April 10, 2023 | Net Health

5 min read

The Power of Pairing EHR and MDS Data Analytics Together for SNFs

In today’s value-based care environment, long-term post-acute analytics (LTPAC) have become essential for skilled nursing facilities (SNFs) to succeed, stay competitive and achieve the objectives of the Triple Aim for participation in value-based care initiatives. Predictive analytics are changing healthcare with insights that help clinicians identify patients at risk for adverse events and poor health outcomes.

Analytics from clinical data provide decision-making support to facilitate the implementation of care pathways and evidence-based best practices to manage clinically complex patients with multiple comorbidities.

High-performing predictive algorithms go beyond the identification of single risk factors. They also consider interdependent factors that contribute to the outcome. For example, predictors such as weight and conditions like diabetes and hypertension, especially when multiple comorbidities are present, tend to negatively impact a wound’s likelihood of healing.

Predictive algorithms can be created leveraging data from both EHR and Minimum Data Set (MDS) data. Predictive analytics derived from EHR and MDS data are best used in a complementary way, providing comprehensive insights to guide patient care. In this blog, we examine how EHR- and MDS-based analytics each bring value and the potential synergy that exists when both are used together.

Learn about the history of Electronic Health Records (EHRs)

The Merits of EHR Data-Based Analytics

EHR data-based analytics are primarily used to identify and manage acute changes in a patient’s condition so a clinician can further assess the patient and intervene to manage and prevent complications. For example, a patient develops a fever, declines slightly in activities of daily living self-performance, and has decreased fluid intake.

An EHR-based predictive algorithm may identify these descriptive indicators and determine that the patient is at risk for readmission to the hospital within the next few days. Once alerted to this change in condition and imminent risk, the clinician can perform an assessment so the care team can intervene quickly to treat the patient and mitigate the risk.

There are some drawbacks to EHR-based analytics. Because post-acute EHR data is not yet standardized and is proprietary to each EHR vendor, the size of the data sets and benchmarking capabilities may be limited. Much EHR data is not structured (e.g., progress notes are largely free text), which is challenging to use in predictive models.

Developing algorithms may require the use of additional technologies, such as optical character recognition (OCR), to identify predictors – and they may be less reliable as a result. In addition, analytics is not a core competency for most post-acute EHR vendors.

Your Advanced Analytics Solution for Improving Post-Acute Performance

Access the Datasheet

The Merits of MDS Analytics Data for Skilled Nursing Facilities

MDS-based patient-level analytics are used to manage the risk of adverse outcomes through the interdisciplinary comprehensive assessment and care planning process. Minimum Data Set analytics can help health care professionals avoid adverse events like falls, pressure ulcers, and rehospitalization by developing individualized care planning interventions based on a patient’s risk factors.

While it may be possible to work on eliminating some risk factors, others may need to be managed to prevent complications.

Unlike EHR data, MDS information is highly structured and standardized through the national MDS database. Driven by comprehensive clinical assessment and a review of the resident’s functional capabilities, the data allows the development of valid and reliable predictive models that are clinically relevant with robust benchmarking capabilities. Analytics-focused companies have a core competency in data science and MDS assessments.

The Complementary Partnership of EHR- and MDS Analytics for Skilled Nursing Facilities

While EHR data and MDS-based analytics are effective individually, they’re not mutually exclusive when it comes to providing the best patient care possible. When data and analytics are used together, clinicians at nursing homes get the right analytics, at the right time, for the right purpose, which ultimately results in the right decisions for nursing home patients.

A great example of comprehensive assessment is the way these analytics can be used in a complementary way to prevent rehospitalization, a key performance outcome for SNFs. A patient with a chronic lung disease in skilled nursing care for a short-term rehabilitation stay following a hospitalization is identified to be at moderate risk for readmission by the MDS-based predictive algorithm with predictors including COPD, CHF, oxygen therapy, and incontinence.

The interdisciplinary care team considers these factors when developing the patient’s care plan, including mental health, with a focus on managing them and preventing an acute exacerbation of her chronic illness. During the patient’s stay in certified nursing homes, she develops a mild cough and worsening shortness of breath.

An EHR-based predictive algorithm identifies that she is now at high risk for readmission to the hospital and alerts the care team.  A nurse assesses the patient, notifies her physician, and interventions are quickly ordered to manage the acute exacerbation of symptoms in the SNF to prevent a rehospitalization.

Find out how you can achieve better patient outcomes and even greater value by choosing the right analytics partner with Net Health Point Right®. Schedule a demo with us today. 

Understanding Claims vs. MDS-Based Insights for SNFs

Access the ebook


Your Rehab Therapy EMR: The Key to Documentation EfficiencyImproving Seniors’ Timely Access to Care Act (S.3018/H.R.3173)7 Ways to Establish Greater Credibility in Local Rehab Therapy Marketi…New Mexico Nursing Facility ValueBased Payment (NF VBP) Workgroup Part…Why Net Health Approach to Analytics is UniqueFriends with Benefits: Making Media Relations a Key Strategy for Rehab…


Share this post

Subscribe and See More