MOBILE, INFORMED & CONNECTED TM

1. MOBILE, INFORMED & CONNECTEDTM T-2 Electronic Medical Records in Long Term Care October 8, 2007 10:30am – 12:30pm

2. Presentation Agenda Introductions What is an EMR? LTC Slow in Adopting EMRs and Perceived Barriers “Big Bang Benefits” of an EMR Valley View Case Study Simple Benefits that Impact More than Just Dollars Certification Process and Survival with an EMR Implementation & Adoption of an EMR Questions & Answers

3. The participant will be able to: Define an EMR Explain similarities between paper record and EMR List 5 benefits of an EMR in a LTC facility Identify how an EMR affects the Certification Survey Identify truth behind perceived barriers when implementing an EMR Learning Objectives

4. The IOM 2003 Patient Safety Report describes an EMR as encompassing: “a longitudinal collection of electronic health information for and about persons Immediate electronic access to person- and population-level information by authorized users; Provision of knowledge and decision-support systems that enhance the quality, safety, and efficiency of patient care and Support for efficient processes for health care delivery.” What are Electronic Medical Records?

5. What are Electronic Medical Records? The 1997 IOM report “The Computer-Based Patient Record: An Essential Technology for Health Care” defines an EMR as: “A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information.”

6. What are Electronic Medical Records? The American Health Information Management Association defines three essential capabilities of an EMR: • To capture data at the point of care, • To integrate data from multiple internal and external sources, and • To support caregiver decision making.

7. Adoption of EMRs in LTC According to the February 2007 Report on Health Information Exchange in Post-Acute and LTC from the HHS Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term Care Policy: • Only 1% of SNFs adopting EMRs vs. Hospitals adoption rate at 18% and MD offices at 15%. • Projected to increase in 5 years to 14% in SNFs, up to 41% in Hospitals, and up to 38% by MDs.

8. Fear of the unknown; surveillance outcomes Differences in staffing patterns between acute and long term care LTC requires a multi-disciplinary “holistic” approach versus “disease-centric” approach in acute care Resources, training/re-training, turn-over rates Doubts in clinical usefulness and accuracies Financial burdens Why the Different Adoption Rates?

9. Models of Care in LTC vs. Acute Care Disease Focus Less oversight Short LOS- measured in days. Comprehensive Level of Care Strict Regulations with State & Federal oversight Average LOS- months-years vs. days.

10. Improve Quality Care Avoid Adverse Drug Events Improve Quality Measures Enhance Resident Safety Improve Operational Efficiencies and Reallocate Staff Increase Reimbursements Objectives for Implementing EMRs

11. Introduction to the Benefits of EMRs The real benefits one NYS Nursing Home realized upon implementation of a full EMR…. • Increased reimbursement • Pharmacy cost savings • Decrease in medication errors • Improved Quality of Care • Timely ability to gather data and run critical reports • Improved oversight of facility operations by leadership • Integration of tools with clinical intelligence • Clinician ease with timely access of resident records • Improved staff satisfaction • Improved survey compliance

12. Valley View Case Study • Goshen, NY • 520 Beds • 4 Buildings • 15 Units • Sub-Acute Rehabilitation • Long Term • Dementia/Alzheimer's • Palliative Care • Over 600 Employees

13. Valley View’s Business Issues Business Issues Lost Revenue • Medicare billing inefficiencies • Inaccurate data capture Increasing Costs • Formulary non-compliance was resulting in escalating drug costs Inefficient Work Flow • Renewal process lengthy and error prone • Difficult to manage off-hour admissions • Cumbersome communication within facility • Nursing staff mired in paperwork Resident Safety Concerns • Difficult to manage quality with paper and retrospective MDS data • Incomplete or ambiguous orders • DUR alerts missed or late • Less time on resident care due to inefficiencies • Clinician and staff frustration high • In danger of losing reference lab • Inefficiencies resulted in an underlying concern for resident safety

14. Business Processes Automated Direct Financial Benefit Additional Efficiencies Valley View’s Return on Investment • Medication order renewal process • Formulary updates, communication and control • Facility communication and order data entry (telephone, ADT, etc.) • Pharmacy communication and order data entry • Resident identification, alert and room/bed assignment * Through attrition • 92% reduction in adverse drug events (from avg. of 2.81 per month to .23 per month) • 9% additional time for over 200 employees (700 hours per week) to focus on direct resident care • Reporting (resident safety, quality indicators, DUR, shift productivity, census) • Compliance with State, Federal and accreditation audits, surveys and ad hoc requests • 5 FTE Staff Reduction* • Medication savings • Renewal efficiencies • Efficiencies in formulary training • Consultation forms • Medicare billing improvement • Lab billing improvement $ 250,000 $ 262,000 $ 120,000 $ 8,000 $ 20,000 $ 15,000 $ 10,000

15. Survey process is an open book test: Each employee should know the survey tasks Know how the EMR will interface with each survey task: Entrance – Practice preparing all reports that are expected upon the surveyors entrance into the facility Tour – Explain what surveyors are looking for during the tour phase of survey, medication pass observation. Explain quick Do’s and Dont’s for staff: There is no regulation that states an employee must have an answer within a split second, “I’ll get back to you on that.” Don’t make up answers just in order to give an answer. If you are unfamiliar with a specific area of the EMR the surveyor is requesting that is not a deficiency. Surveillance Process

16. Quality of Life Assessment Contains 3 parts: Resident interviews Group interview Family interview and resident observation Information Gathering During Survey

17. Medication Pass Observation 20-25 medication opportunities for error are observed. Error? An additional 20-25 opportunities for error are observed. Information Gathering During Survey

18. Medication Pass Observation While Observing the medication pass the surveyor will review: • Every medication is given with 5 Rights, • In accordance with physician orders & standards of practice. • Focus on drugs with a high potential for Adverse Drug Reactions. • Medication Nurse is aware of potential s/s that may be exhibited in a resident receiving a medication with a high potential for an ADR or those medications on the Beers List. Electronic Medication Administration Record (eMAR) Online Drug Reference Guide

19. Quality Assessment & Assurance Review To determine if there is a functioning QA process which addresses concerns. Abuse Prohibition Review To determine if a facility has developed and operationalized policies and procedures related to resident abuse. Information Gathering During Survey

20. Proper screening, training, identification, investigation, protection, reporting and response are key elements the surveyor will review every time they are on-site in accordance with the SOM. What are the top 5 deficiencies cited? Abuse/Neglect Awareness & Prevention

21. Abuse/Neglect Awareness & Prevention Identify those residents that are at risk for abuse, neglect or mistreatment. Ascertain approaches for difficult to manage residents are incorporated into the Comprehensive Care Plan and the CNA’s plan of care. Hall coaching and support for those staff on units with harder to manage individuals.

22. Facts about EMRs & the Survey Process A nursing home survey is resident centered, not medical record centered. A NH survey starts with observation of the resident, the surveyor backs into the record to corroborate evidence. An EMR is a medical record, it replaces its paper predecessor. An EMR is less vulnerable to HIPAA related deficiencies than a paper medical record.

23. Facts about EMRs & the Survey Process Timely, accurate information during the survey process reduces staff frustration and stress in attempts to find misplaced forms and documentation. Compiling information and documentation for the IDR should be easier, more efficient with clear audit trails through the use of an EMR. No employee is required to know every answer when questioned, it is OK to remind staff they can say “I’ll get back to you on that”.

24. Empowering Your Staff Document, document and document the nursing process, changes in plans of care and the implementation process. Engage, educate and empower your staff to utilize every skill and embrace a new tool in providing QOC.

25. Leadership Education & Culture Change Communication Demonstration Job-Based Training Support Overcoming the Barriers to Adoption

26. Implementing an EMR in LTC Leadership Support Change Management Pre-Implementation Go Live & Support Peer Mentor & Training Account Management 1 2 3 4 5 Optimum User Adoption & Customer ROI

27. Workflow analysis and benchmarking Customize training based on workflow findings Develop customized assessment forms Order and Care Plan libraries Labor-Management Committee Hardware & network assessment and installation Integration testing and validation for billing, pharmacy, lab, radiology and hospital Pre-Implementation Pre-Implementation 1

28. Orientation and Engagement program Establish Peer Mentor program and training strategy Conduct and analyze readiness surveys Departmental meetings to get buy in demonstrate functionality Communicate training schedule and plan to staff and administration Change management programs across all three shifts Change Management Change Management 2

29. Schedule training for each discipline and department Peer Mentor training Setup classroom onsite with laptops, PDA’s and training materials Customized training for each discipline with small class sizes Onsite training for weeks for all three shifts and weekends Peer Mentoring & Training Peer Mentor & Training 3

30. Rollout phased in by unit to avoid disruptions to facility On-the-job user support for every shift including weekends Activation and verification for each module Vendor provides 24/7/365 phone and web-based customer support Account Manager monitors adoption and outcomes Go-Live & Support Go Live & Support 4

31. Dedicated Account Manager to ensure on-going customer satisfaction Benchmarks to track and analyze metrics before, during and after the implementation: Resident Safety Training Satisfaction Usability and Adoption Resource Utilization Operating Costs & Reimbursement Account Management Account Management 5

32. Utilizing Technology in health care facilities is no longer the future…. IT is TODAY!!!

33. Questions ?

34. MOBILE, INFORMED & CONNECTEDTM 360 West 31st Street Suite 302 New York, NY 10001 212-268-4242 www.sigmacare.com