Long-term care facilities historically have been reluctant to adopt Health Information Technology (HIT) and automated workflow. Only 1% of skilled nursing facilities in the country now use a full Electronic Medical Record system. Most of the reluctance is related to financial constraints and the associated risks of a failed implementation. The Quality of Care Demonstration Project, funded by a grant from the State of New York, was designed to show how long-term care can begin the transition to HIT with seed money for adoption. In this project, 20 skilled nursing facilities were selected to participate making the program one of the first large-scale deployments of HIT in long term care. After a thorough request for proposal (RFP) process, SigmaCare® was chosen as the mobile EMR system for the project.
One of the skilled nursing facilities participating in the Demonstration Project, the Highfield Gardens Care Center, is a 200-bed facility located in Great Neck, New York. The facility offers short-term rehabilitation, long-term care, palliative care, Alzheimer’s/dementia care, pulmonary therapy, and wound-care services. Management at Highfield Gardens wanted to reduce medication errors and improve reimbursement by enhancing access to accurate real-time data. Management believed the Demonstration Project presented them with a unique opportunity to achieve these outcomes through the grant funded EMR system.
The EMR system was implemented in two phases. The first phase which consisted of Computerized Physician Order Entry (CPOE), Electronic Medication Administration Records (eMAR), Progress Notes, Minimum Data Set (MDS) and Care Plan modules went live in September 2007. The second phase which included CNA Assignments went live in April 2008.
The investment in the EMR system totals $1,062,150 over the five year contact or $212,430 per year. The monthly cost breakdown is outlined below:
Monthly EMR & Leasing Fees
|Third Party Interfaces||
|Hardware & Networking Components||
|Hardware & Network Installation||
|Leasing & Finance Charge||
Highfield Gardens reported a significant improvement in their ability to monitor activity across the facility in real-time. In the paper environment, auditing was particularly time-consuming and always retroactive. Using the real-time dashboard in the EMR, Highfield Gardens is able to monitor medication documentation throughout the shift, which was not possible in a paper-based environment. A common misconception held by the long-term care industry has been that direct care workers, such as LPNs and CNAs, would have difficulty adopting new technology. This was disproven by Highfield Gardens as evidenced by their high user adoption rates immediately after going live with SigmaCare:
|MAR/TAR On-Time Documentation||99.2% with SigmaCare compared to 85% on paper|
|CNA On-Time Documentation||99.3% with SigmaCare compared to 40% on paper|
Direct care workers reported how using the technology represented a turning point in their careers. Pat Dugan, the Administrative Nurse Manager, characterized the technology as “a good thing which is bringing nursing forward. I never thought I would say this or be an advocate for this type of technology but I’m very on-board”. Moshe Bain the administrator also witnessed the change. According to Mr. Bain the system has empowered the CNAs with point-of-care technology.
Because of the increased speed and accuracy of MDS data capture with the EMR Highfield Gardens has shortened the turnaround time for Medicare claims to two weeks. Completion of each MDS book has decreased from three days to under an hour. Nursing also reported time savings with medication refills which used to require peeling off medication labels and faxing to the pharmacy. With SigmaCare refills are sent electronically to the pharmacy by the nurse as needed during med-pass.
Clinical & Quality Outcomes
Since the inception of the EMR, Quality Indicators & Quality Measures (QI/QM) have improved across the board. QI/QM improvements can be attributed to real-time alerts and reminders on the dashboard such as pain and vitals follow-up during med pass. In addition the automatic triggers of quality indicators based on real-time clinical events and the automatic triggering of RAPs from MDS both improved the care planning process. The quality indicators that improved 50% or more are highlighted in the following table:
|Baseline 1/07-9/07||Post EMR 1/08-9/08||
|1.1 Incidence of New Fractures||3.67||1.06||71.12|
|2.1 Residents who have become more depressed or anxious||12.23||8.98||26.57|
|4.1 Incidence of cognitive impairment||1||0.41||59|
|5.2 Had catheter inserted or left in bladder||3.47||2.06||40.63|
|7.2 Prevalence of tube feeding||11.63||7.22||37.92|
|9.2 Residents who spend most of their time in a bed or chair||0.9||0||100|
|10.1H Prevalence of antipsychotic use in the absence of psychotic or related conditions (High Risk)||83.33||33.33||60|
|10.1L Prevalence of antipsychotic use in the absence of psychotic or related conditions (Low Risk)||33.87||0||100|
|10.3 Prevalence of hypnotic use more than two times a week||4.13||0||100|
|11.1 Residents who were physically restrained||6.87||3.75||45.41|
|11.2 Prevalence of little or no activity||0.23||0||100|
|12.1 High Risk residents with pressure ulcers||26.33||21.24||19.33|
|12.2 Low Risk residents with pressure ulcers||4.33||3.24||25.17|
|13.2 Short Stay Residents who had moderate to severe pain||16.67||7.82||53.09|
|13.3 Short Stay residents with pressure ulcers||43.17||26.29||39.1|
Operational Cost Savings
Since implementing SigmaCare®, Highfield Gardens realized operational cost savings which contributed to the facility’s overall return on investment. Through reduction in paperwork and administrative burden, the facility reduced its staff overtime and use of agency nurses. Reduction in agency nurses resulted in savings of $24,876 per quarter or $99,504 annually. Reduction in staff overtime resulted in savings of $64,469 per quarter or $257,875 annually.
|Operational Cost Savings||Quarterly||Annual|
|Agency Nurses LPN’s||$24,876||$99,504|
|Nursing Staff Overtime||$64,469||$257,875|
Pharmacy Cost Savings
Increased formulary compliance which is made possible by SigmaCare’s CPOE module drove down pharmacy costs at Highfield Gardens. Pharmacy costs decreased 6% on average or $34,156 annually. When the standard 10% inflation rate for medications is applied, the facility realized a 14% decrease in pharmacy costs or $83,953 annually.
|No Inflation||10% Inflation Rate|
As illustrated in the table below, Medicare Part A reimbursement rates improved 15% on average or $62.84 per day, from $416 to $479. The reimbursement rate improvement led to a total revenue increase of $916,515 based on 28.22 Medicare Part A beds. This reimbursement increase can be attributed to pre-population of the MDS with CNA data as well as the improved timeliness of MDS submissions. Increased accuracy in documentation by direct-care workers using the point-of-care SigmaCare® technology accounted for more documentation of rehabilitation minutes and consistently higher ADL scores.
|Increased Reimbursement||Percent Increase|
Return on Investment
During the first year after the full EMR implementation, the total annual revenue at Highfield Gardens increased $647,271 and costs decreased $441,330, resulting in a net gain of $876,171 after the cost of $212,430 for the EMR is subtracted.
By the end of the five year contract, the facility’s total revenue is expected to increase by $2,589,084 and cost savings by $1,765,320 resulting in a net gain of $3,292,254—a total return on investment of 310%.
|Net Gain Per Year|
|Total Revenue Increase||$647,271|
|Total Cost Savings||$441,330|
|Year 1 EMR Investment||($212,430)|
Total Net Gain
(Revenue + Cost Savings - Investment)
|Return on Investment Over 60-Month Contract|
|Total Revenue Increase||$2,589,084|
|Total Cost Savings||$1,765,320|
|Total EMR Investment||($1,062,150)|
Total Net Gain
(Revenue + Cost Savings - Investment)
|Total Return On Investment||310%|