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Electronic Health Record Adoption and Interoperability among U.S. Nursing Facilities in 2016

ONC Data Brief 39 | September, 2017

Carla S. Alvarado, PhD, MPH; Kathleen Zook, MPH, RN; JaWanna Henry, MPH

The use of electronic health records (EHRs) can facilitate the exchange of patient health information during transitions of care between acute-care and skilled nursing facilities (SNFs). Long-term care and post-acute care (LTPAC) providers, including SNFs, were not eligible to participate in the Medicare and Medicaid Electronic Health Record Incentive Programs. However, LTPAC providers are increasingly reported as major exchange partners of providers that were eligible to participate in this program (1). Also, the "Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap" (the Roadmap) aims to propel the adoption and use of EHRs in LTPAC settings (2). The Roadmap defines the four key domains of interoperability as electronically sending, receiving, finding, and integrating or using key clinical information from outside sources.

This brief presents key measures on EHR adoption and interoperability from a 2016 nationally representative sample of SNFs. This brief also describes variation in EHR adoption and interoperability by SNF characteristics and examines the extent to which these facilities have information electronically available at the point of care.

Highlights
A majority of SNFs (64%) used an EHR in 2016.
Figure 1: Percent of SNFs that used an EHR, 2016

Figure 1. Percent of SNFs that used an EHR, 2016. This figure is a pictorial representation of the percent of SNFs that used an EHR in 2016. There are 10 buildings displayed in a row. Each building represents 10% of the population. Six of the buildings are shaded to indicate that 64% of the SNFs used an EHR in 2016.
SNFs rates of EHR adoption did not significantly differ by facility size or rural/urban geographic location.
Figure 2: EHR adoption rates by SNF characteristics, 2016

Figure 2. EHR adoption rates by SNF characteristics, 2016. This set of 3 bar graphs represents EHR adoption rates by SNF size, profit status, and urban/rural location in 2016. The first bar graph shows that 68% of small (less than 50 licensed beds), 65% of medium (51-99 licensed beds), and 62% of large (greater than 100 licensed beds) SNF used an EHR. The second bar graph shows that 62% of for-profit SNFs and 70% of non-profit SNFs used an EHR. This difference is statistically significant at p<0.05. The third bar graph shows that 67% of rural SNFs and 62% of urban SNFs used an EHR.
Almost two in 10 SNFs used both an EHR and an HIO.
Figure 3: Percent of SNFs using EHRs or HIOs, 2016

Figure 3. Percent of SNFs using EHRs or HIOs, 2016. This pie chart represents the percent of SNF that used EHRs or health information organizations (HIOs) in 2016. Thirty-one percent used neither an EHR nor a HIO, 46% of SNFs used an EHR alone, 18% percent used an EHR and a HIO, and 4% percent used a HIO alone.
Three out of 10 SNFs exchanged (sent or received) patient health information with outside organizations.
Figure 4: Percent of SNFs reporting the ability to electronically send, receive, find, and integrate patient health information, 2016

Figure 4. Percent of SNFs reporting the ability to electronically send, receive, find, and integrate patient health information, 2016. This bar graph represents the percent of SNF that were able to send, receive, find, integrate and exchange (send or receive) patient health information in 2016. Twenty-nine percent of SNFs were able to send, 23% receive, 20% find, 9% integrate, and 7% were able to do all four: send, receive, find, and integrate. Twenty-nine percent of SNFs were able to exchange, defined as send or receive.
SNFs that used an EHR and an HIO engaged in the four domains of interoperability at substantially higher rates than SNFs that used an EHR alone.
Table 1: Interoperability domains (send, receive, find, and integrate) by SNFs characteristics, 2016

SOURCE: 2016 QuintilesIMS/SK&A Nursing Home Facilities Census - EHR Supplement, n=813

NOTES: Methods of Exchange: HIO Alone category omitted due to small sample size.
Rural: located in a non-Metropolitan Statistical Area.
§ See Appendix for survey question.
* Difference between previous sub-category is statistically significant (p<0.05)
^ Difference between first and third sub-category is statistically significant (p<0.05)

Over half (62%) of SNFs had clinical information from outside encounters electronically available at the point of care.
Figure 5: Frequency with which SNFs reported having clinical information from outside encounters electronically available at the point of care, 2016

Figure 5. Frequency with which clinical information from outside encounters was electronically available at the point of care, 2016
Nine of 10 (86%) SNFs that used EHRs and HIOs had patient health information electronically available from outside sources at the point of care.
Figure 6: The frequency of clinical information from outside encounters electronically available at the point of care by EHR and HIO use, 2016

Summary

SNF patients may have complex chronic care needs that result in frequent transitions between their homes, acute, post-acute, and long-term care settings (3). Patient care coordination and continuity of care are paramount in this setting where transitions of care are common (4), (5). Thus, EHR adoption and interoperability of SNFs' health information systems is critical to facilitating transitions of care (6).

In 2016, 64% of SNFs used EHRs to manage patient health information. The adoption rates of EHRs significantly varied by profit status. More non-profit SNFs (70%) used an EHR compared to for-profit facilities (62%). There were no significant differences in EHR adoption rates by rural and urban location, nor by bed size. The use of HIOs varied across facilities. Almost half (46%) of SNFs used an EHR alone. However, about a fifth of SNFs (18%) reported using both EHR and HIO.

Three out of ten SNFs electronically exchanged (sent or received) patient health information. Twenty percent of SNFs found patients' health information from sources outside their facility through various means such as web-portals, remote access to another facility, or an HIO. Nine percent of SNFs reported that their staff was able to easily integrate patient health information from outside sources into their EHR, that is, without scanning or manual entry. However, only seven percent of the facilities reported the ability to engage in all four interoperability domains.

The ability of SNFs to send, receive, find, and integrate varied by facility characteristics. For example, large SNFs integrated patient health information from outside sources at a higher rate (12%) than medium-sized facilities (6%). Non-profit SNFs electronically exchanged patient health information at a higher rate (36%) than for-profit facilities (27%). Moreover, SNFs using both an EHR and an HIO reported significantly higher levels of interoperability across all domains than those facilities that did not use an EHR or HIO.

Overall, 62% of SNFs reported having clinical information from outside encounters electronically available at the point of care. For SNFs with both an EHR and an HIO, 86% had patient health information electronically available at the point of care. This is a 39% increase over the average.

EHR adoption rates among SNFs lag compared to acute care settings as do rates of engagement in the different interoperability domains (7). Consistent with hospitals and office-based physicians, SNFs are more likely to electronically send and receive patient health information than to find and integrate electronic health information (2). The EHR adoption lag in SNFs may be in part due to their ineligibility to receive financial incentives to adopt and use EHRs under the Centers for Medicare and Medicaid Services' EHR Incentive Programs. Researchers have identified barriers to EHR adoption across long-term and post-acute care settings, the most salient of which is the initial cost of EHR adoption, followed by user perceptions, and implementation problems among others (8), (9).

In spite of barriers, SNFs' EHR adoption is higher than those of other long-term and post-acute care service providers such as adult day service centers (10). Drivers of EHR adoption for SNFs may be due to the EHR and health information exchange investments made by hospitals (8), (11). The Improving Medicare Post-Acute Care Transformation Act of 2014 and efforts like the State Medicaid Director Letter #16-003 are additional levers to facilitate interoperability among SNFs (12), (13), (14). Our findings suggest that factors like HIO participation are also important to advancing interoperability among SNFs. Future research on the adoption and use of EHRs and other health IT (e.g. tele-health) among LTPAC providers, including hospice providers, home health agencies, and home and community-based services providers, is necessary to identify and address barriers that hinder the coordination and continuity of care for patients in these settings.

Definitions

Electronic Health Record (EHR): An Electronic Health Record (EHR) is an electronic version of a patient's medical history that is maintained by the provider over time, and may include all of the key clinical data relevant to that person's care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.

Health Information Organization (HIO): A group of organizations within a specific geographic (state or regional) area that share health care-related information, often via health information exchanges, according to accepted health care information technology standards.(15).

Interoperability: The ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user. This brief further specifies interoperability as the ability for health systems to electronically send, receive, find, and integrate or use health information with other electronic systems outside their organization.

Long-term care and post-acute care (LTPAC): Providers that provide long-term care services sin settings uch as skilled nursing facilities (SNFs), nursing facilities (NFs) home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), hospice, and community-based settings (e.g. group homes, assisted living facilities), among others.

Skilled Nursing Facility (SNF): Survey respondents that self-identified as a skilled nursing facility. Skilled nursing facilities traditionally provide short-term sub-acute care for persons recuperating from a hospitalization or an acute condition. See Data Source and Methods section for more detail on sample of nursing homes.

Data Source and Methods

The data presented in this brief are from the private company, QuintilesIMS (formerly SK&A). QuintlesIMS is a provider of U.S. healthcare reference information including EHR adoption. In collaboration with ONC, QuintilesIMS fielded a 10 question telephone survey between September and November of 2016. Refer to the appendix for the subset of questions asked in the survey and presented in this brief.

One thousand facilities rendering LTPAC services were surveyed. Of the facilities surveyed, 813 self-identified as a SNF and of those 782 (96%) were CMS Medicare-certified skilled nursing or nursing facilities. CMS certification was verified using the CMS September 2016 Provider of Services file.

Significant differences noted throughout the data brief were tested using p < 0.05 as the threshold.

References

1. Patel V., Pylypchuk Y., Henry J., & Searcy T. (July 2016) Variation in Interoperability among U.S. Non-federal Acute Care Hospitals in 2015. ONC Data Brief, no.37. Office of the National Coordinator for Health Information Technology: Washington DC. Available at: https://dashboard.healthit.gov/evaluations/data-briefs/variation-interoperability-non-federal-acute-care-hospitals-2015.php

2. Connecting Health and Care for the Nation A Shared Nationwide Interoperability Roadmap. Office of the National Coordinator for Health Information Technology. 2015. Available at: https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf

3. Care Coordination Tool for Transition to Long-Term and Post-Acute Care. The National Learning Consortium and the Health Information Technology Research Center. 2014. Available at: https://www.healthit.gov/sites/default/files/nlc_ltpac_carecoordinationtool.pdf

4. Burke, R. E., Juarez-Colunga, E., Levy, C., Prochazka, A. V., Coleman, E. A., & Ginde, A. A. (2015). Rise of postacute care facilities as a discharge destination of US hospitalizations. JAMA internal medicine, 175(2), 295-296.

5. Tian W. (AHRQ). An All-Payer View of Hospital Discharge to Post-acute Care, 2013. HCUP Statistical Brief #205. May 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb205-Hospital-Discharge-Postacute-Care.pdf

6. Kruse, C. S., Mileski, M., Alaytsev, V., Carol, E., & Williams, A. (2015). Adoption factors associated with electronic health record among long-term care facilities: a systematic review. BMJ open, 5(1), e006615.

7. 2016 Report to Congress on Health IT Progress: Examining the HITECH Era and the Future of Health IT. Available at: https://dashboard.healthit.gov/report-to-congress/2016-report-congress-examining-hitech-era-future-health-information-technology.php

8. Cross, D. A., & Adler-Milstein, J. (2017). Investing in Post-Acute Care Transitions: Electronic Information Exchange Between Hospitals and Long-Term Care Facilities. Journal of the American Medical Directors Association, 18(1), 30-34

9. Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health affairs, 24(5), 1103-1117

10. Centers for Disease Control and Prevention. QuickStats: Percentage of Long-Term Care Services Providers That Use Electronic Health Records and Have a Computerized System for Electronic Health Information Exchange, by Provider Sector and Type of Electronic Health Information United States, 2014. MMWR: November 20, 2015 / 64(45);1278. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6445a8.htm

11. Long-Term and Post-Acute Care (LTPAC) Providers and Health Information Exchange (HIE). Office of the National Coordinator. August 2016. Available at: https://www.healthit.gov/sites/default/files/ltpac_providers_and_hie_082516_final_2.pdf

12. IMPROVING MEDICARE POST-ACUTE CARE TRANSFORMATION ACT OF 2014 - IMPACT Act of 2014 - Public Law 113-185 - 113th Congress (2013-2014). Available at: https://www.congress.gov/bill/113th-congress/house-bill/4994/text

13. IMPACT Act: Connecting Post-Acute Care across the Care Continuum. Centers for Medicare & Medicaid. Available at: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2016-02-04-IMPACT-Act.html

14. SMD #16-003. Availability of HITECH Administrative Matching Funds to Help Professionals and Hospitals Eligible for Medicare EHR Incentive Payments Connect to Other Medicaid Providers https://www.medicaid.gov/federal-policy-guidance/downloads/smd16003.pdf

15. Scheid D, Yeaman B, Nagykaldi Z, Mold J. Regional Health eDecisions: A Guide to Connecting Health Information Exchange in Primary Care. (Prepared by the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, and Norman Physician Hospital Organization, under Contract No. 290-07-10009-5.) AHRQ Publication No. 13-0018-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2013.

Acknowledgements

The authors are with the Office of the National Coordinator for Health Information Technology (ONC). The data brief was completed under the direction of Seth Pazinski, Director of the Office of Planning, Evaluation, and Analysis and Talisha Searcy, Director of Research and Evaluation for the Office of Planning, Evaluation, and Analysis. Other staff that contributed to this document include: Yuriy Pylypchuk and Vaishali Patel from OPEA, and Liz Palena-Hall from the Office of Policy at ONC.

Suggested Citation

Alvarado, C. S., Zook, K., & Henry, J. (September 2017) Electronic Health Record Adoption and Interoperability among U.S. Nursing Facilities in 2016. ONC Data Brief, no. 39. Office of the National Coordinator for Health Information Technology: Washington, DC.

Appendix

Appendix Table 1: Survey questions assessing EHR adoption and interoperability among skilled nursing facilities

Appendix Table 2: Characteristics of sample of SNFs