Health information technology (HIT), while an increasing priority for long term care providers, often triggers questions about whether the potential is more promise than reality. HIT is expected to help make daily work more smooth and efficient for clinicians while supporting improvements in delivery of care and associated resident outcomes. In practice, however, there are often unexpected challenges.
Learning how to use technology takes time and considerable effort, and, once mastered, the technology may disappoint frontline caregivers who struggle with integrating the new HIT into daily practice.
Described in this article is an approach for implementing HIT by showing frontline staff how to leverage it to support clinical decision making. This approach makes a clear connection between HIT use and quality improvement (QI) and focuses on care process improvements to impact outcomes.  

An Approach That Works

Known as Quality Improvement Integrated into Information Technology (QI-IT™), it is an approach based on principles of QI, information analytics, clinical workflow reengineering, and more than 10 years of experience working with more than 100 skilled nursing facilities to implement quality improvement strategies as part of HIT implementation.
The purpose of this article is to describe the QI-IT approach and better explain why and how quality improvement considerations should be explicitly integrated into the process of implementing HIT in skilled nursing facilities to help narrow the gap between clinician expectations and reality.
For organizations that may be struggling to gain user acceptance of newly installed HIT, disappointed with the results, or struggling with establishing an explicit link between HIT and improved clinical processes and outcomes, this article may offer helpful insights.
At the core of the QI-IT approach is the idea that when specific quality improvement goals, clinical processes, and outcome improvements are integrated into facility strategies and plans for using information technology, then there is a clear QI-IT link and expectation that HIT will support the hands-on caregiver team using clinical best practices on a routine basis.
By employing specific QI objectives, the HIT implementation discussions take on an added dimension, and frontline staff are encouraged to think about HIT’s purpose beyond automating paper processes.
For example, implementing HIT to promote earlier identification of residents at risk for pressure ulcers, falls, or hospital transfers is a tangible goal, versus implementing to improve resident clinical care in general. Confirming the specific care processes and outcomes to improve sets a framework that frontline staff understand and helps identify particular aspects of processes that will impact resident care.
There are three guiding principles of the QI-IT approach. While these principles might be intuitive, the extent to which they are considered simultaneously with HIT implementation plans should be objectively assessed in order to maximize the potential of HIT and gain user acceptance.
The principles are: Focus on QI objectives, improved processes, and outcomes first; leverage capabilities of HIT to support specific QI objectives; and be strategic when integrating HIT into workflow.
An important factor embedded in all three principles is involvement of multiple disciplines and frontline staff throughout, whereby the entire care team focuses on QI goals, processes, and information needs and how HIT supports them. 

Applying QI-IT

Two scenarios illustrate the impact of QI-IT. In the first scenario, a facility automates its admission assessment form as part of a plan to automate all nurse assessments. To this end, the facility team creates a replica of the existing admission assessment forms in the new computer system. Minor revisions are made to the online admission assessment, but it appears very similar to the paper forms.
The team is pleased with the new electronic admission assessment and is optimistic that nurses will adapt readily to completing the form online because the form will be familiar to nurses, requires no change to workflow, and does not entail new learning.
The electronic system provides updates to the automated assessments, and the facility is pleased to have the ability to see progress of the assessments, which aids in the management of outstanding work or overdue or incomplete documentation.
The nurses find the online admission assessment form easy to use, medical records staff monitor status and follow up with nurses who have not completed admission assessments, and work has been streamlined.
However, the team is not able to say that HIT is helping to identify resident needs or risks in a more timely manner, nor are they able to say that they are better coordinating care with physicians and other disciplines.
In another scenario, QI-IT is used. The facility automates its admission assessment process with the goal of using HIT as a tool to promote earlier identification of high-risk factors for new admissions, ensure appropriate care plan interventions are in place, and improve communication to the entire care team.
Applying QI-IT principles prior to implementing HIT prompts the multidisciplinary team to review the admission assessment form, including the information that is recorded, the processes used to complete them, and how other disciplines use the assessment information.
Opportunities for process improvement are explored throughout the review. One commonly identified improvement is the management of risk factors for new admissions. Specifically, the team would like to ensure resident risks are identified upon admission and communicated among disciplines in a more timely manner.
In addition, they want appropriate risk assessments completed in a timely and consistent manner and appropriate care plan interventions to be in place for each risk identified during the admission assessment process.
The team discussion also expands to consider the HIT dynamic and analytic capabilities.
For example, the discussion centers on how HIT can prompt the ongoing review of high-risk factors on a consistent basis. In this process, the high-risk factors assessed on admission are confirmed, and the team ensures that the risk elements are included when designing the admission assessment. Input from multiple disciplines and users of admission assessment data help identify information gaps, and workflow issues are uncovered.
The HIT implementation discussion broadens to a review of care process and information needs and how HIT supports frontline caregiver practices. Disciplines involved in the management of each risk are invited to participate. Discussion with the HIT vendor includes a review of the facility’s requirements for admission assessment data entry as well as how information will be used.

A Different Perspective

Too often, facilities start HIT implementation by automating existing paper and paper processes. What is often overlooked is that current processes are not set up to use HIT optimally. As illustrated in the scenarios above, rather than simply automating existing forms or reports, the QI-IT approach encourages facility teams to think about implementing HIT from a different perspective—one that looks at how HIT is supporting improvements in the care delivery process.
Spend time up front to review current practices, drill into the details of information and communication flow, and identify where and how best practices can be integrated into frontline daily work.
Linking HIT to specific QI goals makes where and how HIT is used very concrete. It becomes a tool for improved information access and synthesis, clinical decision making, and care coordination.
Computers alone simply automate data processing without fundamentally impacting the way information is used or the quality of care. By embedding quality improvement principles into the implementation of HIT, data  can be harnessed for greater purposes, including the improvement of daily workflow routines, the effective monitoring and evaluation of resident progress, and clinical decision support tools that support delivery of care based on clinical best practices.
Sandy Hudak, MS, RN, and Siobhan Sharkey, MBA, are principals at Health Management Strategies, a health care consulting group focused on quality improvement and HIT implementation. Michal Engleman, PhD, a consultant working with HMS, is a professor in the Department of Sociology at the University of Chicago.