Electronic Health Records in Nursing Homes

Team: Michelle Ko (UCSF), Laura Wagner (UCSF), Onyinyechi Okwandu (UCSF)


A growing share of nursing homes and skilled nursing facilities use electronic health records (EHRs), but its adoption is still not widespread. Prior research has reported that the need for training and the culture change associated with EHRs are important barriers to implementation. Greater satisfaction with EHRs in nursing homes is associated with good training resources and effective implementation strategies.


Key Questions:

  • How do long-term care facilities prepare their workforce for adoption of EHRs?
  • Has the implementation of EHRs changed staffing models? Has EHR implementation changed staff roles and workflow in long-term care facilities?
  • Have changes in staffing, roles, and/or workflow influenced long-term care facility productivity and quality of care?
  • Does use of EHR facilitate transitions in care for patients both entering long-term care facilities from other sites of care, such as hospitals and emergency departments, and being transferred to these health care providers?



UCSF Health Workforce Research Center authors Michelle Ko, MD, PhD, Laura M. Wagner, PhD, RN, FAAN, Onyinyechi Okwandu, MPH and Joanne Spetz, PhD have published their report, Health Information Technology Implementation: Implications for the Nursing Home Workforce. The authors find that although Health Information Technology (HIT) has the potential to improve quality of care, resident quality of life, and health in nursing homes, its implementation in these sites may be delayed due to the new demands it places on staff. This combined literature review and qualitative study interviewing key informants in NHs characterizes the effect of HIT on workforce perceptions and care processes, the training needs associated with HIT implementation, and the infrastructure needed for the workforce to effectively use HIT.

The report finds that nursing homes generally lacked systematic processes for HIT implementation and underinvested in training. New staff evidenced greater interest in learning HIT implementation skills and serving as point persons for other staff. Evidence for productivity gains due to HIT was inconclusive, with unreliable wireless connectivity cited as the most frequent barrier to uptake. No study or interview revealed a direct relationship between HIT impact on the workforce and patient health outcomes or the delivery of care.

The authors conclude that nursing homes are unlikely to realize potential gains in productivity and quality of care without initial investment in training of their workforce. Future research should examine whether HIT leads to improved health and quality of life for residents.

Journal Article

Ko, M, Wagner, L, Spetz, J. Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training, Inquiry, 2018, 55: 1-10.


Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes’ implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semi-structured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and under-invest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.


For questions, contact: Michelle Ko, MD, PhD, Primary Care Research Fellow, UCSF, [email protected]