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

Long-term Care Environment

Federal Laws/Mandates OBRA 1987 –Resident Assessment Instrument (RAI) Helps clinical staff to gather and analyze information in order to improve a resident’s 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 resident’s problems, strengths, needs, and preferences in order to improve or maintain function.

MDS 2.0 Sample See appendix 2

Terence Cardinal Cooke’s Solution

Data Process Flow

TCC MDSs Completion ( )

Care-Planning (old)

Care-Planning (new) TCC’s unique care plans (see appendix 3)

Nursing Orders Accountability Records (NOARS) See appendix 4

American Health Care (AHC) Software

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

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

Technology = Efficiency Essex County Correctional Facility –Xybernaut’s 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

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

Final Words

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

Appendix 2 Sample of an MDS 2.0 form (on next 3 pages)

Appendix 3 Sample of TCC’s new care plans (on next 2 pages)

Appendix 4 Sample of TCC’s new Nursing Orders Accountability Records (NOARS, on next 3 pages)

Appendix 5

Appendix 6 Article from Nursing Homes Magazine (on next 2 pages)