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The American Journal of Managed Care December 2015
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Characteristics of Residential Care Communities That Use Electronic Health Records
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Characteristics of Residential Care Communities That Use Electronic Health Records

Eunice Park-Lee, PhD; Vincent Rome, MPH; and Christine Caffrey, PhD
Select organizational characteristics and geographic locations were independently associated with the use of any electronic health record system among residential care communities.
RCCs That Used Any Type of EHR System and Basic System

About 20.2% of RCCs used any type of EHR system in 2012, and 3.1% of RCCs had a basic system with all 6 selected computerized capabilities. Among RCCs that used any EHR system, 7% had none of the selected computerized capabilities; 18% had 1 to 2 capabilities; 36% had 3 to 4 capabilities; 24% had 5 capabilities; and 15% had all 6 capabilities. More than two-thirds of RCCs that had 5 of the 6 selected capabilities for a basic system did not have the capability to view laboratory or imaging results.

The percentage of RCCs that used any type of EHR system ranged from 15% in the South Atlantic to 32.9% in the West North Central (Table 1). Compared with the national average of 20.2%, a higher percentage of RCCs in New England (23.2%), East North Central (26.3%), and West North Central (32.9%) divisions used any type of EHR system. The percentage of RCCs that used any EHRs in the South and West regions were either lower than or comparable to the national average.

Characteristics Associated With RCCs That Used Any EHR System

Compared with for-profit RCCs, a higher proportion of nonprofit or government-owned RCCs used any type of EHR system (Table 2). About a quarter of chain-affiliated communities (25.2%) and those owned by other organization(s) or part of a CCRC (27%) used any type of EHR system, respectively. Compared with 11.9% of small RCCs, 33.4% of extra-large RCCs used any EHRs, and a greater proportion of RCCs located in the Midwest (28.9%) used any type of EHR system than those in other regions. About 88.7% of residents were non-Hispanic white in RCCs using any type of EHR system compared with 82.1% in RCCs that used no EHRs. The RCCs using any EHR system had a lower percentage of residents needing assistance with eating (23.9% compared with 29.2%) and bathing (66.9% compared with 72.9%), and for whom RCC provided assistance with medication management (88.7% compared with 91.4%) than those that used no EHRs, respectively. 

RCCs that were chain affiliated (odds ratio [OR], 2.24; 95% CI, 1.63-3.07) were more likely to use any EHRs than those that were not (Table 3). RCCs owned by another organization(s) or part of a CCRC (OR, 1.60; 95% CI, 1.19-2.15) had 60% increased odds of using any type of EHR system compared with those that were not owned by other organization or part of a CCRC. Compared with small RCCs, large RCCs (OR, 2.16; 95% CI, 1.35-3.44) were more than 2 times as likely to use any EHR system; extra-large RCCs had higher odds of using any EHR system than small RCCs (OR, 1.81; 95% CI, 1.01-3.25). The odds of RCCs in the Midwest to use any EHR system were 1.9 times, 2 times, and 1.6 times higher than the odds of RCCs in the Northeast (OR, 0.53; 95% CI, 0.36-0.79), South (OR, 0.50; 95% CI 0.33-0.77) and West (OR, 0.61; 95% CI, 0.42-0.90) regions, respectively. None of the variables indicating nursing employee HPRDs and resident case-mix in the model were significantly associated with the use of any type of EHR system. 

DISCUSSION
Nationally, 1 out of every 5 RCCs (20.2%) used any type of EHR system in 2012, whereas 3.1% had all 6 selected capabilities that met this study’s definition for a basic system. RCCs in the New England division and divisions in the Midwest region (ie, West North Central, East North Central) used any type of EHR system at a significantly higher rate than the national average. Geographic differences persisted in multivariate analyses when the effect of geography was assessed by the 4 Census regions. RCCs in the Midwest region were more likely to use any type of EHR system than those located in all other regions. A similar pattern was observed among office-based physicians and nonfederal acute care hospitals: states in the Midwest region had a higher proportion of office-based physicians and hospitals with a basic EHR system than the national average, respectively.12,29 With more hospitals and office-based physicians in the Midwest region using EHRs, there may have been greater external influence exerted on RCCs in the region to adopt EHRs than those in other regions, as the RCCs share information and coordinate care with the hospitals and physicians. In addition, based on additional analyses, RCCs located in the Midwest were more likely than those in other regions to be chain affiliated and owned by other organizations or part of a CCRC—both of which are associated with a higher likelihood of EHR system adoption. Lower EHR system adoption rates have been found among primary care providers in areas with a high concentration of minority and low-income populations designated as health professional shortage areas.13,14 Due to data limitations, small area variation in EHR use could not be examined using the 2012 NSLTCP data. However, Census region differences observed in this study suggest that lower EHR use in RCCs is in regions with a higher percentage of minority population and lower median household incomes. These findings suggest the presence of disproportionate barriers to EHR adoption across healthcare settings in certain areas irrespective of the providers’ eligibility for HITECH incentives. 

RCCs that were larger, chain-affiliated, and owned by other types of organization(s), or were part of a CCRC, were more likely to use any EHR system independent of other factors. These findings are similar to findings of previous studies on RCCs using the 2010 NSRCF data. Larger bed size and chain affiliation are consistent factors associated with the use of EHRs in RCCs, as well as in nursing homes, home health and hospice agencies, and residential care settings.15,16,22,27 A considerable amount of financial and human resources is required to use EHRs, especially when there is no financial incentive for RCCs and other long-term care providers—this can be particularly unfavorable to independent or small providers that are not chain-affiliated or part of a multi-level healthcare system.

A number of resident case-mix characteristics were examined in relation to RCCs’ use of any type of EHR system. In bivariate analysis, RCCs that used any type of EHR system had a higher percentage of non-Hispanic white residents, and lower percentages of residents needing any assistance with eating and bathing, and treated in a hospital ED. However, when size and other organizational and geographic characteristics were controlled for, resident case-mix variables were no longer independently associated with any EHR use. One possible explanation for this might be that the use of EHRs in RCCs may be driven largely by organizational characteristics and geographic locale, rather than by resident case-mix or care needs. In addition, it is possible that RCCs may have adopted select computerized capabilities (eg, clinical notes, orders for prescriptions) to care for the type of residents they serve, which require smaller financial investment and easier adjustments to changes in work flow than adopting an EHR system. 

Limitations

A few of the study's limitations are worth noting. First, due to the cross-sectional nature of the survey, causal inference should not be drawn from the findings. Second, there was a low overall response rate of 55.4%. The potential for bias is unknown; however, given that a higher proportion of extra-large RCCs were excluded from the study due to missing data than smaller sized RCCs, there could be a slight underestimate of communities using any EHRs. Lastly, although the sampling design used in the NSLTCP allows state-level estimation, reliable estimates could not be presented for all 50 states and the District of Columbia because of low response rates in some states. Yet, to the best of our knowledge, this study is the first to provide estimates for the use of any type of EHR system among RCCs at the geographic level that is smaller than the Census region.

CONCLUSIONS
The study’s findings suggest that overall, it is the RCCs that are larger, chain-affiliated, multi-level providers (eg, CCRCs), located in the Midwest region, that are more likely to use any type of EHR system. There is growing evidence that EHR use facilitates communication and care coordination, especially during care transition across settings. This study used the latest, nationally representative data on RCCs to fill current gaps in the literature. The study results indicate that about 20.2% of RCCs used EHRs in 2012—a much lower prevalence than what has been reported in studies examining eligible providers under the financial incentives offered in the HITECH Act, which for office-based physicians was about 71.8%.30

As RCCs serve increasingly less healthy and more disabled residents, improved communication and effective care coordination among RCC staff and across different care settings are critical, especially during care transitions. It will become increasingly important to monitor RCCs’ use of EHR systems and their capabilities to exchange standardized clinical information with other providers. The estimates presented in this study can be used to establish a baseline for monitoring trends in EHR use among RCCs. 

Author Affiliations: Division of Health Care Statistics, National Center for Health Statistics (EP-L, VR, CC), Hyattsville, MD. 

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (EP-L, VR, CC); acquisition of data (CC); analysis and interpretation of data (EP-L, VR, CC); drafting of the manuscript (EP-L, VR, CC); critical revision of the manuscript for important intellectual content (EP-L, VR, CC); statistical analysis (EP-L, VR, CC).

Address correspondence to: Eunice Park-Lee, PhD, Division of Health Care Statistics, National Center for Health Statistics, 3311 Toledo Rd, Hyattsville, MD 20782. E-mail: eparklee@gmail.com.
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