Feature 1 October 2018, p46

The march of progress is sometimes painfully slow.

And it’s personal to Cheryl Field, chief product officer for Prime Care Technologies, a leading data warehouse and claims clearinghouse in long-term care.

Her company offers providers hosting, managed services and cloud software — the conduits needed to facilitate the exchange of vast amounts of data known collectively as the electronic health record.

The irony isn’t lost on Field, whose high-tech career stands in such deep contrast to her other job as custodian of a large, bulging manila file folder full of paper and compact discs, which she dutifully brings along while serving as driver and devoted companion for a loved one needing transportation to important healthcare appointments.

“If you’re not convinced where assisted living is with EHR, look no farther than the ambulance driver who takes that big manila folder with him every time there’s an emergency,” says Field, who unbegrudgingly carries that ever-growing paper folder in one hand and her relative’s hand in the other during each 100-plus mile drive to a hospital, doctor’s office or lab, and back to the assisted living community her loved one calls home.

Stakeholders in assisted living have long supported EHR, and all have varying degrees of patience. But as providers are quickly beginning to realize, EHR adoption is the new price of admission to a world that demands seamless transitions and accurate diagnoses. To turn a phrase, a world where everyone — from clinicians, caregivers and residents to information technology companies themselves — are all on the same digital page.

Slow but steady

As recently as a year ago, the National Study of Long-Term Care Providers concluded that more than 75% of assisted living communities were not using EHRs. Yet two years earlier, a survey of assisted living providers by LeadingAge and PointClickCare revealed almost half had invested in EHRs, compared with 80% adoption rates among skilled nursing providers.

For now, it’s safe to say, at least anecdotally, that assisted living owner-operators have received the message loud and clear.

For some, rising acuity levels are enough to push adoption, as Brett Meyers, M.D., vice president advisory services for Stratus Interoperable observes.

“I believe that the combination of increasing acuity in ALFs and other settings, along with truly mobile and portable record systems, is driving the need and adoption for electronic health records,” says Meyers, who also serves as a long-term/post-acute case business and clinical operations analyst. “It is increasingly important to have a clear understanding of a patient’s care plan and share it with staff and with clinical resources quickly when required.”

Other vendors say assisted living companies tend to be EHR converts when a compelling business case presents itself.

“The assisted living market is definitely seeing an increase of awareness regarding the necessity of technology tools to manage the increasingly complex assisted living environment,” says Trisha Cole, chief operating officer of Medtelligent. “This increase seems to be driven by the need for efficiency in operation.”

Prime Care Technologies’ Field senses that organizational heft and presence also is a factor in adoption. “The organizations that are part of larger entities are much more accepting and readily adopting because their business lines are attached to other parts of the post-acute care continuum, where they have seen how critical it is to have standardization of data,” she says. But among the smaller independents, “I don’t see them ramping up as quickly,” she  adds.

For those on the fence, it’s often a matter of underestimating the level of sweat and commitment needed to make an EHR work, according to Patrick Hart, who leads the senior living business unit for MatrixCare. Although many are convinced that an EHR platform is the path toward providing better care and measurable outcomes, “their hesitation lies in understanding the impact it will have on staff as they learn to document, while still being front and center with their residents and patients and providing care.”

“In short, there is very much a willingness to adopt, but not necessarily the experience or sophistication to do so fully,” adds Nickolo Villanueva, vice president of engineering and client services for vcpi. “In their rush to transition and adopt, it is often easy to overlook the requirements associated with such an endeavor. This includes the simple infrastructure transition, including devices, network connectivity, wireless and the security around proper implementation and management of this now critical service. Even more basic is the proper adoption of the processes around the use, retention, training and support of them.”

Needs less unique

With acuity levels rising in assisted living, there seems to be very little that makes their needs unique from skilled nursing.

“Many still want something that is easy to use and implement, offers affordability and is current technology,” says Hai Le, vice president of sales for BlueStrata EHR. “There may be some workflows that are specific to assisted living, such as the med-pass and assessments, but that is something most traditional SNF EHRs can accommodate.”

Of course, cloud computing has made cost even less of an issue, according to Meyers, who asserts that “current cloud offerings that run completely on a tablet and are implemented and trained in minutes instead of months make the use of EHRs more appealing.”

Priorities, meanwhile, are different from the skilled side for obvious reasons.

“Robust features are just as important,” Meyers says. “However, in that environment, the patient care plans revolve more around long term goals and quality of life and less on the measures of rehabilitation progress.”

Cole believes that although skilled nursing facilities need robust software as a gateway to receiving payments from the government and to being a preferred facility with a high star rating, “assisted living communities are not beholden to these same standards as they are predominately private-pay environments, so [they] are more motivated by the need to run a profitable and sustainable business.”

In sum, assisted living priorities can change as quickly as the level of acuity in their resident population, and thus, their priorities are an EHR solution that’s “extremely efficient and user friendly for staff while meeting each state’s specific requirements,” Cole adds.

The return on investment argument also is a bit different, says David Carter, LNHA, vice president of advisory services for Stratus Interoperable.

“Many are still using a manual system or a light version of an EHR compared to skilled care facilities,” he says. “Cost should not be an issue, since many facilities enjoy a higher margin than a nursing home.” And so, the ROI arguments usually revolve around issues such asimproved workflow, risk mitigation, justifiable service levels and the biggest one of all — improved overall resident care; Carter adds.

Although the level of sophistication EHR systems provide make it a simple ROI argument, it’s not always the case, Cole says.

“Generally speaking, paper and basic electronic software seems ‘good enough’ for most practices, and a large number of popular software providers fall short of addressing the workflow needs of assisted living communities, because many technologies were born out of skilled nursing, have rigid formatting based on federal regulations, and do not allow for flexibility assisted living requires,” she adds.

What’s the holdup?

Firms such as MatrixCare have compelling reasons for assisted living to invest: maximizing occupancy and profitability, improving care and minimizing risk.

And firms such as CareMerge tout things such as improved resident engagement, seamless reporting, more accurate assessments and lower staff turnover.

So why are some still holding back?

One compelling reason: They aren’t required to. Yet.

Although operators can more easily leverage cash flow, many operators still struggle with all the myriad costs, Villanueva says.

Prime Care Technologies recently partnered with the National Center for Assisted Living to develop the AL Cost Calculator, which allows providers to assess how costs are allocated across residents. It’s no surprise EHR costs are front and center, Field says.

“I think it’s harder for independent operators to take on the expense to have electronic health records,” she says. “The intent of it was to help them understand the overall cost of getting into EHR and help some of those sites that haven’t yet fully embraced EHR through alternative means.”

According to Doron Gutkind, chief software architect for Lintech, two key issues are the main reason holdouts still exist among the assisted living community.

One is the lack of standardization. “Over the years, most facilities have developed their own internal set of unique assessments and care plans,” he says. “The lack of any industry-wide standards for assessments and care plans, and the resistance of staff to change, has caused frustration to staff and a ‘tendency’ to remain paper-driven.”

The other barrier is variations in levels of care. “Assisted living facilities currently serve residents with a wide spectrum of needs and levels of care,” Gutkind adds.

“These range from residents who function mostly independently to residents who require some assistance with most of their daily activities.”


There is no doubt that EHRs will be broadly embraced and implemented in this ever-changing business called assisted living.

The biggest hurdle of all remains interoperability, Field says. “From a security perspective, interoperability becomes an issue on technical standards and practice,” she says. “It is a challenge and remains so. I think we’re about five to 10 years out from being fully interoperable across the continuum.”

That’s not to say the industry can’t take the requisite baby steps to get there.

“For now, we just need to find ways to modernize that manila folder,” Field says. “We’re trying to solve some of those interoperability issues one customer at a time.” n