Abstract
Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.
Keywords: telehealth, health information technology, electronic medical records, Home Health Care, quality of care, technology adoption
Introduction
Home Health Care (HHC) agencies are one of the leading providers of post-acute care serving over 3.5 million Medicare beneficiaries and providing 110 million home visits annually.1 Over half of HHC patients are admitted following acute care.2 A smooth transition to HHC is essential to reducing hospital readmissions and providing optimal quality care,3 but the transition can be disrupted by ineffective information-sharing at hospital discharge and deficiencies in care coordination and communication between providers.4-8
Health information technology (HIT) can potentially solve some of these issues by improving information exchange, care coordination, and communication between providers.9,10 HIT includes tools such as electronic medical records (EHR), point of care (PoC) documentation, and telehealth (or telemedicine), which is defined as “the use of telecommunications and information technology to provide care and communication across distance.”11 EHR and PoC documentation can facilitate integration of health data into patient records and sharing of data across healthcare providers,12 which is especially important in HHC as patient records need to be accessible to field clinicians to ensure complete documentation and timely care decisions.13 Telehealth services have been shown to decrease costs per visit and total treatment costs per patient.14 In addition, telehealth in HHC has been found to be associated with improved patient functioning and reduced rehospitalizations, although studies have been limited to subpopulations of HHC patients with specific health conditions such as congestive heart failure.15-19
Despite the potential for HIT to improve the efficiency and quality of care,11,20,21 many HHC agencies have been slow to adopt EHR and telehealth services.13,22,23 A national survey from 2007 showed that less than half of U.S. HHC agencies (43%) reported the use of EHR, and even fewer utilized electronic PoC documentation (29%) or telemedicine technology (21%).23 Minimal uptake of telehealth services is likely due to severe limitations (geographic and originating site) on Medicare reimbursement if services are provided in the home.24 As the years progress, HIT is becoming more important than ever given the pace of technological advances, the growing shift from acute care, and changes to healthcare delivery that arose during the Coronavirus Disease 2019 (COVID-19) pandemic. Temporarily, through COVID-19 Public Health Emergency (PHE) 1135 Waivers, the Centers for Medicare and Medicaid Services (CMS) lifted some restrictions on reimbursement of telehealth services provided in the home.25 So far, expansion of Medicare telehealth services has not been made permanent and will expire at the end of the PHE.25 Given that prior research is more than a decade old, little is known about recent HIT adoption among U.S. HHC agencies. As part of a broader study focused on infection prevention and control and quality improvement, conducted just prior to the COVID-19 pandemic, we aimed to: (1) describe the challenges associated with the adoption of HIT, and (2) examine agency characteristics associated with HIT adoption in U.S. HHC agencies.
Methods
We conducted a multi-methods study utilizing qualitative interviews with HHC staff followed by a national survey of HHC agencies linked to agency-level data. Data collection for both qualitative and quantitative aims is described in detail elsewhere.26,27 This research was approved by all 3 of our Institutional Review Boards.
Qualitative Interviews
From March to November 2018, an interdisciplinary research team comprised of 5 members conducted individual qualitative interviews26 with 3 to 5 staff from each HHC agency representing a variety of roles. Agencies were purposively selected to obtain variation in geographic region, rural/urban location and Quality of Patient Care (QoPC) Star Rating.26 A total of 41 staff from 13 U.S. HHC agencies representing all 4 geographic regions participated in in-depth phone interviews which lasted 45 to 90 minutes. Participants included administrators/clinical managers (39%), field RNs/clinical coordinators (29%), nurse educators/quality improvement coordinators (17%), home health aides (10%) and infection preventionists (5%). The semi-structured interview guide is available upon request and focused on topics related to infection prevention and control and quality improvement in HHC; however, most questions pertaining to EMR and telehealth services were more general (i.e., does your agency use electronic medical records?; how are EMR used with respect to infection prevention and control?; with respect to quality improvement?; what type of services are provided by your agency?). We used thematic analysis to identify emerging themes28 and followed the Consolidated Criteria for Reporting Qualitative Research.29 An initial set of codes was developed based on the review of 5 transcripts by all team members using inductive open coding. A draft codebook was compiled after 3 weekly meetings and 2 more transcripts were coded by all team members to ensure consistency. A final codebook was then created and refined throughout the coding process. All transcripts were coded using NVivo 12 (QSR International, Burlington, MA).
Survey
Informed by the qualitative interviews, we conducted a nationally-representative survey27 of HHC agency administrators/clinical managers from November 2018 to December 2019. All active U.S. Medicare-certified HHC agencies (N = 11,549) based on the June 2018 Provider of Services (POS) file were eligible; a stratified random sample of 1506 agencies was selected for recruitment. The survey was administered both electronically and in paper format and included specific questions about infection prevention and control and quality improvement in HHC. However, there were also general questions about: use of EHR (excluding those used only for billing/required for the Outcome and Assessment Information Set [OASIS]), types of devices provided to staff for electronic PoC documentation, use of telehealth services, whether telehealth was utilized for patients with specific diseases/conditions and the types of technology used to deliver these services.
Surveys with at least 50% of the questions answered (n = 536) were linked with the June 2019 POS file and the July 2019 Home Health Compare30 and Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS)31 survey data, as well as the 2017 Post-Acute Care and Hospice Provider (PAC-PUF) data.32 Data on agency characteristics were included, such as: number of distinct beneficiaries, geographic location (Core Based Statistical Area [CBSA] Urban-Rural Designation33 and the 2013 National Center for Health Statistics [NCHS] Urban-Rural Classification Scheme for Counties),34 census region (Northeast, Midwest, South, West), ownership status (forprofit, nonprofit, government), agency oversight (hospital, Visiting Nurse Association), Medicare hospice participation (if agency participates in the Medicare program as a hospice), branch operation (if agency operates any branches), Quality of Patient Care (QoPC) Star Rating, and HHCAHPS Summary Star Rating.
We computed weighted frequencies, means, and standard deviations (SD) using probability weights to account for sample design and nonresponse by strata. χ2 and t-tests were used to compare the presence of EHR (yes/no) and telehealth (yes/no) by agency characteristics. Multivariable logistic regression models with robust standard errors clustered at the agency level were utilized to examine agency characteristics associated with use of EHR and telehealth. Statistical analyses were conducted using Stata 15 (StataCorp LLC, College Station, TX).
Results
Qualitative Findings
Four themes emerged from our qualitative interviews: (1) Reflections on providing home healthcare without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; and (4) Challenges with EHR and other HIT.
Reflections on providing home healthcare without EHR.
While most participating agencies (n = 11, 84.6%) had an EHR, 2 (15.4%) agencies were still using paper-based chart documentation. It was clear that the agencies without an EHR had unique challenges related to their inability to electronically record patients’ health information. We heard about how the lack of EHR affected care coordination and timely communication with other providers. A field RN from a small, for-profit, rural agency (11) in the Midwest described her experiences with paper-based documentation and what could have been achieved if an EHR was available: “All of [the charting] is done on paper. It’s affecting [my day-to-day] a lot. … We have bill charts that is basically an envelope that has patient information in it… that’s what we take out into the field with us, but when we go back to the office the next day, those field charts are left at our desk. Then, I go out into the field and start seeing a patient, well, [another provider] finally calls me back the next day, and they’re giving me orders, or they’re wanting to clarify what I called the day prior on. If I had a computer right there, then I could go ahead, enter that order in and not have to worry about finding the piece of paper.”
The inefficient and time-consuming aspects of paper charting were also mentioned. The same staff member (field RN, Agency 11) described how paperwork impacts her daily routine and patient interactions. “My paperwork is due by 10:00 in the morning, we’re not on computers… If I know that I’ve got at least 2 hours-worth of paperwork, I’m gonna get there at 7:30 in the morning, and leave at 9:30 and start seeing patients… I mean, I document as much as I can in the homes, but there’s just so many different factors… One being, that you already feel like the patient doesn’t receive enough attention from health care workers.”
The other challenge that we heard from staff at agencies using paper-based documentation is the overwhelming process of selecting an appropriate EHR system. An administrator from a nonprofit, urban agency (5) in the Northeast described her experience in the midst of this process and also the perceived benefits to the agency once a system is selected. “I’ve spent about 15 months looking at a dozen different [EHR] systems. My head spins… We need to make a decision and move forward. [One of the delays] has been resources because it’s a very costly investment… One of the pluses about going to an EHR is that there will be many advantages to our procedures and operations around the data that we’re able to collect… We certainly want to be providing high-quality care… We don’t want to not be screening clients appropriately.” Staff at agencies without an EHR felt that implementation of an EHR would help to alleviate many issues related to workload and improve timely communication.
Benefits of EHR.
In agencies with an EHR in place, several participants described positive aspects of those systems. We specifically asked about EHR with respect to infection prevention efforts and participants mentioned that EHRs often assisted field clinicians with documenting infections, and helped notify other clinicians to the presence of infections and/or antibiotic usage through alerts, specific tabs, or system-generated emails. A clinical manager at an urban, nonprofit agency (1) in the South explained: “If a patient has an infection, like a MRSA infection or something like that, you can flag the chart so that, anybody going into the chart, there’s a banner that pops up to say to use precautions in that way.” A few participants also talked about collaborating with EHR systems to make sure standard or custom infection control alerts/tabs were included in their agency’s platform. As described by an infection preventionist from a large, nonprofit agency (10) in the South, “Historically, we relied purely on clinician reporting of infections. My first year in the role I had two infections reported, so either we were doing a really good job with our patients or we were totally underreporting. Then, [the EHR company] built two [infection reporting] forms in the chart, (one) when [the clinicians are] in documenting on a visit, and (two) a notification form. It’s something that we built from the ground up.”
Having infections documented in the EHR allowed agencies to ensure proper care coordination, as reported by a clinical manager from a rural, nonprofit agency (7) in the South: “As far as looking at charts to see were any new medications started and the nurse didn’t report the infection? Just little things like that we’re able look at all of our documentation. Years ago, we used to be on paper, and now we’re on iPads. It’s really helping a lot.” Participants described the ways in which having an infection tab in the EHR improved the ease of reporting. An administrator from a rural agency (8) in the South described: “What’s nice is our EHR provider just recently added an infection control tool where we can track any kinds of infections. We are able to do all of our reporting through our EHR instead of paper charting, which is the only way [previously] that we had to chart infection prevention and control.” These agencies harnessed EHR functionality to improve surveillance and quality of collected data and utilized these data to drive quality improvement.
Benefits of other HIT.
When asked about any recently implemented quality improvement initiatives, a few agencies noted that they had invested in other aspects of HIT besides EHR. Participants explained how these new investments aided them with interdisciplinary communication and care coordination. In terms of initiatives, one urban, nonprofit agency (3) in the Northeast invested in a telehealth system to remotely monitor segments of their patient population and prevent rehospitalizations. Their clinical manager shared with us: “We have telemedicine services here. We have a nurse in-house that monitors… [and] may determine that a visit is required because there’s a weight gain or a change in the vital signs… It’s a great tool. It helps us keep people out of the hospital.” Other agencies purchased secure messaging platforms, which they found to be extremely helpful in improving communication and care coordination among agency clinicians. An administrator from a small, rural agency (6) in the South said: “We use an encrypted texting system… That is how I will shoot out messages about, ‘Hey, remember your infection reports. If you have any patients that’s had infections since they’ve been on service. You need to…’ We used to not be able to. We were like dinosaurs out there.”
Challenges with EHR and other HIT.
Despite noting the benefits of EHR and other HIT, several staff expressed ongoing difficulties and barriers to their use. Some stated that they were still learning different aspects of the EHR system in order to generate reports and analyze infection-related data. For example, an infection preventionist from one agency (6) shared with us the challenges that she encountered: “Being able to extract that [infection] data from our EHR is very challenging. We just got a clinical-informatics nurse, and I’m hoping that that nurse is going to be able to work with our EHR, so that I get accuracy in device-days to really figure this out. Because what’s the point? I’m not going be able to compare my data…” A quality improvement supervisor from another agency (1) had similar difficulties: “We are just learning how to get the reports off of [our new EHR]. We want to, you know, similar to our previous electronic record for surveillance. It’s kind of a process still… This is our first quarter that we’re preparing our data.”
Participants also discussed general usability of their current EHR system, and one agency (6) seemed to have challenges that overshadowed the drawbacks of paper charting. Their clinical manager lamented the situation that the agenda clinicians are in: “It’s horrible. [The EHR is] a lot more work than the paper charting was. The amount of paper that we use now I think is crazy compared to what we did use. Trying to get everybody on the same page has been a struggle.” Another staff member at the same agency (6) discussed additional problems including the ability of their EHR system to interface with external systems, such as an affiliated hospital. The agency administrator reported: “We did not use it for electronic health records until just a year ago. It’s a horrible system… Me and the clinical manager have ability to pull records from our hospital, but… [our EHR system] does not interface at all [with the hospital].”
Agencies also encountered new issues once enhanced interdisciplinary communication was in place through the EHR. A clinical manager at an urban, for-profit agency (4) in the West talked about how the system was always “on” and therefore he felt the responsibility to be, as well. “[Our clinicians] do all the visits all day, and before dozing off at night, they can finish all their documentation in their own bed… That’s one of the disadvantages of that system. It’s always turned on 24/7, and I have the obligation to respond [to questions from direct reports], whatever time of the day, if necessary.” Despite all of the benefits of HIT, the challenges encountered by HHC staff in implementing these systems prevented HHC agencies from taking full advantage of their functionality.
Survey Findings
Use of EHR in Home Health Agencies (HHA).
In total, 536 eligible HHA survey respondents completed our survey (response rate = 35.6%) representing a weighted total of more than 11,000 HHAs. Overall, 10% of the agencies reported not having an EHR system, and an additional 2% were in the process of acquiring one (Table 1). Within the prior year, 13% reported that their agency switched to a different EHR. Among those who switched, over half reported that this change enhanced care coordination and accuracy of patient records (55% and 53%, respectively). About a third (35%) reported that switching to a new EHR reduced the time spent on charting and another third (33%) reported that it increased charting time. Over half (58%) provided tablet computers to staff for electronic PoC documentation while 19% of agencies provided no devices to staff.
Table 1.
EHR and Telehealth Use by Urban/Rural Location.
| Total (N = 11,513) | Urban (N = 9842) | Rural (N = 1671) | ||
|---|---|---|---|---|
| % | p-Value | |||
| Presence of EHR | ||||
| Yes | 87.7 | 87.2 | 90.2 | .301 |
| No | 10.2 | 10.4 | 8.8 | .571 |
| In the process of acquiring | 2.2 | 2.4 | 0.9 | .207 |
| Total (N = 11,549) | Urban (N = 9878) | Rural (N = 1671) | ||
| % | p-Value | |||
| Devices provided to HHA staff for electronic point of care documentation* | ||||
| Notebook PCs | 25.9 | 24.1 | 36.6 | .002 |
| Tablet Computers | 58.1 | 57.7 | 60.2 | .585 |
| Smart phones or other portable handheld devices | 32.6 | 33.7 | 25.1 | .038 |
| Other | 2.8 | 3.0 | 1.7 | .367 |
| No devices available | 18.5 | 20.0 | 9.9 | .003 |
| HHA switched to different EHR system in the past year† | ||||
| Yes | 12.5 | 13.2 | 8.5 | .113 |
| No | 72.0 | 70.9 | 77.6 | .095 |
| In the process of changing | 3.1 | 2.9 | 4.1 | .462 |
| Use of telehealth service† | ||||
| Yes | 16.0 | 15.0 | 22.2 | .037 |
| No | 79.2 | 80.0 | 74.1 | .116 |
| In the process of acquiring | 4.1 | 4.3 | 2.9 | .409 |
| Total (N = 1888) | Urban (N = 1518) | Rural (N = 370) | ||
| % | p-Value | |||
| Technologies used for telehealth service* | ||||
| Telephone (voice only) | 69.4 | 69.8 | 67.7 | .825 |
| Video | 17.7 | 17.1 | 19.8 | .720 |
| Texting | 12.8 | 13.6 | 9.6 | .525 |
| Website | 36.7 | 39.0 | 27.2 | .220 |
| Mobile apps (using smartphones, tablets or other portable devices) | 45.1 | 46.3 | 39.9 | .530 |
| Other | 9.8 | 7.9 | 17.2 | .156 |
| Telehealth service targets specific diseases/conditions | ||||
| Yes | 92.4 | 94.7 | 83.3 | .059 |
| No | 6.3 | 4.3 | 14.6 | .075 |
| Don’t know | 1.2 | 1.0 | 2.1 | .597 |
| Total (N = 1745) | Urban (N = 1437) | Rural (N = 308) | ||
| % | p-Value | |||
| Specific disease(s)/condition(s) targeted by telehealth service* | ||||
| Heart failure | 99.1 | 100.0 | 95.0 | .003 |
| Diabetes | 39.6 | 38.3 | 45.4 | .512 |
| Asthma/COPD | 66.9 | 66.3 | 69.8 | .739 |
| Wound care | 9.5 | 10.0 | 7.4 | .670 |
| Other | 13.8 | 12.1 | 21.4 | .241 |
Note. All data shown are % and weighted. p-Values in bold are statistically significant at α < .05. Totals varied due to missing data or skip patterns. Column totals may not add to 100% due to: * response choices were select all that apply, or † responses were mutually exclusive but Other and Don’t Know categories are not shown. COPD = Chronic Obstructive Pulmonary Disease; EHR = Electronic Medical Record; HHA = Home Health Agency.
Use of telehealth by HHAs.
When asked whether their agency currently offered a telehealth service, 16% of respondents reported that they currently had a service and an additional 4% reported that their agency was in the process of acquiring one (Table 1). In agencies with telehealth, the most frequently reported technology used to deliver the service were telephone with voice only (69%), mobile apps using smartphones, tablets or other portable devices (45%), and website (37%). The use of video or texting to connect patients with providers were reported less frequently (18% and 13%, respectively). The vast majority of agencies with telehealth (92%) utilized the services for patients with specific diseases or conditions, including heart failure (99%), asthma/COPD (67%), and diabetes (40%).
EHR and telehealth use by urban/rural location and HHA ownership.
We compared EHR and telehealth use by urban/rural location (Table 1). The presence of EHR did not differ significantly by urban/rural location. HHC agencies in rural areas were less likely to provide any devices to their staff for PoC documentation than agencies in urban areas (10% vs 20%, respectively, p = .003). However, the use of telehealth services was more frequently reported in rural HHC agencies as compared to those in urban locations (22% vs 15%, respectively, p = .037).
The presence of EHR differed significantly by agency ownership (Table 2). For example, only 3% of nonprofit agencies reported that they did not currently have an EHR as compared to 12% for-profit agencies (p = .001). The reported use of telehealth services also varied by ownership with the use of these services more frequently reported by nonprofit agencies as compared to for-profit agencies (29% vs 13%, respectively, p = .001).
Table 2.
EHR and Telehealth Use by HHA Ownership.
| Total (N = 11,513) | Nonprofit (N = 1834) | For-profit (N = 9272) | ||
|---|---|---|---|---|
| % | p-Value | |||
| Presence of EHR | ||||
| Yes | 87.7 | 92.6 | 86.7 | .078 |
| No | 10.2 | 3.0 | 11.5 | <.001 |
| In the process of acquiring | 2.2 | 4.4 | 1.9 | .315 |
| Total (N = 11,549) | Nonprofit (N = 1834) | For-profit (N = 9307) | ||
| % | p-Value | |||
| Devices provided to HHA staff for electronic point of care documentation* | ||||
| Notebook PCs | 25.9 | 50.4 | 20.5 | <.001 |
| Tablet Computers | 58.1 | 52.1 | 59.6 | .183 |
| Smart phones or other portable handheld devices | 32.5 | 36.8 | 31.5 | .323 |
| Other | 2.8 | 3.2 | 2.7 | .839 |
| No devices available | 18.6 | 4.4 | 21.6 | <.001 |
| HHA switched to different EHR system in the past year† | ||||
| Yes | 12.5 | 9.8 | 13.2 | .356 |
| No | 71.8 | 79.1 | 70.2 | .066 |
| In the process of changing | 3.1 | 3.7 | 3.0 | .693 |
| Use of telehealth service† | ||||
| Yes | 16.0 | 28.8 | 13.3 | <.001 |
| No | 79.2 | 62.0 | 82.8 | <.001 |
| In the process of acquiring | 4.1 | 8.9 | 3.1 | .068 |
| Total (N = 1888) | Nonprofit (N = 528) | For-profit (N = 1274) | ||
| % | p-Value | |||
| Technologies used for telehealth service* | ||||
| Telephone (voice only) | 69.4 | 54.1 | 74.5 | .066 |
| Video | 17.7 | 37.4 | 10.7 | .006 |
| Texting | 12.8 | 12.5 | 12.3 | .985 |
| Website | 36.7 | 39.8 | 36.3 | .754 |
| Mobile apps (using smartphones, tablets or other portable devices) | 45.1 | 53.0 | 42.6 | .370 |
| Other | 9.8 | 12.7 | 7.7 | .433 |
| Telehealth service targets specific diseases/conditions | ||||
| Yes | 92.4 | 89.9 | 93.0 | .614 |
| No | 6.3 | 5.7 | 7.0 | .796 |
| Don’t know | 1.2 | 4.4 | 0.0 | .181 |
| Total (N = 1745) | Nonprofit (N = 445) | For-profit (N = 1185) | ||
| % | p-Value | |||
| Specific disease(s)/condition(s) targeted by telehealth service* | ||||
| Heart failure | 99.1 | 98.4 | 99.4 | .580 |
| Diabetes | 39.6 | 34.9 | 39.6 | .693 |
| Asthma/COPD | 66.9 | 78.9 | 63.8 | .160 |
| Wound care | 9.5 | 7.9 | 10.9 | .686 |
| Other | 13.8 | 22.8 | 10.4 | .172 |
Note. All data shown are % and weighted. p-Values in bold are statistically significant at α < .05. Totals varied due to missing data or skip patterns. Column totals may not add to 100% due to: * response choices were select all that apply, or † responses were mutually exclusive but Other and Don’t Know categories are not shown. COPD = Chronic Obstructive Pulmonary Disease EHR = Electronic Medical Record; HHA = Home Health Agency.
Predictors of EHR and telehealth use by HHA characteristics.
In bivariate analyses, agencies without an EHR were more likely to be smaller (with ≤ 100 distinct beneficiaries annually) than agencies with an EHR (53% vs 24%, p = .0001). The use of EHR also varied significantly by geographic location and ownership (Table 3). Telehealth use varied significantly by agency size (i.e., number of distinct beneficiaries), geographic location, census region, ownership, agency oversight, Medicare hospice participation, and branch operation (Table 3). The QoPC and HHCAHPS Summary Star Ratings varied significantly by agency use of telehealth services but not by agency use of EHR.
Table 3.
Presence of EHR and Telehealth by Agency Characteristics.
| EHR | Telehealth | |||||
|---|---|---|---|---|---|---|
| Yes (N = 10,061) |
No (N = 1170) | Yes (N = 1852) |
No (N = 9143) |
|||
| % | p-Value | % | p-Value | |||
| Distinct beneficiaries | ||||||
| ≤ 100 | 23.9 | 53.4 | <.001 | 9.4 | 30.2 | <.001 |
| 101-200 | 16.4 | 8.2 | .167 | 9.7 | 16.6 | .136 |
| 201-500 | 20.7 | 8.8 | .065 | 22.6 | 18.4 | .419 |
| >500 | 39.0 | 29.6 | .255 | 58.3 | 34.8 | <.001 |
| Geographic location | ||||||
| Large central metro | 33.9 | 53.9 | .015 | 15.3 | 39.5 | <.001 |
| Large fringe metro | 20.7 | 3.0 | .013 | 23.7 | 18.9 | .367 |
| Medium metro | 22.0 | 21.4 | .941 | 26.5 | 20.5 | .291 |
| Small metro | 7.8 | 9.1 | .795 | 13.6 | 6.8 | .078 |
| Micropolitan | 7.9 | 6.2 | .510 | 12.9 | 6.8 | .007 |
| Non-core | 7.4 | 6.5 | .718 | 8.1 | 7.2 | .677 |
| Census region | ||||||
| Northeast# | 10.0 | 5.7 | .372 | 18.2 | 8.1 | .005 |
| Midwest | 25.9 | 26.6 | .930 | 22.5 | 26.1 | .509 |
| South | 44.7 | 41.3 | .690 | 51.8 | 44.1 | .239 |
| West | 26.4 | 19.4 | .315 | 7.5 | 21.6 | .011 |
| Ownership | ||||||
| For-profit | 80.6 | 90.0 | .031 | 66.2 | 85.4 | <.001 |
| Nonprofit | 15.7 | 4.7 | .005 | 27.4 | 11.2 | <.001 |
| Government | 3.7 | 5.3 | .414 | 6.3 | 3.4 | .177 |
| Agency oversight | ||||||
| Hospital | 8.7 | 5.1 | .184 | 13.8 | 7.3 | .030 |
| Visiting Nurse Association | 6.7 | 2.6 | .318 | 12.1 | 5.0 | .017 |
| Medicare hospice participation | 5.0 | 1.4 | .059 | 11.2 | 3.0 | <.001 |
| Part of a system of branches | 14.7 | 19.0 | .506 | 27.2 | 13.0 | .003 |
| Mean (SD) | p-Value | Mean (SD) | p-Value | |||
| QoPC Star Rating† | 3.33 (0.99) | 3.05 (1.13) | .310 | 3.65 (0.91) | 3.21 (1.01) | <.001 |
| HHCAHPS Summary Star Rating† | 3.76 (0.98) | 3.55 (0.97) | .479 | 4.05 (0.75) | 3.65 (1.02) | .001 |
Note. Data are % or mean (SD). All data shown are weighted. p-Values in bold are statistically significant at α < .05. EHR= Electronic Medical Record; QoPC = Quality of Patient Care; HHCAHPS = Home Health Care Consumer Assessment of Healthcare Providers and Systems.
Category includes Puerto Rico.
16.79% and 35.07% of agencies had missing values for QoPC Star Rating and HHCAHPS Summary Star Rating, respectively.
Table 4 reports our multivariable analyses. We found HHAs located in large fringe metropolitan areas (e.g., suburban areas) were 9 times more likely to report the use of EHR compared to central metropolitan HHA and nonprofit HHAs were almost 3 times as likely to report the use of EHR as for-profits (OR = 9.21, p = .039 and OR = 2.97, p = .049, respectively). HHAs located in micropolitan areas (e.g., nonmetropolitan county with a population of 10,000-49,999) were over 2 times more likely to report use of telehealth and nonprofit HHAs were almost 2 times as likely to report use of telehealth as for-profit (OR = 2.54, p = .041 and OR = 1.95, p = .028, respectively). Smaller HHA with <100 distinct beneficiaries were less likely to use these services compared to HHAs with >500 beneficiaries (OR = 0.31, p = .003).
Table 4.
Predictors of Presence of EHR and Telehealth Service in Multivariable Analysis.
| EHR | Telehealth | |||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p-Value | OR | 95% CI | p-Value | |
| Distinct Beneficiaries | ||||||
| >500 | Ref | Ref | ||||
| 201-500 | 2.298 | 0.634, 8.332 | .206 | 0.898 | 0.431, 1.869 | .77 |
| 101-200 | 1.683 | 0.429, 6.609 | .456 | 0.437 | 0.177, 1.080 | .073 |
| <100 | 0.415 | 0.171, 1.004 | .051 | 0.308 | 0.143, 0.664 | .003 |
| Geographic location | ||||||
| Large central metro | Ref | Ref | ||||
| Large fringe metro | 9.208 | 1.121, 75.645 | .039 | 1.819 | 0.783, 4.222 | .164 |
| Medium metro | 1.304 | 0.516, 3.295 | .575 | 1.671 | 0.698, 4.002 | .249 |
| Small metro | 1.604 | 0.343, 7.498 | .548 | 2.387 | 0.764, 7.453 | .134 |
| Micropolitan | 1.366 | 0.540, 3.458 | .51 | 2.542 | 1.039, 6.215 | .041 |
| Non-core | 1.425 | 0.498, 4.082 | .509 | 1.697 | 0.599, 4.812 | .32 |
| Census region | ||||||
| South | Ref | Ref | ||||
| Northeast# | 1.255 | 0.296, 5.318 | .758 | 1.545 | 0.720, 3.317 | .264 |
| Midwest | 0.789 | 0.295, 2.109 | .636 | 0.619 | 0.312, 1.226 | .169 |
| West | 0.613 | 0.237, 1.586 | .313 | 0.414 | 0.149, 1.148 | .090 |
| Ownership | ||||||
| For-profit | Ref | Ref | ||||
| Nonprofit | 2.967 | 1.003, 8.778 | .049 | 1.947 | 1.076, 3.521 | .028 |
| Government | 1.079 | 0.288, 4.051 | .91 | 2.015 | 0.554, 7.332 | .287 |
| Medicare hospice participation | 3.026 | 0.333, 27.481 | .325 | 2.311 | 0.843, 6.338 | .104 |
| Part of a system of branches | 0.614 | 0.223, 1.689 | .345 | 1.416 | 0.736, 2.723 | .297 |
Note. p-Values in bold are statistically significant at α < .05. EHR = Electronic Medical Record.
Category includes Puerto Rico.
Discussion
This study provides a snapshot of the use of EHR and telehealth by U.S. HHC agencies prior to the COVID-19 pandemic. However, the data for the qualitative interviews and survey were collected as part of a broader study on infection prevention and control and quality improvement in HHC; therefore, our findings should be interpreted with that limitation in mind.
In the decade since surveys showed minimal uptake of EHR and telehealth use,13,23 we found an increase in EHR use in HHC agencies but continued low use of telehealth. These results demonstrate that challenges remain in the full usability and implementation of EHR. Moreover, our survey found that most telehealth services adopted by HHC agencies were focused on specific health conditions (e.g., heart failure). Prior research has demonstrated that EHR use improves workflow, and the collection of routine clinical assessment data can also be used for quality improvement and development of clinical risk prediction models for infection prevention.35 However, our interview participants reported difficulties in analyzing infection-related data, generating infection and quality reports, and interfacing EHR with external systems. Similar challenges were described in a qualitative study of HHC clinicians who described challenges with EHR adoption, including hardware issues combined with lack of field support, lack of training, and poor EHR usability and functionality.36 These challenges related to HIT adoption may be more pronounced in HHC as field RNs spend the majority of their time off-site, making training and IT support more complicated.
Integration of EHR systems among healthcare settings remains a major issue due to the highly fragmented EHR market.12 This lack of interoperability between EHRs used by hospitals, HHC agencies, and other healthcare providers can impair care coordination and lower quality of care.37-41 These challenges may inadvertently lead to higher workloads due to the need to transcribe paper notes into the EHR and resolve HIT issues, which may decrease user satisfaction with the EHR system. As indicated by our study participants, the switch to a new EHR system increased the time clinicians spent on charting, suggesting that there may be an initial learning curve associated with instituting new technology resulting in an initial increase in workload. While nursing organizations should encourage the integration of HIT into nursing curricula to reduce this learning curve and familiarize nurses with using HIT,42 developers of HIT also need to gather input from end users to generate more user-friendly platforms.
In our study, more rural agencies reported the use of telehealth services compared to agencies in urban locations. Telehealth use and adoption have been shown to be higher in hospitals located in more remote areas as these hospitals tend to have reduced access to specialty services, and therefore they are more likely to depend on other centers for specialty services through telehealth.43 The ability to provide services through telehealth is especially important in these rural and underserved areas and can help improve access to healthcare44 by allowing agency staff to virtually care for more patients without having to travel great distances.45 Additionally, telehealth can allow HHC agencies to connect their patients with specialists (e.g., wound care specialists) who may only be available in academic medical settings.46
We also found that nonprofit agencies were more likely to report use of telehealth and less likely to report that they did not have an EHR compared to for-profit agencies. Prior research has also reported that nonprofit agencies were more likely to use EHR than for-profit agencies.23 Similarly, another study reported that for-profit agencies were less likely to have adopted EHR or telemedicine.13 These differences in the adoption of HIT may indicate a misalignment of economic incentives in HHC to invest in HIT, potentially due to lower willingness to absorb the costs and initial inefficiencies associated with implementation.
At the time of our survey, only 16% of agencies utilized telehealth. Furthermore, participants reported that telemedicine was largely limited to telemonitoring of patients with specific chronic conditions. Although the use of telehealth is likely to have increased since the emergence of COVID-19, the initial lack of services may have affected the way that HHC agencies were able to react to the pandemic. The COVID-19 pandemic greatly disrupted the way that healthcare is delivered in the home, with telehealth becoming an essential method for care delivery.47-49 Prior to the pandemic, CMS posed major barriers to HIT adoption by HHC agencies by severely restricting Medicare reimbursement of telehealth visits and excluding HHC from participating in HIT incentive programs.12 The temporary waivers in place during the COVID-19 PHE hold the potential to drastically change healthcare delivery by HHC agencies if made permanent. Patient and caregiver satisfaction with HHC service delivery via telehealth appears comparable to that of in-person visits.50-52 However, during the rapid implementation of telehealth in HHC, several challenges were encountered, such as lack of internet/device access in the home, technical difficulties and impairments (sensory/cognitive) that prevent patients from virtually interacting with providers.52,53 Future research should examine the impact of HIT on patient outcomes, including readmissions, the way that the COVID-19 pandemic impacted the implementation and HIT use in HHC, and scalable solutions to address HIT implementation challenges.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute of Nursing Research and the Office of the Director of the National Institutes of Health under award number R01NR016865. This research was also supported by a grant from the Alliance for Home Health Quality and Innovation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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