Question

The benefits of information technology for providers, consumers, and the system in long term care

Answer 1

The benefits of information technology for providers, consumers, and the system in long term care:

This report is part of a larger initiative to improve HIT infrastructure and introduce HIE capability to nursing homes across Rhode Island. Despite the benefits of efficient transfer of health information, technology is not a panacea that can be casually applied to solve the many problems facing nursing homes today. Although instrumental in facilitating efficient and effective care delivery, technology alone is insufficient.⁸ This Rhode Island study is the first, to our knowledge, to characterize which nursing homes are more likely to have an adequate HIT infrastructure and are therefore better positioned to use an electronic HIE to improve care management for their residents. Our results may have important implications for facilities working toward HIT implementation. In the sections that follow, we discuss the importance of access to statewide HIE systems, the impact of the nursing home business model, personnel issues, and the role of the medical director, especially to influence policymaking.

Health Information Exchange

The presence of computers with Internet access in all clinical areas is significant because of the many potential benefits of HIE to nursing homes, particularly in the context of national efforts to improve care management. A survey of HIT stakeholders from nursing homes with relatively advanced technology infrastructure identified the need for further interconnectivity as the most important goal for advancing patient safety and quality of care for nursing home residents.²³ As patients move between settings, care becomes increasingly fragmented, and HIE systems such as CurrentCare can support physicians and other nursing home staff in better caring for residents who have been recently discharged from the hospital.²⁴ Nursing home residents also benefit when their nursing home data is available for physicians outside of the facility, such as when a resident is transferred to an emergency department for urgent evaluation.

In addition to opening up the facility to information exchange capabilities, having Internet-accessible computers available to clinical staff provides access to useful online healthcare references, such as PubMed, Medscape, and subscription-based reference tools, at the point of care. Finally, these technologies support participation in public reporting initiatives, incentive programs, infection control efforts, and quality improvement programs, such as INTERACT II (Interventions to Reduce Acute Care Transfers).^16,25

Impact of Business Model

We found that not-for-profit facilities, compared with for-profit facilities, and chain-affiliated facilities, compared with unaffiliated facilities, were more likely to have computers in clinical areas, even after adjustment for potential confounders. Leadership at not-for-profit nursing homes may be more likely than their for-profit counterparts to consider spending scarce resources on non-mission–critical activities, such as improving their technology infrastructure. This different prioritization of discretionary spending, combined with the tax advantages afforded not-for-profit facilities, might mean that they have more capital available to make investments in HIT in the absence of external levers.

At the same time, for nursing homes that are part of a corporate structure such as a chain, the costs related to HIT purchase and implementation are frequently borne by the corporation, which can also take advantage of group purchasing options not available to smaller, unaffiliated settings. Importantly, there remains some significant ongoing costs associated with implementing HIT that all facilities must consider, including the need for continued technical support as well as regular hardware and software updates.¹⁶

Personnel Issues

Chain-affiliated nursing homes, which tend to be larger than independent facilities, are also more likely to have IT personnel to assist them in making and installing technology purchases. We observed that many of the nursing homes funded under this program were overwhelmed by the task of making these kinds of technology decisions and welcomed the guidance provided by the contracted computer technicians.

Our data also provided evidence, although not statistically significant, of an inverse relationship between staffing levels and HIE readiness. Possibly, in facilities with higher staff-to-resident ratios and the associated higher staffing rating, greater emphasis is placed on improving staffing levels at the expense of investing in technology infrastructure.

Another important consideration for medical directors and other leaders is the operational and staffing context in which many nursing homes function. High staff turnover rates and a persistent shortage of qualified personnel, particularly among direct care staff, continue to plague the industry and far exceed the rates seen in other healthcare settings.^26-28 The lack of continuity of personnel and the need to constantly recruit and train new staff pose significant challenges to HIT initiatives.¹⁶Furthermore, comparatively high staffing shortages may mean that facilities are not adequately staffed for HIT planning and implementation efforts. Low familiarity with computer technology among direct care staff and resistance to change can present additional barriers.²⁹

Role of Medical Directors

All of these factors combine to present unique challenges for medical directors, not only for the implementation of HIT in these settings, but also for ensuring the ongoing use of these technologies for patient care. These challenges represent a significant opportunity for medical directors, who have a vested interest in encouraging successful technology adoption in their facilities. Medical directors, administrators, directors of nursing, and other key staff can play an important role in promoting the effectiveness of these tools by enabling a well-trained workforce and instituting policies on the use of the technologies. Trends in HIT adoption are heavily influenced by government policies, and medical directors are in a unique position to advocate for the inclusion of LTC in HIT legislation and funding programs.⁷ Currently, nursing homes are not eligible for incentive payments for meaningful use under the Medicare & Medicaid EHR Incentive programs.³⁰ However, as the results of this initiative show, even a limited amount of financial support can have a significant impact. Although each facility was eligible to receive up to $2000, with the assistance of the technology consultant, the majority of facilities were able to fully cover their critical technology needs with less money.

Study Limitations

We recognize some limitations of this study. Information about the use of the new computer systems across all nursing homes is not available, and it is possible that facilities may not be making optimum use of the technology. These data come from one state, Rhode Island, and although we were able to include every nursing facility in our study, this may still limit the generalizability of our findings to other regions of the country.

Conclusion

Although there are many challenges associated with adoption of HIT in nursing homes, these technologies can play an essential role in meeting the complex and diverse needs of nursing home residents. In this era of rapid changes to the HIT landscape, the lag in technology adoption in LTC is likely to have far-reaching consequences for the ability of nursing homes to meet the growing demands of the industry while ensuring high-quality care for their residents. This study presents a potential strategy for successfully improving nursing home IT infrastructure and can guide medical directors as they plan for increased HIT capacity in their institutions. Our findings will hopefully serve to inform policy efforts and the priorities of grant-giving agencies. Moreover, our results illustrate the large impact that relatively inexpensive state-level programs can have on systematically supporting HIT adoption to improve IT infrastructure. Such programs can play a key role in enabling facilities to take advantage of the benefits of electronic information exchange and support a higher quality of care.