No Turning Back to the ‘Old Ways’

Operators increasingly adopt electronic health records to improve efficiencies and reduce costs, but it’s a tough transition.

By Eric Taub

New technologies that start out as frivolous extravagances often become necessities.

In 1885, seven years after Thomas Edison filed his first patent for “improvements in electric lights,” 300,000 bulbs were sold in the United States. By 1914, more than 88 million were in use.

The first flat-panel, high-definition televisions cost thousands of dollars, but the pricing has since dropped to a few hundred dollars. Today, it’s the rare home that still relies on a picture-tube television.

More recently, Wi-Fi has gone from a nice luxury to an absolute necessity. That’s true whether the user is in a home, a hotel or an assisted living community.

The ubiquity of Wi-Fi in elder care facilities has served as a catalyst for another technological breakthrough that’s rapidly becoming a necessity — electronic health records (EHR).

“Wi-Fi has become standard. A decade ago you couldn’t assume that,” says Kim Kessler, product vice president for Caremerge, a Chicago-based supplier of EHR software. “What started as a luxury is now table stakes for assisted living.”

Certified nursing assistants (CNAs) who enter residents’ rooms need to have connectivity on their iPads, adds Kessler. “Five years ago, we would have been tossed out if we said CNAs needed iPads in the hallways.”

“We have Wi-Fi in all our communities,” points out Lisa Rogers, senior vice president of health and wellness for Milestone Retirement Communities, a network of 85 owned and managed facilities based in Vancouver, Wash., and spread across 18 states. “It’s a prerequisite for EHRs, and our residents expect it.”

A bumpy transformation 

When Seniors Housing Business last looked at the use of EHRs in assisted and independent living communities more than two years ago, their adoption was spotty, and their level of acceptance varied.

The switch then from a pen-and-paper environment was often a time-consuming challenge. Jim Altrichter, at the time a senior vice president for risk management at Milestone, said then that switching to an EHR system by Eldermark required three weeks of staff training. And with high staff employee turnover, constant training instruction became a necessity.

Switching to electronic medical records is “disruptive,” Travis Palmquist, a vice president for senior living at PointClickCare said at the time. “Make no mistake, when you bring in EHR, you’re changing the way people work.” PointClickCare is an EHR provider based in Mississauga, Ontario.

Two years later, attitudes have changed. The time spent teaching caregivers how to use EHR software has taken a back seat to the benefits derived from it.

An increase in the number of residents suffering from multiple chronic diseases, the aging of the assisted and independent living populations, rotating and insufficient staffing, and the trend to “age in place” have all contributed to the need to increase operating efficiencies and reduce costs.

As a result, the adoption of EHR in senior living communities has skyrocketed. In 2017, 66 percent of skilled nursing facilities used EHRs, according to the Office of the National Coordinator for Health Information Technology.

The same strong numbers hold true for senior living facilities. In a recent study conducted by LeadingAge, the nation’s largest association of nonprofit aging service providers in the country, close to 76 percent of the nation’s 200 largest nonprofit, multi-site senior living organizations use EHRs, as well as the majority of single-campus senior living communities.

New era in healthcare

Senior living staff “must deal with increasing health conditions that assisted living residents have,” says Majd Alwan, LeadingAge’s senior vice president of technology. “People are older, sicker, and frailer.”

Communities use EHRs because “assisted living facilities must coordinate better with physicians, and have more information on an individual’s health condition. We’re now closer to a medical model, where communities need to hire people who can manage health conditions,” adds Alwan.

The senior living market has become increasingly important for the providers of EHR solutions. Senior living, which includes assisted living, independent living and memory care “is our fastest growing segment, two years running,” says John Damgaard, president of MatrixCare, an EHR supplier. It is now the third largest market for the company, after skilled nursing and continuing care retirement communities.

The reason for the company’s success in senior living, he said, is “there is so much more complexity in patients, so much medicine administration. The assisted living community of today looks like the skilled nursing facility of five to 10 years ago.”

Damgaard says EHR adoption has become a necessity for several reasons. For one, a dearth of skilled health workers means that employees are stretched ever thinner. Declining assisted living occupancy rates coupled with increased competition from rival communities has lowered pricing and forced increased efficiencies.

The United States has an estimated 72 million baby boomers, the oldest of which turn 73 this year. Even after they reach their late 70s and 80s, there will still be a limited population that can afford the $6,000 to $10,000 monthly rent typical of high-end communities. “The portion of the population that has the assets to afford that premium price is being exhausted,” says Damgaard.

Those who can only afford lower price points, and those relying on Medicaid to pay, will further drive down operator revenues. “You’ll have to operate as lean as possible to make money on that level of reimbursement,” says Damgaard.

Thanks to the information available in an EHR about resident needs and desires, staff members only need to check on those residents who need help or attention. “You don’t have to have a worker waste time going from room to room when some residents prefer to be alone. EHRs are a labor force multiplier,” explains Damgaard.

The result, he added, is that pen-and-paper-based communities no longer make sense. “You run out of the ability to have enough sticky notes on a board to keep track of things.”

Adapt, or else

While some employees used to the “old ways” might welcome a return to a pen-and-paper-based system, there’s no turning back, says Michael George, a registered nurse and head of IT for Lutheran Senior Services (LSS), a St. Louis, Missouri-based operator of communities that offers a full continuum of care.

“If we went back to pen and paper tomorrow some would welcome it, but it wouldn’t work because we’ve gained a lot of efficiencies and safeguards. We could not maintain the level of service and high quality we strive for without EHRs,” says George.

The operator relies on EHRs to produce one record for one resident, containing all the marketing and health information that every member of the team needs. The information can be documented and made available to nurse assessment coordinators, without being forced to rely on telephonic communications.

The software used by LSS — Netsmart — also gives George the ability to tie the operator’s system into various local hospitals. Using Netsmart’s Carequality Interoperability Framework, LSS can query hospitals’ systems without needing to use a separate login, allowing it to easily access progress notes, an emergency room visit or an entire summary of a resident’s hospital stay.

Prior to the implementation of Carequality, that type of information was received on paper. Now, LSS doesn’t need to scan, index and update the record.

As EHR adoption has increased, so too have the capabilities of EHR products. No longer simply an electronic version of a paper form, EHR providers have begun to integrate big data, artificial intelligence, and machine-learning capabilities into their products, giving customers the ability not just to record patient health information, but to predict medical events and, at times, act to prevent them.

MatrixCare uses artificial intelligence to reduce the drudgery and sometimes “torturous” intake process for a new resident, according to Damgaard. “We look at the last million residents with similar attributes and we can recommend an optimal service plan based on those encounters.” The result: what would have been a four-hour interview is reduced to 15 minutes.

The company is taking a similar approach to fall reduction. Its software determines the reasons for previous falls by evaluating data stored in the cloud, and then predicts the likelihood of a fall for a resident based on similarities in that individual’s balance capability, medicine regimen, social isolation, and other factors. This allows the staff to intervene before a fall occurs by, for example, engaging a resident in more social activities.

Damgaard says the company is “just at the very beginning of applying machine learning to make MatrixCare more proactive and predictive.” In addition to fall detection, he expects to eventually incorporate big data sets into the EHR product to also manage nutrition and monitor moods.

George of LSS also looks forward to using big data to predict resident behaviors, but he’s decided to do it on his own, rather than rely on his EHR provider, Netsmart. “We decided we’d get more bang for our buck if we did it in-house, so we could incorporate our own employment and financial data,” he says.

EHRs can help detect subtle changes in an individual’s physical or mental condition, Caremerge’s Kessler points out, by tracking activities of daily living (ADLs), providing proof that an individual has showered or asked for help. “We give operators the ability to record how care revenue changes over time,” says Kessler, “and this predicts changes in a resident’s acuity.”

Adoption costs vary widely

EHR benefits are predicated on the belief that their use will save money over time. Typical buy-in costs depend on the level of service, whether the software is installed in-house or cloud-based, how much training and support is needed, and whether a wide range of features are employed.

A MatrixCare EHR solution costs between 50 and 75 cents per resident per day ($15 to $22 per month) when purchased under a cloud-based subscription model, according to Damgaard. Initial deployment and training can range from $5,000 to $10,000 per community.

Caremerge estimates that EHR products will cost an operator between $4 and $16 per resident per month, depending on the level of ongoing support, and whether the software is installed at the facility or used via the cloud. Caremerge itself is fully cloud-based.

Having used EHRs for six years, Lisa Rogers of Milestone Retirement Communities says that regardless of the cost she can’t imagine running the business without them.

“The beautiful thing about EHRs is that we can help our communities from afar, anywhere in the country,” says Rogers. The company monitors medication adherence, fall incidence, ER visits and other variables, allowing Milestone to spot trends quickly and create an action plan.

The data helps the operator determine why certain events occur, such as the time of day or year when falls typically occur. “We can then adjust care plans, allowing our residents to receive more timely care,” says Rogers. “That also impacts our financial health, as we can bill additionally when more care is needed.”

The biggest change occurring in the industry, according to Dawn Iddings, Netsmart’s senior vice president, is that potential clients in assisted living recognize that they’re way behind in implementing technologies that can improve their business. “They’re in regretful mode,” says Iddings. “They’re all anxious to get on board.” Speaking practically, “we need to keep residents healthy to keep occupancy rates up.”

For those who have introduced EHR software, there are no regrets. “We could not live without an EHR system,” says George of LSS. “Unequivocally, not.”