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

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) .