Use of Electronic Information Systems in Nursing Homes, United States 2004

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   Research Paper    Use of Electronic Information Systems in Nursing Homes: UnitedStates, 2004 H ELAINE  E. R ESNICK , P H D, MPH, B ARBARA  B. M ANARD , P H D, R OBYN  I. S TONE , D R PH,M AJD  A LWAN , P H D Abstract  Objectives:  This study sought to define the extent of utilization of 12 types of electronic informationsystem (EIS) function in U.S. nursing homes (NH), to relate EIS utilization to selected facility characteristics and tocontrast these findings to previous estimates of EIS use in NH. Design:  This study used data from the National Nursing Home Survey (NNHS), a nationally representative, cross-sectional sample of U.S. NH. Measurements:  Data on current use of EIS in 12 functional areas, including administrative and resident careactivities, were collected. Information was also collected on facility characteristics including ownership, bed size,and whether the facility was a member of a chain. Results:  Essentially all (99.6%) U.S. NH had  1 EIS, a figure that was driven by the nearly universal use of EISfor Minimum Data Set (MDS) reporting (96.4%) and for billing (95.4%). Nearly 43% of U.S. NH had EIS formedical records, including nurse’s notes, physician notes, and MDS forms. EIS use ranged from a high of 79.6%for admission, transfer, and discharge to a low of 17.6% for daily care by certified nursing assistants (CNAs).Ownership, membership in a chain, and bed size were associated with use of selected EIS. Larger facilities andthose that were part of a chain used more EIS than smaller standalone facilities. Conclusion:  In 2004, NH use of EIS for functions other than MDS and billing was highly variable, butconsiderably higher than previous estimates.   J Am Med Inform Assoc.  2009;16:179–186. DOI 10.1197/jamia.M2955. Introduction Nursing homes (NH) have been thought to lag behindother health care settings in the adoption of health infor-mation technologies (HIT). 1 However, few studies havecharacterized the use of HIT or, more broadly, electronicinformation systems in NH, or the relationship betweenfacility characteristics and use of electronic informationsystems at a national level. This article addresses basicgaps in existing knowledge of electronic informationsystems use by providing the first national estimates of their use in 12 functional areas in United States NH andcontrasting these findings to published estimates in NHand in other health care settings. Background Rationale for Need As in other provider settings, adoption of electronic infor-mation systems in NH has the potential to add value byimproving efficiency in administrative and operational ar-eas, and more importantly, by helping to integrate servicesand improve quality of care. 2 Because quantitative data thatcan be tracked over time are a core requirement for contin-uous quality improvement (CQI), it follows that improve-ment in systems that facilitate data collection and trackingfor patient care can also facilitate CQI. Challenges to Adoption Well-described barriers to implementation of electronic in-formation systems include lack of access to capital byproviders, high initial costs with uncertain payoff, complexsystems, and lack of data standards that permit exchange of data, privacy concerns, and legal issues. 3 Relatively fewhigh-quality studies have demonstrated the value of elec-tronic information systems for cost-effectiveness, efficiency,and quality of care. Nonetheless, there is potential for NHproviders and resident populations to benefit substantiallyfrom electronic information systems. For this reason, bench-marks on use of electronic information systems in the NHsetting are valuable. However, when evaluating the incor-poration of information technologies into provider settings,one must adopt and apply standardized definitions of electronic information systems—a feature lacking in previ-ous studies. This methodological issue can lead to difficulty Affiliations of the authors: Institute for the Future of Aging Services,American Association of Homes and Services for the Aging (HER,RIS), Washington, DC; Department of Medicine, Georgetown Uni-versity, (HER), Washington, DC; American Association of Homesand Services for the Aging (BBM, MA), Washington, DC; Center forAging Services Technologies, American Association of Homes andServices for the Aging, Washington, DC (MA).Correspondence: Helaine E. Resnick, PhD, MPH, American Associ-ation of Homes and Services for the Aging, 2519 ConnecticutAvenue, NW Washington, DC 20008; e-mail:    .Received for review 8/08/2008; accepted for publication10/13/2008 Journal of the American Medical Informatics Association Volume 16 Number 2 March / April 2009  179  in interpreting data within and between studies. Recently,standard definitions were released by the National Alliancefor Health Information Technology (NAHIT). 4 With one notable exception—a report focused on medicationadministration records 5 —previous quantitative studies of electronic information systems in NH focused on singlestates 6,7 or particular segments of the industry, such asmembers of a trade association or interest group. 8,9,10 Otherreports on electronic information systems use and barriers touse in the NH setting have provided important information but are based on case studies, expert panels, or qualitativemethodologies that have limited generalizability and repro-ducibility. 1,11,12,13 Research Question Responding to existing gaps in the literature and to meth-odological limitations of previous reports of electronic infor-mation systems in U.S. NH, we analyzed data on use of electronic information systems in U.S. NH from the firstnationally representative study to collect this information. Methods Study Design and Data Collection In the 2004 National Nursing Home Survey (NNHS), 1,500facilities were selected from a sampling frame of approxi-mately 16,000 U.S. NH at that time. The sampling frame wasdrawn from two sources: (1) the Centers for Medicare andMedicaid Services Provider of Services file of U.S. NH, and (2)state licensing lists. Of the 1,500 sampled facilities, 283 refusedto participate and 43 were considered out of scope for one ormore of the following reasons: the NH had gone out of  business, it failed to meet the definition used in the survey, orit was a duplicate of another facility in the sample. A total of 1,174 NH participated, resulting in a response rate of 81%. 14 Use of Electronic Information Systems The Facility Component of the NNHS survey consists of data collected during an in-person interview with the NHadministrator. Respondents were presented with a cardlisting 12 functional areas, and asked to select all areas thatwere supported by electronic information systems in theirfacility. The wording of the question was, “Does {facility}currently use electronic information systems for any of thetasks on this card?” The 12 areas that were assessed were: ã  Admission, discharge, and transfer ã  Physician orders ã  Medication orders and drug dispensing ã  Laboratory/procedures information ã  Patient medical records ã  Medication administration information ã  Minimum data set (MDS) ã  Dietary ã  Daily personal care by nursing assistants ã  Billing/finance ã  Staffing/scheduling information ã  Human resources/personnel information.No definition of electronic information systems was pro-vided overall, or for any of the specific functional areas, withone exception: a help screen clarified for respondents that“patient medical records include nurse’s notes, physiciannotes, and MDS forms.”Each of the electronic information system functional utiliza-tion variables was coded as yes/no. A variable representingany use of electronic information system was derived fromthese 12 variables. A second variable representing use of electronic information systems to support functions otherthan billing and MDS was also created. Similarly, a variablerepresenting the total number of electronic informationsystems used in each NH was derived by summing  yes responses for each item (n  12 functions maximum), and acorresponding variable was created representing the totalnumber of systems supporting functions other than billingand MDS (n    10 functions maximum). We also createdthree variables to represent different combinations of elec-tronic information systems related to electronic healthrecords (EHR). For the purposes of this report and tofacilitate comparison with previous studies, a facility withelectronic patient medical records was said to have “EHR A”capabilities; a facility with electronic patient medical recordsplus electronic information systems for three additionaldirect care functions (physician orders, medication orders/drug dispensing, and laboratory/procedures information)was said to have “EHR B” capabilities; and a facility with allof the electronic functions in EHR B plus medication admin-istration information was said to have “EHR C” capabilities. Facility Characteristics The 2004 NNHS contained information on ownership status(for-profit vs. all others, including nonprofit, local, and stategovernment and Veterans Affairs). The terms for-profit andnot-for-profit are used to describe this variable. Variablesdescribing whether the facility was a member of a chain(yes/no) and the number of beds (3–49, 50–99, and 100  )were also recorded. Statistical Analysis Analyses were conducted with the PROC SURVEYFREQprocedure in SAS, which takes into account the strata,cluster, and weight variables that define the complex sam-pling approach used in the NNHS. This procedure was usedto generate proportions and to conduct chi-square tests. Invarious analyses, we examined facility characteristics inrelation to use of individual electronic information systems,and we also examined these characteristics in relation to thetotal number of systems that were in place at the time of thesurvey. Reported p-values are for chi-square tests of differ-ences in proportions of these cross-tabulated data. The finitepopulation correction was used per National Center forHealth Statistics recommendations for the NNHS Facilitydata file. Data are presented in a manner that applies to allU.S. NH in 2004, and estimates are based on at least 30observations, because fewer observations could be unreli-able. Results Table 1 summarizes selected facility characteristics of NH inthe 2004 NNHS. Slightly more than half of U.S. NH weremembers of a chain, and 61.5% were for-profit. Electronicinformation systems data were available for 1,172 of 1,174facilities in the NNHS, representing approximately 16,054facilities nationwide in 2004. Essentially all (99.4%) NH hadat least one electronic information system, a figure that wasdriven by the fact that nearly all facilities had systems forfederally required MDS reporting (96.4%) and for billing(95.4%; Figure 1). After exclusion of MDS and billing, 91.6% 180  Resnick et al.,  EIS Use in Nursing Homes: United States 2004  of NH had at least one electronic information system, withnearly 80% of facilities using electronic systems for admis-sion, discharge, and transfer. Beyond MDS data capture and billing, there was marked variability in the extent to whichU.S. NH utilize electronic information systems for othertasks. For instance, only 17.6% of NH used electronic infor-mation systems for daily personal care by nursing assistants,and less than half used these systems to support physicianorders, medical records, the laboratory, and medicationadministration.There was considerable variability in the total number of electronic information systems used by NH (Figure 2). Although Panel A suggests that only a small proportion of facilities had 2 or fewer systems, only 10%, Panel B, whichconsiders the 10 functional areas other than MDS and billing, shows that nearly 30% of facilities had two or fewersystems in place. Regardless of whether MDS and billing areconsidered,   5% of U.S. NH used electronic informationsystems for all 12 of the functional areas that were assessedin the 2004 NNHS.Compared to for-profit NH, not-for-profit facilities usedelectronic information systems more often for laboratory(45.4% vs. 38.9%, p  0.05) and human resources/personnelinformation (65.8% vs. 54.3%, p    0.001) and less often fordietary information (46.4% vs. 54.3%, p    0.05). Facilityownership was unrelated to electronic information systemuse in other areas. Those NH belonging to a chain hadgreater use of electronic information systems than freestand-ing facilities for admissions/discharge/transfer (82.7% vs.76.0%, p    0.01), dietary (57.2% vs. 44.2%, p    0.0001), billing (97.4% vs. 93.0%, p  0.001), and daily personal care by nursing assistants (16.9% vs. 11.9%, p    0.02; data notshown).Figure 3 shows that facility size was related in a stepwisemanner to electronic information systems use for admissions(p  0.0001), dietary (p   0.0001), billing (p   0.0001), andhuman resources (p    0.0003). Larger facilities were morelikely to have electronic systems supporting these functions.Utilization of electronic information systems differed by NH bed size (p  0.0001, Figure 4) and by NH membership in a chain (p  0.05). Larger facilities and those that were part of a chain tended to have a greater number of electronicinformation systems. Facility ownership category was notassociated with the number of systems utilized.Table 2 presents relevant comparisons from the authors’ bestknowledge of national estimates of EHR utilization in vari-ous health care settings. 15,16,17,18 The EHR adoption in NHcompares favorably to those in physician offices and possi- bly to those in hospitals. Nearly all nursing homes (96%) haddetailed electronic patient assessment information in 2004via the MDS. A smaller proportion (43%; EHR A) hadelectronic systems that included both the MDS and nurses’ Table 1 y Selected Characteristics of Nursing Homes,United States, 2004 TotalPercent Weighted NCharacteristicTotal* 100.0 (16,081)Member of ChainYes 54.2 (8,709)No 45.8 (7,372)Bed size3–49 13.9 (2,242)50–99 37.3 (6,005)100–199 42.5 (6,840)  200 6.2 (994)OwnershipFor-profit 61.5 (9,889)Nonprofit 38.5 (6,192)*Data are weighted using SAS SURVEYFREQ. Some categories maynot add to 100.0 due to rounding. F i g u r e 1.  Use of electronic in-formation systems in nursinghomes: United States, 2004.  Journal of the American Medical Informatics Association Volume 16 Number 2 March / April 2009  181  and physicians’ notes. About 20% (EHR B) had even morecomplete EHR functions, including physician orders, medi-cation orders, and laboratory information. Discussion Significance This report provides one of the first nationally representa-tive assessments of electronic information system utilizationin U.S. nursing homes. It provides quantitative data regard-ing functional use of electronic information systems in 12areas, offers new insight into use of these systems for bothclinical and nonclinical functions, and provides a baselinefor benchmarking future comparative work.Previous work suggested that NH lagged behind otherhealth care sectors in adopting electronic information sys-tems. A report prepared for the National Commission forQuality Long-Term Care concluded that “long-term care hasadopted information technology solutions even more slowlythan the rest of health care.” 19 That conclusion, whichcarried over to the Commission’s Final Report, and similarreports 20 are based on a 2006 report describing estimatesfirst assembled in 2004. That report compared estimates by asmall number of experts regarding information technologyadoption in NH, hospitals, and physician offices. 1 In con-trast, our results, derived from a nationally representativedirect sampling of NH, indicate considerably higher adop-tion rates, are consistent with reports from single states andsmaller surveys, and compare favorably to adoption rates of selected electronic information systems in physician officesand in hospitals.Several of the current results contrast markedly with thefrequently cited 2006 report. 1 The latter report estimatedthat 77% of NH used electronic information systems for billing, whereas our survey indicates that 95.3% of NH didso in 2004. The 2006 report estimated that 1% of NH had“computerized physician order entry”; the NNHS surveyassessed use of electronic information systems for “physi-cian orders”, and indicated that 48.5% of U.S. NH did so.Finally, the 2006 report estimated that 1% of NH had F i g u r e 2.  Distribution of elec-tronic information systems innursing homes: United States,2004. Distribution in panel A in-cludes MDS and billing; distribu-tion in panel B excludes thesefunctions. F i g u r e 3.  Use of selected electronic information systemsin nursing homes, by bed size, United States, 2004. 182  Resnick et al.,  EIS Use in Nursing Homes: United States 2004
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