C A LIFORNIA HEALTHCARE FOUNDATION s n a p s h o t The State of in California: Use Among Hospitals and Long Term Care Facilities 2008
Introduction For hospitals and long term care facilities, full utilization of health information technology (HIT) offers an opportunity to improve quality, prevent treatment errors, and boost the efficiency of the care they provide. However, as the findings in this snapshot show, the vast majority of California hospitals and long term care facilities have been slow to implement HIT. Barriers include the cost of new technologies, acceptance of them by staff, and a dearth of technology products that can readily be integrated into existing information systems. Among the snapshot highlights: Only 13 percent of hospitals have fully implemented electronic health records (EHRs). Without full implementation, hospitals will continue to encounter challenges in sharing and using clinical information and coordinating patient care. Only 12 percent of hospitals have fully implemented bar coding to track pharmaceuticals, and 25 percent of hospitals use this technology to track lab specimens. The initial cost of information technology tops a long list of HIT barriers, followed by staff acceptance of new technologies and an absence of well-trained clinical staff for process redesign. Only about one-fifth of long term care facilities use HIT for clinical purposes. The large majority use it exclusively for business or administrative purposes. Until the business case for adopting HIT becomes more apparent and the tools become more userfriendly and useful the safety, efficiency, and quality advantages that HIT can foster will continue to elude these institutions. contents HIT in Hospitals Use of EHRs....................... 3 EHR Uses....4 Accessibility of EHRs................ 5 Use of Electronic Patient Tracking/ White Board...6 Use of Bar Coding...7 Sharing of Electronic Patient Information...8 Fully Implemented RFID Systems...9 HIT Financing in Hospitals Financing HIT Systems.............. 10 Capital Investment/Spending for HIT... 11 Projected Capital Investment/ Spending for HIT................. 12 Investment in HIT Operations...13 Projected Spending on HIT Operations. 14 Barriers to HIT Adoption...15 HIT in Long Term Care Facilities Implementation of HIT.............. 16 Use of HIT...17 Barriers to HIT Adoption...18 Top Clinical IT Priorities............. 19 Sources and Methodologies...20 2008 California He a lt h Car e Fo u n d at i o n 2
Use of EHRs in Hospitals, in Hospitals Thirteen percent of hospitals reported Fully implemented 13% that they have fully implemented an electronic health record (EHR) system. Not implemented 45% Partially implemented 42% Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 3
EHR Uses in Hospitals, in Hospitals Thirty-one percent Implemented Considering Implementing Not Implemented of hospitals reported Use Fully Partially Testing Yes, within 3 years Access to patient demographics 60% 29% 1% 7% 4% Review lab results 55% 35% 2% 6% 3% Enter lab orders 50% 35% 2% 8% 5% Enter pharmacy orders 39% 36% 4% 17% 5% Access to medical history/physical 36% 41% 3% 16% 4% Review radiology images (including PACS*) 36% 42% 4% 11% 7% that they have fully implemented an EHR feature that enables them to receive real-time drug interaction alerts. Access to current medical records (observations, orders) 34% 47% 1% 15% 4% Real-time drug interaction alerts 31% 39% 3% 23% 4% Access to patient flow sheets 25% 46% 3% 22% 4% *Picture archiving and communication system. Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 4
Accessibility of EHRs at Various Hospital Locations, in Hospitals Forty-six percent of Implemented Considering Implementing Not Implemented hospitals reported Use Fully Partially Testing Yes, within 3 years Emergency department 46% 15% 2% 30% 8% Hospital inpatient departments 44% 17% 1% 32% 6% On-site clinics 42% 17% 1% 29% 12% On-site MD offices 37% 15% 1% 33% 15% Off-site clinics 34% 18% 1% 29% 18% Off-site MD offices 33% 18% 2% 33% 13% Other outpatient settings 29% 17% 2% 37% 16% Post-acute care settings 22% 10% 1% 42% 25% that they have fully implemented EHRs in the emergency department, 44 percent in inpatient departments, and 42 percent in on-site clinics. Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 5
Use of Electronic Patient Tracking/White Board in Hospitals, in Hospitals Thirty-one percent of Implemented Considering Implementing Not Implemented hospitals reported that Use Fully Partially Testing Yes, within 3 years Emergency department 31% 42% 5% 12% 11% Surgery 6% 45% 5% 30% 14% Nursing units 6% 42% 5% 33% 14% Hospital-wide 5% 42% 5% 32% 17% they use an electronic patient tracking system or electronic white board in their emergency department. Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 6
Use of Bar Coding in Hospitals, in Hospitals Twenty-five percent Implemented Considering Implementing Not Implemented of hospitals reported Use Fully Partially Testing Yes, within 3 years Lab specimens 25% 44% 1% 25% 6% Tracking pharmaceuticals 12% 34% 5% 43% 6% Pharmaceutical administration 11% 7% 4% 73% 5% Supply chain management 14% 13% 2% 63% 9% Patient identification 19% 35% 4% 35% 7% that they have fully implemented bar coding for laboratory specimens. Fewer use bar coding for pharmaceuticals or patient tracking. Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 7
Hospital Sharing of Electronic Patient Information with MDs/Labs, in Hospitals Share with Yes No Three-quarters of hospitals reported that Physicians in private practice 76% 24% they share electronic, Labs Free-standing imaging centers Retail pharmacies Long term care facilities 74% 26% 18% 82% 9% 91% 46% 54% patient-specific health care information with physicians in private practice and with labs. Public health department 32% 68% School clinics 4% 96% Other hospitals 22% 78% Payers 65% 35% Pharmacy benefit managers 6% 94% Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 8
Radio Frequency Identification Systems (RFID) in Hospitals, in Hospitals Partially implemented 5% Testing 7% No hospitals reported having a fully implemented RFID system, but half plan to implement one within three years. Not implemented 38% Plan to implement within 3 years 50% Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 9
How Hospitals Fund HIT Systems, Financing in Hospitals The great majority of hospitals reported that Capital budget 83% n=122 they finance their HIT systems in part through Operational budget 69% n=102 their capital budget. Nearly one-quarter rely in part on grants. Grants 23% n=34 Bonds 10% n=14 Loans 5% n=8 Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 10
Capital Investment and Spending for HIT in Hospitals, Financing in Hospitals HIT as a Percent of Total Capital Investment in Prior Year (n=147) 0 20% Total HIT Expenditures in Prior Year (n=117) $0 100K $101 500K $501K $1M $1.1 5M Most hospitals reported spending up to 20 percent of all their capital investment on HIT in the last fiscal or calendar year. Most hospitals spent $1.1 to $5 million on HIT in the last year. 41 60% 81 100% 21 40% Unknown/ No response 61 80% $25.1 50M $5.1 10M $10.1 25M No response Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 11
Projected Capital Investment and Spending for HIT in Hospitals, Financing in Hospitals HIT as a Percent of Total Expected Capital Investment in the Next 3 Years (n=147) 0 20% Total Expected HIT Expenditures in the Next 3 Years (n=118) $0 100K $101 500K $501K $1M $1.1 5M $5.1 10M Most hospitals expect to spend up to 20 percent of their total capital investment on HIT in the next three years. Most hospitals expect to spend $10.1 to $25 million on HIT during that period. 21 40% $10.1 25M 41 60% 81 100% NA/No response 61 80% $75.1 100M $25.1 50M $50.1 75M Unknown/ No response Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 12
Hospital Investment in HIT Operations, Financing in Hospitals Percent of Total Expenditures for HIT Operations (n=147) 0 1.0% 1.1 2.0% Total Expenditures for HIT Operations (n=116) $0 100K $101 500K $501K $1M $1.1 5M $5.1 10M Most hospitals reported that they spent 2.1 to 3.0 percent of their total expenditures on HIT operations (noncapital costs) in the last fiscal or calendar year. Most 2.1 3.0% $10.1 25M hospitals spent $1.1 to $25.1 50M $5 million on operational 3.1 5.0% 10.1+% 5.1 10.0% $50.1 75M HIT costs in the last year. Unknown/ No response Confidential/ No response Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 13
Projected Spending on HIT Operations in Hospitals, Financing in Hospitals Percent of Total Expected Expenditures for HIT Operations in the Next 3 Years (n=146) 0 1.0% 1.1 2.0% Total Expected Expenditures for HIT Operations in the Next 3 Years (n=115) $0 100K $101 500K $501K $1M $1.1 5M $5.1 10M Most hospitals expect to spend 2.1 to 3.0 percent of total expenditures on HIT operations in the next three years. Most hospitals expect to spend 2.1 3.0% $25.1 50M $100.1 125M $10.1 25M $50.1 75M $75.1 100M $1.1 to $5 million on HIT operations in that period. $125.1 150M 10.1+% 3.1 5.0% 5.1 10.0% Unknown/ No response $150.1 200M $200.1+M Confidential/ No response Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 14
Barriers to HIT Adoption in Hospitals, Financing in Hospitals The largest number Significant barrier Somewhat of a barrier Not a barrier Initial cost of HIT investment 49% 45% 6% of hospitals reported that the initial cost of Acceptance of technology by clinical staff Availability of well-trained clinical staff for process design Ability to support ongoing costs of hardware/software with current systems Interoperability of hardware/software with current systems 40% 51% 9% 25% 67% 8% 19% 71% 10% 17% 60% 23% HIT investment was a significant barrier to adoption, followed by clinical staff s acceptance of the technology. Inability of technologies to meet needs 12% 53% 35% Availability of well-trained HIT staff 11% 42% 47% Fear that technology will become obsolete too quickly Inability to comply effectively with HIPAA costs 5% 30% 65% 5% 36% 59% Source: American Hospital Association and California Hospital Association. Surveys. 2006/2007. 2008 California He a lt h Car e Fo u n d at i o n 15
Implementation of HIT* in Long Term Care Facilities, in Long Term Care Facilities Nearly half of skilled Full/partial implementation or in process 25% 44% 46% nursing facilities (SNFs) with more than one System being developed 0% 0% 5% 11% SNFs (multifacility) SNFs (free-standing) RCFEs (more than 75 beds) facility reported they have implemented or are implementing some In system selection stage 7% 6% form of HIT. Far fewer In planning stage (timeline established) 0% 7% 14% free-standing SNFs reported such progress. Gathering information (no timeline established) 32% 35% 39% 0% Have not started 18% 11% *Health information technology (HIT) is defined as technology used to collect, store, retrieve, and transfer clinical, administrative, and financial health information electronically. Notes: SNF is a skilled nursing facility; RCFE is a residential care facility for the elderly. Source: : Are Long Term Care Providers Ready? California HealthCare Foundation. April 2007. 2008 California He a lt h Car e Fo u n d at i o n 16
Use of HIT in Long Term Care Facilities, in Long Term Care Facilities About one-fifth of all SNFs* RCFEs (more than 75 beds) 97% long term care facilities reported that they use 83% some form of HIT for clinical purposes. Nearly all nursing homes and 83 percent of residential care facilities for the elderly (RCFEs) indicated they use such technology 21% 17% 18% 22% for business or administrative purposes. Charting Medication Administration Clinical Purposes Business/Administrative Purposes *Includes hospital-affiliated, multifacility, and free-standing skilled nursing facilities. Notes: SNF is a skilled nursing facility; RCFE is a residential care facility for the elderly. Source: : Are Long Term Care Providers Ready? California HealthCare Foundation. April 2007. 2008 California He a lt h Car e Fo u n d at i o n 17
Barriers to HIT Adoption in Long Term Care Facilities, in Long Term Care Facilities Fifty-six percent of Lack of capital resources 44% 54% 78% skilled nursing facilities with more than one Lack of professional HIT staff 31% 44% SNFs (multifacility, n=32) SNFs (free-standing, n=27) RCFEs (more than 75 beds, n=13) facility, and 85 percent of residential care facilities 62% for the elderly cited lack HIT product not integrated with other systems 44% 56% of integration with other systems as a significant 85% barrier to HIT adoption. 53% Staff lack computer skills 48% 85% 17% Lack of reimbursement for using HIT 60% 29% Notes: SNF is a skilled nursing facility; RCFE is a residential care facility for the elderly. Source: : Are Long Term Care Providers Ready? California HealthCare Foundation. April 2007. 2008 California He a lt h Car e Fo u n d at i o n 18
Top Clinical IT Priorities in Long Term Care Facilities, in Long Term Care Facilities After administrative and Clinical documentation* 66% 93% financial functions, clinical documentation is Clinical data exchange 50% 60% SNFs RCFEs the top HIT priority for long term care facilities. Medication administration 33% 60% Care planning 33% 40% Monitoring and messaging systems 27% 33% Electronic prescribing 27% 33% *Activities of daily living, daily notes, physician orders, and results. Electronic communications of resident information with physicians, hospitals, and providers in the community, and insurance eligibility information available on one system for Medicare, Medi-Cal, and HMOs. Blood pressure, blood glucose, weight scales, and electronic thermometers. Notes: SNF is a skilled nursing facility; RCFE is a residential care facility for the elderly. Source: : Are Long Term Care Providers Ready? California HealthCare Foundation. April 2007. 2008 California He a lt h Car e Fo u n d at i o n 19
Sources and Methodologies The American Hospital Association surveyed about 4,000 hospitals in the fall of 2006. More than 1,500 about 31 percent of all community hospitals in the United States responded. The AHA sent its survey form via email and fax to chief executive officers, who could complete it on paper or on a secure Web site. Seventy-one California hospitals participated, a state-level response rate of about 20 percent. To supplement these data, between July and September of 2007, the California Hospital Association contacted 414 hospitals in the state that did not respond to the AHA survey. CHA received 76 additional responses, increasing the total response rate among California hospitals that participated in both the AHA and CHA surveys to 30 percent. In 2006, the California HealthCare Foundation supported research to better understand the health information technology (HIT) readiness of skilled nursing facilities (SNFs), residential care facilities for the elderly (RCFEs), and other providers in the state. This research included a literature review, nonrandom surveys, and focus groups. The survey of long term care providers was conducted in collaboration with Give Us Your Feedback Was the information provided in this report of value? Are there additional kinds of information or data you would like to see included in future reports of this type? Is there other research in this subject area you would like to see? We would like to know. Please click here to give us your feedback. Thank you. the California Association of Health Facilities and Aging Services of California, which distributed the survey form to a select list of HIT decision-makers at facilities with an interest in HIT. Forms went to 150 SNFs of any size and to 50 RCFEs with more than 75 beds. The SNF and RCFE response rates for more information were 47 percent and 24 percent, respectively. Participants completed 82 of 103 forms electronically; the other 21 were completed on paper at the end of five focus groups. The focus groups, which included administrators, nursing directors, and care managers, were convened in Los Angeles, Sacramento, and Fremont in October 2006. C A LIFORNIA HEALTHCARE FOUNDATION California HealthCare Foundation 1438 Webster Street, Suite 400 Oakland, CA 94612 510.238.1040 www.chcf.org 2008 California He a lt h Car e Fo u n d at i o n 20