Clinical Information Systems in Nursing Homes - An Evaluation of Initial Implementation Strategies

Clinical Information Systems in Nursing Homes - An Evaluation of Initial Implementation Strategies Alexander GL, Rantz M, Flesner M, Diekemper M, Siem C CIN: Computers, Informatics, Nursing 2007 July/August 25(4) 189-97

Introduction: This article presents qualitative research reporting the results of an evaluation of a CIS deployment at four nursing homes Disclosures: There are no explicit disclosures of conflicts of interest. The study received funding from the Centers for Medicare and Medicaid Services and the National Library of Medicine. Background: Long term care facilities have not deployed clinical computer systems in large numbers. Nursing home staffing and workflow have some unique characteristics that may influence the initial CIS deployment experience Question: The authors do not state an explicit research question. They present the results of qualitative research on the deployment experience of a long term care CIS that uses bedside data collection via portable devices Objective: The research goals are explicitly stated as "...to explore and analyze initial implementation strategies, employee experiences, and factors influencing employee satisfaction…" during the six months after implementation of a new long term care CIS. Methods: the authors recruited long term care facilities by advertising in "association newsletters". The project facilitated partial funding by federal grants. No funds were provided by the vendor to support the research. Each facility selected their own implementation methodology. Data was collected by observation of work on the nursing units and by holding staff focus groups. Issues were stratified as related to implementation strategies and staff reactions to the implementation. The authors then associated the reaction themes with human factor subsystems of Environment, Operator and Machine. Key Findings: Issues that emerged from the focus groups included site preparation, system testing and conversion, start-up, equipment projections and availability of on-site technical expertise. Human factor themes included Perception and Cognition, Change, Workable Systems, Competence, and Connectedness. Perception and Cognition issues included feeling forced to adopt the new system and ease of use opinions both positive and negative. Negatives were driven by lack of IT resource available and equipment issues. Change issues included initial slowness of the system, changes in terminology and location of information, increased accountability and workload and new messaging and documentation systems. Workable system issues included training and responsibility issues both positive and negative and the need for the correct number of devices. Competence issues were driven mostly by mentoring and training and space for training characteristics. Connectedness issues included redesign discussions that emerged from enhanced communication capabilities and a potential reduced need for nursing stations. Discussion: The authors note that the five human factor themes provide a framework for planning future CIS deployments. They suggest creating a framework that explicitly addresses each of these areas at the outset of an implementation. Suggested tactics include the development of a charter, a communication plan, careful assessment of equipment needs, training and a plan for ongoing support after deployment. Reviewer Comments: The article draws attention to some of the characteristics that distinguish long term care from acute care and ambulatory care CIS deployments. The use of focus groups formalizes the solicitation of feedback from users and draws associations between deployment tactics and the resulting opinions of users. This study breaks little new ground and reinforces deployment principles which are commonly understood (but perhaps less commonly implemented) but does extend these principles to the long term care setting. It provides a useful overview to long term care administrators and staff who may be contemplating the move to an electronic medical record.