Information Technology Sophistication in Nursing Homes

Functional Sophistication 

In resident care, functional sophistication refers to the types of resident care activities that are supported by technological devices (eg, physician, nursing, dietary, and restorative documentation/reporting). Each of the facilities in this study was considered to have advanced IT sophistication because they had implemented an EHR with decision support capabilities, electronic data capture of clinical information, and other automated features. However, there were differences in the degree of functional sophistication even within this group of highly sophisticated homes. Key IT stakeholders emphasized different components of the EHR systems available for resident care.

The administrator in one facility noted the variety of IT components and uses, including “… nursing documentation, there's bookkeeping, of course, the Minimum Data Set (MDS) system, our activities, and social service. I haven't done dietary….“ In contrast, an assistant director in charge of education at another facility emphasized the following components of the IT system: “We do our medication administration, and it's all electronic. All of our physical assessments and all of our risk assessments are done on computer. All nurses notes, physician orders.“ He went on to say, “the dietary department, I'm not sure whether she processes her diet orders through the computer or not, but all of our weight management is pulled to run QA [Quality Assurance] reports. Her dietary assessments and nutrition notes are all entered into the system and then are reflected on the record, and the team can pull those up.”

For our purposes, functional sophistication is the degree of diversity supported by technology directed toward the care of residents. An example of this diversity is the use of digital photos in resident care. All but one facility declined to use digital photos for the purposes of documenting wound status. One administrator stated, “No, I haven't done wounds for a number of years, because you get into a liability situation with the picture, they just blow them up and use them against you in court. We do not take pictures of anything.” The nursing and medical records supervisors from another facility explained, “We maintain a photo album for medication delivery, matching the person receiving the medication with their photo in the album…this can present a problem as people change and sometimes people look alike. We haven't started taking and storing digital photos for computer storage. We may occasionally keep wound pictures on a computer, but it is not standard practice.” Another nursing home took pictures of residents’ faces only, uploading them into the clinical information system solely for identification purposes.

Technological Sophistication 

Statements regarding technological sophistication reflect the degree in which technology is used in resident care. An example of increased technological sophistication was discussed by the administrator of the same nursing home noted above. He described a homegrown wireless call-light system he developed and added to the facilities technology, “The call light system is attached to the computerized nursing system which has a series of four incremental pages occurring every four minutes to alert staff. The first level pages the aide on the hall; the second level pages exactly the same; the third level pages the medication aide, the float, the regular hall; and the fourth level pages the nurse. Four minutes later it goes to the next level; it pages everybody until it's answered.” There are added revenues for facilities that have high technological sophistication, the administrator explained, “We sell almost everything that we do with technology. We're a reseller for the wireless nurse call system.”

Integration Sophistication 

Integration sophistication represents the level of internal and external connectivity among departments and clinical settings.11 Goals for system integration are to link processes across different applications and ensure that information is kept consistent within systems. Most facilities in this study had higher levels of internal integration, as opposed to external integration. However, a wide range of internal integration was noted among facilities. Three nursing homes appeared to have taken steps to integrate internal charting mechanisms. For example, 3 nursing homes had integrated electronic charting for nurse assistants, whereas the other nursing home did not allow nurse assistants access to the EHR.

Internal electronic messaging systems, called task lists, were available and being used by three nursing homes to transmit preformatted messages from nurses to nurse assistants about clinical care to be performed. Use of these systems might increase technological and functional sophistication to support clinical communication; however, the level of integration across the system can fluctuate between facilities. For example, a nursing home using the task lists might provide each user (nurse aide and registered nurse) the capability to post messages to other users accounts indicating a higher level of communication capabilities, thus greater integration. In contrast, another home may allow only registered nurses to post messages to a nurse aide account, with nurse aides only being able to visualize but not manipulate the information displayed resulting in poorer system integration. This example illustrates a different level of integration for the same system between 2 different facilities.

Functional Sophistication 

Functional sophistication in the area of clinical support (eg, laboratory, pharmacy, and radiology) again varied. Three nursing homes had clinical decision support systems with clinical alerts for potential resident problems such as hydration status and skin integrity. Although these alerts were available in 3 of the 4 nursing homes, these alerts were used inconsistently.27 For example, one facility had the alerts turned on but ignored them, “We don't use them [alerts] because we don't input everybody's intake. We just have a set group of people [residents] we do intake on.” Another nursing home had the alerts turned on to alert staff of impending resident problems; systems administrators in one facility indicated they used them to make decisions about toileting and nutritional status, and yet other administrators had elected to turn the alerts in the system off. The decision to deactivate the clinical alerts appeared to be related to perceived accuracy and trustworthiness of the alerts.28

Technological Sophistication 

Technical sophistication relies heavily on external connections and adaptable IT systems. All nursing homes had Internet access; however, in most cases Internet access was limited to management. The exception was one nursing home that allowed Internet access to all staff except nurse assistants via a staff break room personal computer (PC). Few external electronic connections existed in these nursing homes.

There also was little external adaptability with clinical support networks in these highly advanced IT homes. In these homes, interfaces that allow interactions between IT users, creating the ability for users to accept commands and display the results generated by other portions of the computer system were not available with clinical support networks. However, there was some evidence that nursing home administrators were beta testing electronic interfaces with external laboratories to enhance clinical support networks.

Integration Sophistication 

Another important aspect of achieving a high level of IT integration is the level of available IT staff to support clinical operations. Only one nursing home had an IT department. The IT department provided a 24/7 help desk for clinical staff. The help desk assisted in troubleshooting, upgrading IT systems, and performing general maintenance. The other nursing homes relied heavily on their administrators, who carried pagers to support IT help and maintenance. There were also varying degrees of IT management experience, which typically consisted of “on-the-job” training. One nursing home appeared to have an extremely competent administrator who had compiled significant knowledge of IT systems and networks. He was outsourcing technology he had developed.

As mentioned, all nursing homes had a rudimentary level of integration sophistication with external clinical support entities such as labs, pharmacy, and radiology. However, there were some indications that external integration was becoming more developed. For example, one administrator described current beta testing for a lab request and reporting system, “…which would automatically notify the lab when they would have to come and pick up a lab [specimen] at the facility on a monthly basis.” Conversely, the other nursing homes relied on paper-based requisitions, fax reports, and telephone communications to facilitate transfer of information from external sources. This is evidence that some clinical support activities were being reengineered to take advantage of what IT can do.

Specific areas of IT support that proved to be helpful for internal IT integration and function included an implementation team to perform upgrades to the clinical information system and to build clinical libraries or knowledge databases, a maintenance staff to fix and track broken equipment, and a centralized point of integration staffed with knowledgeable people who could provide effective troubleshooting and networking.

Functional Sophistication 

Functional sophistication is needed to maintain an operable IT system that will perform clinical processes and activities associated with administrative oversight in nursing homes. Specifically, the use of consultants and outsourcing was found to be especially helpful in cases where an IT department did not exist. In one nursing home where no IT personnel were employed, the administrator used an intern who was getting a Master's degree in information technology to develop the wireless network and user-defined assessments. The administrator described how the intern helped develop user-defined assessments to enhance reporting capabilities: “The first year we chose the hardware, and then the second year I had them do a lot of work entering user-defined assessments. We have a specialized assessment when we put in intake and supplements at meals. So the questions, kind of feedback, and kind of answers you get are dependent on how you set up your input and then develop your report.”

There was evidence administrators who were knowledgeable of IT systems were becoming savvier because of types of sophistication analyzed. Some administrators were developing their own technological solutions such as a “bio-time” clock system for quality improvement. For example, IT systems were being used to validate the timeliness of answering call lights, “Using the bio time clock system, [nurse] aids can punch in by putting their finger on it [scanner], it reads their fingerprint, and if it matches, they go on. Our future plan is to take that technology on the time clock system, integrate that with the nurse call system, and know who answered every call light on every call. It can be used as a base to improve services.”

Finally, administrators who are implementing sophisticated technologies want more sophistication. This was evident in comments regarding magnetic scanning devices used for resident identification: “We are hoping for an update to the use of wand which is less intrusive to the resident as it does not require physical touching to scan. This would be especially helpful at night to keep from disturbing the resident.”

Technological Sophistication 

An important aspect of maintaining technological sophistication for administrative activities is having remote access. All nursing homes had some form of remote access. For example, 2 nursing homes used an application service provider (ASP) model allowing capital expenditures to be folded into monthly operating fees with individual vendors to support internal IT systems. Other nursing homes used remote access as a function of the nursing home being part of a system that owned/operated the systems centrally. For example, 2 nursing homes used remote access to assist in troubleshooting network problems, perform training, or evaluate system security with sister facilities. One administrator explained their networking capabilities: “The server is tied in virtually with a private network between all the sites, and then we're the controller that controls all of that in and out of the Internet. One facility has all the main data as to who can log in and all their other rights and all that…we can pull my documents up at any remote site.” The other 2 nursing homes used remote access to allow vendors to log onto their network to assist with network problems.

All forms of IT sophistication in terms of administrative activities were observed through the administrators’ daily use. In every nursing home there was technology being used to manage accounting, billing, and payroll, and regulatory functions such as the MDS. There was more technological diversity in applications for supplies management than in other ones. One administrator described the current use of technology for these purposes: “We have a scanning system for supplies, with its own set of palms, which is automatically linked to billing but not purchasing [a supply chain management application]. These supplies are used by individual residents and patients. We do have an inventory maintenance program but are not using it currently, due to warehouse space issues.”

Integration Sophistication 

Every administrator identified that IT systems were either fiscally or clinically strong in their individual products, however no system had been created with a strong integrated product linking clinical, fiscal, and regulatory needs; creating less integration sophistication for some facilities. This has led to consistent problems with fiscal and clinical interfaces and the development of separate silo systems to facilitate financial and clinical functions. One administrator explained, “The [clinical program] implemented by our facility doesn't talk to the [financial program] and that is the biggest weakness. Another major weakness is that the [clinical program] has no financial capabilities. At this time we have to double enter information into both the [financial program] and the [clinical program] systems.” The administrator also indicated that a new version of the clinical program was forthcoming that would create a more effective interface.

Administrative integration is represented by the level of internal and external integration of administrative functions among departments and clinical settings inside and outside a facility. Higher levels of integration were evidenced by improved administrative reporting capabilities across the system. All administrators reported technological enhancements enabled them to manage human resources more effectively, allowed them to perform audits of clinical areas from anywhere within the network, and provided them with critical clinical information to identify high-risk residents within the system. One informant described how reporting capabilities have been improved because of the technology: “…we are utilizing weekly reports for each nursing home unit, [to monitor] antibiotic therapy, residents who have had an incident, new resident admissions, new medication orders, who is Medicare part A and getting therapy. So it really helps to talk about the high risk patients so we can all be on top of the same thing.”

Descriptions of the usefulness of technology portray how computerization in these settings is moving away from a focus on billing applications and MDS completion to more advanced integrated IT systems that enhance administrative oversight.