Trendspotting: C A L I FOR N I A H EALTH C ARE How IT Triggers Better Care in Nursing Homes F OU NDATION Introduction To help nursing homes effectively link IT with Nursing home executives recognize that health quality improvement (QI), this issue brief information technology IT has the potential highlights a program called On-Time Quality to improve both processes of care and resident Improvement (On-Time QI), which has been outcomes. However, the path between technology implemented successfully in nursing homes.7 Issue Brief adoption and the desired results is often unclear. This program provides clinical decisionmaking As one California administrator put it, “I knew tools that were developed to address common I needed to adopt an EMR but I wasn’t really nursing home problems. Also included in the sure how it was going to improve our outcomes. program are strategies for tool use and guided I didn’t know what to look for in a system; I facilitation for nursing home front-line staff to didn’t know what questions to ask (the vendor).” improve risk identification and care coordination Such uncertainties are not unusual. A national across disciplines. On-Time QI is designed to expert pointed out that even nursing homes that be straightforward for clinicians and promote an are quick to transition from paper to electronic understanding of how to integrate CDS tools into systems “lack a clear understanding of how IT everyday practice. is used specifically in daily processes to improve clinical outcomes.” Unfortunately, research On-Time QI calls for a strategic focus on quality suggests that an organization’s failure to align improvement goals as part of the implementation the information system with its strategies can of IT, not as an afterthought, so that nursing result in lost opportunities, wasted resources, and homes can optimize their technology investments unfavorable performance.1 and improve both care delivery and patient outcomes. By working through the lens of quality Using IT for clinical decision support (CDS) is improvement, the use of information technology one way to concretely link technology to improved becomes more intuitive for front-line staff and process and resident outcomes. CDS tools makes the role of the system more obvious and provide clinical knowledge and resident-specific meaningful in daily practice. The On-Time information to help clinicians make decisions Pressure Ulcer Prevention (On-Time PrU) module that enhance resident care at appropriate times.2, 3 is part of the broader On-Time QI system that The tools can also take over some routine tasks, focuses on pressure ulcer healing, falls prevention, notify clinicians of potential problems, or offer and avoidable transfers to hospitals. suggestions for consideration.4, 5 The literature provides indications that CDS can significantly On-Time QI for Pressure Ulcers: improve the quality, efficiency, and costs of health A CDS Example care in some cases.6 Grounded in clinical best practices, the On-Time PrU program was developed in 2003 in collaboration with front-line nursing home S eptember 2011 teams from 11 facilities in seven states.8 It was designed to meet the unique needs of various users. Each report to leverage the knowledge of certified nursing assistant is linked to one or more process improvement strategies, (CNA) staff and promote proactive care coordination enabling facility teams to select strategies for CDS report and planning using IT. During an 18-month pilot use that align with their internal processes and structure. with 11 nursing homes, a standardized set of CNA documentation elements, five CDS reports, and a series On-Time process improvements are implemented on each of process improvements using CDS tools in daily long term care nursing unit throughout the facility. Full practice were created, tested, and refined; the goal was implementation is defined as implementing four process earlier identification of residents at high-risk for pressure improvements using the On-Time reports. Following are ulcer development. In 2006, an additional 23 nursing two examples of PrU process improvements: homes across the country implemented On-Time PrU, ◾◾ Identify residents earlier who are at nutritional offering further refinements to the CDS reports and CNA risk. Nutritional status is critical for PrU prevention. documentation elements that are part of the module. The On-Time Nutrition Report is used to identify Subsequently, a set of functional IT specifications to and monitor residents at nutritional risk, having support software development of CDS reports by long decreased meal intake and/or weight loss, both term care IT vendors was developed in 2008 and is of which are indicators for high risk of PrU publicly available on the AHRQ website.7 More than development. Four weeks of meal intake averages 75 nursing homes in the U.S. have implemented are trended for each resident, as well as weight On-Time PrU since 2003. changes for the past 7, 30, 90, and 180 days. Process improvements using the Nutrition Report To implement the On-Time PrU program, which takes include a five-minute stand-up meeting held weekly about 12 to 18 months, a nursing home must have with dietary, nursing, and CNAs. This “huddle” long term care IT software for, at a minimum, CNA is an example of how a team integrates the use daily documentation. Next, the facility confirms that of the Nutrition Report into practice, improves the vendor software includes the On-Time CDS tools. communication across disciplines, and includes CNA The facility collaborates with an On-Time QI facilitator, staff in collaborative discussions. who guides the teams through program implementation, including integration of the five On-Time CDS reports ◾◾ Identify residents at highest risk for pressure into the daily workflow. (See the box on page 3.) The ulcer development. The Trigger Summary Report workflow is reengineered, as needed, with front-line uses known risk criteria — meal intake, weight, staff collaboration, to promote optimal use of each urinary incontinence, bowel incontinence, and Foley CDS report. catheter use — to focus staff on high-risk residents to determine if they need additional follow-up, Nursing homes that implemented the program such as referrals, tests, or changes in the care plan. participated in a national collaborative; this was a forum Process improvements using the Trigger Summary that provided the opportunity for cross-facility discussion Report include identifying high-risk residents on a and learning and helped bolster participants’ confidence weekly basis, enhancing rehabilitation team focus on during technology or staff challenges. these residents, and monitoring unit-level trends of high-risk triggers. All On-Time PrU reports use CNA daily documentation; the reports can display information in a variety of ways 2  |  California HealthCare Foundation At a Glance: On-Time QI for Pressure Ulcers Three Objectives Three Beginning Steps 1. Leveraging knowledge of certified nursing assistant 1. Establishing an engaged project leadership team that (CNA) staff, who serve as primary informants to licensed includes the administrator or director / assistant director staff. of nursing. 2. Supporting collaborative clinical decisionmaking of a 2. Designating a multidisciplinary clinical team to champion multidisciplinary team using CDS reports that summarize the QI effort including nurse managers, wound nurses, resident information. CNAs, staff development, QI, dietitians, rehabilitation, restorative, and social workers. 3. Establishing practices for proactive risk identification and early intervention to prevent pressure ulcers (PrUs) as 3. Identifying a facilitator/consultant who is responsible part of front-line caregivers’ daily work. to facilitate the implementation process, mentor clinicians to use data for effective clinical decision­ Four Categories of Tools making, and serve as a resource to the facility team 1. Set of CNA documentation data elements developed and IT vendor. and refined by more than 50 facilities to standardize and streamline documentation processes and incorporate Three Implementation Phases key measures of clinical best practices for CNAs and 1. Preparation includes creating action items related care team use. to IT, identifying staff and facilitator resources, and establishing the work plan. 2. Clinical decisionmaking reports (On-Time CDS tools) are viewed weekly and contain trended information 2. Process improvement implementation involves the using daily CNA data: (a) Completeness Report for facility team working with a facilitator to implement CNA documentation; (b) Nutrition Report; (c) Weight On-Time CDS tools and process improvements. Summary Report; (d) Trigger Summary Report; and 3. Impact monitoring includes gathering and reporting (e) Priority Report. impact data at baseline and ongoing. 3. Process improvements linked to the use of each On-Time QI report. 4. Tracking tools for each of the reports, to monitor the effectiveness of process improvement efforts. Findings were located. Results from the initial pilot project in On-Time PrU has been implemented in more than 2003 – 05 and the dissemination efforts taking place 75 nursing homes as of this writing. The sites include from 2006 to the present have been published in two for-profit and nonprofit facilities ranging in size from 50 journal articles and several AHRQ Final Reports.8 – 11 to more than 500 beds. In order to assess the impact, each Administrators, directors of nursing, and QI directors facility provided data on pressure ulcer and weight loss at six nursing homes that participated in On-Time PrU outcome measures pre- and post-implementation. were interviewed to learn where and how the program provided value. They were asked how the program In addition, facilitators gathered feedback from influenced their IT implementation processes, how the participating nursing home teams, and interviewed programs informed their understanding of the role of IT stakeholders in New York, Washington, DC, and in clinical decisionmaking, and how the daily practice of California, where most of the participating facilities their clinical teams was affected. Trendspotting: How IT Triggers Better Care in Nursing Homes  |  3 To put the findings into a broader perspective, national Another benefit participants noted was increased experts and early adopters of IT in long term care were CNA involvement as key informants to licensed staff. also interviewed for their insights on what is needed to Explained a director of nursing in DC, “For our CNAs, support integration of CDS and QI in long term care and we progressed from their role of entering data to looking examples of successful implementations. Their responses at reports and then participating in team discussions supported the On-Time program approach and strategies. driven by the information on the reports. They attend every meeting and have a place at the table.” A CNA in The impact of the On-Time program is measured in Washington, DC, said, “Reviewing the reports with the improved clinical outcomes, clinical processes, and dietitian, nurse, and other CNAs is very helpful. We have staff experience. For nursing homes fully implementing a lot of information to share and now we feel like we are On-Time PrU, there was marked improvement in the being listened to.” A director of nursing in New York following areas: agreed that, “Communication has improved among the entire multidisciplinary team and CNAs are much more ◾◾ In-house pressure ulcer incidence rates declined in confident interacting with the licensed staff.” a range of 42% to 55%; ◾◾ CMS quality measure for high-risk residents with Care coordination and proactive care planning improved pressure ulcer declined in a range of 30% to 33%; with the use of CDS tools, which help summarize and and synthesize large volumes of data so that information is usable and meaningful to front-line staff. Multiple ◾◾ CMS quality measure for weight loss declined in a disciplines were able to review CDS reports together range of 12% to 18%. and work collaboratively to make timely decisions; this The findings indicated that high-risk residents were strengthened relationships among disciplines, according identified earlier and more consistently, and that this to interviewees. A director of nursing in New York affected clinical processes and staff experiences. As explained, “On-Time reports helped the team to focus stated by a director of nursing in New York, “Prior to discussion on the root cause of trends or changes. Using On-Time, we were trying to piece resident information this approach, the team was not reacting to problems but together, intervening after the fact, scrambling to connect rather responding to resident changes and risks before the the information. Now we get information early and problem occurred—in this case, skin breakdown. Using we intervene early.” Participants noted that the tools the reports and process improvements together push us to go beyond single data points to provide resident trends think and act more in an interdisciplinary way.” and offer a broader clinical picture. Following residents over time is therefore a key component of the On-Time The program engages front-line staff and encourages implementation. The experts agreed it is important to get thoughtful consideration on how and where CDS will be people out of thinking “incidence” care and episodic care, embedded into the clinical workflow of each clinician, and more toward trends and subtle changes in order to be and emphasizes a shared use of CDS tools across proactive. One director of nursing explained, “We have disciplines. In fact, participation in On-Time increased learned by participating in this project that the resident understanding of IT value by front-line clinical teams, story isn’t in one data point; the story is in the trend. some of whom were unaccustomed to using technology. That is where the value is and that is what the On-Time As noted by one director of nursing in Ohio, “We are reports show us.” not computer people. We needed help to implement new processes and think about uses of information.” By 4  |  California HealthCare Foundation engaging front-line clinicians in discussions about specific The experts emphasized the importance of facilitation quality improvement efforts, On-Time shifted the focus in program implementation. The Office of the National away from mere data entry and toward concrete resident Coordinator (ONC) stated, “Facilities cannot simply outcomes, making the benefits of the new technology turn on the system and expect IT to lead to improved more apparent. process and outcome measures. Technology alone will not lead to improved quality and new IT tools will not Insights from Thought Leaders be used just because they are available in the system. Interviews with 15 leading experts helped to frame the Here, with On-Time, you have a program that offers context of where and how On-Time can provide value CDS tools and strategies for use.” One DC stakeholder to a nursing home. Nearly all agreed that IT is poorly noted that On-Time serves as “a path toward IT use optimized in nursing homes today; benefits of new and adoption. Through guided facilitation, facilities technology are largely unrealized as facilities continue to learn how to leverage IT to impact quality. Nursing focus technology efforts on compliance and automating homes won’t get there without help; there are too many paper processes. For the most part, they said, IT is competing priorities, tight budget, staff turnover, reduced not being leveraged to access tools to support clinical reimbursement from Medicare and Medicaid.” decisionmaking. The experts emphasized that successful use of IT to Further, they noted, nursing homes tend to use electronic support clinical decisionmaking requires a seamless information similar to paper-based information within integration into clinical workflow. One expert said, “Too their existing processes like quarterly minimum data often IT operates as a static product causing disruptions set (MDS) assessments or care planning and monthly and requiring workarounds to existing workflow in order QI monitoring. Over time, it is common for nursing to use.” Because On-Time integrates IT into the clinical homes to realize that re-engineering workflow and using workflow, staff members learn to think of the technology decision-support tools to optimize IT are necessary for as a dynamic support that can adapt to their changing good results. The experts foresee successful nursing homes needs. in the future as stepping beyond technology installation and focusing instead on how to integrate IT into clinical Finally, the national experts emphasized the importance workflow, using CDS tools and analytics to proactively of linking quality improvement with IT as a business guide care coordination across settings. A leading expert imperative, as the link between QI and payment becomes commented that where and how IT is used to improve stronger. Near-term possibilities affecting the long term care processes and impact resident outcomes “is critical to care marketplace include: bundled payments covering nursing home survival.” hospital stay, physician care, and 30 days post-discharge; and non-reimbursement for “never events” such as However, the experts stressed that health IT is valuable pressure ulcers and falls. These potential payment changes only to the extent that it provides information to the intensify the need for consistent and reliable processes clinicians in a usable format. This point, they noted, that follow best practices and deliver quality outcomes. A is well-established in the literature. One respondent leading expert said, “Remember that you are building a remarked, “If the clinician has to go through too much data system for the purpose of care management, not for information then they get paralyzed. Information needs the purpose of eliminating paper documentation.” to be presented in a way that makes sense to the clinician. The On-Time reports do that.” Trendspotting: How IT Triggers Better Care in Nursing Homes  |  5 Conclusion Fortunately, a solid and growing foundation of CDS use The principal learning from the On-Time PrU experience has been established for nursing homes. The On-Time QI is that the benefits of IT for a nursing home extend well program is expanding beyond pressure ulcer prevention beyond the elimination of paper documentation, remote to pressure ulcer healing, falls prevention, and avoidable availability of information, and efficient workflow. It transfers to emergency departments and hospitals. illustrates how IT-supported clinical decisionmaking, care Furthermore, collaboration with long term care IT coordination, and proactive care planning can result in vendors has expanded over the years and is expected improved resident outcomes. to continue to do so. Currently, ten long term care IT vendors have integrated On-Time requirements into their As nursing homes gain a better understanding of the software, citing their confidence in the stability and wide value of health IT using CDS tools combined with applicability of the On-Time requirements.12 As one process improvement strategies like On-Time, there is vendor explained, “When it comes to requirements, we increased likelihood of broader support for technology want to be sure the customizations are reusable.” Another adoption. Facilities that have implemented On-Time vendor noted, “We didn’t have to deal with copyright PrU are positioned to make better decisions about IT issues since requirements were in the public domain; it implementation, are more informed about the potential was an easy decision for us.” of CDS tools, and therefore are more willing to adopt new tools and change existing processes in the interest The continued implementation and expansion of CDS of improved care. Although implementing IT is not an used at the front-line will allow nursing homes to build immediately appealing prospect for many nursing home a track record of effective IT use, which can expand their staff members, leveraging the technology to better manage understanding of how and where IT can be leveraged to resident care is desirable to nursing home administrators improve care. and front-line staff alike. It is important to note that the widespread adoption of information technology and CDS is affected by Authors Sandy Hudak, MS, RN, and Siobhan Sharkey, MBA, factors external to nursing homes. For example, despite principals, Health Management Strategies, Inc., Austin, TX recognized need for IT implementation in clinical settings, long term care providers are not included in C o n t r i b u to r s current federal government funding for IT support. One Susan Horn, PhD, senior scientist at Institute for Clinical nursing home CEO warned that, the potential of IT in Outcomes Research and vice president for research at long term care “is doomed to failure if nursing homes do International Severity Information Systems, Inc., Salt Lake not receive incentive dollars.” Experts agree that many City, UT nursing homes are in a “wait and see” mode regarding William Spector, PhD, senior social scientist, Agency for IT adoption. In all On-Time implementation efforts Healthcare Research and Quality, US Department of to date, grant dollars have been provided to nursing Health & Human Services, Rockville, MD homes to offset the costs of buying and implementing the new technology. If the implementation of On-Time Michal Engleman, PhD, Department of Sociology at the and comparable CDS tools is to become a new industry University of Chicago, Chicago, IL standard in long term care, more funding will need to be allocated specifically for this purpose. 6  |  California HealthCare Foundation About the F o u n d at i o n 7.On-Time QI was developed with funding from the Federal The California HealthCare Foundation works as a catalyst to Agency for Healthcare Research and Quality (AHRQ), in fulfill the promise of better health care for all Californians. collaboration with the California HealthCare Foundation. We support ideas and innovations that improve quality, See: www.ahrq.gov/RESEARCH/ontime.htm. increase efficiency, and lower the costs of care. For more 8.Horn, SD, Sharkey, SS, Hudak, S, Gassaway, J, James, R, information, visit us online at www.chcf.org. Spector, W. (2010). Pressure ulcer prevention in nursing homes: A pilot study implementing standardized nurse Endnotes aide documentation and feedback reports. Advances in 1.Challenges and Barriers to Clinical Decision Support Skin & Wound Care, 23(3), 120 – 131. (CDS) Design and Implementation Experienced in the Agency for Healthcare Research and Quality CDS 9.AHRQ Final Reports summarized on website, Demonstrations. Contract Number: 290-04-0016. www.innovations.ahrq.gov. Last accessed February 14, Prepared by: AHRQ National Resource Center for Health 2011. Information Technology. Authors: June Eichner, MS, 1 0.Sharkey, SS, Hudak, S, Horn, SD. (2011, January). Maya Das, MD, JD, NORC at the University of Chicago; On-Time Quality Improvement Manual for Long-Term Care AHRQ Publication No. 10-0064-EF March 2010. Facilities. AHRQ Publication No. 11-0028-EF. Rockville, 2.Osheroff, JA, Pifer, EA, Teich, JM. Improving Outcomes MD: Agency for Healthcare Research and Quality, with Clinical Decision Support: An Implementer’s Guide. www.ahrq.gov. Chicago: Healthcare Information and Management 1 1.Sharkey, SS, Hudak, S, Horn, SD, Spector, W. (2011). Systems Society (HIMSS), 2005. Leveraging certified nursing assistant documentation 3.Buntin, MB, Burke, MF, Hoaglin, MC, Blumenthal, D. and knowledge to improve clinical decision making: “The Benefits of Health Information Technology: A The On-Time quality improvement program to prevent Review of the Recent Literature Shows Predominantly pressure ulcers. Advances in Skin & Wound Care, 24(4), Positive Results.” Health Affairs, 30, no.3 (2011): 182 – 184. 464 – 471. 1 2.IT vendors that have integrated On-Time requirements 4.Osheroff, JA. (2009). Improving Medication Use and as of this writing: Resource Systems-Care Tracker; Outcomes with Clinical Decision Support: A Step-by-Step Optimus EMR; LINTECH; Melyx Corporation; Reliable Guide. Chicago, IL: The Healthcare Information and Systems; SigmaCare; American Data; Healthcare Systems Management Systems Society. Connection; PointClickCare; and HealthMEDX. 5.Chaudhry, B, Wang, J, Wu, S, et al. “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care.” Annals of Internal Medicine May 16 2006;144(10):742 – 752. 6.Booz Allen Hamilton. Evaluation Design of the Business Case of Health Information Technology in Long-Term Care: Final Report. Washington, DC: US Department of Health and Human Services, ASPE Office of Disability, Aging and Long-Term Care Policy. July 2006. Available at: www.aspe.hhs.gov. Trendspotting: How IT Triggers Better Care in Nursing Homes  |  7 Appendix A: Interviewees On-Time Implementers and IT Vendors Thought Leaders: Douglas Tucker, NHA, Administrator CEOs and CIOs of Long Term Care Organizations Country Villa Woodman, CA Michael Torgan, President Country Villa Health Services Lori Cooper, NHA, MPA, Administrator Stonebrook Healthcare Center, CA John F. Derr, RPh, Strategic Technology Golden Living LLC Janice Johnson, RN, BSN, Director of Nursing Bonnie Williams, MS, BSN, RN, Director of QI Peter Kress, MA, Vice President and Chief Information Officer Carroll Manor Nursing and Rehabilitation Center, DC ACTS Retirement-Life Communities, Inc. Sonia DeSouza-Brown, RN, Assistant Director of Nursing Larry Wolf, Health IT Strategist Johanna Graham, RN, Nursing Rehabilitation/ Kindred Healthcare Wound Care Coordinator Alan Crommett, MSHSA, Chief Information Officer Lynette Harry-Rutherford, RN, Inservice/ Skilled Healthcare Informatics Coordinator Gurwin Nursing and Rehabilitation Center, NY Thought Leaders: Stakeholders Sandra Smith, LMSW, CNHA Administrator Jim Koontz, MBA Chris Urbano, RN, Director of Nursing Quality Care Health Foundation (QCHF) Leslie Campbell, RN, Nurse Unit Manager Mary Fermazin, MD, MPA Seton Health Schuyler Ridge, NY Vice President, Health Policy and Quality Measurement Anita Peffer, Director of Patient Services Chief Medical Officer, Health Services Advisory Group, CA Robin Miller, RN, Registered Nurse Assessment Coordinator Kim Harris-Salamone, PhD, MPA Hennis Care Center, OH Vice President, Health Information Technology Beth Dichter, PhD Health Services Advisory Group (HSAG) New York Department of Health Jennie Harvell, MEd, Senior Policy Analyst Veronica Damesyn-Sharpe, MHSA Department of Health and Human Services DC Health Care Association Office of the Assistant Secretary for Planning and Evaluation (ASPE/HHS) Megan D’Angelo, Senior Director, SNF/AL Clinical Product Development Janhavi Kirtane, MBA PointClickCare Elizabeth Palena Hall, RN, MIS, MBA Mauricio Vejar, VP IT Office of National Coordinator (ONC) Country Villa Health Services Majd Alwan, PhD, Vice President HealthMEDX LeadingAge / Center for Aging Services Technologies (CAST) Heike Burk, RN, Client Services Rebekah Gardner, MD Rick Zirbel, Software Developer Quality Partners of Rhode Island (QPRI) American Data Brent James, MD, Chief Quality Office Intermountain Health Care Mary Jane Koren, MD, MPH Commonwealth Foundation 8  |  California HealthCare Foundation