Results from Groundbreaking Nursing Home Study (Episode 44)

September 25, 2018

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Darcy Grabenstein: Hello from SmartLinx Solutions. Today’s guest is Gregory L. Alexander, PhD, RN, FAAN, Interim Associate Dean of Research and Professor at the University of Missouri Sinclair School of Nursing. Dr. Alexander’s nursing specialties include clinical informatics and human computer interaction. His interest areas are Gero-informatics research and national health policy, along with IT effects on quality of care in nursing homes and long-term care. He also focuses on development, organizations, and health policy about nursing practice that impacts geriatric patients. His doctoral studies centered on human factors decision support and long-term care. Welcome, Greg, thanks for joining us today.

Gregory Alexander: Thank you very much for having me.

DG: Today I’d like to focus on your report, “A National Report of Nursing Home Quality Measures and Information Technology 2017 Through 2022,” for which you and coauthor Dr. Richard Madsen, also affiliated with the University of Missouri, received a nearly $2 million research grant. The two main research questions driving the study are: What are the trends in information technology (IT) adoption in US nursing home facilities or two years; and: How are two-year trends in IT adoption in US nursing homes related to nationally reported quality measures (QMs). So Greg, first please tell us the methodology that you used for this study.

GA: Sure. So this study is an ongoing study. We’re actually in our fifth year of this study. It’s a longitudinal survey design. What that means is that every year on an annual basis we’re recruiting nursing home facilities from around the country, each state including Alaska and Hawaii, to participate in an annual survey that measures nine dimensions of what I call IT sophistication (information technology sophistication). And information technology sophistication is measured in three healthcare domains, including resident care, clinical support (like laboratory, pharmacy, and radiology), and then administrative activities, so look at IT-specific applications across each of those three dimensions. And then within those three dimensions we also measure three dimensions of IT sophistication. And those include IT capabilities, extent of IT use, and degree of IT integration with external and internal partners to the facility that’s taking this survey. So in other words, what you can do is you take these three by three dimensions and domains, and you’re able to see what sort of IT capabilities there are in resident care or what types of IT capabilities there are in clinical support, such as lab and pharmacy and radiology. You could also look at the extent of use of these capabilities and see how well people are utilizing the technology and what the trends in that extent of use are over a period of time. And then you could look at how well things are beginning to be integrated across these facilities that are completing the survey. And what we do is we take each of the surveys, and there is a score for each of those nine dimensions and domains and plus a total IT sophistication score, and we’re able to look at those scores and we’re able to trend those to see what the trends are in each of those dimensions and domains and then we download on a quarterly basis the nursing home compare data that is publicly reported and freely available through the Centers for Medicare and Medicaid that every facility that has Medicare and Medicaid patients is required to report into. And we look at those quality measures and we correlate those quality measures with the quarter in which the facility has completed their annual survey. And so actually what we do is we do an average of four quarters, beginning with the quarter that they’ve completed their survey in, and so we look at a broad block of the quality measures to get a better sense of the average, and then we look at the correlations between the trends in the IT sophistication as well as the quality measures.

DG: Thank you, that’s a lot of information, very thorough. I’m really impressed, your research is innovative because it includes the first national assessment of nursing home QMs in IT sophistication. At SmartLinx, our focus is on workforce management solutions for nursing homes, so we’re heavily invested in IT, so I’m very interested in this. And our audience is no stranger to the Centers for Medicare and Medicaid services to nursing home compare data which we incorporate into our modules. So how does the CMS data tie in with your study?

GA: Well, what we do is we look specifically at each of the quality measures. We’ve also looked at some of the other measures like staffing that is reported—RN staffing, LPN staffing, as well as CNA staffing that is reported within the nursing home compare data set. And we also look at some of the safety measures that are in there, such as when a facility receives a tag for poor quality care, we try to correlate, and we have correlated some of the trends in information technology sophistication in each dimension and domain with those safety issues that are occurring. And so those are a little bit different articles than the one that we’re talking about today. The one we were talking about today is just basically the two-year trends in nursing home IT sophistication related to quality. And what we found is that, especially in resident care domain, under the IT sophistication dimension of IT capabilities, extent of use and IT integration, there were several quality measures that were significantly correlated with changes. So for example, under the resident care extent of use of IT—so in other words, as IT extent of use increases in resident care, the quality measure related to low risk of bowel or bladder incontinence appears to go down. And what that means is that there is a relationship between the increasing amount and extent of use of IT in resident care and a reduction in the amount of incontinence that is occurring, so they go in opposite directions. Another one that’s sort of interesting is pressure ulcers, and these are with new or worsened pressure ulcers. And as the extent of use of IT in resident care increases, there appears to be a reduction in the amount of pressure ulcers that are occurring. We have several quality measures across each of the dimensions and domains that are discussed in the article that have to do with the relationship between nursing home quality and the use of IT in those facilities. I’m a nurse and I’ve worked in long-term care a long time, and one of the things we’ve always been told as nurses is that technology will make a difference and the quality of care that we perform will always be—that technology will help us spend more time with patients, we’ll be by the bedside more often. But I was always a little bit reluctant about that one, I was doing clinical work more as a clinician. So I decided to begin a career studying that to really prove that. And it appears that technology does make a difference. But I think there are a lot of issues with technology in relationship to how it affects workflow and those kinds of things that are still left unexplained. And I think it’s worth investigating these systems that the nurses are using to care for these residents and how it’s affecting quality.

DG: Definitely. One important finding is that significantly more facilities had gains than losses in IT sophistication over the two years. What other key findings did the study reveal?

GA: Yes, so one of the areas that we found that there was a great sort of fluctuating trend—in other words, some facilities appeared to adopt technology and to be able to utilize it and increase their capabilities and have it increase extent of use and greater integration. And other facilities seemed to lose capabilities and did not use technology over the two-year spread. They would actually lose some. In fact we had some facilities that reported 100% of the IT capabilities and extent of use degree of integration we had asked them about in year one, and then in year two they had gone to 0%. And so we were very interested in what was causing that fluctuation, because that’s not what we had expected. So this was primarily one of the areas that this fluctuation was occurring in was in clinical support. And so we began to ask some questions of some of the administrators that had these fluctuations. I had conducted some interviews and talked to these individuals, the administrators of these facilities that had these large fluctuations. And we found that some facilities would adopt technology in clinical support like lab or pharmacy, or even radiology, and they would find that the systems were difficult to integrate, for various reasons they had trouble implementing the capabilities that were part of that technology and then therefore they couldn’t use them as well. So they spent a lot of time and effort and money implementing these technologies that didn’t work for them, so then they abandoned them. And so we were interested in those kinds of fluctuations as well as fluctuations that weren’t quite as great. But it’s interesting to us to discover that there are systems that are being adopted, there is some reason for that, you know. Our questions are: What is causing that fluctuation? What is it that administrators or people that are managing these systems not seeing prior to adoption that would have helped them to make better decisions about the technology they use? And so we’re trying to provide feedback about those types of systems, and we’re trying to understand a little bit about the decision process that nursing home administrators are making in relationship to the technology they’re purchasing.

DG: Very interesting. I know we would be interested in more details on that. Based on your results, Greg, do you have any advice for vendors of IT solutions geared for the senior care industry, such as SmartLinx?

GA: Yes, well I think that it’s important to engage the nursing home early and often and the staff at the nursing home, not only the people that have purchasing power, but also the staff and the people at the bedside that are going to be using the technology. One of the things that we found in our study also is that whenever we asked people to complete an annual survey, we asked the administrator to make the decision about who completed the survey. So we wanted it to be somebody who was in charge of information systems, somebody who had knowledge of the systems that were in place in the nursing home. So it wasn’t supposed to be just an innocent bystander who was given another task to do, they were actually supposed to have some responsibility for technology implementation and knowledge of it. So as a result, we felt like we had a fairly good proxy estimation of the staff that were in charge of these systems, and they weren’t typically people that you would expect to be in charge of an IT system implementation, for example directors of nursing, minimum data set coordinators. Sometimes the facility would have a CIO, but that was less often than when they would just have somebody that might be a manager or an administrator of a specific domain within the nursing home, but not necessarily IT-specific. It seemed to be something that was an add-on. And the problem with that, I know from a nursing perspective, is that nurses aren’t trained to implement or manage information technology, that’s not their purpose. So when it gets added on to their regular positions, to troubleshoot and target IT systems that they’re using, I think there is not a great success of adoption, and there is a need for better training and better understanding about how these systems work. And to do that you have to involve staff at the lowest levels who are even going to be using the technology as well as the people at the top. And we have to educate better. We have to educate the workforce better.

And I have a new book out, if you don’t mind I’ll plug that. It is a book that is about implementation of information systems in nursing homes. And it is sort of a primer on processes and protocols to consider as nursing homes are adopting technology. Actually it’s written more for the long-term care angle. There are some facilities, including assisted living and other types of facilities along the continuum of care that are beginning to adopt technology because it’s important for patients as they’re moving across these settings to have consistent information following them. And so there is a book, it’s available on Amazon.com, and I’m an author on that book, it was just released a couple weeks ago.

DG: Hot off the press.

GA: It is actually. And it’s a useful book in the sense that it’s a primer, it helps people to understand the basics of health information technology implementation and the language behind that, so that they can communicate thoughtfully about technology and it sort of knows the questions to ask as they’re beginning to think about technologies to implement.

DG: Great. Thank you for sharing that with us. Getting back to the study, based on the results so far, how can nursing homes use the findings to improve outcomes and quality of care? In other words, how can they put it into action?

GA: Yes, so we have been providing a lot of feedback reports for every facility that participates. So one of the benefits of filling out the study and participating in the work is that each facility will get a sense of where they fall on the continuum in each dimension and domain of IT sophistication. So they can see how they compare to other facilities nationally. And we’ve had about 815 facilities participate from across the nation. And so we’ve trended those 815 facilities over three years. They’re from every state, they’re from every size, every location—rural, urban, metropolitan, small town. They’re there from every bed size and ownership. And so we’ve considered that as we’ve done our adoption of our survey and putting the survey out there, because we wanted to make sure it was reflective of the true population of homes of all different sizes and shapes. And so that feedback mechanism then can allow them to develop strategies to adopt technology in a specific dimension or domain that they may not be strong in. They can also see where they’re very strong in areas that others might not be. And in some ways, that can help a facility administrator who is doing strategic planning to think about how to integrate their systems and who has similar types of technology in the region where they’re located and how can they utilize their technology best to build better systems of connectivity, not only with other facilities but with clinical support facilities like labs and pharmacies. They’re very interested in understanding how technology is being used in a facility and what technologies help them in building better systems with their external partners. Hospitals would be very interested in utilizing that information because hospitals are trying to reach out, and we find that there is a big trend in health information exchange, and so better information systems allow better information exchange and sharing of information, which I think is something that is on the cusp of becoming national. There’s a national plan I believe being developed for that type of activity, and nursing homes need to be ready for that. So seeing where you are in the current and how you relate to other facilities gives you an edge, and I think that would be important for their boards and their stakeholders to know.

DG: Definitely. I just did a podcast recording on transitions of care, and I see a lot of the same issues coming up about sharing of information on patients or residents. Greg, where do you see that healthcare information technology (HIT) headed for the nursing home sector?

GA: So one of the areas that I think will grow in the future is use of technologies that residents and caregivers and families are able to access and to participate in communicating about the care of the people that they care about who are in these facilities. Right now we’re still struggling I think as an industry with adoption of information systems, although they are getting better. Trends are showing in the study, you’ll find a nice graph of two-year trends, trends in every dimension and domain have increased over the last two years. We just finished our third wave of studies back in December and I have data on the three-year trends. And the three-year trends are showing even greater growth in each dimension and domain. So health information technology is becoming more widespread in nursing homes. But that is mainly healthcare information technology that is used by staff, clinicians, administrators. There are very few facilities that are utilizing resident-centered or patient-centered types of technologies to adopt technology that would allow a patient’s family to communicate with them through some sort of a personal portal or to be able to participate in the care. Many of the family members live far away, they don’t just live down the road. So there is a need for better communication, better understanding about the daily care of people in these facilities, and I think technology that’s focused on a patient-centered environment can help inform people, and that’s going to improve satisfaction, hopefully make care safer because the resident will actually get what they want and the family will be informed. And they have a right to participate in their own care. So I believe these systems are probably in our future, very near future. And decision support analytics, I think in nursing homes, another area is decision support analytics. With the trends in increasing technology, these big data sets are going to become more important. We have a history of that with the CMS Medicare nursing home compare data, which is a large big data set of nursing home quality measures and safety measures, as well as staffing. But I think there is much more that can be used out of electronic information systems that are collected about residents and in some cases perhaps self report, different kinds of bedside assessments utilizing the patient’s input and the resident’s and caregiver’s input might inform us better about actually how a resident is doing rather than rely on the subjective reports of professionals who are trained of course but you know, involving the resident patient in that I think is becoming something more important and will be in the future.

DG: Definitely. All good points. Greg, I have one more question for you. I know that this study goes through 2022, but do you have any follow-up studies planned?

GA: Yes, we do. We are currently conducting—finishing up a study. It’s called a Delphi panel study, and we have about 32 experts from around the country that have participated in our annual survey for several years. And we recruited them to participate in another study to develop a tool that would allow us to stage a nursing home by their level of IT sophistication in each of the dimensions and domains. And so with the staging tool, we can actually look at a facility that has no technology, at a stage 0 all the way up to a stage 6.

DG: No technology?

GA: Yes, well that’s very rare. But you might find a facility that might have no technology in a clinical support area. Like maybe they have no technology related to lab results reporting. So it gets down to very specific forms of capabilities. And to be able to trend those very specific forms of technology capabilities is important you know, because not everybody has the capability to receive and send reports about radiology or pharmacy, things that are typically not on site in a nursing home. So we trend those, so there could be facilities that have pockets of no technology within a specific dimension and domain all the way up to a level 6, that is where the residents are actually able to implement and provide feedback into the information that system. That’s a stretch right now, very few facilities have the capability and have implemented a portal like that. So yes, we have a broad range in that staging criteria, and we’re just about finished with that staging criteria. And then what we’ll do with that model—it’s called an IT maturity model—and what we’ll do is we’re doing another national survey over the next four years where we’re actually trending technology again. So by the end of the study in 2022 we’ll have about seven to eight years worth of trended data about technology in each of these dimensions and domains of IT sophistication in nursing homes across the nation.

DG: Well thank you so much, Greg, for providing greater detail on your report, it truly is groundbreaking. And to all our listeners, thank you for taking the time to tune in. For more information on the Sinclair School of Nursing at the University of Missouri, visit Nursing.Missouri.edu. And if you’d like to learn more about SmartLinx and our fully integrated suite of workforce management solutions, including our payroll-based journal reporting tool, visit us online at SmartLinxSolutions.com.

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