by Gregory L. Alexander PhD, RN, FAAN
University of Missouri, Sinclair School of Nursing
This column was made possible by an educational grant from
Alexander, G. (February, 2012). Guest Editor. Considerations for Clinical Design and Usability of IT in Long Term Care. Crucial Conversations about Optimal Design Column. Online Journal of Nursing Informatics (OJNI),16 (1). Available at http://ojni.org/issues/?p=1250
Information Technology (IT) systems implemented in long term care, such as nursing homes are more commonly used today in the care of frail elder patients than in the past few years. Patient care models incorporating the use of IT systems by nurses and other ancillary staff are gaining wider acceptance by leaders managing the long term care of patients. For example, pioneers in aging services among 19 different organizations noted technologies are being implemented to facilitate strategic initiatives, including: 1) infrastructure technologies supporting wireless networking to connect staff of multisite organizations, 2) safety technologies such as fall detectors or electronic call systems, 3) health and wellness technologies to monitor medication compliance and remote sensor monitoring of residents to monitor functional status, 4) documentation technologies enabling point of care documentation at the bedside or other locations, and 5) social networking technologies to connect residents with family, peers and their retirement community1. Successful deployment and use of these technologies by their end users depends greatly on their clinical design and usability. The purpose of this editorial is to discuss relevant clinical design and usability issues for technologies which are fast becoming part of the long term care landscape.
Commonly held goals of good clinical design and usability in healthcare are to improve the efficiency, effectiveness and satisfaction with technological tools used by end users2. Each technological innovation implemented into a clinical setting should have met rigorous clinical design and usability standards before being implemented3. Optimal clinical design and usability of patient care technologies is required because their effect on patient outcomes is often critical to life. For example in long term care, nursing home staff deploying electronic sensor mats to detect patient movement out of bed or around the room (a type of safety technology) can encounter problems if mats are not positioned correctly, which could leave patients vulnerable to falls. Current systems using these safety monitoring methods do not provide adequate means to track positioning of mats in patient rooms nor are these systems integrated with other electronic health information. Furthermore, electronic sound devices connected to the fall alarms on the sensor mats are typically not integrated with nursing staff communication systems (a type of infrastructure technology), so if nursing staff are not within ear shot of the alarm they could miss important cues, which could result in a fall and life- threatening injuries even though mats are in proper position.
Future clinical IT designs will change the nature of data collection, facilitate clinical decision making, and enhance nurse care coordination. New research using sensor technologies embedded into carpets or using motion sensing Kinect technologies embedded into patient residences demonstrates that new methods of fall detection are on the horizon for nurses4. Additionally, new methods for integrating early illness warning systems to notify staff directly when activity level has changed are being used in clinical settings. The key to success for these inventions are that inventors including engineers are working side by side with health care professionals and patients as they are developed, implemented, and used in actual clinical settings. During these critical interactions, clinical design and usability goals are repeatedly reviewed and discussed, creating better use of systems through knowledge sharing and meeting expectations of end users5. Engineering these systems to meet good clinical design and usability goals should improve quality of patient care, including those associated with falls.
Despite its promise for improving care, the use of sophisticated technologies such as fall detection systems, described previously, have few links established with key quality measurement systems in long term care. Therefore, the impact of achieving good clinical design and usability of innovative technologies is limited by the fact that we don’t know how patient care outcomes are affected by quality improvement initiatives incorporating clinical design and usability goals. This has been a limiting factor in the implementation of clinical design and usability methodologies to support system development. With our limited scope of the value of good clinical design and usability on actual patient care outcomes (e.g. long term care quality measures) few administrators may be willing to incur the costs of these important assessments.
There are many sets of patient outcomes that could be used as benchmarks to assess good usability and clinical design measures. Primary resident outcomes in long term care as measured by Quality Measures for nursing homes are found in publicly available Minimum Data Set information known as Nursing Home Compare6. Nursing Home Compare is a dataset that can be downloaded and/or searched by anyone in the world who wants information about US nursing homes. Facilities that care for higher-risk residents will typically have higher Quality Measures; likewise, facilities that care for lower-risk residents will have opportunities for lower Quality Measures. Risk adjustments make the results in the dataset comparable between facilities by reflecting the quality of care provided rather than differences in resident populations7. Few links have been made between the use of these Quality Measures and use of IT in nursing homes. No links have been made between the use of nursing home Quality Measures and clinical design and usability goals.
In long term care, prior research has been conducted in Missouri nursing homes demonstrating that Quality Measures are significantly correlated with greater IT sophistication8. IT sophistication was defined as the types of IT used, extent of use, and degree of integration. Quality Measures that are significantly correlated with nursing home IT sophistication included residents’ with declining activities of daily living and residents experiencing increased incontinence. As IT sophistication increased, residents experiencing decline in daily living activities increased, which might indicate that nursing home staff using IT documentation systems had more complete records of resident activities and so detected more episodes of decline. In contrast, increasing IT sophistication in Clinical Support processes, that include computerized laboratory results reporting, were associated with improved incontinence Quality Measures. Clinical Support IT systems reduce incontinent episodes by fostering earlier communication and treatment for residents with urinary tract infections.
Even though these outcomes are encouraging, there is no real connection between what makes the IT more valuable from the viewpoint of patient outcomes and good clinical design and usability. More than likely some clinical design and usability features of these technologies were critical to their success. For example, one of the nursing homes, in the study described, had high levels of IT sophistication use and IT administrators had implemented interactive features that caused computer screens to change colors from grey to pink when activities of daily living tasks, like turning and repositioning, were documented electronically by nurse assistants. These color changes made it easier for nurses to track what activities of daily living were completed by nurse assistants on a consistent and timely basis9. However, nurse assistants did not always view these changes as positive, because their work was under the watchful eye of their peer. Furthermore, nurse assistants in nursing homes have never documented their information in a permanent medical record before, so the scope of their work was changing as the electronic health record was implemented. Ongoing training and communication of all staff played an important role in decreased resistance to use of the information system. Certainly, these clinical design and usability issues could facilitate changes in patient outcomes, thus quality measures. It is critical that connections between clinical design and usability and patient outcomes be explored to maximize the opportunities and benefits of these systems for end users and patients.
(1) Leading Age CAST. Preparing for the Future: Developing Technology-Enabled Long-Term Services and Supports for a New Population of Older Adults. Washington DC: Centers for Aging Services Technologies; 2011.
(2) Alexander GL, Staggers N. A systematic review on the designs of clinical technology: Findings and recommendations for future research. Advances in Nursing Science. 2009;32(3):252-279.
(3) Staggers N, Rodney M, Alafaireet P, et al. Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model. Chicago, IL: HIMSS; 2011.
(4) Stone E, Skubic M. Passive in-home measurement of stride to stride gait variability comparing vision and kinect sensing. Proceedings, EMBC 11; Boston, MA: IEEE Engineering in Medicine and Biology Society; 2011:6491-6494.
(5) Alexander GL, Rantz MJ, Skubic M, et al. Evolution of an early illness warning system to monitor frail elders in independent living. Journal of Healthcare Engineering. 2011;2(2):259-286.
(6) Centers for Medicare and Medicaid. Nursing Home Compare. http://www.medicare.gov. 2005 February 4. Query: does date belong here? If so , should probably change format or use direct URL of page you used. Maybe this one [http://www.medicare.gov/NHCompare/Home.asp]
(7) Medicare Quality Improvement Organization Program. Chapter 4: Risk Adjustment. NursingHome Quality Initiative: Quality Measures Resource Manual Version 5 0. 2008 October; http://www.qualitynet.org. Accessed January 22, 2011. Query: does date belong here?
(8) Alexander GL, Madsen R. IT sophistication and quality measures in nursing homes. Journal of Gerontological Nursing. 2009;35(7):22-27.
(9) Alexander GL, Madsen R. A case study in communication strategies used for pressure ulcer prevention in a nursing home with high IT sophistication. 11th International Congress on Nursing Informatics 2012. In press 2012.
Proofed by Paula Lane.