nursing homes face challenges in the coming years due to an increased number of elderly .
quality will be under pressure , expectations of the services will rise , and clinical complexity will grow .
modern clinical information systems with decision support may be part of that . based on clinical experience and information about 513 long - term patients
, we believed that there could be failure of the blood - thinning treatment of patients with atrial fibrillation .
atrial fibrillation is an independent risk factor for developing a stroke , and in the elderly it is one of the most important causes of stroke .
the current guidelines in force are that all over-75s with atrial fibrillation are to be anticoagulated , but increasing age often produces the opposite effect with decreased prescriptions to the oldest [ 3 , 4 ] .
there is good evidence showing that inappropriate weight loss in the elderly materially impairs their quality of life and life prospects .
a significantly increased risk has been shown for secondary complications like pressure sores , infection , depression , and functional impairment [ 8 , 9 ] as well as increased mortality [ 1014 ] .
the high consumption of psychopharmaceuticals in nursing homes has been emphasized in a number of studies .
23% of the demented nursing home population in bergen was found to be on antipsychotics .
the prevalence of psychoactive drugs has been well documented earlier , but some years ago [ 15 , 16 ] .
double - blind studies have shown little symptom reduction connected with the use of antipsychotics as compared with placebo [ 17 , 18 ] .  
. often test results are not followed up . in a meta - analysis , kawamoto and
colleagues dealt with studies on the effectiveness of decision - making support tools and found that 68% of the systems showed significant improvement in practice . a clinical decision support system ( cdss )
decision - making support is closely correlated with structured record information , because the decision - making support tools have to respond to correct information in the record  for example , pathological test results .
the traditional medical approach focuses on the individual , with particular emphasis on symptoms , signs and test results emerging from the encounter with individual patients . in order to ensure accessible and correct treatment for all patients ,
it is also possible to operate using population - directed control measures , for example , keeping track of the proportion of a patient population on a specific drug .
this is especially applicable in nursing homes where about 75% of patients are demented and can not take responsibility for their own followup .
the users ' views on data systems are important for the real - term prospects of disseminating such tools .
nurses ' views on electronic patient records have been studied at a major hospital in florida .
of 100 nurses , one - third felt that electronic patient records resulted in a reduced workload and roughly the same proportion preferred being able to provide documentation at the patient 's bedside , but said that this was often made difficult .
a quarter thought that documentation was improved and the use of electronic patient records would improve patient safety .
nurses with experience of information technology consistently had more positive views than those without such experience .
in this project , we wanted to study whether decision support as part of an electronic , structured patient record system , together with targeted education , could improve the quality of medical treatment while avoiding negative impact on job satisfaction among users .
we performed a prevalence study to quantify the proportion of long - term patients with atrial fibrillation that were being given warfarin , were taking neuroleptics , and had not been weighed for the last 30 days .
then , a before - after intervention study was done . the before - after study was conducted as a double cross - sectional design . instead of randomization
, we decided to use the proportion of patients on digitalis , thyroxin , and antidiabetics as internal controls ( participants exposed to the same study , but these drugs were not part of any concrete intervention and were unlikely to undergo any changes by external factors . ) .
the proportion of patients on neuroleptics was in addition followed as a time series ( a sequence of data points , measured typically at successive times spaced at uniform time intervals ) [ 2628 ] in two nursing homes from 23 october 2008 to 15 july 2010 .
the prevalence ( before ) survey was performed among long - term residents in seven nursing homes ( n = 513 ) .
bergen , norway has approximately 250,000 inhabitants and 37 nursing homes ( 2,300 beds ) .
medical students conducted the data collection , which consisted of copying medication cards , weighing by means of a local tool , but standardized clothing , and finding previously recorded weight / date .
electrocardiography ( ecg ) to diagnose atrial fibrillation was performed and a standardized set of blood samples analysed at the laboratory of the bethany hospital .
the recorded data were keyed into excel and the drugs coded according to the anatomic therapeutic chemical ( atc ) drug register .
the nursing homes were selected based on approximately similar size , function , and public ownership .
they were comparable in terms of nursing staff and financing , but some differences existed with regard to other variables ( table 1 ) . after quantifying clinical issues through the before - survey , we installed an electronic , structured patient record system which included decision support .
the system had been developed and operating at lvsen educational nursing home ( developing institution ) for several years , funded by the norwegian medical association and the norwegian research council .
installation and training were carried out in the last quarter of 2008 , and 6 of the 7 nursing homes were running the system on a daily basis from january 2009 for 12 months .
after the active intervention period , the number of nursing homes running the system was reduced to three institutions , owing to contracts between bergen municipality and another vendor having been signed before the project started .
lvsen nursing home and two of the study institutions continued and were the only institutions available for follow - up data .
the system incorporated filters and alarms within several areas , but we decided to test 4 filters and 2 reminders .
population filters were predefined filters that produced lists of patients according to criteria in seconds .
( list and proportion ) , ( b )  patients taking warfarin  ( list and proportion ) , ( c )  patients with the diagnosis atrial fibrillation and their treatment status  ( list and proportion ) , and ( d )  patients not weighed for last 30 days 
( list and proportion ) . tested reminders visible in each patient 's record , if the criteria were met , were ( a )  patient has diagnosis of atrial fibrillation but is not on warfarin  and ( b )  patient not weighed for last 30 days .  figures 1 and 2 demonstrate how this was arranged within the application .
results from the before - study were presented to the participating doctors during the first 12 months of intervention through three two - hour lectures .
two institutions ( e and f in table 1 ) participated in the after - study . to collect the data we used the population filters in the medical record system to find the proportions of patients on endpoint drugs , internal controls , and patients not weighed for the last 30 days . before - data
were extracted from the prevalence study for institutions e and f ( n = 183 ) for the before - after analysis .
institution e participated with an additional department ( 22 patients ) in the intervention study ( n = 205 , after ) .
to study user satisfaction , we performed an anonymous survey among the doctors , nurses , assistant nurses , and physiotherapists ( n = 504 ) .
16 questions about position and several aspects of their view on the functionality of the application were presented .
questions were closed , with a score from 1 to 5 ( worse  better ) .
the survey was constructed by a group of study nurses from the institutions , with technical organization by the vendor . for the prevalence ( before ) survey ,
the recorded data were keyed into an excel worksheet and the drugs coded according to the anatomical therapeutic chemical ( atc ) drug register . to compare proportion of populations , pearson 's chi - square test was used . to compare distribution of continuous variables , kruskal - wallis ' nonparametric one - way analysis of variance was performed .
straight counts were performed in excel , but jmp 8 was generally used for statistical analyses .
in the prevalence study , all long - term patients in 7 nursing homes were examined ( n = 513 ) .
the before - after study included all long - term patients in two institutions ( n = 183 before , 205 after ) , also no drop - outs .
272 ( 54% ) users responded to the questionnaire , tables 2 and 3 . in the prevalence study of 484 long - term patients ecg - ed ,
of 91 atrial fibrillation patients , 14.2% were anticoagulated with warfarin , that is , 2.5% of all patients .  
at the two institutions ( e and f ) participating in the before - after study , the proportion of patients taking neuroleptics was reduced from 33.0% to 21.5% ( n = 183 before/205 after , chi - square test , p = 0.015 ) , that is , a difference of 11.5% ( 95% ci : 2.3 to 20.6% ) .
warfarin increased from 3.0% to 9.8% ( p = 0.013 ) , that is , a difference of 6.8% ( 95% ci : 1.6 to 12.1% ) .
use of digitoxin did not increase significantly ( 8.0% versus 8.5% ; p = 0.1 ) , thyroxin was not reduced ( 10.0% versus 8.6% , p = 0.765 ) , and antidiabetics did not increase ( 10.0% versus 10.5% ; p = 0.996 ) , figure 4 .
the proportion of patients not weighed for the last 30 days was reduced from 72.6% to 16.0% ( p < 0.001 ) ,   that is , a difference of 56.6% ( 95% ( ci : 47.5 to 64.5% ) .
the time - series for proportions of patients using neuroleptics is presented in figure 3 .   in the user survey ( n = 272 , 54% ) , 43% reported great or slightly better job satisfaction .
endpoints changed significantly during intervention by increased use of warfarin , decreased use of neuroleptics , and a higher weighing rate .
the role of nursing homes in the delivery of social and health care services differs between , as well as within , countries .
nursing homes in many countries are managed as part of social care . in norway ,
such study designs should generally be used in a context where they build on appropriate theoretical , qualitative , and modelling work , particularly in the development of appropriate interventions .
we feel that we have properly documented the fields in need of improvement and thus study objectives .
baseline and follow - up data for the first cross - sectional sample were collected , by the prevalence study ( before ) and ( in the case of the second sample ) after the intervention , respectively . as it was not possible to collect
follow - up data for everyone included in the first study ( for political reasons ) and the patients included in the second sample were not identical to those in the first due to deaths , the two samples were compared using methods for comparing unpaired data .
this is a weakness , but to compensate for the 40% or so annual death rate in nursing homes , the sample size would have had to be much higher to be able to use patients as their own controls , and this may not have been advisable when testing front - end technology in the first study .
our design must be seen in light of the immaturity of research in nursing homes in general . as far as we know ,
neither recent data exist on the prevalence of atrial fibrillation in a nursing home population and the use of warfarin , nor is information available on how well basic procedures like weighing are conducted .
there was therefore a need to do a prevalence study , to define valid endpoints , and to do an intervention study .
it may be claimed that we should have separated the tasks , but nursing homes are in great need of improvement strategies and time is short before the elderly wave is set to impact heavily on nursing home demands .
financial and political limitations played a role too , obstructing any possibility of performing a full - scale follow - up study .
but conversely , it would have been a challenge , in a randomized trial within one municipality , albeit with 37 institutions to choose from , to avoid study group pollution and the  hawthorne effect  [ 29 , 30 ] . starting out with a comprehensive and expensive randomized study
would probably not have been ethical due to all the uncertainty and possible threats from new information technology systems , and hence probably difficult to fund .
when we started , we did not know if it was possible to install the application , educate , and prepare for critical daily use in 7 institutions with 500 to 800 users within a timeframe of 4 months .
looking back , this may be regarded as the most convincing result of the project .
we used a design where we evaluated endpoints in a before - after study with internal controls [ 2628 ] .
the stability of internal controls throughout the intervention reinforces the internal validity of the study .  
awareness of the performance process  is responsible , through education , for the changes measured . yet without any performance figures , it is not possible to focus on changing processes , so the two ways of influencing results are not independent factors .  
the technology made it possible to monitor performance without time - consuming traditional studies and made performance feedback possible .
this is a relatively new concept in medical research , made possible by structured medical input applicable to automatic and continuous analysis .
consequently , the proportion of patients taking neuroleptics could also be followed using time - series , giving more detailed information about the changing process and strengthening the validity of the effect results . as a critical information element
, drugs were punched into each patient record at an early stage of the implementation process and this gave us a sufficient  before - point  on the time - series .
we discovered that the significant change in the before - after study was due to only one of the participating institutions and that this institution showed up a clear brake in the curve at the point of intervention startup .  
we see from the time - series on neuroleptics ( time - series are part of the patient record system ) that the tool also provides a deeper understanding of the change process . by observing the curves ,
figure 3 , we learn something about possible variation in the use of neuroleptics during the year .
this makes one think that performance feedback , over time , may equal performance around a  total average  .
other authors have concluded that evaluative studies should report on usage patterns and progression of outcomes over time .
very few authors have reported on feedback at institutional level with performance comparisons . at vaccination clinics ,
however , it has been shown that performance feedback at institutional level can improve quality .
logically , this may be one way of influencing both generalized over- and undertreatment in institutions .
our own research ( same material , and publications to come ) has shown that differences between comparable nursing homes do exist , significantly . with regard to both the proportion of patients using cardiovascular and psychoactive medications , and weight loss and weighing routines , we found significant differences between the 7 nursing homes participating in the prevalence survey ( same study , different publications ) .
we hope to continue our research based on this feedback method to test if this is a way to increase equality and quality among a bigger number of institutions .
technology is a tool only , without any impact , if managers and practitioners are not reacting to warnings and are not exploiting the population filter function !
the structured electronic patient record system with decision support we tested can improve drug treatment and monitoring and better implementation of procedures .
it can easily be installed for use in nursing homes . controlled studies on a broader spectrum of clinical and administrative parameters
 
 background . nursing homes face challenges in the coming years due to the increased number of elderly . 
 quality will be under pressure , expectations of the services will rise , and clinical complexity will grow . 
 new strategies are needed to meet this situation . 
 modern clinical information systems with decision support may be part of that 
 . objectives . to study the impact of introducing an electronic patient record system with decision support on the use of warfarin , neuroleptics and weighing of patients , in nursing homes . methods . a prevalence study was performed in seven nursing homes with 513 subjects . 
 a before - after study with internal controls was performed . 
 results . 
 the prevalence of atrial fibrillation in the seven nursing homes was 18.8% . 
 after intervention , the proportion of all patients taking warfarin increased from 3.0% to 9.8% ( p = 0.0086 ) , neuroleptics decreased from 33.0% to 21.5% ( p = 0.0121 ) , and the proportion not weighed decreased from 72.6% to 16.0% ( p < 0.0001 ) . 
 the internal controls did not change significantly . 
 conclusion . 
 statistics and management data can be continuously produced to monitor the quality of work processes . 
 the electronic health record system and its system for decision support can improve drug therapy and monitoring of treatment policy . 
1. Background
2. Material and Methods
3. Results
4. Discussion
5. Conclusions