Advancing Health Information Technology Roadmaps in Long Term Care

Abstract

Background:

Our purpose is to provide evidence that health information technology should be a mainstay of all future health and social support services for older people globally, both within and across community and residential care services.

Methods:

This work was conducted in two phases. In phase I, the authors conducted a focused exploration by selecting a convenience sample of four long term care health information technology roadmaps, developed by members of four different long term care health information technology collaboratives in United States, Australia, United Kingdom, and New Zealand. During Phase II the research team carried out an extensive systematic review of existing literature sources (2000–2018) to support roadmap assumptions.

Results:

Using converging domains and content, we offer recommendations among five aged care roadmap domains: Strategy/Vision, Continuing Care Community, Services and Support Provided, External Clinical Support, and Administrative. Within these domains we provide recommendations in five content areas: Innovation, Policy, Evaluation, Delivery Systems and Human Resources. We recommend future strategies for LTC HIT roadmaps that include 61 emphasis areas in aged care in these content areas and domains.

Conclusions:

The roadmap provides a navigation tool for LTC leaders to take a strategic and comprehensive approach as they harness the potential of health information technologies to address the challenges and opportunities of LTC in the future.

1. Introduction

Globally, advancing health information technology (HIT) to support aging populations is critically important (1). This need arises not simply on account of increasing numbers of older people, but because of the disproportionate number who have, particularly in their later years, chronic conditions that may require long-term care (LTC). Chronic conditions are defined as those requiring ‘ongoing management over a period of years or decades’(2). They include such health problems as diabetes, arthritis, Parkinson’s disease, heart disease, different forms of dementia, respiratory and ocular problems (such as glaucoma and macular degeneration).

Naturally, the growth in both need and demand for health care services for older adults has placed substantial challenges on health providers. In order to respond to this need and demand, the importance of accurate and sufficient health information increases in order to facilitate accurate diagnoses and appropriate treatments. A parallel imperative is in place that calls for the greater use of what is a burgeoning range of technologies used by patients (whether at home or in care settings) or by clinicians’ or care providers’ in managing health data (including that which is held in their EHR (electronic health record) or PHR (personal health record) viz. HIT. Services that relate to the former (technologies in the home that help give people access to health services) come under the rubric of telehealth and which, when taken together with HIT, comprise eHealth (3).

The context for this paper is that clinicians must play a role in achieving higher levels of quality in LTC, if quality of care is to be maintained in this health care sector, HIT carries a higher degree of importance. The paper draws on a thorough literature review undertaken by researchers in four countries (Australia, New Zealand, the United Kingdom and the United States) in order to identify essential elements of LTC HIT roadmaps.

The essential elements of LTC HIT roadmaps would warrant the attention not just of strategists, policy-makers, clinicians and academics; but also designers of LTC HIT software - that must necessarily have the functional capacities associated with service provision; sufficient flexibility to allow access and use by patients as well as authorized professionals; and built in safeguards to protect against data theft and cyber-attacks. The broad context of the work is one in which, for the United States (U.S.) and Canada, strategic health policy goals center on improving patient outcomes while incorporating HIT across care continuums (4). Elsewhere, professional organizations (e.g. European Federation of Medical Informatics, Asia Pacific Health Information Management Systems Society, International Medical Informatics Association) are promoting policy drivers and benchmarking implementation of HIT and decision support in healthcare, more specifically, in support of the care of older people (5, 6). But, in either case, despite policy drivers (e.g. meaningful use in the U.S.) and the growing levels of need and demand, IT adoption rates in LTC which provide services for older people are slower than other health care sectors (e.g. acute care)(7, 8). Such slow adoption rates are thought to be due to limited financial resources for implementing and sustaining LTC technologies; deficits in human capital to support knowledge, skills, and experiences required to execute and maintain HIT; and finally, a shortage of vital networks supporting adoption, use, and information sharing using technology (9).

The purpose of this paper is to provide evidence that, given the growing need and demand, HIT should be a mainstay of LTC roadmaps globally. This affirmation will be addressed through responses to the following research questions: 1) What are the common domains and content areas of international LTC HIT roadmaps being used to guide research and policy development? 2) How does the evidence based literature relating to extant policy frameworks, and the conclusions drawn, support the domains and content areas that are common to international LTC HIT roadmaps?

Methods

This work comprised two phases. Phase I included focused explorations of a convenience sample of four LTC HIT roadmaps, developed by members of the four different countries involved (10–12). The researchers used primary sources (e.g. original documents and artifacts) to describe the history of these roadmaps as they developed. They presented and discussed the historical context of each HIT roadmap from each country during four separate webinars. Collaborative members who participate in professional organizations and businesses that audit government policy and lead IT research initiatives for LTC communities introduced roadmap content for each country. The researchers used content derived from professional organizations to identify common themes and developed an international LTC HIT framework that incorporated these themes. Historical contexts were evaluated with external and internal critiques to increase authenticity and worthiness of evidence (13). Meaning was inductively derived with qualitative content analysis methods by allowing domains and content areas to emerge directly from the LTC HIT roadmap data. The outcome was a combined descriptive summary of LTC HIT roadmap data (14). All the members of the international collaborative agreed upon definitions for categories.

Phase II included an extensive systematic review of existing literature sources. The literature was captured during a professional search conducted in Ovid Medline, which is the National Library of Medicine® (NLM) premier bibliographic database. Search terms, strategies used, and results are illustrated in Figure 1.

Figure 1:

Search Strategy and Results for Supporting Literature (2000–2018)

The identified literature was then organized by primary author’s name, publication year, type of technology considered, outcome measures for each study, and geographic location determined by primary author (See Supplementary File 1). The researchers systematically reviewed literature to support assumptions about roadmap domains, and content areas. Researchers agreed on five domains in five content areas.

• innovation (considering the nature of changing technologies including those specifically impacting on HIT);

• policy (accounting for policy imperatives that call service integration between primary and secondary levels and for s stronger patient-focus);

• evaluation (ensuring that service frameworks allow for careful monitoring of outcomes);

• healthcare delivery systems (promoting effective collaboration between all stakeholders); and

• workforce issues (or human resources, acknowledging that system changes require leadership and the development of new knowledge and skills – sometimes crossing old professional boundaries).

Investigators attempted to align literature sources with a distinct domains and content areas. Sources were cited with appropriate domains and content areas to support investigator assumptions (see Table 1).

Table 1:

Content Areas and Domains from Multi-national LTC Roadmaps with (Supporting Citations)

LTC Roadmap Domains	Technology Content Areas
	Innovation	Policy	Evaluation	Delivery Systems	Human Resources
Strategy/Vision	Increase emerging care delivery and payment models for LTC sectors. Create international and national digital authorities to promote use of meta-national datasets to increase coherence, equivalence and standardization of IT use and impact across the continuum of care, including LTC sectors Search for practical examples of IT usage in long term care settings	Tie use of centralized intelligent IT systems for appropriate monitoring, service use, and financial incentives to form a basis for longitudinal care coordination Harness partnerships to encourage IT research and development, improve technology uptake, innovation, and create sustainable LTC services Promote international informatics initiatives in all LTC sectors to develop sustainable, actionable, and generalizable evidence based strategies for assessment and quality improvement	Incorporate health intelligence to leverage stakeholder interactions, outcomes at individual and population levels Promote user centered design strategies during research and development of all patient and clinician facing IT systems	Create partnerships across the care continuum, enabling meaningful interoperable Health Information Exchange (HIE) tailored to the needs of all stakeholders Encourage stakeholders to leverage emerging technologies, expand health intelligence, changing provider relationships, and optimizing coordination services to enhance their “well-aging”	Identify caregiver, clinician, service worker, administrative and support staff, and executives connected to people, processes, and information used in the health system Develop a Digital Literacy Strategy for all types of LTC stakeholders to ensure they have skills to IT based products and services Leverage technology innovations to enhance workflow, care delivery, for improved outcomes
	(15–20)	(21–24)	(25–29)	(30, 31)	(32, 33)
Community Based Care	Reduce barriers to care delivery systems innovation Showcase tools, models, approaches, case studies and success stories that promote autonomy and independence Cross reference and coordinate quantified self and clinical data science Support research and development of emerging technology: Virtual Clinics, Wearables, Social Inclusion, Supported Discharge, Mobile Health Develop health intelligence expertise in LTC, services and support including in research and education	Support cross cutting data exploration activities in all care settings to support longitudinal care planning with all stakeholders Co-design strategies with consumers, families, and carers to be proactive in preparing for future LTC sector needs Develop and support a healthcare that is system agnostic removing distinctions between different settings of care Incorporate right to self-determination activities for use of emerging technologies to meet individual health care needs	Harmonize quality measures across the spectrum of care Advance person-centered assessments, quality measures Leverage “big data” to monitor and improve business service, care delivery processes, customer experiences, costs interactions and outcomes	Promote adoption of health intelligence and clinical decision support by LTC Create strategies to adopt patient facing IT that supports person centered longitudinal care initiatives Conduct feasibility studies and assess system safety	Promote innovative approaches that use real-time connections as a baseline standard Identify and promote case studies of business processes and models leveraging connected workers Challenge clinicians to redesign clinical pathways and processes that presume connected workers, patients and environments Promote workforce education and training for person-centered care that leverages technology use while maximizing security and privacy
	(34–45)	No Literature Sources Found	(46–51)	(9, 52–57)	(58)
Services and Support Provided	Encourage research, development, and dissemination of assistive technology enabling consumers to remain in the community longer	Consider newer life satisfaction measures for aging populations including social participation, emphasizing IT use	Evaluate usage and perceptions of technology for non-pharmacologic therapies Adopt technology that simplifies activities of daily living Design solutions that promote remote connectivity between residents and providers Adhere to systems with evidence based guidelines for better decision making	Create strategies to adopt clinician facing IT that supports person centered longitudinal care initiatives Support the creation of care navigators who use IT to respond to stakeholders needs across the care continuum Advance dialogues about how clinicians engage with personal health records	Encourage vendors to develop information systems which support the worker for: secure mobility, socialization, communication, workflow, intelligence, interoperability
	(59–68)	No Literature Sources Found	(69–80)	(7, 81, 82)	(83)
Clinical Support External to Facilities	Incorporate approaches using evidence based clinical rules in clinical processes used by all types of stakeholders	Seek out systems and software that promote real-time access to the information and enable communication with external stakeholders Discuss regulatory efforts and growing use of IT by disciplines external to facilities	No recommendations in this domain/content area in existing roadmaps reviewed	Advance HIE/PHR exchange (consumer centric tools; Communication technologies; decision support) Engage providers in HIE supported by use of vocabulary, data content, and secure transport interoperability standards Engage partners in meaningful HIE to provide safe and timely care delivery Recognize need for data exchange in emerging payment models to improve communication about care delivery	Educate on how and when to use HIE, involving all stakeholders involved in exchange Build networks of stakeholders that have ongoing input into the clinical processes of care and documentation being shared by personnel using the HIE
	(84–86)	(87, 88)	No Literature Sources Found	(11, 89–97)	(98)
Administrative	Improve awareness of funding initiatives implemented to support new payment models and clinical outcomes achieved	Promote adoption and sustainability of business foundation systems in LTC Pay for performance independent of setting	Support the advancement of transparent pricing and quality performance systems Increase awareness of staff perceptions and attitudes during IT implementation Discuss implementation methods for specialized monitoring equipment	Align financial incentives between clinicians, providers, and clinical support services in all healthcare sectors	Identify worker core health IT competencies Encourage best practices for security and privacy in the use of connected technologies and smart environments
	(99)	(26, 100)	(101–108)	No Literature Sources Found	No Literature Sources Found

2. Results

3.1. Content Analysis of International LTC HIT Roadmaps

Analysis of roadmaps from the four countries produced five LTC domains and five technology content areas that were consistently represented across roadmaps (Table 1). Within roadmap domains and technology content areas, 61 emphasis areas consistently emerged across all four roadmaps.

3.2. Research Literature on LTC HIT

The literature search resulted in 141 articles that were retained for further analysis. Sixty-one of the articles were not included for various reasons (see Figure 1). After further backward-forward searching, 19 additional articles were included. Of the 99 articles remaining in the study, 54% included U.S. studies, 26% European, 13% Australasia and 5% Asian. Most literature (63%) was published in informatics and clinically focused journals. Few (8%) articles were published in gerontology journals. Both the types of technology and health outcomes measured in this literature were discussed by the researchers.

After a review of article content (Phase II), emerging roadmap domains and content areas (Phase I) were applied to the research identified in the literature. Existing LTC HIT research was found in the content areas of Evaluation (32%), Innovation (32%), Healthcare Delivery Systems (22%), Policy (14%), and Human Resources (14%). Within these content areas, majority of research related to Community Based Care (26%) and Services and Support Provided (26%). The other categories comprised Strategy/Vision (20%), Clinical Support (16%), and Administrative activities (12%). (See Supplementary File 1) Interestingly, none of the research literature included in this analysis, focused on Evaluation in Clinical Support External to Facilities, Policy in Community Based Care and Services/Support Provided, Administrative Activities and Human Resources. These gaps suggest that further research is needed to guide LTC HIT development in these domains and technology content areas being emphasized by LTC HIT experts in roadmaps.

4. Discussion

In this paper, authors conceptualized a LTC HIT roadmap as a navigation tool including a framework to guide strategic initiatives. Five LTC HIT roadmap domains and content areas were identified from four existing IT roadmaps in as many countries. These domains and content areas can assist LTC leaders to identify actionable and measureable strategies to achieve a better vision for LTC HIT.

Given the pace of technological development and the growth in need and demand for LTC, there is clearly an urgent need for LTC HIT roadmaps that incorporate HIT into future structures and planned services. The fact that many of the new technologies facilitate the collection and analysis of data that relates to LTC, both for (older) people in home or institutional settings, means that there is a need for greater attention to HIT in the LTC sector. Moreover, despite the slowness in uptake of many of the technologies, the trends drawn from this systematic review indicate that developments around LTC HIT maybe increasing rather than slowing. This is explained by the extent to which there are concerns about the challenges (both in the health and social care sectors) of caring for the growing number of older people. Thus, it must be noted, this is as worldwide phenomenon, with increasing survivorship being associated with us all living with (sometimes multiple) long-term conditions. The associated costs of caring create an imperative that technological innovations are harnessed to enable higher levels of care to be provided and to enable more and more older people to play a part in their own care(109). eHealth developments are important facilitators of the latter(110).

To address these trends, entrepreneurs with specialized expertise in LTC HIT have been raising awareness of HIT’s benefits since the turn of the century. However, gaps still exist, for example, use of HIT in the domain of clinical support external to facilities (i.e. used in support of living in their own homes). Evidence discovered in this review demonstrated LTC facilities, such as nursing homes, have slower rates of adoption in clinical support HIT (i.e. laboratory, pharmacy, and radiology) over time. But, little is known about why this is the case. Furthermore, in existing roadmaps reviewed, there are no recommended guidelines for evaluation of external clinical support systems. Perhaps because, in most cases, these technological systems are not part of the true infrastructure, but are often part of contracted services in LTC facilities(111). Slow adoption rates may continue because successful adoption typically requires confidence in HIT vendors; high levels of support for HIT systems; a lack of interoperability between systems or elements of them; and poor IT fit within existing work patterns (111). Currently, there appears to be few policy frameworks that offer explanations for these shortcomings so that other healthcare providers could benefit from the lessons learnt(112). Until such gaps are addressed, LTC leaders may struggle to make evidenced based decisions to enhance the quality and content of their LTC HIT roadmap strategies.

The researchers found additional gaps in research related to roadmap domains and content areas in policy under community based LTC care. Some of the shortcomings relate to the absence of longitudinal care plans for older people with care needs; and a lack of co-design by which the recipients of care (and carers, often family members) might be involved in the design of the technology and the related systems for care provision. Such involvement can help to empower many older people and can remove some of the stigma associated with LTC (113). Research gaps were also evident in LTC administrative activities under healthcare provision systems where emphasis areas included aligning financial incentives with various LTC stakeholders so that HIT adoption and use is maximized across settings. Also, in the area of human resources there are shortcomings in relation to the competency of staff in relation to the support to older people for whom technologies may be provided.

5. Limitations

As has been noted, the roadmap domains and content areas were designed through discussion and debate between LTC HIT experts (the researchers) in four different countries. Roadmap domains and content areas in other countries are likely to have distinctive cultural, social, economic, or technological infrastructures which may not relate to the domains and content areas for roadmaps set out in this paper. It follows that facilitating discussion between LTC leaders at international conventions to discuss such roadmap domains and content would, given the rapidly developing context, be a very worthwhile activity to pursue in the future. Already, the organizers of the 2019 Medical Informatics conference in Lyon France in association with the 1st European Union-China Health Summit on Medical Innovation and Collaborative Technology Transfer have begun to create a blueprint for a joint mission in aging between these two countries.

Another limitation is that research initiatives described in the literature oftentimes may have crossed more than one domain and content area. But each literature source was classified into particular domain and content area that was a best fit. LTC administrators who use this HIT framework are encouraged to think broadly across the domains and content areas to ensure the robustness of their strategic planning and/or the formulation of a roadmap that relates to their particular geographical, political, technological or cultural context.

Finally, the research team only used one database source (Medline) with a limited number of search terms to support and substantiate the assumptions being made across the collaborative roadmaps. Other databases including social sciences or discipline specific databases may have provided other important results, such as, evidence of IT in home health settings, which seems to be missing from our search results.

6. Conclusion

In 2017, HIT was ranked 4/10 for topics facing the future of LTC (114). LTC leaders acknowledge that HIT can add value to their systems for care provision and should be a major element within future roadmaps in this sector. It has been noted that the LTC HIT roadmap domains and content areas, set out in this paper, were developed with expert input from just four countries (Australia, New Zealand, United States and the United Kingdom). We recommend that other content and domains should be developed for other countries trying to implement an LTC HIT roadmaps. The current framework identifies five domains and content areas for roadmaps. This will be of substantial value to LTC providers who need to consider how HIT should ‘fit’ in the context of their short, medium and long term planning. The framework provides, therefore, a tool that LTC leaders should use to make decisions about strategic and comprehensive approaches to harness the potential of LTC HIT to address future challenges and opportunities. However, there are gaps that still persist in this framework, both in recommendations for service delivery (especially in clinical support external to facilities) and associated evidence to guide recommendations. These gaps need to be addressed through rigorous research or policy setting initiatives as technologies evolve in these areas.

Summary Points.

What was already known on this topic:

• Improved processes of care that lead to better quality of care are needed to support increasingly older and frail people living in aged care facilities around the world.

• Health information technology contributes to improved processes of care and enhances quality in healthcare, but little is known about technologies impact in aged care communities.

What this paper adds:

• An international aged care roadmap with HIT including a framework and organizational scheme with 5 domains for planning and provision of aged care, and within these domains 5 technology content areas.

• The roadmap provides a navigation tool for aged care leaders to take a strategic and comprehensive approach to address challenges and opportunities for HIT in aged care in the future.