1.  A nursing home telehealth system: keeping residents connected

Author(s): Daly JM, Jogerst G, Park JY, Kang YD, Bae T

Source: J Gerontol Nurs 2005 Aug;31(8):46-51.

Summary: 

Nursing home telehealth systems can add a new dimension to health care delivery for individuals residing in long-term care settings.  Live video and detailed images of nursing home residents can now be transmitted in real time via the Internet. This article describes the nursing home system e-TeleHealth, which allows residents and long-term care health professionals to connect with experts not available on-site. E-TeleHealth uses a rollabout station that includes a computer and monitor on a movable arm, as well as capabilities for videoconferencing, electronic stethoscope, otoscope, dermascope, dentalscope, and electrocardiogram use. Challenges in implementing telehealth systems in long-term care can include Internet connectivity problems, software glitches, operator error, costs, and the lack of reimbursement for telehealth services. While technology is changing the delivery of health care services, more pilot tests of telehealth systems must take place, appropriate system modifications must be made, and reimbursement procedures must be addressed at a legislative level.

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2.  Community readiness for a computer-based health information network

Author(s): Ervin NE, Berry MM

Source: J N Y State Nurses Assoc 2006 Spring-Summer;37(1):5-11.

Summary: 

The need for timely and accurate communication among healthcare providers has prompted the development of computer-based health information networks that allow patient and client information to be shared among agencies. This article reports the findings of a study to assess whether residents of an upstate New York community were ready for a computer-based health information network to facilitate delivery of long term care services. Focus group sessions, which involved both consumers and professionals, revealed that security of personal information was of concern to healthcare providers, attorneys, and consumers. Physicians were the most enthusiastic about the possibility of a computer-based health information network. Consumers and other healthcare professionals, including nurses, indicated that such a network would be helpful to them personally. Nurses and other healthcare professionals need to be knowledgeable about the use of computer-based health information networks and other electronic information systems as this trend continues to spread across the U.S.

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3.  Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders

Author(s): Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH

Source: J Am Geriatr Soc 2007 Sep;55(9):1451-7.

Summary: 

Nursing homes are the setting of care for growing numbers of our nation’s older people, and adverse drug events are an increasingly recognized safety and quality concern in this population. This article describes the costs and benefits of computerized physician/provider order entry (CPOE) with clinical decision support (CDS) for the various stakeholders involved in long-term care (LTC), including nurses, physicians, the pharmacy, the laboratory, the payer (e.g., the insurer), nursing home residents, and the LTC facility. Multiple stakeholders will incur the costs related to implementation of CPOE with CDS in the LTC setting, but the costs incurred by each may not be aligned with the benefits, which may present a major barrier to broad adoption. Consideration of these costs and benefits suggests that financial incentives to physicians and facilities may be necessary to encourage and accelerate widespread use of these systems in the LTC setting.

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4.  Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care

Author(s): Rochon PA, Field TS, Bates DW, Lee M, Gavendo L, Erramuspe-Mainard J, Judge J, Gurwitz JH

Source: J Am Geriatr Soc 2005 Oct;53(10):1780-9.

Summary: 

Although computerized physician order entry (CPOE) has been successfully implemented in many acute care hospitals, few descriptions of its use in the long-term care (LTC) setting are available. This report describes the experiences of one LTC facility in developing and implementing a CPOE system with clinical decision support (CDS). Even when a facility has the necessary resources and "institutional will," many challenges are associated with the implementation of this application (continual commitment from vendors, buy-in from key physicians). The system was designed to meet the needs of healthcare providers in the LTC setting, in particular by informing prescribing decisions, reducing the frequency of prescribing and monitoring errors, and reducing adverse drug event rates. Based on experience adopting this technology early, 10 insights are offered that it is hoped will assist others who are considering the implementation of CPOE systems with CDS in the LTC setting.

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5.  Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting

Author(s): Field TS, Rochon P, Lee M, Gavendo L, Subramanian S, Hoover S, Baril J, Gurwitz J

Source: J Am Med Inform Assoc 2008 Jul-Aug;15(4):466-72.

Summary: 

A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.

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6.  Prescribers' responses to alerts during medication ordering in the long term care setting

Author(s): Judge J, Field TS, DeFlorio M, Laprino J, Auger J, Rochon P, Bates DW, Gurwitz JH

Source: J Am Med Inform Assoc 2006 Jul-Aug;13(4):385-90.

Summary: 

Computerized physician order entry (CPOE) with clinical decision support (CDS) has been shown to improve medication safety in adult inpatients, but few data are available regarding its usefulness in the long-term care setting. The objective of this randomized controlled study was to examine opportunities for improving medication safety by determining the proportion of medication orders that would generate a warning message to the prescriber via a computerized CDS system and assessing the extent to which these alerts would affect prescribers' actions. Long-term care facilities must implement new system-level approaches with the potential to improve medication safety for their residents. The number of medication orders that triggered a warning message in this study (19.6%) suggests that CPOE with a CDS system may represent one such tool. However, the relatively low rate of response to these alerts (31%) suggests that further refinements to such systems are required, and that their impact on medication errors and adverse drug events must be carefully assessed.

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7.  Technology implementation and workarounds in the nursing home

Author(s): Vogelsmeier AA, Halbesleben JR, Scott-Cawiezell JR

Source: J Am Med Inform Assoc 2008 Jan-Feb;15(1):114-9.

Summary: 

This study examined workarounds related to implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes. As a part of a larger study, this qualitative evaluation identified workarounds associated with the implementation of an electronic medication administration record. Workarounds presented two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team. This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.