An understanding of information systems and their features can help long-term care facilities comply with the upcoming Minimum Data Set 3.0.

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hen the Minimum Data Set (MDS) was created in 1990, information technology concerns were an afterthought at best. Now, however, with the pending release of MDS 3.0, information technology is becoming more or less an obsession.
       Already, long-term care administrators cannot think of complying with MDS 2.0 without also pondering how they can best use information technology to ease the process. But the thoughts promise to become even more consuming, as administrators now have to focus on how information technology will play a role—most assuredly, an increased one—when the pending MDS 3.0 comes to fruition.
       What is more, information technology concerns are becoming a sticking point as regulators and others in the long-term care industry grapple with the specific computer- and data-related requirements of MDS 3.0. The fact that the pending iteration of MDS, which is slated to go in effect sometime in 2007, needs to mesh with the healthcare industry’s movement toward increased computerization—specifically, the government’s push for electronic health records (EHRs) and interoperable health information technology—means that long-term care facility administrators need to think well beyond the parameters of MDS 3.0 when piecing together overall information technology plans for their facilities.
       Although it is difficult to predict exactly what technologies will be needed as long-term care becomes an increasingly computerized industry, a look at information system features that can help provider organizations more effectively comply with the current and future versions of the MDS, as well as an overview of some of the information technology concerns related to how MDS 3.0 will interact with broader information technology initiatives, will help long-term care facility executives get a better handle on what is needed now and what to expect in the future.

The Evolving MDS Challenge

       Complying with MDS requirements has been a challenge from day one. The development of these data requirements pertaining to the assessment of long-term care facility residents was authorized by Congress as part of the Omnibus Budget Reconciliation Act of 1987. The original intent of the legislation was to use the data from the MDS for care-planning and quality-monitoring purposes. The tool, however, has evolved to incorporate additional purposes, such as payment and survey.
       As a result, effectively complying with MDS has never been an easy task. Consider just how pervasive the MDS is. To start, it is part of the federally mandated process for clinical assessment of all residents in Medicare-certified facilities. This process provides a comprehensive assessment of each resident’s functional capabilities and helps facility staff identify health problems. Resident Assessment Protocols (RAPs) are part of this process, and they provide the foundation upon which a resident’s individual care plan is formulated.
       What is more, long-term care facilities do not have a choice when it comes to complying with MDS. The assessment forms are completed for all residents in certified facilities, regardless of the source of payment for the individual resident. The MDS assessments are required for residents on admission to the facility, then periodically within specific guidelines and time frames.
       Most commonly, responsibility for completing and transmitting the MDS forms falls into the hands of nursing staff at long-term care facilities—adding another cumbersome task for nurses who are already juggling numerous responsibilities. The task proved especially burdensome when MDS was first introduced and clinicians were required to complete the entire process via traditional paper methods.
       With the introduction of MDS 2.0 in 1990, however, came the use of electronic transmission of MDS data by all Medicare-certified facilities. The electronic transmission was intended to ease the entire MDS process and provide enhanced analytical capabilities for state agencies, including electronic transmission from the state databases to a federal repository, integration with performance indicators for quality oversight, and survey planning by state agencies. In addition, electronic transmission of MDS data allowed for a basis for the Prospective Payment System (PPS); research directed at improving quality of care; feedback to providers; and dissemination of information to purchasers, beneficiaries, and others. At the time, the Health Care Financing Administration (HCFA), now known as the Center for Medicare & Medicaid Services (CMS), provided funding for facilities to buy computers to perform these functions.
       Facility managers, of course, are most concerned about using information technology to more efficiently and accurately collect, document, and transmit MDS data. Why? Sub-optimal handling of the MDS can lead to less than optimal care and sub-par reimbursement. Consider the following: Medicare recipients make up 11% of the long-term care patient mix, with Medicare reimbursement being driven off the accurate and timely completion of MDS data forms.¹ Mistakes in these forms, however, run rampant. For example, a 2000 study of 25,000 MDS assessments found that 68% contained at least one data error.²
       Such mistakes can be costly.

Table 1

For example, coding an activity of daily living as an “ADL 15” instead of an “ADL 16” can result in lost reimbursement of $53.58 per day for just one resident. That’s $20,000 per year if the mistake is made daily. And, if the mistake is made for a number of residents, the missed revenue can soar to astronomical heights. As a result, long-term care facilities need to implement systems with the features that help improve the MDS process (see Table 1).

One Facility’s Approach

       Carol Redfield, nursing director at Rocky Mountain Care (Bountiful, Utah), realizes just how important it is to have a system that helps to get things right. “Accuracy is the biggest challenge in MDS reporting,” she says. To make the process more accurate and efficient, Rocky Mountain has been automating the process for the past 5 years with the HomeSys Long-Term Care System from InfoSys, Inc. (Schaumburg, Ill).
       The system’s Clinical Advisor MDS Manager module helps keep Rocky Mountain in compliance with all CMS regulations governing the collection, submission, and retrieval of MDS information. MDS Manager uses a calendar-based approach to visually display when residents’ MDS data must be collected, completed, and transmitted. The system tracks assessment periods for all residents and produces online and printed reports to proactively notify staff of the onset of MDS and PPS milestones. Before assessments are completed, MDS Manager performs CMS edit checks that identify potentially problematic responses. The system also tracks roster, census, Resource Utilization Groups (RUGs), RAPs, and care plan data associated with the MDS to give facilities flexible reporting options to analyze facility costs, resource utilization, and clinical outcomes.
       Best of all, though, the system makes it easy for nursing staff to comply with MDS. First off, nurses and other clinicians can input information via computer workstations or point-of-care, pen-driven handheld devices. Multiple clinicians can update an individual assessment at the same time, thereby eliminating the workflow snags commonly associated with paper forms. In addition, tabs are displayed across the top of input screens for easy access to various sections of the MDS.
       What is more, data entered into one section of the MDS is automatically transferred to other sections that require the same information, saving clinicians from having to re-enter the same data over and over.
       Clinicians can easily perform online edit checks for in-process assessments at any time to correct errors before an MDS is completed. Responses that require additional care planning are highlighted in red. Progress notes can be attached to any section of the MDS to ensure comprehensive documentation, and a detailed audit trail tracks the user, time, and date of all MDS updates.
       In addition, the new CareVoyant system from InfoSys will make complying with MDS requirements even easier. CareVoyant uses the latest Microsoft.NET technology to distill, analyze, and display real-time key performance indicators collected from various HomeSys modules and external sources. The solution includes secure messaging and role-based decision support tools that prompt defined users, based on their function within an agency, with the specific knowledge they need to make informed decisions.
       For example, if MDS documentation is required, the system will automatically notify the clinician responsible for the documentation, eliminating the need for the clinician to scroll through the system to see what documentation or care is required for certain patients. In addition, clinicians and managers will access real time information via configurable, graphically oriented “digital dashboards.” These screens will enable users to instantly view their own key performance indicators and proactively spot trends, anomalies, and exception conditions before they develop into problems.

MDS 3.0: The Information Technology Challenge

       Although these system functionalities can help long-term care organizations effectively deal with the current iteration of MDS and will likely come in handy with the pending version, additional information technology concerns are likely to come into play.
       As the federal government keeps pushing for increased computerization in healthcare, MDS 3.0 is likely to be required to interface or integrate with EHRs and clinical systems across the continuum of care. For example, MDS 3.0 will have to receive and dispense patient data as this information travels across the continuum from physicians to hospital to long-term care facility to hospice to home care.
       This connectedness is intended to get healthcare providers to focus on the same goals as patients move across the continuum of care. In addition, with the information following patients, administrative and care processes will be streamlined considerably. Such interconnectedness is not unique to the MDS effort, however. As a matter of fact, the rising need for such overall interoperability is what initially led Randy Stulce, information technology manager at Rocky Mountain, to purchase and install the InfoSys systems.
       “We needed something that is open, so we could transfer data back and forth between various programs and departments,” he says.
       With this interoperability in place, Rocky Mountain is able to work much more efficiently, adds Jerri Carroll, accounting coordinator.
       The need for such integration is expected to become even greater with the release of MDS 3.0. Eventually, the vision is for the MDS to be populated by data that is directly and seamlessly imported from the EHR.
       In addition, President Bush and the Department of Health and Human Services (HHS) have made the implementation of interoperable health technology a priority. To this end, CMS is now working to make the MDS data synchronize with standards that are emanating from the government’s Consolidated Health Informatics (CHI) task force, an interagency group that is working to standardize the collection, analysis, and exchange of healthcare information across the entire health care industry.
       The goal is to match, as much as possible, some of the MDS 2.0 and the emerging MDS 3.0 content with CHI-recommended terminology standards and to demonstrate how this standardization will support the use of messaging standards also endorsed through CHI. Other potential changes that could have an impact on information technology follow.
• CMS has committed to using XML technology with MDS 3.0 to make system changes easier for providers to accomplish and maintain. As such, nursing home managers should make sure that their technology vendors also use XML technology.
• CMS will be using tables that describe a patient’s ability or status based on a scale of 1–4. Having an information system that uses similar tables—such as those in HomeSys—will make complying with the new MDS 3.0 much easier.
• With MDS 3.0, the reporting tool will not provide as much latitude as with MDS 2.0. As a result, there will be less room for interpretation, and clinicians will need to pay close attention to accurate reporting.
• There will be a conversion of the MDS 2.0 databases to the 3.0 format. Facilities will have to submit files in the new format. However, CMS is expected to provide a grace period, during which files submitted in the old format will still be accepted.
• Currently, MDS systems in most nursing facilities contain all MDS data in an electronic format. However, as the situation stands now, the paper copy is the only version of an MDS that is legal for payment or forensic purposes, since no electronic signature standards exist. However, the Health Insurance Portability and Accountability Act (HIPAA) requires HHS to develop an electronic signature policy, and CMS is close to publishing a proposed standard for electronic signatures. And, of course, facility managers will want to work with vendors that can quickly incorporate standardized electronic signatures into their information systems.