Medical Informatics in Institutional Long-Term Care: Terra Incognita

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• Medical Informatics in Institutional Long-Term
  Care Terra Incognita
• Anthony J. Lechich, M.D.
• Mattie Smith, R.N.
• Darrell B. Cohn, B.A.

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Long-term Care Environment
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Federal Laws/Mandates

• OBRA 1987
• Resident Assessment Instrument (RAI)
• Helps clinical staff to gather and analyze
  information in order to improve a residents
  quality of care and quality of life
• Minimum Data Set 2.0 (MDS 2.0) is the RAI of
  choice
• HCFA (CMS)
• Goals of HCFA automation of the MDS 2.0
• Clinical utility
• Payment system
• Quality improvement
• MDS 2.0
• It is a standardized assessment instrument
  consisting of more than 400 items, used to help
  identify a residents problems, strengths, needs,
  and preferences in order to improve or maintain
  function.

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MDS 2.0 Sample

• See appendix 2

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Terence Cardinal Cookes Solution
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Data Process Flow
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TCC MDSs Completion (2000-2002)
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Care-Planning (old)
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Care-Planning (new)

• TCCs unique care plans (see appendix 3)

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Nursing Orders Accountability Records (NOARS)

• See appendix 4

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American Health Care (AHC) Software
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Project Progress (as of 12/12/2002)

• 2 pilot floors in progress
• Hospital-8 is entering in all MDSs into the AHC
  system and using the new care plans
• Cohen-9 is being trained on the system
• 20 more units to go once all aspects of the
  system are fully functional
• Working with AHC to fine-tune their clinical
  software to fit our clinical needs
• Grants
• Johnson and Johnson Community Healthcare Program
  grant
• Robert Woods Johnson Foundation Long Term Care
  Workforce Initiatives grant

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Implementation Challenges

• Modifying the clinical software to fit our needs
• Finding server space to house enormous amounts of
  data
• Dealing with the need to archive old data
• Rolling this out to other CHCS nursing homes
• The work TCC has done will be incorporated into
  other CHCS facilities
• They can modify our processes to fit their own
  needs
• There is the potential for friction to acceptance

CHCS
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Technology Efficiency

• Essex County Correctional Facility
• Xybernauts Mobile Assistant V (attaches to the
  hip)
• Security firms
• Wireless systems
• American Health Care
• Further automation
• Decision support solutions
• Automated alerts, recommendations, warnings
• Instructional flow paths for clinicians
• Touch screen technology
• See appendix 6 for recent article

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Results of Automation

• Culture change
• Meeting the changing needs of the nursing home
  population
• All caregivers have to acclimate to the new
  computerized system
• Using the MDS as a clinical tool
• Data mining
• Scouring the care plans for CNA related material
• Trending with respect to patient diagnoses
• Trach-tubes
• Pressure ulcers
• HD

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Final Words
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Appendix 1

• Abstract
• Terence Cardinal Cooke Health Care Center
  (TCCHCC), a 729-bed residential care facility in
  Manhattan, is automating the time consuming
  federally mandated resident assessments that are
  performed on all Skilled Nursing Facility
  residents at least six (6) times per year. We
  will provide a commentary on the current (lack)
  penetration of clinical computer system
  enhancements in Nursing Home care in the US and
  describe our own approach to the automation
  issues. We will demonstrate our progress in
  utilizing the current mandated data tool to
  automatically produce care plans. Care planning
  for the nursing home interdisciplinary teams is
  the pivotal clinical activity that, when manually
  performed, can hardly be done. The software
  approach, implementation barriers, and new short
  and long-term automation targets will be
  presented.
•  
• With this presentation we hope to stimulate a
  transfer of ideas from the usual hospital focus
  to the nursing home. Because nursing home MIS
  budgets are far less than hospitals, they are an
  even less forgiving proving ground for new
  systems. Furthermore, the interdisciplinary
  nature of the clinical activity demands a larger
  spectrum of trainees. On the positive side there
  is a predictability and repetitive quality of the
  documentation and a huge potential for job
  satisfaction in nursing that favors progress in
  this exciting new area of Medical Informatics.
•  
• Please visit our Web site at http//informatics.tc
  chcc.org

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Appendix 2

• Sample of an MDS 2.0 form (on next 3 pages)

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Appendix 3

• Sample of TCCs new care plans (on next 2 pages)

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Appendix 4

• Sample of TCCs new Nursing Orders Accountability
  Records (NOARS, on next 3 pages)

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Appendix 5
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Appendix 6

• Article from Nursing Homes Magazine (on next 2
  pages)