than what was expected. An important way to protect your organization is to make the vendor contract contingent on project milestones and based on project outcomes, not hours involved. We also recommend adding contract language that allows an organization to refuse payment for any vendor-controlled cost overruns. (Vendor-supplied agreements typically promise only an “estimate” of implementation costs based on vendor-recorded hours, while calling for fees of up to $125 per hour for overruns– even when caused by the vendor.) Timeliness penalties are also becoming more common, and can help ensure a vendor keeps to the established timeline.

During the post-selection phase, it’s important to maintain open and honest communication with the vendor. If you run into issues or challenges, don’t be afraid to speak up. It’s also sometimes useful to keep 2nd and 3rd choice vendors engaged, as it’s never too late to change direction based on outcomes of the implementation process. While switching mid-stream may seem expensive or wasteful, it’s far worse to end up with a vendor not committed to your success.

EHR Implementation Guide: Part Two – Implementation and Optimization

 

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

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Embracing an Adoption Model for EHRs

While aging services providers slowly move forward in implementing electronic health records, a lack of workflow redesign and adoption practices continue to hamper providers’ efforts to realize the full potential of these computerized systems. Chief among the challenges are 1) inconsistent and poorly designed training programs, 2) disconnects between old workflow patterns and new opportunities, 3) a lack of data governance structures,  and 4) failure to embrace optimization opportunities.

1) Inconsistant and Poorly Designed Training Programs

Providers and vendors continue to waste significant resources during training and implementation phases by blasting webinar-based training to classrooms full of staff. Not only is this training style time-consuming and expensive, it is ineffective at building proficiency in users. Why is this important? Research has shown that adults learn much better when concepts are tied to the work they are expected to do. In the case of EHRs, the goal should be to have proficient users– in other words, staff are able to use the application effectively to do their job– as opposed to knowing a complex set of modules and screens.

By listening to and/ or watching a remote user walk through screens and screens of capabilities, staff are likely to retain very little once the training is completed. Instead, training should be developed and deployed around workflow and roles, using a well-designed simulation environment that closely matches the new system. The savings from this approach alone can make retaining an external, experienced EHR consulting firm cost-effective.

Once systems are implemented, providers should develop strong training programs that can be consistently provided to new staff. A reliance on web-based training modules leads to poor proficiency and increased variation in usage and data entry, as does training provided solely as part of a traditional floor orientation program. Instead, providers should take the time to develop (and keep updated) a training program that includes simulation, facility-specific guides, and leadership oversight to ensure continuity of information and practices.

2) Workflow Challenges

EHRs offer a tremendous opportunity to remove significant waste from operations. From hunting down charts to keeping documentation in one place, an EHR can bring order to chaotic paper charts. Because of this, new workflows oftentimes need to be developed to take advantage of these opportunities. Role for medical records, MDS nurses, billing staff and floor nurses all need to be examined to determine the most effective mechanisms for entering and maintain data in an EHR. The challenge is that even during an EHR build and design phase, paper-centric thinking reigns. This creates a bias towards old systems that leaves most implementations under-powered and underutilized.

Charting and review systems need to be assessed, as EHRs typically provide visibility into areas that previously required redundant systems to manage. Any parallel information systems being used after implementing an EHR should be carefully examined to ensure there isn’t a duplication of data or efforts occurring. Without direct assessment and action, it’s not uncommon for providers to waste 10-15% of their resources maintaining outdated or redundant systems and databases.

3) A Lack of Data Governance Structures

Very little literature has been written or developed regarding data governance in long-term care, and it’s likely that most providers do not have a formalized process for managing the integrity of data entered into an EHR, resulting in unnecessary variation, lowered resident outcomes, and less useful analytics and performance measures. To remedy this, providers need to develop a model for data governance and create processes to define and manage the information entered into the EHR. This means defining roles and responsibilities around the data that is entered, and developing systems and practices to standardize and sustain the data. Compliance should be measured on an ongoing basis, and frequent adjustments should be implemented as new needs are identified.

4) Failure to Embrace Optimization Opportunities

Optimization is the ongoing process of evaluating, improving, and sustaining an EHR over the product life-cycle. For many providers, however, an EHR simply becomes part of the background infrastructure after implementation is complete. For workflows that were not redesigned during implementation, extra or unneeded work often continues indefinitely. Workarounds to problematic features are typically developed and shared by floor staff, which can circumvent opportunities for useful analytics and reporting. In addition, new features developed by vendors are sometimes under- or un-utilized as they are typically buried in pages of product announcements and updates that are rarely viewed. In fact, it is not uncommon for legacy users– those who have had systems the longest– to be among the vendors’ lowest utilizers.

Providers should develop an ongoing optimization strategy that includes frequent observations of staff usage, regular discussions with the EHR vendor on new and planned enhancements, and collaboration with other users to discuss issues, workarounds, and innovative practices.

Have a little more time? Check out this excellent webinar from HIStalk on adoption success factors.

Have a little more time? Watch this excellent HIStalk webinar on long-term adoption.

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

Ready to get started? So are we!