Barriers and Facilitators to Implementation and Adoption of EHR in Home Care

Home care using skilled nursing services is an increasingly important and effective way to deliver care to and manage chronic illness in the older population. Yet home care providers often face challenges to providing, planning, and coordinating high-level care because of limited resources and communication mechanisms. Good communication on patient data, status, and care plans is essential for ensuring efficiency, patient safety, and high quality care. The use of electronic health records (EHRs) in home care is likely to improve communication and access to patient health information and lead to better health care decisionmaking and outcomes. However, while use of EHRs in hospital and ambulatory care settings has been widely studied, little research has been done on their use in home care settings.

This study assessed the barriers, facilitators, and impact of implementing an EHR in a home care agency. The project team hypothesized that implementation of a point-of-care EHR would result in significant improvements in patient, workflow, and financial outcomes. In addition, the project team developed recommendations for Meaningful Use (MU) objectives in long-term and post-acute care (LTPAC) settings.

The specific aims of this project were to:

• Examine the impact of EHR implementation in a home care agency by comparing patient, workflow, and financial outcomes before and after point-of-care EHR implementation.
• Identify the barriers and facilitators to point-of-care EHR adoption and implementation in home care.
• Propose design, implementation, and policy recommendations that address the barriers and facilitators to implementation and meaningful use of the EHR in home care.

The EHR was implemented at a home care agency in Philadelphia that provides care to 1,200 patients a month. The project used a mixed-methods evaluation that included an embedded interrupted-time-series design. Quantitative data on EHR usage, patient outcomes, clinical documentation completion, reimbursement, and clinician satisfaction was collected. Patient, workflow, and financial outcomes were compared before and after the implementation. The analysis was informed with prospective data from observations of clinicians using the EHR, clinician satisfaction surveys, and clinician followup interviews. The project team compared observed EHR functionality and EHR functionality described in software documentation to develop recommendations for home care MU objectives.

When comparing data from the pre- and post-implementation periods, the project team found that the EHR had minimal impact on patient outcomes. Its use did significantly improve clinician’s time-to-completion of documentation and timing for submission of billing for reimbursement. Not all clinicians used the EHR as intended. Challenges to adoption included: 1) frequent hardware problems coupled with lack of field support; 2) need for better initial and on-going training; and 3) mismatch of EHR usability, functionality, and workflow resulting in decreased efficiency. Facilitators to adoption included support for team communication and improved timeliness of availability of clinical data. Based on their findings the project team developed a list of 43 home care point-of-care EHR criteria recommendations. These recommendations were shared with the Certification Commission for Health Information Technology and AHIMA to inform the development of MU objectives in LTPAC settings.