Exchange Considerations

The technical hurdle of getting electronic information into and out of a long-term care facility presents another issue. EHR systems provide the means for data exchange in many HIEs and will play a role in long-term care integration.

At CRISP, Finney said the job of linking a long-term care facility will prove similar to the integration work the company already performs with ambulatory practices.

The integration project involves some exceptions, however. CRISP will have to learn about a long-term care-specific EHR that it hasn't previously encountered. In addition, an ambulatory practice can typically make do with a list of medications and dosages, while a nursing home may also need details on how to administer medicine, Finney said.

But an EHR system may prove beyond the financial resources of long-term care organizations. HIEs acknowledge this situation as they pursue workarounds.

CRISP, for instance, is exploring a service that would let long-term care facilities receive hospital discharge summaries via fax or network printer. Finney said the technical issues are still being worked out.

 "The goal is to bring some of the benefit of health information exchanges to some of the smaller and potentially less well-funded facilities," he said.
Web-based portals are another HIE option for long-term care outreach.

 "We know not everyone is going to afford an EHR, so we've built into the framework an online workflow tool," Albritton said.

The Massachusetts e-Health Institute is looking at a Web portal as well. As part of its $1.7 million challenge grant, the organization recently started work on a long-term care project dubbed IMPACT – Improving Massachusetts Post Acute Care Transfers.

HIE components, such as portals, must fit a long-term care facility's workflow, said Larry Garber, an internist and medical director for informatics at the Fallon Clinic, which is on the IMPACT project team. That accommodation may call for paper as well as electronic communication.

Garber, who is also principal investigator on the IMPACT project, pointed to the example of a long-term care facility sending patients to an emergency room via ambulance. While transporting the patient, the ambulance crew needs information on a patient's medications and allergies.

 "They need something in their hand that they can read," Garber said. "For the foreseeable future that is going to be a piece of paper."

Hospitals, on the other hand, want information electronically. Garber said tools currently in development will let staff at a long-term care facility go to a portal, enter patient information to be sent electronically to a hospital, and print out hard copy of that information for the ambulance crew.

The ambulance use case underscores the need to thoroughly hash out the information needs of all parties involved in care coordination.

Kremer said the process will increasingly include long-term care representatives. "You hear a lot of discussions on transitions of care nationally now," he said. "I think you are going to see a lot more focus on long-term care."