Building a Health Information Technology Infrastructure in Long-Term Care

Affiliations:

¹Mathematica Policy Research, Oakland, CA

²Healthcentric Advisors, Providence, RI

³Brown University School of Public Health, Providence, RI

⁴Case Western Reserve University, Cleveland, OH

⁵State of Rhode Island Executive Office of Health and Human Services, Cranston, RI

⁶Alpert Medical School of Brown University, Providence, RI

Abstract: There is increasing interest in the potential of health information technology (HIT) to improve quality of care, prevent medical errors, and increase administrative efficiencies in the nursing home setting. The purpose of this study was to identify characteristics of nursing homes that were predictors of high versus low levels of technology adoption. Using data collected as part of a systematic technology needs assessment among Rhode Island nursing homes, the authors assessed the baseline level of technology adoption prior to a statewide initiative to assist nursing homes with the purchase and installation of computers in clinical areas. The results showed that only 36% of the nursing homes in the state had computers with Internet access placed in all clinical areas. Not-for-profit and chain-affiliated nursing homes were more likely to have computers in clinical areas, positioning them for easier participation in a health information exchange. These findings can guide nursing homes as they plan for increased HIT capacity in the ongoing initiative to improve quality and management of care for their residents.

Key words: Health information technology, health information exchange, nursing homes, patient safety, care transitions, electronic health records.
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Physicians, healthcare administrators, and policymakers increasingly recognize the potential of health information technology (HIT) to improve quality of care, prevent medical errors, increase administrative efficiencies, and lower costs.^1-3 To date, most initiatives have focused on expanding HIT in primary care and hospital settings, with comparatively less attention placed on long-term care (LTC) settings.⁴ Despite this, there is significant consensus that implementation and meaningful use of HIT can be crucial to the mission of nursing homes, both in terms of improved quality of care and workflow efficiency.^5-7 Implementation of HIT in nursing homes can support a wide range of functions, including communication during care transitions, quality and regulatory reporting, clinical documentation, medication management, development of individualized care plans, and management of chronic illnesses.⁸

Nursing home residents, a population with complex healthcare needs, experience frequent transitions between healthcare settings.^9,10 These individuals typically have multiple chronic illnesses that may require medical attention from various specialists, often resulting in duplication of services, care fragmentation, and inaccurate, incomplete, or delayed transfer of health information.¹¹ Electronic exchange of health information, implemented in the context of a robust HIT infrastructure, is an important tool to help coordinate care for these patients. By giving providers across settings access to timely, accurate, and comprehensive health information, health information exchange (HIE) systems can contribute to a reduction in unplanned care and rehospitalizations, and can improve healthcare outcomes.¹² The business and clinical cases for implementing more effective technology in nursing homes will only be strengthened as the LTC sector continues to grow. The US Census Bureau projects a sharp rise in the number of older Americans moving into LTC settings, as members of the baby boomer generation reach retirement age and begin to use these services.¹³

Although there is increasing momentum in the implementation of HIT in nursing homes, the majority of facilities historically have functioned using mostly paper-based systems and have been slow to implement technology.^14,15 Even now, when computer technology is implemented in nursing homes, it is often for administrative or operational purposes, with comparatively little use of the clinical applications that have the greatest potential to positively impact quality of care and outcomes for patients.^7,14,16 In fact, it is often the case across healthcare settings that technology with functions for targeting financial savings are prioritized over technologies with functions for improving safety and quality benefits. This is likely due to the up-front financial investment and loss in productivity that might accompany the implementation of a new computing system.¹⁴ Changes to current healthcare policy (eg, financial incentives to adopters of HIT, or regulatory measures) will likely be necessary to speed up the adoption of HIT in the effort to create a functioning national health information network.^14,15

Precise rates of HIT use in nursing homes are unclear; there are no reliable national estimates of adoption of electronic health records or other forms of HIT, and existing research lacks consistent definitions and methodologies.¹⁷ However, findings from several major studies indicate that adoption of information technology (IT) in nursing homes lags considerably behind other settings for reasons that are multifaceted.^15,18 Many facilities lack basic infrastructure, such as the hardware systems, software, and high-speed Internet access, that are necessary for the implementation of more robust applications like clinical decision support and electronic health records.⁷ Also, to maximize the benefits of these systems, they must be available to direct care staff and be accessible at the point of care, a condition absent in many nursing homes.^19,20

Our Study in Rhode Island

Our systematic assessment of health technology needs in Rhode Island nursing homes offers an example of some of the challenges to implementation of HIT systems in the LTC setting. We assessed the baseline level of technology adoption in all 84 licensed nursing homes in Rhode Island in 2011, prior to a statewide initiative to assist nursing homes with the purchase and installation of computer technology for clinical areas. The aim of this study was to identify the characteristics of facilities with high versus low levels of technology adoption. In doing so, we hoped to shed light on some of the current barriers to expansion of HIT infrastructure in nursing homes, and elucidate the factors necessary to establish successful HIE across settings, with the ultimate goal of improving care for nursing home residents.

Project Background

Since 2010, the State Health Information Exchange Cooperative Agreement Program has been funding states’ activities to build on existing efforts to advance health information exchange while working toward nationwide interoperability. In total, 56 states, eligible territories, and qualified state-designated entities have received awards for this purpose. The Rhode Island Quality Institute (RIQI) was one of these awardees.²¹ As part of a statewide public-private partnership, we worked with RIQI to spur nursing home participation in Rhode Island’s HIE, called CurrentCare. CurrentCare uses an opt-in consent model requiring authorization at the individual patient level before a patient’s information can be shared through the exchange. As such, the participation of nursing home leadership was critical for enrollment of residents into the HIE.

Prior to the current study, a preliminary assessment of IT adoption in Rhode Island nursing homes found significant deficits: only 39% of facilities had computers at some or all nursing stations. Based on this finding, we expected that there would be a substantial gap in nursing home readiness to participate in the proposed statewide HIE. As part of this project, upon completion of the baseline assessment, nursing homes were provided funds to address their basic IT needs to ensure that minimum standards for participation in CurrentCare were met. 

Recruitment of Nursing Home Leadership

Nursing home leadership was recruited in three waves from 2008 to 2011. Recruitment involved a multi-tiered campaign using listserv postings, newsletters, and communications from state agencies. In addition, key project staff approached medical directors and other nursing home leaders individually, and a presentation was made to the Rhode Island Medical Directors Association to obtain participation in the initiative. To ensure that data-sharing partners and data types within the HIE were relevant to the nursing home setting, LTC leaders were also invited to participate in the governance of CurrentCare. Finally, we leveraged existing relationships with the medical directors of the nursing homes to obtain their support for the project. Using this combination of strategies, CurrentCare secured the participation of 100% of nursing homes in the state.

Technology Assessment and Implementation

We contracted with two computer consultants to conduct comprehensive technology needs assessments across facilities from July 2009 to November 2011. They assessed the technology infrastructure of each of the nursing homes based on the following five factors: (1) presence of a computer at every nursing station in the facility; (2) minimum hard drive size and processing capabilities of each computer (as required by the HIE); (3) availability of a high-speed Internet connection; (4) productivity and antivirus software; and (5) accessories including printers, wireless routers, surge protectors, and network cables. Based on the technology needs assessments, the consultants provided each nursing home with a list of the software, desktop hardware, and accessories they would need to be able to take part in the HIE. They also provided assistance in identifying deals and discounts where applicable, and provided installation support free of charge for the facilities.

Nursing homes were eligible for reimbursement of hardware and software (up to $2000) if they agreed to participate in CurrentCare and offer enrollment to their residents, and if the needs assessment determined that the facility lacked adequate infrastructure to access CurrentCare at each nursing station. Technology purchases were prioritized based on the critical needs and the unique structure of each facility. In all cases, the goal was to ensure the existence of desktop computers with high-speed Internet access that met the processing requirements for the HIE at all of the facility’s nursing stations.

Reimbursement for technology purchases was provided by the Medicaid Transformation Grant, which directed the nursing homes to buy the recommended hardware or upgrades and then provided reimbursement, and towards the end of the project through funding by the Beacon Communities Program. Free installation of purchased equipment by consultants was included unless nursing home staff preferred to install the software or hardware themselves. Following installation, the technology consultants provided confirmation that the computers were in their respective clinical care areas, had network connectivity, and possessed the minimal processing requirements to access the HIE.

Baseline Nursing Homes Characteristics

Information about each nursing home was derived from Medicare’s Nursing Home Compare website. We obtained information on trade association membership from the websites of the Rhode Island Health Care Association and LeadingAge RI. Finally, geographic location (ie, rural or urban) for each facility was identified using the Census Bureau’s 2010 Urban and Rural Classification Criteria.²² We classified nursing homes on a scale of 1 to 3 based on the county in which they were located. A score of 1 indicated the most rural counties, with more than 30% of the total population of the county living in a rural setting as defined by the Census Bureau; a score of 3 indicated a largely urban area, with less than 10% of the total population of the county in a rural setting. We refer to this variable as the “rurality” of each facility. We used Stata data analysis and statistical software for all analyses. This study was reviewed and granted exempt status by the Brown University Institutional Review Board.

Results

The majority (79%; n=67) of the nursing homes were for-profit facilities, 25 (29%) were members of a chain, and 70 (84%) were members of a trade association. Nursing homes ranged in size from 20 to 260 beds with an average of 104 beds per facility. The majority of facilities (79%) were located in the most urban counties. All nursing homes participated in Medicare, and all except one participated in Medicaid. None of the facilities was located in a hospital. One nursing home was in a continuing care retirement community.

Each of the nursing homes underwent the technology assessment; 54 (64%) of the 84 nursing homes studied had significant gaps in their technology infrastructure and were authorized to receive funding through the program. Of the 54 facilities that received funding, 32 (59%) did not have computers in all clinical care areas. The remaining 22 (41%) facilities had computers in all clinical areas, but had systems that did not meet the minimum processing, hard drive, or operating system requirements necessary to participate in the HIE.

The likelihood of each nursing home having an Internet-accessible computer in each clinical area prior to the implementation of the statewide program was calculated, controlling for the following variables: profit status, chain affiliation, rurality, overall rating, and staff rating. In the adjusted model, facilities with Internet-ready computers were significantly less likely to be for-profit (adjusted odds ratio [AOR], 0.18; 95% confidence interval [CI], 0.43-0.76) and more likely to be affiliated with a chain (AOR, 6.57; 95% CI, 1.71-21.58), compared with facilities that did not meet the basic requirements at baseline. Interestingly, with every 1-star increase in staff rating, the odds of that facility having a computer with Internet access in all clinical areas decreased by 45% (AOR, 0.56; 95% CI, 0.30-1.02). 

Discussion

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.¹⁶ Furthermore, 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.

Acknowledgements: The authors would like to acknowledge the Rhode Island Quality Institute (RIQI), which partnered with the Rhode Island Department of Health to develop, implement, and expand CurrentCare, and which now owns and manages its operations. We were fortunate to work with RIQI to spur nursing home participation in CurrentCare and to complete the technology assessments and computer installation across all of the state’s nursing homes. We also wish to acknowledge the Rhode Island Health Care Association, LeadingAge RI, and the Alliance for Better Long Term Care for their support in this project.

The analyses on which this study is based were performed by Healthcentric Advisors under contract HHSM 500-2011-RI10C, titled “Utilization and Quality Control Peer Review for the State of Rhode Island,” and sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services (DHHS). Additional funding and assistance came from RIQI through the Office of the National Coordinator for Health Information Technology’s Beacon Communities Program. Lynne Chase, in her role as senior program administrator of the Safe Transitions Project team at Healthcentric Advisors, provided support during manuscript development and final revisions. The content of this publication does not necessarily reflect the views or policies of the DHHS, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors report no potential conflicts of interest.

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Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Elizabeth Babalola, MPH, Mathematica Policy Research, 505 14th Street, Suite 800, Oakland, CA 94612; eobabalola@yahoo.com