Identifying certification criteria for home care EHR Meaningful Use.

Meaningful Use (MU) objectives require that electronic health records (EHR) are certified and meet a selected subset of Certification Commission for Health Information Technology (CCHIT)1 criteria to qualify for financial incentives. These criteria have been developed for hospital and ambulatory settings, and recently finalized for long-term post-acute care (LTPAC).2 MU is intended to achieve health and efficiency goals that include improved transitions in care between hospital, physician, and LTPAC settings, such as home care. Anticipating the imminent development of LTPAC MU objectives, the next step for informaticists, long term care organizations, and policy makers is to select MU objectives from LTPAC CCHIT criteria. The purpose of this study was to formulate recommendations regarding LTPAC CCHIT criteria for MU objectives based on observations of point-of-care EHR use by home care clinicians. Home care is very different from hospital and ambulatory settings. Home care is an increasingly important and effective way of transitioning patients from hospital to home and of managing chronic illness using skilled clinical services (e.g., nurses, therapists, social workers) in the home. Over three million Medicare beneficiaries discharged from the hospital receive nearly 104 million home care visits annually.3 To date, 29% of the 10,000 home care agencies in the United States report having implemented point-of-care EHR.4 This home care EHR adoption rate translates into home care agencies’ having made a large investment in EHRs. Furthermore, significant additional investment may be required for existing point-of-care EHRs to meet CCHIT standards and imminent MU objectives. This investment should enable home care agencies to benefit from financial incentives related to MU. However, we lack knowledge of the similarities and differences between home care point-of-care EHR characteristics and the certification criteria. In addition, information management is different in home care than it is in hospital or ambulatory care. The challenges of team planning and communication, insufficient information, and computer use in the demanding home environment set home care apart. Home care clinicians have clinical practice needs and issues that differ markedly from those of clinicians in ambulatory or hospital settings. Home care engages multiple care providers (e.g., physicians, nurses, physical and occupational therapists, speech/language pathologists, social workers) to work together as a team in communicating and care planning as they provide care. However, unlike hospitals and ambulatory settings, each practitioner visits the patient in the home at different times independent of each other. Being in the patient’s home creates a different clinician/patient relationship than that found in hospitals or physician practices. Patient contact by home care clinicians is intermittent (2–3 times per week initially, then 1–2 times per week for an average of 5–6 weeks). The information source at the start of care is limited to hospital discharge referral documentation, which is often inadequate.5,6 With independent behavior and lack of baseline information, communication is critical to the success of home care patient outcomes. Communication among clinicians is not face-to-face; instead it is achieved via telephone, voice mail, or electronic charting. In the patient’s home, where physicians and other health professionals are not physically present, the clinician makes a telephone call if collaboration is needed. As in hospitals and ambulatory sites, point-of-care EHR in home care is intended to enable clinicians’ access to the most current patient health information at the appropriate time in the clinical process. Furthermore, home care clinicians must be able to both set up and use the computer during each visit to patients’ unpredictable and unique home environments.7 In contrast, clinicians in hospital and ambulatory settings use the EHR in a relatively consistent and familiar controlled environment. As in any health care setting, good communication among clinicians in home care is essential for patient safety and quality of care.8 The amount and quality of information available to health care professionals has an impact on patient outcomes and quality of care.8–10 Multiple studies from acute care demonstrate the issues and consequences of impaired communication.11–14 Community-based providers complain they do not receive sufficient information about patients’ conditions,15,16 and they do not receive hospital discharge summaries soon enough.5 In one study, 28% of home care nurses felt they provided more care than was necessary. 17 It is critical, therefore, that MU objectives support team communication in home care and thus enable clinicians to provide the best quality of care for patients. This study sought to apply a reduced set of LTPAC CCHIT criteria to a home care EHR to assess their presence and make recommendations for home care EHR CCHIT criteria to be included in MU recommendations. LTPAC CCHIT criteria were developed for long term care settings such as nursing homes and includes home health settings such as hospice and home care. The published LTPAC CCHIT has 51 categories which contain 413 criteria. For example, the category (category code and title are provided), ‘LT 01 Patient record and demographics’ contains 23 criteria; one criteria is ‘LT 01.13 Store directions to patient’s home as free-text.’2 The recommended criteria for home care were identified by comparing the home care point-of-care EHR to the LTPAC criteria.