Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes

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.

Opportunities in interdisciplinary care team adoption of electronic point-of-care documentation systems

We conducted three evaluation studies in community and hospital settings to examine point-of-care documentation system adoption among interdisciplinary care team clinicians. In the community settings, quantitative methods included documentation time-to-completion and a clinician satisfaction survey. Qualitative methods included observations and follow-up interviews. Qualitative data and quantitative data were merged comparing findings along themes. In the hospitals, qualitative scenario testing results indicated clinician system adoption was universal, though not always timely. At all sites, mismatch between system functionality and workflow was a barrier to clinician system access during patient care and reduced clinician efficiency. Clinicians at all settings were satisfied with their ability to access other clinicians' notes, without increased interdisciplinary team communication. Clinicians did not identify any systems impact on patient outcomes. To facilitate adoption, clinicians should see the value of using the system as intended by receiving system data feedback that shows improvement of patient care and patient safety.

Challenges and facilitators to adoption of a point-of-care electronic health record in home care

Electronic health records (EHRs), intended to improve the clinical process, are understudied in home care. The researchers assessed clinician satisfaction, informed by workflow and patient outcomes, to identify EHR adoption challenges. The mixed methods study setting was a Philadelphia agency with 137 clinicians. Adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow resulting in decreased efficiency. Adoption facilitators were support for team communication and improved clinical data timeliness. Opportunities for improved adoption included sharing with front-line clinicians EHR data related to patient care and health outcomes.

Interdisciplinary care team adoption of electronic point-of-care documentation systems: an unrealized opportunity

We conducted three health care evaluation studies in community and hospital settings to examine adoption of point-of-care documentation systems among interdisciplinary care team clinicians. Both community studies used a mixed methods design to assess actual system usage and clinician satisfaction. In the hospitals, scenario testing was used. Results indicated clinician adoption of the systems was universal, although not always timely with: (1) a mismatch between system functionality and workflow which was a barrier to clinician system access during patient care and reduced clinician efficiency; (2) no increase in interdisciplinary team communication; and (3) no impact on patient outcomes identified by clinicians. To facilitate adoption, clinicians should see the value of using the system as intended by receiving patient care and patient safety feedback that uses system data.