Characterizing Workflow to Inform Clinical Decision Support Systems in Nursing Homes

Abstract

Background and objectives: Clinical decision support systems (CDSS) hold promise to influence clinician behavior at the point of care in nursing homes (NHs) and improving care delivery. However, the success of these interventions depends on their fit with workflow. The purpose of this study was to characterize workflow in NHs and identify implications of workflow for the design and implementation of CDSS in NHs.

Research design and methods: We conducted a descriptive study at 2 NHs in a metropolitan area of the Mountain West Region of the United States. We characterized clinical workflow in NHs, conducting 18 observation sessions and interviewing 15 staff members. A multilevel work model guided our data collection and framework method guided data analysis.

Results: The qualitative analysis revealed specific aspects of multilevel workflow in NHs: (a) individual, (b) work group/unit, (c) organization, and (d) industry levels. Data analysis also revealed several additional themes regarding workflow in NHs: centrality of ongoing relationships of staff members with the residents to care delivery in NHs, resident-centeredness of care, absence of memory aids, and impact of staff members' preferences on work activities. We also identified workflow-related differences between the two settings.

Discussion and implications: Results of this study provide a rich understanding of the characteristics of workflow in NHs at multiple levels. The design of CDSS in NHs should be informed by factors at multiple levels as well as the emergent processes and contextual factors. This understanding can allow for incorporating workflow considerations into CDSS design and implementation.

Keywords: Clinical decision support; Information technology; Institutional/residential care; Multilevel work; Organizational and institutional issues.