Rural Nursing Homes Lag in IT Sophistication

By Jamie Santa Cruz

Technology in nursing homes in rural areas and smaller towns tends to lag significantly behind that found in more densely populated areas.

The subject of health information technology (IT) and its connection to quality of care in various health care markets has received significant attention in recent years. New research from the University of Missouri reveals that there are significant disparities in health IT between rural and urban nursing homes—a gap the researchers suggest is a point of concern.1

"Nursing homes that implement technology tend to have better quality. Any facility that is interested in improving quality should consider some forms of technology to improve clinical care, clinical communication, and care coordination," says Gregory L. Alexander, PhD, RN, a professor in the Sinclair School of Nursing at the University of Missouri and lead author of the study.

The study, the first national assessment of nursing home IT sophistication since 2004, relied on a cross-sectional survey of 815 nursing homes across all 50 US states. The survey, conducted between January 2014 and July 2015, examined three different dimensions of IT sophistication (IT capabilities, extent of IT use, and degree of IT integration) in three different domains (resident care, clinical support, and administrative activities).

The survey found that nursing homes in rural areas and smaller towns tended to lag significantly behind those found in more densely populated areas. This was true across all three domains examined and for almost every dimension of IT sophistication. In particular, there were significant differences in the degree of IT integration between rural and urban settings.

Although significant discrepancies exist, there is reason for optimism due to the fact that IT adoption is increasing across all types of long term care. Alexander and colleagues are currently trending IT adoption over a three-year period, and the current study is based on findings after the completion of the first two of the three years. "In every subscale of IT sophistication, there has been an increase in total IT sophistication from year one to year two," Alexander says. "So there appears to be some level of adoption occurring nationally in most nursing homes […] regardless of where they're located. So that's a positive sign."

According to Alexander, the growth may be due to national incentives for IT adoption provided to hospitals and ambulatory services; IT adoption in those settings may have influenced nursing homes. However, he adds, the growth that is occurring is happening at a slow rate.

Reasons for Disparity
The finding of significant disparity between rural and urban settings is not a surprise, says Michelle Dougherty, senior health informatics researcher at RTI International. Much of the disparity can be attributed to organizational differences between rural and urban organizations. Rural nursing homes, she says, tend to be smaller, and smaller organizations often lack the financial resources to fund major IT initiatives.2 They also tend to lack knowledgeable staff capable of implementing an advanced IT system.

Rural and urban nursing homes are often competing for the same resources in terms of staffing, Alexander says, and in many cases rural organizations are simply unable to attract the necessary talent. "One of the big issues in implementing technology in long term care is that you need somebody who is knowledgeable about long term care and also knowledgeable about IT system implementation," he says.

Aside from the mere size of an organization, the type of ownership characteristic of rural vs urban nursing homes helps to explain disparity in health IT. According to Dougherty, rural nursing homes tend to be single owner or community owned, rather than being part of large chains that have corporate IT resources to help implement sophisticated systems.

Sophisticated IT Systems and Link to Quality of Care
The lag in rural IT sophistication is a source of concern, Alexander says, because prior research shows that nursing home IT sophistication has a meaningful impact on quality of care. Nursing homes that have advanced, well-integrated technology systems, for example, are better able to detect declines in residents' daily activity levels; they also are better able to address problems such as incontinence and pressure ulcers.3

The major problem resulting from lack of IT sophistication is the fact that it compromises connectivity in a world that is becoming increasingly more connected, Alexander says. "Younger nurses or younger clinicians who are coming out of nursing schools right now are pretty tech savvy. They know how to use technology. They want to be connected. In a nursing home where you have less connectivity, it may not be as enticing an area to go to."

Not only does lack of connectivity make an organization less enticing to providers, but it also results in delays in care. In settings where the only means of connectivity is through faxes—or worse, postal mail—communication is necessarily slower, which sets patients up for lower quality of care. Nursing homes without advanced IT systems may have relatively sophisticated communication systems, such as pictures on patient doorframes to indicate fall risk or similar signage, but since these communication systems are not electronic, they are not shareable, Alexander says.

Some nursing homes have piecemeal technological solutions, but while these represent a step in the right direction, they are often not sufficiently comprehensive. For example, many nursing homes lack on-site clinical support services such as a lab, radiology services, or a pharmacy, Alexander says. "Oftentimes you'll find facilities that have integrated some technology related to lab or a technology that is related to radiology, but those two technologies don't communicate with each other," he says. Without a level of IT sophistication that allows communication across such systems, health care providers are hampered in their ability to make decisions at the same time they are caring for a patient.

Meanwhile, nursing homes that do have advanced IT systems benefit significantly from the built-in clinical decision support tools and workflow tools typically associated. More comprehensive IT systems, Dougherty says, put up flags or prompts when action is required. In organizations using remote monitoring and integrated electronic health records (EHRs), flags and prompts pop up in real time. Such real-time alerts are highly useful for the prevention of problems such as pressure ulcers, where a notification at the end of the day or a day later is too late, Dougherty says. "When you start to integrate the technology and tools into clinical practice so that it is happening in real time and not after the fact […], that's when you begin to see the real ways that IT can assist."

Keys for Improving IT Sophistication
For long term care systems looking to improve their technological capabilities, Alexander says it's not necessary to implement a highly sophisticated system overnight. "There are some intermediate uses of technologies that are beneficial," he says. "Some systems do not have full EHRs, but the systems they do have are very effective at improving quality. Then there are some facilities that don't have anything at all. If you can get a system to move from having absolutely nothing to incorporating some form of technology, we believe quality will get better."

To move toward a more sophisticated IT system, Dougherty says, the main key is to have a champion at the leadership level. Champions are important not only for spearheading the initial implementation of a new system, but also in reassessment. A poorly implemented system that adds extra work for nurses results only in frustration and wasted time, she says. The organization's IT champion has a critical role in monitoring how the system is being used, how the workflow progresses, where breakdowns are occurring, and how they can be fixed. "The champion is crucial," she says. "It really takes someone to be in that champion/leadership/superuser role to help an organization fit it into their workflow in an optimal way."

Safeguarding Quality in the Absence of Advanced IT Systems
As for nursing homes that currently lack sophisticated IT capabilities yet want to offer quality care, Alexander suggests there are some ways to compensate. One of the most sophisticated nontechnological systems, for example, is the use of colorful icons on residents' doors that inform providers of specific risks for that resident. The problem with this system is that if a patient leaves his or her room, it is difficult to have an icon system follow him or her. But such a system can be effective in the absence of a more advanced solution, Alexander says.

Organizations must be creative about helping information flow, even if not electronically. For example, Alexander says, when nursing homes store information only at a nurse's desk, it may not be easily accessible to a nurse at the far end of the unit. Nursing homes need to strategize on ways to make information more mobile and ease its flow, such as via medication carts able to store large amounts of information but also have the capacity to follow patients and go from the nursing unit to the dining room, for example.

More fundamentally, Alexander says, organizations without advanced IT must focus resolutely on the basics of good care: hydration, making sure residents are getting up and moving around, keeping them active, and interacting with them to observe any changes. "Technology is just a means of helping to support that," he says.

An Eye Toward the Future
Although nursing homes can adopt many practices to ensure quality of care even without sophisticated IT systems, organizational leaders need to think in terms of more advanced IT systems in the future, Dougherty says.

"We're at a time with changes that are happening in health care—in terms of both the delivery models and the payment models—where clinical technologies are going to be more and more important," she says. "As hospitals and physicians become more sophisticated, their expectations for their clinical partners are increasing as well. We're just now seeing some of that happen in the more urban areas, where those who can't communicate electronically or immediately share information with their clinical partners are […] losing referrals and admissions. Leaders have to recognize that the market is changing."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
1. Alexander GL, Madsen RW, Miller EL, Wakefield DS, Wise KK, Alexander RL. The state of nursing home information technology sophistication in rural and nonrural US markets [published online June 22, 2016]. J Rural Health. doi: 10.1111/jrh.12188.

2. Kruse CS, DeShazo J, Kim F, Fulton L. Factors associated with adoption of health information technology: a conceptual model based on a systematic review. JMIR Med Inform. 2014;2(1):e9.

3. Alexander GL, Madsen R. IT sophistication and quality measures in nursing homes. J Gerontol Nurs. 2009;35(7):22-27.