Incorporating INTERACT II Clinical Decision Support Tools into Nursing Home Health Information Technology: Page 3 of 3

November 10, 2011

Assembling an Integrated Team

The team responsible for the design process includes a facilitator, frontline staff, and software developer. The facilitator serves as a liaison between frontline staff and the software developer. He or she also works with clinicians to translate paper tools into software development requirements. Clinical staff members are key stakeholders who provide clinical expertise and working knowledge of clinical operations and workflow.

Confirming Data Elements

In this step, paper tools to be automated are analyzed at the data-element level to gain understanding of each element’s use and to compare each element against same or similar elements already available in the facility’s system. Redundancies and inconsistencies are highlighted during this process. The goal is to minimize additional documentation burden and to leverage existing documentation to the extent possible.

Translating CDS Tools From Paper to NH HIT

After the data elements from paper tools are defined and confirmed, the next step is to translate the CDS tools from paper to NH HIT for use in actual practice. This includes developing the content, formatting the information, and establishing the algorithms or rules that will produce the alert, reminder, or report.

Integrating CDS into Workflow

The final step in the design stage is to confirm how each CDS tool will be integrated into the daily workflow of the clinician end-user. Processes should be outlined to show who will be using CDS tools and describe how often they will be used. Use cases (defined as a description of steps or actions between a clinician and a software system that leads the user towards something useful) are helpful to describe the process to the system’s clinician end-users to ensure feasibility and integration into workflow.

Pilot Testing and Implementation

Once the design is completed, the requirements have been integrated into NH HIT, and an implementation plan has been established, it is helpful for the facility to conduct a pilot test on at least one nursing unit. This is done to confirm usability by clinicians in the real-world setting and identify changes to design or workflow that may be required before facility-wide implementation is undertaken. Establishing a full implementation rollout plan requires designating resources for training and information technology support, changing management plans to handle anticipated and unanticipated barriers to implementation, providing feedback mechanisms for ongoing refinement and management, and establishing a process to monitor impact.


The INTERACT quality improvement intervention and related paper-based tools have demonstrated the potential to enhance the detection, management, and communication of acute change in condition among NH residents, and to reduce the incidence of potentially avoidable hospitalizations.
Developing INTERACT II CDS tools in an interoperable format that would enable widespread dissemination and integration into various NH HIT products could lead to sustainable improvement in resident and clinician process and outcome measures, including a reduction in unplanned transfers and potentially avoidable hospital admissions. Possible next steps include the development of HIT specifications for INTERACT II CDS tools, embedding and testing the CDS into various NH HIT products, and formally evaluating the impact of the CDS on various resident and clinician process and outcome measures.

Work on this paper was supported in part by a grant from the Commonwealth Fund (to Dr. Ouslander), and grants from the Agency for Healthcare Research and Quality, R01HS018721 and the National Institute on Aging, K07AG033174  (to Dr. Handler).

Dr. Handler is from the Department of Biomedical Informatics and Division of Geriatric Medicine, University of Pittsburgh School of Medicine, the Geriatric Research Education and Clinical Center, the Veterans Affairs Pittsburgh Healthcare System; Geriatric Pharmaceutical Outcomes and Geroinformatics Research and Training Program, University of Pittsburgh; and is Medical Director, Long-Term Care Health Information Technology, University of Pittsburgh Medical Center Senior Communities, Pittsburgh, PA. Ms. Sharkey and Ms. Hudak are from Health Management Strategies Inc., Austin, TX. Dr. Ouslander is from the Charles E. Schmidt College of Medicine and Christine E. Lynn College of Nursing Florida Atlantic University, Boca Raton, FL.


We thank the nursing home staff who participated in The Commonwealth Fund–supported quality improvement project on INTERACT and provided comments that helped form the basis of this paper.



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