Impact of Electronic Health Records on Long-Term Care Facilities: Systematic Review

Background Long-term care (LTC) facilities are an important part of the health care industry, providing care to the fastest-growing group of the population. However, the adoption of electronic health records (EHRs) in LTC facilities lags behind other areas of the health care industry. One of the reasons for the lack of widespread adoption in the United States is that LTC facilities are not eligible for incentives under the Meaningful Use program. Implementation of an EHR system in an LTC facility can potentially enhance the quality of care, provided it is appropriately implemented, used, and maintained. Unfortunately, the lag in adoption of the EHR in LTC creates a paucity of literature on the benefits of EHR implementation in LTC facilities. Objective The objective of this systematic review was to identify the potential benefits of implementing an EHR system in LTC facilities. The study also aims to identify the common conditions and EHR features that received favorable remarks from providers and the discrepancies that needed improvement to build up momentum across LTC settings in adopting this technology. Methods The authors conducted a systematic search of PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and MEDLINE databases. Papers were analyzed by multiple referees to filter out studies not germane to our research objective. A final sample of 28 papers was selected to be included in the systematic review. Results Results of this systematic review conclude that EHRs show significant improvement in the management of documentation in LTC facilities and enhanced quality outcomes. Approximately 43% (12/28) of the papers reported a mixed impact of EHRs on the management of documentation, and 33% (9/28) of papers reported positive quality outcomes using EHRs. Surprisingly, very few papers demonstrated an impact on patient satisfaction, physician satisfaction, the length of stay, and productivity using EHRs. Conclusions Overall, implementation of EHRs has been found to be effective in the few LTC facilities that have implemented them. Implementation of EHRs in LTC facilities caused improved management of clinical documentation that enabled better decision making.


Title Findings Relevant to Review
The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study [27].
Original research, primary data collection.
Inconclusive results for effectiveness and efficiency:  No difference in time spent on activities before and after EHR implementation,  no change in proportion of time spent on oral communication, except at 23 months' postimplementation,  no major change was seen in documentation time, except at 23 months' post implementation time spent on all activities remained unchanged after introduction of her. Unintended adverse consequences of introducing electronic health records in residential aged care homes [28]. Report Ineffectiveness: This study showed negative results after introducing EHRs in residual aged care facilities like difficulty in access, Inefficiency: Increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up.
Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities [29].
Original research, secondary data collection.
Effectiveness: Results indicated that overall completeness and comprehensiveness rates of the admission forms were higher using electronic health records compared to paperbased records and enhanced quality of documentation in resident admission forms was recognized in the electronic documentation frameworks.
Caregivers' Time Utilization before and after the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility [30].
Original research, primary data collection.

Inefficiency:
The amount of time spent by personal care givers on documentation increased.

Can Electronic Tools Help
Improve Nursing Home quality [31].
Original research, primary data collection.

Effectiveness:
• Increased proportion of patients timely taking their doses • Patients taking neuroleptics gradually decreased from 33 to 25 percent • No change in internal controls

Title
Findings Relevant to Review Aged Care IT in Australia -the Past, Present and Future [32].
Original research, primary data collection.

Effectiveness:
The use of HIT in the LTC community gives ready access to specialty care services who look for patients that way. Efficiency: EHRs can facilitate the business end of aged care. The use of HIT in aged care forces legislation on accountability, security, privacy, and confidentiality. EHRs can also increase communication within a facility with lead to secondary effects of efficiency.
Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff [33].
Original research, primary data collection.
Inefficiencies: There was no significant difference in efficiency using an electronic nursing documentation system.
The benefits of introducing electronic health records in residential aged care facilities: A multiple case study [34].
Original research, primary data collection.
Effectiveness: Residential aged care facilities (RACFs) demonstrated improvements in quality of care. Efficient: RACFs demonstrated improvements in data management, working environment and educational benefits.
Experiences with electronic health records: Early adopters on long-term care facilities [35]. Original research, primary data collection.
Effectiveness: implementation of evidence-based practices Efficiency: operational improvements were achieved through increased access to resident information, cost avoidance, increased documentation accuracy.
The Use of Bedside Electronic Medical Record to Improve Quality of Care in Nursing Facilities: A qualitative analysis [36]. Original research, primary data collection.

Effectiveness:
The results reported that the use of a bedside EMR in nursing homes improved quality of care, better communication with physicians, and easy access to clinical information. Inefficiency: Staff reported EHRs to be time consuming.

The changes in caregivers'
perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home [37].

Effectiveness:
The caregivers perceived EHR as a provision of accurate, legible and complete information. They reported that there is a reduction in data repetition errors. These benefits were recorded during first 6 months after introducing EHR, but were not maintained at 18-21 months.

Title
Findings Relevant to Review Original research, primary data collection.
Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-Inclusive care for the elder sites [38].
Original research, primary data collection.
Inefficiency: Results showed that where the EHR utility was complex to work with or did not assist the clinical workflow, clinicians did not adopt the EHR as expected.
Initially, clinicians were dissatisfied, but upon usage they showed increased satisfaction Integrated care through diseaseoriented clinical care pathways: experience from Japan's regional health planning initiatives [39].
Original research, primary data collection.
Efficiency: These 'inter-provider critical paths' ensure effective integration (hand-offs) between various providers and levels of care ranging among primary care practitioners, acute care hospitals, rehabilitation hospitals, long-term care facilities and home care.
A pragmatic study exploring the prevention of delirium among hospitalized older hip fracture patients: Applying evidence to routine clinical practice using decision support [40]. Original research, primary data collection.

Ineffectiveness:
The electronic medical records when applied to delirium prevention strategies, failed to decrease delirium rates among the patients with hip fracture