Nursing Home Information Technology (IT): Optimal Medication and Care Delivery (Utah)

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We implemented a health information technology (health IT) system with added best-practices decision support modules in seven nursing homes and evaluated the impact on care processes, resident health outcomes, and staff efficiency and satisfaction.

The study: 1. Led a collaborative partnership to analyze and redesign clinical workflow, integrated research-based best practices into daily work using health IT to improve clinical practices, and sustain measurable improvements in health outcomes. 2. Implemented and used health IT to improve clinical practice via user-friendly technology coupled with intensive workflow analysis and redesign, comprehensive documentation, compilation of summary information by resident or resident population, adherence to clinical guidelines, accurate and timely medication administration, and ongoing review and changes to resident plan of care to meet resident needs based on best practices. 3. Impacted resident health outcomes by integrating research-based best practices into daily work using health IT. Comprehensive evaluation addressed: a. What is the impact of health IT on resident clinical outcomes: fewer pressure ulcers, fewer hospitalizations, and less use of restraints? b. What is the impact of health IT on preventable adverse events: less weight loss, less decline in ADLs, fewer adverse drug events? 4. Distill and summarize lessons learned about what is critical for successful implementation of health IT in nursing homes, including facilitators, barriers, and strategies to address them.

Nursing Home Information Technology (IT): Optimal Medication and Care Delivery - 2008

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS04-011: Transforming Health Care Quality through Information Technology (THQIT)
  • Grant Number: 
    UC1 HS 015350
  • Project Period: 
    09/04 – 09/08, Including No-Cost Extension
  • AHRQ Funding Amount: 
  • PDF Version: 
    (PDF, 86.18 KB)

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

Summary: The objective of this grant was to implement a health information technology (IT) system with added best practices decision support modules in 15 participating nursing homes (NHs) and evaluate impact on care processes; resident health outcomes, including pressure ulcers (PrUs); and staff efficiency and satisfaction. Fourteen of the 15 NHs were not-for-profit and facility size averaged 100 beds, ranging from 50 to 250 beds. Project work spanned 3 years: 1 year for planning, 1 year for initial implementation, and 1 year for continued implementation and sustainability strategies. Facilities implemented health IT incrementally, focusing implementation in one or more areas: 1) certified nursing assistant (CNA) daily documentation; 2) registered nurse (RN)/clinical team care delivery and planning activities; and 3) medication administration. Starting 6 months after implementation, and each 6-month period thereafter, the project team re-measured areas assessed at baseline in order to evaluate change over time using data from Centers for Medicare and Medicaid Services’ (CMS) Nursing Home Compare and staff feedback on workflow.

All 15 NHs implemented health IT for CNA documentation and clinical reports to summarize CNA information into meaningful trends (e.g., weight loss, meal intake, and other indicators) for high risk of PrU development. All 15 nursing homes implemented health IT for various components of nursing documentation. Also, five facilities implemented health IT for electronic medication administration record/electronic treatment authorization record, but because of vendor delays the implementation did not occur fully until the last year of the project.

Facilities experienced positive impact on workflow and staff morale including improved documentation completeness, reduced time gathering and compiling information, improved access to information and multi-disciplinary communications, and staff satisfaction with technology versus paper processes. There were overall decreases of 18 percent in the CMS high-risk PrU and weight loss quality measures in 18 months.

Specific Aims

  • Implement a health IT solution in NHs that will improve clinical practices and health outcomes through electronic CNA documentation; clinical decision support focused on incontinence care, nutrition management, skin assessment, behavior management, and restorative care best practices; and electronic medication documentation and administration. (Achieved)
  • Identify health IT implementation best practices in use of technology in NHs through: collaborative, multi-disciplinary partnerships of NH provider leadership and implementation teams, evaluation team, and health IT vendor; workflow analysis and clinical process redesign efforts throughout each stage of implementation; and ongoing assessment of implementation processes and refinement based on results. (Achieved)
  • Conduct comprehensive evaluation of the role of health IT in changing clinical practices and improving resident safety, quality of care, and health outcomes, focusing on: clinical practices, including documentation and care planning; clinical outcomes, including fewer PrUs and less weight loss; provider satisfaction; and efficiency of care delivery. (Achieved)

2008 Activities: 2008 activities included analysis and dissemination.

Impact and Findings: Each facility team monitored outcomes and processes pre-and post-implementation as part of the effort to identify promoters and/or challenges to implementation of health IT and assess the impact. The project team assessed impact in four major areas:

  • Workflow: How does health IT implementation impact daily workflow for providers?
  • Provider Adoption and Attitudes: How does health IT implementation impact staff satisfaction?
  • Health Outcomes: How are changes in clinical practice using health IT associated with improved health outcomes for NH residents?
  • Lessons Learned: How can lessons learned from the project impact future implementation efforts and dissemination of health IT into nursing homes?

CNA Staff Feedback: Over 325 CNAs provided feedback indicating improvement from baseline (pre-health IT) compared to 18 months post-implementation in the following areas: spending the right amount of time documenting resident information, receiving enough information about the resident at the beginning of the shift to provide quality resident care, understanding what needs to be done for the residents before starting work, and not having to document 2 days worth of documentation at the same time because of not having time to do it the previous day.

Nursing Feedback: Over 125 nurses provided feedback indicating improvement from baseline to 12 months post-implementation in the following areas: able to review CNA documentation for completeness before the end of the shift, CNAs understand care to be provided to the residents at the beginning of their shift, spending the right amount of time on shift report to communicate resident needs, aware of all residents on their unit who have PrU(s) or significant weight loss or decreased meal intake and transmit these to CNAs, and taking minimal effort to assemble resident summaries for the Minimum Data Set (MDS) nurse.

Minimum Data Set for Nursing Home Residents Feedback: Based on feedback from 26 MDS coordinators, the following areas of impact were found: time to gather MDS information decreased approximately 24 minutes for an admission assessment, 28 minutes for a significant change assessment, 10 minutes for an annual assessment, and 8 minutes for a quarterly assessment. Facilities reported that this was especially true for Section G of the MDS (activities of daily living [ADLs]). MDS coordinators reported improved completeness and accuracy in several areas: behaviors, bathing, urinary continence, ADLs–toileting, and ADLs–eating.

Dietary Feedback: Based on feedback from 19 dietary staff, the following questions showed improvement: change from zero percent daily or weekly weight change calculations per resident by dietary staff to 40 percent, dietary staff participation in care planning meetings, nurses notifying dietary staff when a resident has significant decreased meal intake, and finding information about resident behaviors.

Clinical Outcomes: The pre- and 18-months post-health IT implementation data for the CMS quality measure (QM) for high risk residents with PrUs decreased overall from 10.8 to 8.9, a decline of 18 percent. The CMS QM for unintended weight loss decreased overall from 9.2 to 7.5, a decline of 18.5 percent.

Selected Outputs

Horn S. On-Time Quality Improvement for Long-Term Care: Using Nursing Home IT for Optimal Care Delivery (PowerPoint File; Web Version Icon indicating the linked content is archived.). AHRQ 2008 Annual Conference presentation: September 2008, Bethesda, MD.

Bergstrom N, Smout R, Horn S, et al. Stage 2 pressure ulcer healing in nursing homes. J Am Geriatr Soc 2008 Jul;56(7):1252-8.

Horn SD, Gassaway J. Practice-based evidence study design for comparative effectiveness research. Med Care 2007 Oct;45(10 Supl 2):S50-7.

Grantee’s Most Recent Self-Reported Quarterly Status: The project had concluded.

Milestones: Progress is completely on track.

Budget: On target.

Nursing Home IT: Optimal Medication and Care Delivery - Final Report

Horn S. Nursing Home IT: Optimal Medication and Care Delivery - Final Report. (Prepared by International Severity Information Systems, Inc under Grant No. UC1 HS015350). Rockville, MD: Agency for Healthcare Research and Quality, 2009. (PDF, 184.99 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 

Lessons Learned, Successes, and Barriers

PDF: Lessons Learned, Successes, and Barriers (PDF, 40.34 KB)
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.

Long-Term Care Facilities Embrace Health Information Technology

Susan Horn, Ph.D.Utah-based Project Finds Success in National Project

Think you can't make health information technology (IT) work in long-term care facilities? Susan Horn, PhD, disagrees; she has done it. The first thing she'll tell you is this: Don't go by the book. Bring the entire clinical care team to the table, engage them in IT decision-making, and listen to them. Then make resident-centered choices, not facility-centered ones.

"Health IT - without the people behind it to design it right and make it work - is not enough on its own," says Horn, senior scientist, Institute for Clinical Outcomes Research, and vice president for research, International Severity Information Systems, Inc. "Just matching provider requirements with existing information technology products is an incomplete solution. It has taken a teamwork approach to see this project blossom."

With funding from the Agency for Healthcare Research and Quality, Horn and her team created a nationwide project to integrate information technology in nursing homes and long-term care facilities, with several ambitious goals:

  • Create partnerships to establish best treatment practices that improve clinical outcomes
  • Streamline clinical documentation processes with standardized data points
  • Standardize electronic documentation, databases, and user interfaces
  • Create weekly outcome feedback reports for the care planning team
  • Reduce rates of pressure ulcers, which are common among nursing homes residents

If that sounds like a lot of work, consider the results: The project has reduced the prevalence of pressure ulcers among residents in 11 facilities by 33 percent.

This key to success here is not the technology itself. It's how the technology is adapted to the workflow. Horn's approach has been applied to a number of technologies, ranging from digital pens to customized electronic health records to streamlined documentation systems.

"You can't have a good system without an understanding of how it needs to work in the practice of care," Horn says.

Horn and her team have given frontline workers a voice and an opportunity to design clinical documentation processes that work for them. They have introduced IT to long-term care facility staff as a key element of resident care, rather than as an add-on that generates more work and headaches. And they have shown how the entire resident care team - from the certified nursing assistant (CNA) to the nutritionist to the vendors who provide equipment - needs to be on the same page to guide development of a good system.

"It's the bottom-up approach of how we started working with the facilities," said Horn. "Frontline staff, especially the certified nursing assistants, all have a voice. We ask them what they think the reports, based on their data, should look like to be useful to take better care of their residents. Typical research practices have the researchers going into the care environment, telling staff how to change without really knowing what their unique challenges are, and then not understanding why workers don't implement their changes. That's never been our approach."

The feedback reports, which document a number of resident outcomes, have been key to generating enthusiasm among staff for health IT and creating what Horn calls a "culture of data." When Horn and her colleagues started the project, they produced only four types of feedback reports. Now they are up to 11 - all because of staff demand for more reports.

Mercy Health Partners' four long-term care facilities in southwestern Ohio have been part of Horn's project from the beginning.

"We were very enthusiastic about the opportunity to identify quality concerns and improve quality of care with evidence-based practices, and really pioneer long-term care in a different direction," said Christina Miller, MDS coordinator and project manager at Mercy Health Partners. "But even more gratifying was the chance to be part of a partnership, to share with and learn from other facilities across theUnited States. And you know you're making a difference for residents all over, not only in your facility or your region of the country."

Becky Wilson, restorative nursing coordinator at Christian Home & Rehab Center, another project participant, recalls how involvement of frontline staff through this project transformed the work culture. "It amazes me even to this day how free the CNAs feel to come to the leadership, and suggest something new to try. And the leadership is in tune with their concerns and needs. We can't sit in our ivory tower and say, 'this is how it should be done.'"

Wilson's facility, a 75-bed home in rural Wisconsin, reduced the number of forms used to document care by 50 to 70 percent, simplifying them as well. According to Wilson, this process has saved CNAs time and solidified a team-centered philosophy.

"Staff in long-term care facilities see the data, the reports based on the data they document, the positive changes, and their input all coming together to create a better system," said Horn "They tell us, 'Our work is so much more meaningful because we can see outcomes. And we have no more pressure ulcers developing.'"

Notes: The work of Dr. Horn and her colleagues was recently featured in an article in the Wall Street Journal. Dr. Horn also submitted commentary to Modern Healthcare on technology's role as a tool to improve health care (PDF, 268 KB) .  

This project does not have any related emerging lesson.