The Institute of Medicine is calling for nursing homes to implement and use clinical information systems to support clinical practice 1. Thus, it was suggested, by 2007, nursing homes should have integrated electronic medical records to clinically manage residents and computerized cross checking for drug-dose, drug-lab, and drug-diet verification. To date there is limited evidence that nursing homes are reaching these levels of sophistication, with 1% or less of skilled nursing facilities, for example, incorporating electronic health records into clinical processes 2, 3. In most cases, nursing home technology has been limited to business applications related to billing/claims, eligibility processing, and the minimum data set 4-6. However, innovation does exist and nursing homes using highly sophisticated computerized systems to manage care have been identified7, 8. Through these innovators much has been learned about the ways in which sophisticated technologies can facilitate the exchange of information to thereby improve client safety and quality of care 9-11. The current paper presents an initial evaluation of the concept of IT sophistication in nursing homes using qualitative analytics including field notes collected during interviews and focus groups and axial coding to derive common themes.
IT sophistication is the level of diversity in technological tools and software used to support patient care, clinical support, and administration 12. Greater IT sophistication has been shown to have a positive effect on the ability to provide improved quality of care in acute care settings 13; however, there is limited understanding of the level of IT sophistication present and its effects in nursing homes. Consequently, the purpose of this study was to develop a matrix of nursing home IT sophistication from interviews and focus groups with knowledgeable IT staff using highly sophisticated IT systems. Common themes derived from the interviews and focus groups resulted in a matrix of the attributes describing the dimensions of IT sophistication (functional, technological, integration) in three domains of healthcare (resident care, clinical support, administration). The matrix of nursing home IT sophistication will be used as a framework to measure IT sophistication in future studies.
IT Sophistication in Nursing Homes
IT sophistication was derived from Nolan’s Stage Theory, which has been used to evaluate computer activity and the degree of IT maturation over time 14. Nolan identified four stages that organizations move through on the way to a fully integrated information system. Nolan’s stages include initiation, expansion, formalization, and maturity. These stages represent growth from technology meeting basic isolated organizational needs to a fully integrated system that meets general organizational needs15. For example, a basic isolated system would report employees’ work schedules on a nursing unit; in contrast, a fully integrated system would use employee schedules, financial data, resident census and acuity to support administrative decision making about staffing needs for a clinical unit or facility. The range of integration from isolated to fully integrated information systems creates diversity between facility operations, influences interoperability between internal and external stakeholders and can provide a unique measure for a facility’s level of IT sophistication.
An example illustrating the importance of interoperability of integrated information systems is demonstrated during a transition of care from a nursing home to another healthcare facility. Figure 1 provides a diagram depicting stakeholders (patient, clinician, receiving facility, and transferring facility) involved in the transition of care for a patient between two healthcare facilities16. The range of integration of sophisticated information systems such as electronic health records (EHR) affects the presentation and types of patient care data transferred between facilities. Diverse information can lead to conflicts and consensus about the need for transfer between stakeholders involved in the care of the patient as a result of varied interpretations of the acuity or severity of the health problem17. National efforts are currently underway to standardized clinical information, determine necessary patient data, and to structure information about the intended care to be provided by the consulting clinician or receiving care setting when transitions of care occur18.
Measures of IT sophistication developed from early applications in business firms 19, 20. Recently, IT sophistication has been used to describe measures of diversity among technological tools and software used to support patient care, clinical support, and administration in healthcare 12, 21, 22. Three types of sophistication have been defined through these early applications. The types of IT sophistication include: functional sophistication (types of processes or activities that are computerized); technological sophistication (degree in which technology is used in each clinical area); and integration sophistication (level of integration among internal and external departments and clinical settings) 12, 19, 21, 23.
The potential for IT sophistication in nursing home settings is great. IT solutions can assist in the delivery, support, and management of resident care, provides opportunity for interoperable clinical support networks and facilitates administrative oversight1. For instance, nursing homes with high IT sophistication could collect appropriate clinical data about residents with congestive heart failure with edema (vital signs, weight, fluid intake/output, appetite, medications) and be able to transfer the data to all relevant healthcare team members; such as primary care providers to alert for change in condition, dietary and licensed staff to reassess resident, and nurse assistants to monitor water and fluid intake. In contrast, facilities that use paper and pen based applications or checklists would be considered to have a lower level of sophistication in regard to their IT system; hence treatment plans for residents with congestive heart failure with edema may be implemented slower resulting in more negative resident outcomes. Results from this study of nursing home IT sophistication will be used to develop and investigate performance measures between facilities that have varying degrees of functionality, technological instruments and integration. These measures can then be used to benchmark best practices in IT use to guide development, new implementations and quality improvement initiatives among early adopters of information systems in nursing homes.