Impact of Homecare Electronic Health Record on Timeliness of Clinical Documentation, Reimbursement, and Patient Outcomes

Summary

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.

Citation: Sockolow PS, Bowles KH, Adelsberger MC, Chittams JL, Liao C. Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes. Appl Clin Inf 2014; 5: 445–462 http://dx.doi.org/10.4338/ACI-2013-12-RA-0106

Keywords

Evaluation studies - technology evaluation - clinical information systems - patient care team - aged - homecare

• References

• 1 Resnick HE, Alwan M. Use of health information technology in home health and hospice agencies: United States, 2007. JAMIA 2010; 17: 389-395.
• 2 Staggers N, Weir C, Phansalkar S. Patient Safety and Health Information Technology: Role of the Electronic Health Record. 2008 Available at: http://origin.www.ahrq.gov/qual/nurseshdbk/docs/Stag gersN_PSHIT.pdf. Accessed January 11, 2010.
• 3 Stolee P. The use of electronic health information systems in homecare: facilitators and barriers. Home Healthcare Nurse 2010; 28: 167.
• 4 American Recovery and Reinvestment Act.. ARRA 2009 Jan 9 PL 111-5
• 5 OASIS.. 2011 Available at: www.cms.gov/OASIS. Accessed February 16, 2012.
• 6 Schlenker RE, Powell MC, Goodrich GK. Initial home health outcomes under prospective payment. Health Serv Res 2005; 40: 177-193.
• 7 Shaughnessy PW. et al. Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement. J Am Ger Soc 2002; 50: 1354-1364.
• 8 Sockolow PS, Weiner JP, Bowles KH, Abbott P, Lehmann HP. Advice for decision makers based on an electronic health record evaluation at a Program for All-inclusive Care for Elders site. Appl Clin Inf 2011; 2: 18-38.
• 9 SAS Institute Inc.. SAS/STAT® 9.2 User’s Guide. Cary, NC: SAS Institute; 2008
• 10 Sockolow PS, Weiner JP, Bowles KH, Lehmann HP. A new instrument for measuring clinician satisfaction with electronic health records. Comput Inform Nurs 2011; 29: 574-585.
• 11 QSR International.. NVIVO. 2008: 8
• 12 Sittig DF. Work-sampling: a statistical approach to evaluation of the effect of computers on work patterns in healthcare. Methods Inf Med 1993; 32: 167-174.
• 13 Burns N, Grove SK. The Practice of Nursing Research. 7th ed. Philadelphia: W. B. Saunders; 2013
• 14 Allison PD. Logistic regression using the SAS system: theory and application. Cary: SAS Institute Inc.; 1999
• 15 Twiss A, Pierce M, Schwien T, Ottersburg T, Khuc T. The effect of the prospective payment system on home health quality of care. 2004 Available at: http://oig.hhs.gov/oei/reports/oei-01-04-00160.pdf. Accessed January 25, 2011.
• 16 Milles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks: Sage Publishers; 1994
• 17 Deatrick J, Alderfer M, Knafl G, Knalf K. Identifying patterns of managing chronic conditions. In: Crane R, Marshall E, eds. Families and health: interdisciplinary perspectives. Thousand Oaks. Sage: 2006 p. 62-80
• 18 Sockolow PS, Bowles KH, Adelsberger MC, Chittams JL, Liao C. Challenges and facilitators to adoption of a point-of-care electronic health record in home care. Home Health Care Services Quarterly 2013; 192: 939.
• 19 Walker JM, Carayon P, Leveson N. EHR safety: the way forward to safe and effective systems. JAMIA 2008; 15: 272-277.
• 20 Lau F, Kuziemsky C, Price M, Gardner J. A review on systematic reviews of health information system studies. JAMIA 2010; 17: 637-645.
• 21 Black AD. et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLOS Med 2011; 8: 2013.
• 22 Murtaugh C, Peng T, Totten A, Costello B, Moore S, Aykan H. Complexity in geriatric home healthcare. J Healthcare Qual 2009; 31: 34-43.
• 23 Bakken S. Informatics for patient safety: a nursing research perspective. Annu Rev Nurs Res 2006; 24: 219-254.
• 24 Ammenwerth E, de Keizer N. An inventory of evaluation studies of information technology in health care –Trends in evaluation research 1982–2002. Methods Inf Med 2005; 44 (Suppl. 01) 44-56.
• 25 Sockolow PS, Crawford PR, Lehmann HP. Broadening a general framework for evaluating health information technology through health services research evaluation principles. Methods of Medical Information 2012; 51 (Suppl. 02) 122-130.