The rise of electronic health records in long-term care will streamline communication between providers, ensuring a higher quality of care and containment of costs.

A

year ago, President George W. Bush called for the widespread adoption of interoperable electronic health records (EHRs) in the next 10 years as part of an effort to transform our healthcare system. It is based on a growing consensus that the creation of EHRs will help reduce medical errors, increase the quality of care, and bring greater efficiency to the administrative and financial side of healthcare. EHRs are at the heart of health information systems. Our society is moving to ever-higher complexity in technology. Consider the role of computers, the Internet, and cellular-phone connectivity as examples of how information technology (IT) is changing our personal lives as well as our professional environment. But why do we have new residents coming to our facilities without detailed information on their current status of health, including their medications, allergies, and functional abilities?
       For decades, persons have been promoting the implementation of electronic medical records (EMRs). The idea is convincing: If we can have detailed records on buildings, cars, machines, and household devices, surely we can have comprehensive and detailed healthcare records. Yet it continues to be acceptable that for anyone at any age who needs healthcare, there is no comprehensive record of previous diagnoses (eg, allergies, genetic dispositions), healthcare services provided, or medications used. It is common to have only skimpy, provider-specific (and often specialty-specific) medical notes, sometimes scribbled on paper and partly illegible—and even these are not coordinated or complete with regard to hospitals, specialists, or other care providers. Naturally, this leads to negative results.
       In many cases, healthcare professionals have to act blindly without any background data on the patient, tests have to be repeated, and other practitioners do not know an individual’s previously identified conditions and allergies. The goal is to link the hospital provider, the specialty practice, the nursing home, and home healthcare into a seamless information system so that a provider knows what the other is doing. This is the vision of EHRs.
       They allow for easy refills and digital communication among providers and residents’ relatives. They provide guidance in decision making and, most of all, can provide continuity of care through the Continuity of Care Record (CCR). During the last 3 years, standards experts have worked on a core data set to be available whenever a patient is transferred or referred from one provider to another. The goal is simple—agreement among physician organizations on a data set that can be faxed or sent as an e-mail to any provider and covers all information needed to take care of the person. In this way, continuity of care can be established between providers ranging from a physician’s office to a nursing home to a hospital to a hospice to any place of care. The CCR is being developed and enhanced in response to the need to organize and make transportable a set of basic patient information consisting of the most relevant and timely facts about a patient’s condition. Briefly, these include patient and provider information, insurance information, a patient’s health status (eg, allergies, medications, vital signs, diagnoses, recent procedures), recent care provided, information on advance directives, recommendations for future care (ie, a care plan), and the reason for referral or transfer.
       Physicians, nurses, and ancillary providers (eg, social workers, physical therapists, occupational therapists) will complete the CCR upon referral or transfer or other transition of a patient from one caregiver to another, whether care is outpatient-, inpatient-, or community-based. In other words, the physician’s EMR system will create the CCR or, in some instances (eg, in a hospital,) a nurse will complete the set and e-mail it or fax it to the nursing home. Because the CCR is an XML-based document, it will be both machine- and human-readable, and the data content may be displayed or printed in a variety of formats, including web browsers, PDF readers, and word processors. The CCR will be used differently in the following cases.
       Referral. The referring provider/clinician should transmit the CCR information to the receiving provider in an electronic format, most likely utilizing secure e-mail or Health Level 7 (HL7) protocol and including the reason for referral along with the proposed minimum information.
       Transfer (from an inpatient or institutional setting). The discharging provider/clinician should transmit the CCR to the provider and new care setting where the patient is being sent (to arrive before or with the patient).
       Discharge (without obligatory referral or transfer). The CCR should be provided to the patient in paper or digital format for future use (including visits to the Urgent Care or Emergency departments) as well as whomever the patient designates as the primary care physician or clinician responsible for follow-up care, if needed.
       The CCR can also serve as a Personal Health Record (PHR), containing patient-entered information. A person may keep a copy of the most recent CCR and supplement it, for example, with alternative medicine information and other personal health information.

Major Consensus in the Healthcare Community

       The CCR is one of the great standards achievements of our time. It has been created in cooperation with several professional organizations, including the Massachusetts Medical Society (MMS), the Health Information Management and Systems Society (HIMSS), the American Academy of Family of Physicians (AAFP), the American Academy of Pediatrics (AAP), the American Medical Association (AMA), the Patient Safety Institute (PSI), the American Health Care Association (AHCA), the National Association for the Support of Long Term Care (NASTC), the Mobile Healthcare Alliance (MoHCA), the Medical Group Management Association (MGMA), the American Osteopathic Association (AOA), the American College of Osteopathic Family Physicians (ACOFP), the American Academy of Neurology (AAN), and the American College of Obstetricians and Gynecologists (ACOG).
       Collectively, these cosponsors represent more than 500,000 practitioners, more than 13,000 IT professionals, and more than 12,000 institutions in the long-term care community that provide care to more than 1.5 million elderly and disabled persons. The cosponsors also represent patients, patient advocates, data sources, a large part of the EMR industry, and provider institutions. We are proud that this standard was successfully balloted this month.

Value of the CCR to Healthcare

       The CCR will have a great impact on the quality of care, reduction of medical errors, and containment of costs. Among the potential benefits:
• The next healthcare provider will not have to search for or guess about a patient’s allergies, medications, or current/past diagnoses and other pertinent information
• The next healthcare provider will be informed about the patient’s most recent healthcare assessment and services
• The next healthcare provider will be informed about recommendations of the caregiver who last treated the patient
• As patient demographics will be provided, time and effort will be saved by not having to repeatedly ask a patient for demographic information in detail; rather, this information can be more quickly and easily verified
• A patient’s insurance status will be more easily established; over time, this can be expanded within the system
• Costs associated with the patient’s care will be reduced through, for example, avoiding repetitive tests and basic information gathering
• The effort required to update the patient’s most essential and relevant information will be minimized.

The Content of the CCR

       The CCR is a data set designed to provide all relevant information to a healthcare provider by integrating essential information from various healthcare domains and across specialties. It has header information including where the CCR was created and where it is directed and a footer with such information as reference to external documents like a living will. The main body, however, contains administrative and clinical information, including:
• Payers
• Advance directives
• Support
• Functional status
• Problems
• Family history
• Social history
• Alerts
• Medications
• Medical equipment
• Immunizations
• Vital signs
• Results
• Procedures
• Encounters
• Plan of care
• Healthcare providers
       Experts from AHCA are checking these areas to see whether they are adequate for long-term care. So far, no data elements specific to long-term care have been found that are not included in the CCR.

What Does This Mean for Long-term Healthcare?

       Imagine that any new resident could arrive with a complete set of all relevant and necessary health data. If he or she is coming from a hospital, they may send it to the long-term care facility. If the resident is coming from home, he or she may have a printed CCR with medications, allergies, and all other necessary data upon arrival. Or, the attending physician may e-mail or fax this information.
       When a resident is sent from the long-term care facility to a hospital, for instance, the facility should also create and send a CCR. If an EMR system is used, the CCR will be created automatically. This way, continuity of care is created, and no organization has to act blindly as the relevant information is exchanged.

A Win-Win Situation for All

       The CCR is bringing benefits to long-term care facilities, other healthcare providers, patients, and the healthcare system at large. Long-term care facilities will be able to provide better services when they are informed about the relevant health data of their residents. They also can provide better services by sending residents to acute care facilities with the necessary clinical background information. This will reduce medical errors and eliminate many of the repeat tests. In addition, the CCR allows providers to move from a static environment to a dynamic world where trends can be better identified and healthcare issues better monitored and managed. In summary, the CCR will provide better care and save costs.