Published on in Vol 24, No 2 (2022): February

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/29837, first published .
Implementation of eHealth to Support Assessment and Decision-making for Residents With Dementia in Long-term Care: Systematic Review

Implementation of eHealth to Support Assessment and Decision-making for Residents With Dementia in Long-term Care: Systematic Review

Implementation of eHealth to Support Assessment and Decision-making for Residents With Dementia in Long-term Care: Systematic Review

Review

1Cicely Saunders Institute, King's College London, London, United Kingdom

2Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom

3Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom

4School of Health Sciences, City, University of London, London, United Kingdom

5Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Brighton, United Kingdom

Corresponding Author:

Juliet Gillam, BSc (Hons), MSc

Cicely Saunders Institute

King's College London

Bessemer Road

London, SE5 9PJ

United Kingdom

Phone: 44 7500 708 293

Email: juliet.h.gillam@kcl.ac.uk


Background: As dementia progresses, symptoms and concerns increase, causing considerable distress for the person and their caregiver. The integration of care between care homes and health care services is vital to meet increasing care needs and maintain quality of life. However, care home access to high-quality health care is inequitable. eHealth can facilitate this by supporting remote specialist input on care processes, such as clinical assessment and decision-making, and streamlining care on site. How to best implement eHealth in the care home setting is unclear.

Objective: The aim of this review was to identify the key factors that influence the implementation of eHealth for people living with dementia in long-term care.

Methods: A systematic search of Embase, PsycINFO, MEDLINE, and CINAHL was conducted to identify studies published between 2000 and 2020. Studies were eligible if they focused on eHealth interventions to improve treatment and care assessment or decision-making for residents with dementia in care homes. Data were thematically analyzed and deductively mapped onto the 6 constructs of the adapted Consolidated Framework for Implementation Research (CFIR). The results are presented as a narrative synthesis.

Results: A total of 29 studies were included, focusing on a variety of eHealth interventions, including remote video consultations and clinical decision support tools. Key factors that influenced eHealth implementation were identified across all 6 constructs of the CFIR. Most concerned the inner setting construct on requirements for implementation in the care home, such as providing a conducive learning climate, engaged leadership, and sufficient training and resources. A total of 4 novel subconstructs were identified to inform the implementation requirements to meet resident needs and engage end users.

Conclusions: Implementing eHealth in care homes for people with dementia is multifactorial and complex, involving interaction between residents, staff, and organizations. It requires an emphasis on the needs of residents and the engagement of end users in the implementation process. A novel conceptual model of the key factors was developed and translated into 18 practical recommendations on the implementation of eHealth in long-term care to guide implementers or innovators in care homes. Successful implementation of eHealth is required to maximize uptake and drive improvements in integrated health and social care.

J Med Internet Res 2022;24(2):e29837

doi:10.2196/29837

Keywords



Background

Dementia is a progressive, complex neurodegenerative condition with a multitude of types and clinical presentations. It is the leading cause of death in the United Kingdom [Deaths registered in England and Wales: 2019. Office of National Statistics. 2020.   URL: https:/​/www.​ons.gov.uk/​peoplepopulationandcommunity/​birthsdeathsandmarriages/​deaths/​bulletins/​deathsregistrationsummarytables/​2019 [accessed 2021-12-10] 1] and is projected to have the highest global proportional rise (264%) in suffering associated with a need for palliative care [Sleeman KE, de Brito M, Etkind S, Nkhoma K, Guo P, Higginson IJ, et al. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. Lancet Glob Health 2019 Jul;7(7):e883-e892 [FREE Full text] [CrossRef] [Medline]2]. Dementia is characterized by a complexity of care needs, which advance as the condition progresses [Sampson EL, Burns A, Richards M. Improving end-of-life care for people with dementia. Br J Psychiatry 2011 Nov;199(5):357-359. [CrossRef] [Medline]3]. These needs span multiple domains of health care, and multimorbidity is common [Tonelli M, Wiebe N, Straus S, Fortin M, Guthrie B, James MT, Alberta Kidney Disease Network. Multimorbidity, dementia and health care in older people: a population-based cohort study. CMAJ Open 2017 Aug 14;5(3):E623-E631 [FREE Full text] [CrossRef] [Medline]4]. Symptoms such as pain and breathlessness [Leniz J, Higginson I, Stewart R, Sleeman K. Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study. Age Ageing 2019 Sep 01;48(5):672-679. [CrossRef] [Medline]5,Sampson EL, Candy B, Davis S, Gola AB, Harrington J, King M, et al. Living and dying with advanced dementia: a prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018 Mar;32(3):668-681 [FREE Full text] [CrossRef] [Medline]6] cause significant distress for the person and their caregiver and increase toward the end of life [Hendriks SA, Smalbrugge M, Hertogh CM, van der Steen JT. Dying with dementia: symptoms, treatment, and quality of life in the last week of life. J Pain Symptom Manage 2014 Apr;47(4):710-720 [FREE Full text] [CrossRef] [Medline]7].

Over half of the people with dementia (58%) die in care homes in England [Data Analysis Report Dying with Dementia. Public Health England. 2016.   URL: https:/​/assets.​publishing.service.gov.uk/​government/​uploads/​system/​uploads/​attachment_data/​file/​733065/​Dying_with_dementia_data_analysis_report.​pdf [accessed 2021-12-11] 8]. They are the main providers of end-of-life dementia care, with the average life expectancy on admission for a resident with dementia being 1 to 2 years [End of life care in frailty: care homes. British Geriatrics Society. 2020.   URL: https://www.bgs.org.uk/resources/end-of-life-care-in-frailty-care-homes [accessed 2021-12-11] 9]. The term care home in the United Kingdom refers to both residential and nursing homes. These differ with regard to the provision of input from health care professionals, with nursing homes providing additional access to 24-hour on-site nursing care. Care homes require the resources to deliver multidisciplinary care to meet these advancing and acute dementia-specific needs [Understaffed and overworked: poor working conditions and quality of care in residential care facilities for the elderly. Publications. 2017.   URL: https://digitalcommons.law.ggu.edu/pubs/788/ [accessed 2021-12-11] 10]. Providing access to good quality, continuous care throughout the dementia trajectory is essential. This can be achieved by integrating care homes with primary care, palliative care, and dementia care teams to enable multidisciplinary and specialist input on vital care processes [Briggs AM, Valentijn PP, Thiyagarajan JA, Araujo de Carvalho I. Elements of integrated care approaches for older people: a review of reviews. BMJ Open 2018 Apr 07;8(4):e021194 [FREE Full text] [CrossRef] [Medline]11].

Care needs change and develop over time and cause considerable distress if left unmet [Sampson EL, Candy B, Davis S, Gola AB, Harrington J, King M, et al. Living and dying with advanced dementia: a prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018 Mar;32(3):668-681 [FREE Full text] [CrossRef] [Medline]6]. A comprehensive assessment by a multidisciplinary team to review medical, functional, mental, and social abilities is essential for this population with complex needs [Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011 Jul 06(7):CD006211 [FREE Full text] [CrossRef] [Medline]12]. Interprofessional collaboration is also required to share clinical expertise and experience, best inform complex clinical decisions concerning treatment for multimorbidities, and deliver appropriate care [Disalvo D, Luckett T, Bennett A, Davidson PM, Agar M. Multidisciplinary perspectives on medication-related decision-making for people with advanced dementia living in long-term care: a critical incident analysis. Eur J Clin Pharmacol 2020 Apr;76(4):567-578. [CrossRef] [Medline]13]. Integrating these processes across services is widely acknowledged to improve person-centered treatment outcomes for older people with complex needs [Briggs AM, Valentijn PP, Thiyagarajan JA, Araujo de Carvalho I. Elements of integrated care approaches for older people: a review of reviews. BMJ Open 2018 Apr 07;8(4):e021194 [FREE Full text] [CrossRef] [Medline]11] and reduce detrimental transitions between settings occurring in the final years of life, such as unplanned hospitalization [Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: a qualitative study of patients' and health care professionals' decision making. Palliat Med 2017 Jul;31(7):617-624 [FREE Full text] [CrossRef] [Medline]14].

To integrate services and deliver continuous and coordinated care, established methods of communication are required to share information between systems about residents’ care needs and outcomes. A way to facilitate this is through the use of eHealth [Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 2020 Aug 01;20(1):1193 [FREE Full text] [CrossRef] [Medline]15], which is defined as “health services and information delivered or enhanced through the internet and related technologies” [Eysenbach G. What is e-health? J Med Internet Res 2001 Jun 18;3(2):E20 [FREE Full text] [CrossRef] [Medline]16], encompassing an array of interventions that enable care to be delivered remotely.

The COVID-19 pandemic has had major implications for the use of eHealth in care homes. In response, former barriers to the integration of health and social care services in England have been liberalized, with restrictions on information sharing between services relaxed [Coronavirus (COVID-19): notification to organisations to share information. GOV.UK.   URL: https:/​/www.​gov.uk/​government/​publications/​coronavirus-covid-19-notification-of-data-controllers-to-share-information [accessed 2021-12-11] 17]. The pandemic highlighted the lack of systems for efficiently sharing information between services nationally and internationally [Hanratty B, Burton JK, Goodman C, Gordon AL, Spilsbury K. Covid-19 and lack of linked datasets for care homes. BMJ 2020 Jun 24;369:m2463. [CrossRef] [Medline]18,Comas-Herrera A, Ashcroft E, Lorenz-Dant K. International examples of measures to prevent and manage COVID-19 outbreaks in residential care and nursing home settings. International Long Term Care Policy Network.   URL: https:/​/ltccovid.​org/​2020/​05/​02/​new-report-international-examples-of-measures-to-prevent-and-manage-covid-19-outbreaks-in-residential-care-and-nursing-home-settings/​ [accessed 2021-12-11] 19]. This compromised the delivery of care to meet the escalating health care needs and residents’ quality of life. Innovation was required to communicate between services for the comprehensive assessment of symptoms and management of care and outcomes. eHealth provides a way to do this [Haralambous B, Subramaniam S, Hwang K, Dow B, LoGiudice D. A narrative review of the evidence regarding the use of telemedicine to deliver video-interpreting during dementia assessments for older people. Asia Pac Psychiatry 2019 Sep;11(3):e12355. [CrossRef] [Medline]20].

Objective

There is little evidence to guide the design and implementation of eHealth resources to manage symptoms and concerns for people with dementia in care homes. The key task at hand is to understand how we can scale-up eHealth interventions to embed them in routine care. Despite positive findings regarding their benefit [Schaller S, Marinova-Schmidt V, Setzer M, Kondylakis H, Griebel L, Sedlmayr M, et al. Usefulness of a tailored eHealth service for informal caregivers and professionals in the dementia treatment and care setting: the eHealthMonitor dementia portal. JMIR Res Protoc 2016 Apr 05;5(2):e47 [FREE Full text] [CrossRef] [Medline]21], eHealth interventions are yet to attain widespread implementation in care homes, and the way of effectively achieving this remains unclear. This study aimed to explore factors that influence the implementation of eHealth interventions to support assessment and decision-making regarding care and treatment for people with dementia in care homes.


Design

The review is reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses;

Multimedia Appendix 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

PDF File (Adobe PDF File), 96 KBMultimedia Appendix 1) guidelines. A systematic review, using narrative synthesis and thematic analysis, was conducted to identify common facilitators of and barriers to eHealth implementation in care homes. The synthesis followed the guidance of Popay et al [Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews: A Product From the ESRC Methods Programme. United Kingdom: Lancaster University; 2006.22], which provides a specific direction for reviews concerned with the implementation of interventions. The protocol for this review was registered on PROSPERO (International Prospective Register of Systematic Reviews; registration number CRD42020184587). Before registering this review, a search of PROSPERO was conducted to ensure that no similar reviews were underway. Our final search was performed in the week the review was registered (June 1, 2020). Originally, the scope of the review also included collecting data on intervention effectiveness and key components; however, given the breadth of evidence relating to these outcomes, the findings regarding effectiveness will be reported in a second review.

Search Strategy

A total of 4 databases (Embase, PsycINFO, MEDLINE, and CINAHL) were searched for studies published in English from January 2000, with the final search being on April 28, 2020. The year 2000 was chosen as the cutoff year to exclude eHealth that may be outdated in the context of today’s technological advancements. A search strategy was developed with the help of an information support specialist and informed by scoping the literature for the types of eHealth interventions currently in use (see

Multimedia Appendix 2

Search strategy.

DOCX File , 18 KBMultimedia Appendix 2 for the full search strategy). A combination of Medical Subject Headings terms and keywords was used to develop a strategy based on the following concepts: dementia AND care homes AND eHealth AND assessment OR decision-making. The search strategy was complemented through reference chaining and citation tracking using Google Scholar, following the initial identification of studies from the database search. The eligibility criteria were developed using the PICO (population, intervention, control, and outcomes) acronym, following recommendations on its suitability and enhanced sensitivity when conducting qualitative systematic reviews [Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 2014 Nov 21;14:579 [FREE Full text] [CrossRef] [Medline]23]. The criteria are outlined in Textbox 1.

Eligibility criteria.

Inclusion criteria

  • Population: residents with a diagnosis of dementia residing in a long-term care facility; studies that included residents with dementia in a mixed population
  • Intervention: eHealth interventions that aimed to facilitate comprehensive assessment of care home residents or improve decision-making about care and treatment; eHealth interventions that enable care coordination between practitioners and the sharing of information between settings to facilitate integrated working, such as between care homes and health care services
  • Outcome: data relating to factors that influence or inhibit the implementation of eHealth interventions in care homes
  • Comparator: no restrictors
  • Study design: all study designs that reported data relating to implementation

Exclusion criteria

  • Population: people with a diagnosis of dementia living at home or staying in short-term care or acute care settings; studies that did not mention dementia in the population
  • Intervention: nondigitalized intervention studies; eHealth interventions that did not focus on aiding comprehensive assessment or supporting clinical decision-making; interventions that monitored clinical signs only, such as a motion sensor, or recorded biodata, for example, blood pressure remote monitoring, were out of scope
  • Outcome: not applicable
  • Comparator: not applicable
  • Study design: opinion pieces
Textbox 1. Eligibility criteria.

Study Selection Procedure

Studies identified from the search were exported to Endnote [Hupe M. EndNote X9. J Electronic Resources Med Libraries 2019 Nov 26;16(3-4):117-119. [CrossRef]24]. Duplicates were identified and removed. All titles and abstracts were screened by 1 researcher (JG). Approximately 20% were randomly selected for blinded double screening by 2 independent researchers (TA and EY) as a calibration process to test the application of the eligibility criteria. Once an agreement of 90% was confirmed between the reviewers, the eligibility criteria were applied to all identified studies. This was undertaken to screen for eligibility at the title and abstract screening and again at the full paper review. Discrepancies were resolved through discussion.

Quality Appraisal

The quality of publications was appraised using the Critical Appraisal Skills Programme (CASP) tool [CASP Checklists. CASP-UK.   URL: https://casp-uk.net/casp-tools-checklists/ [accessed 2021-12-11] 25], which was appropriate for the study design. It was conducted by 1 author (JG) and reviewed independently by 2 authors (CE and ND). Where the design was not amenable to the CASP, alternative tools were used, including the Mixed Methods Appraisal Tool (MMAT) [Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Educ Inf 2018 Dec 18;34(4):285-291. [CrossRef]26] and the Joanna Briggs Institute (JBI) critical appraisal tools [Critical appraisal tools. University of Adelaide.   URL: https://joannabriggs.org/critical-appraisal-tools [accessed 2021-12-11] 27]. No studies were excluded only on the basis of their appraised quality; rather, it was conducted to help understand and describe the studies.

Data Extraction

A standardized data extraction tool was developed in Microsoft Excel and informed by the review questions. Extracted data included study aim, country of origin, design, population of interest, setting, eHealth intervention (type, components, and summary), methods of data collection and analysis, outcomes regarding intervention implementation and conclusions, implications, and limitations. Implementation data were extracted from both the results and discussion sections to capture relevant findings relating to the authors’ observations of why an intervention was or was not effective.

Data Analysis and Synthesis

A deductive thematic analytic approach was undertaken, underpinned by the adapted version of the Consolidated Framework for Implementation Research (CFIR) [Safaeinili N, Brown-Johnson C, Shaw JG, Mahoney M, Winget M. CFIR simplified: pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learn Health Syst 2020 Sep 26;4(1):e10201 [FREE Full text] [CrossRef] [Medline]28]. The original CFIR [Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009 Aug 07;4:50 [FREE Full text] [CrossRef] [Medline]29] comprises 5 broad theory-based constructs and 39 subconstructs within these: intervention characteristics, inner setting, outer setting, individual characteristics, and implementation process. It is a comprehensive and practical guide for assessing the potential factors that influence implementation. A recent adaptation of the framework added a sixth construct [Safaeinili N, Brown-Johnson C, Shaw JG, Mahoney M, Winget M. CFIR simplified: pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learn Health Syst 2020 Sep 26;4(1):e10201 [FREE Full text] [CrossRef] [Medline]28], patient needs, acknowledging the importance of person-centered care in health care interventions and the paucity of attention it frequently receives in implementation frameworks. Given the nature of this review, the adapted CFIR was used.

Preliminary synthesis involved tabulation to organize the findings and compare data across different studies. The data from each study were then mapped onto the framework. Common themes that arose across the studies in line with the subconstructs of the framework were then synthesized to form a narrative regarding facilitating elements of and inhibiting barriers to successful implementation. Where data did not align to a subconstruct, an inductive thematic analytic approach was undertaken to avoid biasing data and identify gaps in the framework when applying it to this context. The themes were then developed to identify additional constructs to adapt the framework to this specific context.


Summary

A total of 1055 papers were screened by title and abstract, of which 128 (12.13%) full-text articles were assessed; of the 128 articles, 29 (22.7%) met the eligibility criteria for the review (Figure 1 [Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009 Jul 21;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]30]). The included studies reported 27 unique interventions that aimed to facilitate comprehensive assessment of care home residents or improve decision-making surrounding care and treatment, published between 2000 and 2020. The sample sizes ranged from 5 to 4171 for residents and 6 to 609 for carers. Approximately 31% (9/29) of studies omitted the number of participants.

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart [Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009 Jul 21;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]30].
View this figure

Of the 29 articles, the included studies comprised 7 (24%) randomized controlled trials, 7 (24%) quasi-experimental studies [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31-Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37], 6 (21%) qualitative studies [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38-Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43], 3 (10%) descriptive studies [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44-Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46], 2 (7%) mixed methods studies [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48], 2 (7%) cohort studies [Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49,Gordon SE, Dufour AB, Monti SM, Mattison ML, Catic AG, Thomas CP, et al. Impact of a videoconference educational intervention on physical restraint and antipsychotic use in nursing homes: results from the ECHO-AGE pilot study. J Am Med Dir Assoc 2016 Jun 01;17(6):553-556 [FREE Full text] [CrossRef] [Medline]50], and 2 (7%) cross-sectional studies [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52].

All studies included adults with dementia, focusing specifically on requirements for people with dementia (11/29, 38%) [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31,Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38-Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49,Gordon SE, Dufour AB, Monti SM, Mattison ML, Catic AG, Thomas CP, et al. Impact of a videoconference educational intervention on physical restraint and antipsychotic use in nursing homes: results from the ECHO-AGE pilot study. J Am Med Dir Assoc 2016 Jun 01;17(6):553-556 [FREE Full text] [CrossRef] [Medline]50,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] or within a mixed population (18/29, 62%) [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33-Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44-Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55-Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. The average percentage of residents with dementia was 52.8% in the mixed population studies that reported the proportion (6/29, 21%) [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56]. Approximately 41% (12/29) of studies did not delineate the proportion of residents with dementia [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57-Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] (see Table 1 for a summary of study characteristics).

Table 1. Summary of characteristics of included studies grouped by population residents.
Characteristics, study, and country of originStudy designPopulation (n)Age (years), meanSetting (n)Type of eHealth intervention
Population with dementia and specific requirements

Catic et al [Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49], United StatesaCohortDementia (46)82.5Nursing home (11)Video consultation

Gordon et al [Gordon SE, Dufour AB, Monti SM, Mattison ML, Catic AG, Thomas CP, et al. Impact of a videoconference educational intervention on physical restraint and antipsychotic use in nursing homes: results from the ECHO-AGE pilot study. J Am Med Dir Assoc 2016 Jun 01;17(6):553-556 [FREE Full text] [CrossRef] [Medline]50], United StatesaMatched-cohort studyDementia (115)Not specifiedNursing home (11)Video consultation

Klein et al [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38], AustraliaQualitativeDementia (5)59-88Regional aged care facility (1)PDA

Lee et al [Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53], KoreaQuasi-experimentalDementia (53)Not specifiedNursing home (1)Video consultations and computerized system

Lyketsos et al [Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54], United StatesQuasi-experimentalDementia (not specified)Not specifiedLong-term dementia facility (1)Video consultations

Mitchell et al [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31], United StatesCluster RCTbDementia (402)86.7Nursing home (64)Video decision support tool

Qadri et al [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47], United StatesMixed methodsDementia (not specified)Not specifiedNursing home (3)PDA

Moniz-Cook et al [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32], United KingdomCluster RCTDementia (832)Not specifiedCare home (58)Computerized decision support tool

Piau et al [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39], FranceQualitativeDementia (90)Not specifiedLong-term care facility (10)Video consultations

Shiells et al [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40], CzechiaQualitativeDementia (not specified)Not specifiedNursing home (3)Electronic patient records

Keenan et al [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43], United KingdomQualitativeDementia (not specified)Not specifiedCare home (27)Computerized decision support tool
Population with mixed requirements (dementia and nondementia)

Salles et al [Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45], FranceDescriptiveMixed (304); others: wounds and psychiatric85.6Nursing home (1)Video consultations

Daly et al [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33], United StatesRCTMixed (22)86Long-term care facility (1)Electronic patient records

De Luca et al [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34], ItalyRCTMixed (59)79.1Nursing home (1)Video consultations and tele-counseling

Johnston and Jones [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44], United StatesDescriptiveMixed; dementia (52.5%); others: delirium, depression, and dysthymia79.3Rural skilled nursing facility (1)Video consultations

Krüger et al [Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55], NorwayQuasi-experimentalMixed; dementia (76.6%) and stroke (23.4%)84.4Nursing home (7)Electronic patient records with decision support tool

Mitchell et al [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35], United StatesCluster RCTMixed; dementia (70%)Not specifiedNursing home (intervention=119; control=241)Video decision support tool

Perri et al [Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56], CanadaQuasi-experimentalMixed; dementia (69%); other: cardiovascular, respiratory, frailty, and psychiatric.87Long-term care facility (1)Video consultations

Alexander [Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46], United StatescDescriptiveMixed; dementia (20), Alzheimer (13), and other: osteoarthritis, pneumonia, and cerebrovascular accidentNot specifiedNursing home (3)PDA, electronic patient records, and decision support tool

Mor et al [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37], United StatesRCTMixed (not specified); dementia (30%); others: cardiopulmonaryNot specifiedNursing home (360)Video decision support tool

Vuorinen [Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41], New ZealandQualitativeMixed (not specified)≥65 (intervention)Long-term care facility dementia unit (1)Web-based assessment tool

Weiner et al [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36], United StatesRCTMixed (369)64Nursing home (1)Video consultations

Pillemer et al [Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57], United StatesQuasi-experimentalMixed (761)79.4Nursing home (10)Electronic patient records and PDAs

O’Mahony et al [O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58], United StatesQuasi-experimentalMixed (not specified); dementia, cancer, chronic obstructive pulmonary disease, liver disease, and renal failureNot specifiedSkilled nursing facilities (2)Video consultations

Munyisia et al [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48], AustraliaMixed methodsMixed (not specified)Not specifiedNursing home (1) and specialized home (1)Electronic patient records

Alexander et al [Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42], United StatescQualitativeMixed (not specified)Not specifiedNursing home (4)PDA, electronic patient records, and decision support tool

Bjarnadottir et al [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51], United StatesCross-sectional analysisMixed (not specified)Not specifiedNursing home (927)Electronic patient records

Wakefield et al [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52], United StatesCross-sectional analysis/longitudinalMixed (62); dementia, seizure, Parkinson, and urinary tract infections72Long-term care facility (1)Video consultations

Fossum et al [Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59], SwedenQuasi-experimentalMixed (491)84.5Nursing home (15)Electronic patient records with decision support tool

aArticles from the same study.

bRCT: randomized controlled trial.

cArticles from the same study.

Quality Appraisal

The included studies varied in their quality. In general, the CASP criteria for the experimental studies identified consistent reporting of clear and focused aims, with appropriate methodologies to address the research questions. Weaknesses were related to small sample size, evidence of selection and attrition bias, poor description of analysis, and nonblinding. Descriptive studies were generally well-reported (average 86% of MMAT criteria met) and quasi-experimental studies (average 77.7% of JBI criteria met). The weaker study design used mixed methods (average 50% of MMAT criteria met) and cross-sectional studies (average 56.2% of JBI criteria met). Weaknesses pertained to the management of confounding factors and the integration of qualitative and quantitative data.

Multimedia Appendix 3

Quality appraisal summary table.

DOCX File , 16 KBMultimedia Appendix 3 [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31-Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59], details the quality appraisal results for each study using the respective appraisal checklist.

CFIR Constructs Associated With eHealth Implementation

Table 2 details the respective CFIR constructs and subconstructs that were identified as important determinants for implementation. The number of subconstructs identified per study ranged from 1 to 13, with a median of 6. No major differences in implementation requirements were identified between studies with a specific focus on requirements for people with dementia and studies reporting on dementia within a mixed population (

Multimedia Appendix 4

Differences in implementation requirements.

DOCX File , 18 KBMultimedia Appendix 4). Findings for each CFIR construct and respective subconstructs is presented in turn. Constructs that were identified in ≤2 studies are not presented as a narrative because of insufficient data.

Table 2. Factors identified to influence the implementation of eHealth interventions in a care home (N=29).
CFIRa construct and subconstructsDefinition in the context of care homes and integrated care for people with dementiaTotal, n (%)
Intervention characteristics: aspects of eHealth that might affect implementation success

Intervention sourceHow end users perceive the legitimacy of the eHealth source—whether it has been developed internally as a response to a problem in the care home or externally0

Evidence strength and qualityStakeholder perception of the strength of the evidence supporting the belief that eHealth will produce the desired outcomes from sources such as published literature0

Relative advantage [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36-Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54-Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56]Whether stakeholders perceive eHealth as advantageous over current practice9 (31)

Adaptability [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]How interoperable eHealth is with current care home information technology systems7 (24)

TrialabilityWhether eHealth can be tested initially on a small scale, such as piloted in a small number of care homes0

Complexity [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36-Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58]How simple and user-friendly end users perceive eHealth to be within routine care13 (45)

Design quality and packagingStakeholder perception of the physical presentation of the eHealth intervention0

Cost [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49-Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]Cost associated with implementing eHealth8 (28)
Patient needs: the extent to which resident needs are known and prioritized by the care home

Clinical benefitb [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58]How clinically beneficial eHealth is perceived to be for the resident11 (38)

Person-Centered careb [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]Whether eHealth can be tailored to the individual needs of the resident and care home4 (14)

Resident experienceb [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57]The effect that eHealth has on resident needs and satisfaction with care6 (21)
Outer setting: external influences on eHealth implementation

Cosmopolitanism [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43]The degree to which the care home is networked with others2 (7)

Peer pressurePressure experienced by the care home to implement eHealth0

External policy and incentives [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52-Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]External influences of implementation of eHealth for the care home5 (17)
Inner setting: characteristics of the implementing care home

Structural characteristics [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]The social architecture, age, maturity, and size of the care home4 (14)

Networks and communications [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47]The nature and quality of social networks and communication within a care home1 (3)

CultureNorms and values of the care home0

Implementation climateThe capacity for change and shared receptivity of individuals to eHealth and the extent to which it will be supported within the care home


Tension for change [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]The extent to which stakeholders perceive current practices as needing change1 (3)


Compatibility [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36-Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]The degree of fit between the care home and eHealth in terms of values and existing workflows8 (28)


Relative priorityIndividuals’ shared perception of the importance of implementation within the care home0


Organizational incentives and rewardsIncentives to increase participation with eHealth such as awards and promotions for staff0


Goals and feedbackThe degree to which goals of eHealth are acted upon and feedback to staff0


Learning climate [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]A climate in which staff feel valued in the implementation process and comfortable to participate through encouragement by care home leaders10 (34)

Readiness for implementationIndicators of care home commitment to eHealth implementation


Leadership engagement [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31,Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43]Commitment and involvement of care home managers and leaders in implementation5 (17)


Available resources [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51-Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]The level of care home resources dedicated to eHealth implementation, including money and staff time14 (48)


Access to knowledge and information [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31-Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40-Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]Access to sufficient eHealth training for end users17 (59)
Individual characteristics: end-user individual beliefs, knowledge, and attitudes toward eHealth and implementation

Knowledge and beliefs about the intervention [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45-Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51-Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]End users’ attitudes toward eHealth and its impact16 (55)

Self-efficacy [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]End users’ belief in their own abilities to use the eHealth intervention7 (24)

Individual stage of changeThe phase an individual is in as they progress toward sustained use of eHealth0

Individual identification with organizationEnd user’s perception of their relationship with the care home0

Other personal attributes [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]Individuals’ attributes that affect implementation such as staff willingness, experience, age, or grade7 (24)
Process: stages of the implementation process that can impact its success

Planning [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42-Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56-Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]The degree to which tasks required for implementation of eHealth are agreed in advance13 (45)

EngagingAttracting and involving stakeholders in eHealth implementation


Champions [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]Individuals who are dedicated to driving the implementation of eHealth and overcoming resistance in the care home7 (24)


End usersb [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42-Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]Other stakeholders, including end users and staff, within the care home10 (34)


Opinion leadersIndividuals in a care home who have a formal or informal influence on others’ attitudes toward implementation0


Formally appointed internal leadersIndividuals from within the care home who are formally appointed to implement eHealth0


External change agentsIndividuals from outside the care home who formally influence implementation of eHealth0

Executing [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44]The extent to which eHealth implementation is conducted as planned5 (17)

Reflecting and evaluating [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]Monitoring of eHealth implementation and feedback about its progress7 (24)

aCFIR: Consolidated Framework for Implementation Research.

bAdditional subconstructs identified inductively from the data.

Intervention Characteristics

This refers to aspects of the eHealth intervention that might affect implementation success in care homes and includes findings relating to intervention complexity, adaptability, and cost.

Relative Advantage

eHealth that is perceived as advantageous to an alternative system by improving access to emergency care [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39], increasing efficiency [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55], and reducing paperwork [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47] is more likely to be adopted [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48]. Barriers to uptake include a preference for face-to-face consultations [Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56] and increased time required to organize eHealth consultations [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36].

Adaptability

eHealth is at an advantage if it aligns with data and technology already in use [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]. Concerns on patient privacy and electronic transfer of confidential information act as institutional firewalls [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49] but can be overcome by encrypting data and assigning residents confidential numbers [Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49]. A way to increase the adaptability of a device is through the provision of customizable tools such as drop-down menus [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40]. Incorporating a decision support system in eHealth interventions is advocated to respond to changes in individual residents’ needs by providing alerts and directing staff to appropriate care [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55].

Complexity

eHealth is more likely to be implemented if it is straightforward and user-friendly [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36-Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58]. Simple devices are regarded as more reliable [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48], and it is recommended that more advanced technology be used only where necessary [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36]. Dual systems of paper-based and electronic devices should be avoided to minimize inconsistency [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38] and the complexity of data recording [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48]. Uptake is also influenced by the ease of access to eHealth [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55], with portable tools improving ease of access [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48] and thereby saving staff time [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55]. However, some staff report that handheld devices are easy to break and misplace [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47] and prefer a desktop computer [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40]. Technological difficulties, including software and memory issues [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47], inability of patients and physicians to see or hear each other [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56], and difficulty in obtaining technical support despite frequently requiring it [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56], can impede eHealth implementation [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58]. Providing training and specialist technical support for staff are key to overcoming these barriers [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40-Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56].

Cost

Cost is a major barrier to implementing electronic health records in care homes [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]; for an intervention to be implemented, the benefits must be perceived to outweigh the costs [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51]. eHealth tools that incur no additional financial cost beyond staff time [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49] and installation [Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] can integrate with preassembled data [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37], are cheaper to purchase than full-size computers [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47], and are more likely to be adopted. Uptake is optimized by external funding [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] and intervention outcomes that minimize spending such as reduced resident transition between care settings, for example, unplanned hospitalization [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53], or reduced antipsychotic prescriptions [Gordon SE, Dufour AB, Monti SM, Mattison ML, Catic AG, Thomas CP, et al. Impact of a videoconference educational intervention on physical restraint and antipsychotic use in nursing homes: results from the ECHO-AGE pilot study. J Am Med Dir Assoc 2016 Jun 01;17(6):553-556 [FREE Full text] [CrossRef] [Medline]50].

Patient Needs

This refers to the extent to which resident needs are known, prioritized, and pursued by a care home. A total of 3 novel subconstructs were identified inductively.

Clinical Benefit

An important contributor toward successful implementation is the perceived clinical benefit for residents [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58]. eHealth interventions are reported to help staff focus on the resident’s condition [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47], better manage residents’ symptoms and vital signs [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58], improve safety around medication administration [Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55], enable staff to attend to residents in a timely manner, and identify common behavior patterns [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38]. The positive impact of eHealth interventions to minimize burdensome care transitions has also been recognized. Reduced unplanned hospital transitions are suggested to improve residents’ quality of life [Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45] by preventing disruption in care continuity with attendance to care needs in the care home [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38]. Residents appreciate minimal journeys to acute care settings [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52] and the benefit of emergency telemedicine sessions to deliver timely skilled health care interventions remotely [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39]. Barriers to uptake of eHealth interventions pertained to opinions that the intervention little benefited residents [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48] by inadequately monitoring and identifying resident change or deterioration and failing to improve assessment processes [Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41].

Person-Centered Care

Interventions must be tailored to the individual and accommodate changing resident needs if they are to be successfully implemented [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]. Given the heterogeneous population in care homes and variable incidence of dementia, eHealth interventions will not make a positive difference if they do not have the capacity to assist with dementia-specific needs when required [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45]. Extra consideration must go into ensuring that technology is unobtrusive if used in the presence of this patient group [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52] who may lack the capacity to understand the change in care. Where residents experience cognitive, visual, or hearing difficulties, eHealth must be tailored, such as through the provision of a larger monitor [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52].

Resident Experience

A negative resident experience of eHealth obstructs implementation [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57]. Dissatisfaction stems from devices interfering with the time spent with staff [Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57] and a switch from face-to-face to remote communication [Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56]. Staff report concerns that using eHealth in the presence of residents may be intrusive and dehumanizing [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40]. Concerns tend to diminish with continued use of eHealth tools; however, over time, staff acknowledge that eHealth can improve care quality [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52]. Other residents report no unintentional harm or negative effects on communication [Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57], with 1 study attributing positive findings to residents, reporting that they felt more followed and cared for [De Luca R, Bramanti A, De Cola MC, Trifiletti A, Tomasello P, Torrisi M, et al. Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach. Aging Clin Exp Res 2016 Aug;28(4):753-759. [CrossRef] [Medline]34].

Outer Setting

The outer setting is concerned with external influences on intervention implementation. This was least considered construct across the studies, with the main focus on the ‘External policy and barriers’ subconstruct. External barriers include policies on the medical liability of telemedicine [Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53], licensing requirements that do not allow physicians to consult across different parts of the country [Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. J Am Med Dir Assoc 2014 Dec;15(12):938-942. [CrossRef] [Medline]49], and issues around reimbursement policies [Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52-Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]. External financial support acts as an incentive to circumvent the additional cost barriers to implementation [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54].

Inner Setting

The most commonly considered construct across the studies was the inner setting, referring to the internal characteristics of a care home. These focused on the 2 main subconstructs of implementation climate (compatibility and learning climate) and readiness for implementation (leadership, available resources, and access to knowledge).

Structural Characteristics

The structural characteristics of the care home setting that affect implementation success include the complex patient population, with the heterogeneity of residents’ conditions affecting the compatibility between the intervention and the care home [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Shiells K, Holmerova I, Steffl M, Stepankova O. Electronic patient records as a tool to facilitate care provision in nursing homes: an integrative review. Inform Health Soc Care 2019 Sep;44(3):262-277. [CrossRef] [Medline]60]. Care home size can also affect the uptake of an eHealth intervention, with larger homes facilitating uptake through more comprehensive provision of information technology services or inhibiting uptake with larger home leaders exhibiting more resistance to adoption and delivering training [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].

Implementation Climate
Compatibility

Portable eHealth devices that can be used at the point of care [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] and during nighttime hours [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36] prevent disruption to workflow, thereby facilitating uptake [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]. Interventions are at an advantage if their goals are aligned with those of the care home, for example, improving advance care planning [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37], and they may face resistance if they do not support existing practice [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40]. Providing individually tailored implementation protocols [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37] and delivering the intervention when care homes are maximally staffed can ease adoption [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58].

Learning Climate

Creating a climate within the care home that encourages learning and active participation in the intervention is key [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. Staff members in the frontline must be receptive [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43] and participate if they are to influence patient outcomes [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44] and affect care delivery [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. Changes to personnel at the site [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44] and reluctance from staff [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] undermine a conducive learning climate. Hierarchical staffing can inhibit implementation [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58] if junior staff feel they are unable to speak up [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32] or access the new tools [Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43]. If a learning climate is not fostered, the staff lack practice in delivering an intervention [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32] and opportunities to share and embed their learning to change practice [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].

Readiness for Implementation
Leadership Engagement

Organizational commitment from the top down is crucial [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31,Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43]. Staff leaders and managers who collaborate with the research team [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37] and lead by example through attending training and contributing to data collection [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43] foster an engaged and cohesive workforce [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39]. A lack of enthusiasm from management can lead to delays in implementation and reluctance from other staff [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43]. Unwillingness and resistance from general practitioners to change practice also act as a barrier [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39] and contribute to a fragmented learning climate [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].

Available Resources

Providing extra time for implementation planning [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52] and end-user training [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52] is required to accommodate a change in practice. A collective staff opinion of insufficient time to adjust to change hinders implementation [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. Sufficient bandwidth is required to allow eHealth to function properly [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53], and insufficient bandwidth can lead to significant motion artefact [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44] and jerky motion images [Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53]. Additional space may be required for training, either within the home [Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42] or off site [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. Equipment needs may include extra computers [Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42] and software [Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59], incurring further financial costs [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51]. Reduced staffing [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51], high staff turnover [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58], and staff absence [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43] obstruct the implementation of eHealth interventions. Limited resources can act as a barrier unless benefits can be demonstrated to outweigh costs [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51]. Managers need to consider the additional resources required to accommodate adoption [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].

Access to Knowledge and Information

Providing adequate training to end users is crucial for promoting uptake [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31-Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40-Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. A variety of educational methods are used, including interactive learning strategies [Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56], lectures, exercises, and group discussions [Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. Training is often provided through a cascaded learning train-the-trainer approach [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48]. Preference varies as to receiving training on the job [Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An advance care planning video decision support tool for nursing home residents with advanced dementia: a cluster randomized clinical trial. JAMA Intern Med 2018 Jul 01;178(7):961-969 [FREE Full text] [CrossRef] [Medline]31,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42] or continuously over a designated period in the months leading up to implementation [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48]. Training tailored to individual needs [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48] can help facilitate uptake, whereas inadequate training can negatively influence perceptions of intervention benefits [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48] and how staff disseminate knowledge to colleagues [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. Incorporating a period of joint work and supervision from a qualified external expert can further facilitate the benefits of training [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32].

Individual Characteristics

This pertains to end users’ individual beliefs, knowledge, and attitudes toward eHealth and implementation. The findings focused on 3 main subconstructs.

Knowledge and Beliefs About the Intervention

Fostering a positive end-user attitude toward eHealth is key to ensuring willing adoption. eHealth tools that are perceived as high quality [Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Lee JH, Kim JH, Jhoo JH, Lee KU, Kim KW, Lee DY, et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Dis Assoc Disord 2000;14(2):94-101. [CrossRef] [Medline]53] and efficient [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55], by cutting back on paperwork [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47] and providing instant access to data [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48], are more likely to be adopted. Interventions judged to improve staff understanding and knowledge [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58] and benefit residents [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58] are more likely to be used. eHealth devices that improve overall job satisfaction [Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56] while providing additional benefits, such as reducing staff anxiety [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38], and social features that enrich staff lives outside of work [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47] encourage use. Conversely, negative attitudes toward eHealth act as barriers to implementation. These include concerns regarding a lack of care improvement [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58], a preference to deliver care in person [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56], and concerns of inequity in health care provision, resulting in difficulty obtaining family consent [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39]. Other barriers include a lack of positive impact on staff workload [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Vuorinen M. Registered Nurses' experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for long-term care facilities in New Zealand in 2017. J Res Nurs 2020 Mar;25(2):141-155 [FREE Full text] [CrossRef] [Medline]41,Salles N, Lafargue A, Cressot V, Glenisson L, Barateau M, Thiel E, et al. Global geriatric evaluation is feasible during interactive telemedicine in nursing homes. European Res Telemedicine / La Recherche Européenne en Télémédecine 2017 Jul;6(2):59-65. [CrossRef]45], concerns over increased time and effort because of implementation [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Wakefield B, Buresh K, Flanagan J, Kienzle M. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004 May;52(5):789-793. [CrossRef] [Medline]52,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58], and uncertainty about the purpose of eHealth and how it works [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46]. This indicates the need for comprehensive training to highlight the benefits and importance of implementing the intervention [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48].

Self-efficacy

Self-efficacy refers to an individual’s belief in their own capabilities to implement an intervention. Low self-confidence in ability [Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] and apprehension toward using new technology [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Qadri S, Wang J, Ruiz J, Roos B. Personal digital assistants as point-of-care tools in long-term care facilities: a pilot study. Educ Gerontol 2009 Mar 10;35(4):296-307. [CrossRef]47] can act as barriers to implementation. These can be overcome by providing sufficient training, which is tailored to individual needs [Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48], and on-hand technical support [Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Perkins S, et al. Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 2003:709-713 [FREE Full text] [Medline]36,Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56].

Other Personal Attributes

Other issues that affect implementation relate to staff willingness and commitment to ensuring that the intervention is executed as planned [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. A lack of experience can also act as a barrier if senior members of staff consider more junior members to be less capable of participating [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] because of age, grade, educational background, or experience [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. However, demonstrating that training designed for medical caregivers is effective across disciplines and grades should help dispel these notions [O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58].

Implementation Process

This concerned reporting on the stages of the implementation process that affect its success. A novel subconstruct was inductively identified to capture data related to engaging end users and other stakeholders.

Planning

Insufficient planning and preparation for change can result in overwhelmed staff perceiving eHealth to be incompatible with their care home [Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51], technology systems and facilities being inundated [Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42], and essential care being omitted [Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46]. Poorly planned study timelines can lead to a low number of participants if enough time is not allocated to recruitment [O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58] and to implementation impact being undetected if insufficient time is allocated to following up and monitoring outcomes [Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,Pillemer K, Meador RH, Teresi JA, Chen EK, Henderson CR, Lachs MS, et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012 Feb;24(1):92-112 [FREE Full text] [CrossRef] [Medline]57,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. Time must also be allocated to prospectively explore different types of eHealth to ensure suitability [Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54]. Multiple strategies are required to initiate a change in behavior and routine practice [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Klein B, Clinnick L, Chesler J, Stranieri A, Bignold A, Dazeley R, et al. Supporting regional aged care nursing staff to manage residents' behavioural and psychological symptoms of dementia, in real time, using the Nurses' Behavioural Assistant (NBA): a pilot site 'end-user attitudes' trial. Stud Health Technol Inform 2018;246:24-28. [Medline]38]. Developing contingency plans to support the program [Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] and establishing a team whose primary goal is to assist implementation can help facilitate uptake [Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. Staff members must be fully informed of the aim of the intervention [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43] and have full clarity of their designated role to achieve maximum impact [Perri G, Abdel-Malek N, Bandali A, Grosbein H, Gardner S. Early integration of palliative care in a long-term care home: a telemedicine feasibility pilot study. Pall Supp Care 2020 Feb 18;18(4):460-467. [CrossRef]56].

Engaging: Champions

Engaging individuals is key to successful implementation. This is often done through designating champions—individuals from within an organization responsible for driving and supporting implementation [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32,Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48,O'Mahony S, Marthone P, Santoro G, Horn C, Selikson S, Powell T, et al. Preliminary report of a pilot tele-health palliative care and bioethics program for residents in skilled nursing facilities. Palliat Care 2009 Dec 08;3:PCRT.S3296. [CrossRef]58,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. To be successful, there must be a sufficient number of assigned champions in each home [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. They must be committed to the position [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43] and not feel undermined by others in leadership roles [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. Designating champions is often undertaken by the team manager [Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] to ensure they are appropriately able to support other staff members [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011 Feb;80(2):116-126. [CrossRef] [Medline]48].

Engaging: End Users

Engaging champions alone is insufficient; other staff members must be involved for successful implementation [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Alexander G, Rantz M, Flesner M, Diekemper M, Siem C. Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Comput Inform Nurs 2007;25(4):189-197. [CrossRef] [Medline]42-Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. For a change in the quality of care to be observed, staff engagement must be sustained [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43], with all disciplines, including frontline staff [Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002 Sep;28(9):14-23. [CrossRef] [Medline]33,Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14(2):76-79. [CrossRef] [Medline]54] and corporate leaders, committed to implementation [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37]. Involving end users in the design and development of technology [Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, et al. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: two years follow-up. Geriatr Nurs 2020;41(6):1000-1005 [FREE Full text] [CrossRef] [Medline]39,Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020 Jul 13;20(1):159 [FREE Full text] [CrossRef] [Medline]40,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59] and considering individual requirements is key if an intervention is to be embedded in a new context.

Execution

Low intervention fidelity is a challenge in complex care home settings [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35], and residents often do not receive the intervention as planned [Moniz-Cook E, Hart C, Woods B, Whitaker C, James I, Russell I. Challenge Demcare: management of challenging behaviour in dementia at home and in care homes. Programme Grants Appl Res 2017;5(15). [CrossRef]32]. Flexible protocols tailored to the care home environment should be developed [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-75. [CrossRef] [Medline]44]. Barriers to successful execution include lengthy gaps between initial contact with participants and data collection and intervention activity, which can undermine the coherence of the intervention [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].

Reflecting and Evaluating

Ongoing evaluation of progress is vital to ensure a new intervention is effectively embedded [Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37,Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43,Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46,Bjarnadottir R, Herzig C, Travers J, Castle N, Stone P. Implementation of electronic health records in US nursing homes. Comput Inform Nurs 2017 Aug;35(8):417-424 [FREE Full text] [CrossRef] [Medline]51,Krüger K, Strand L, Geitung J, Eide GE, Grimsmo A. Can electronic tools help improve nursing home quality? ISRN Nurs 2011;2011:208142 [FREE Full text] [CrossRef] [Medline]55,Fossum M, Alexander GL, Ehnfors M, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. Int J Med Inform 2011 Sep;80(9):607-617. [CrossRef] [Medline]59]. This can be done using routine data collected through the eHealth tool [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43], through in-person visits to the home, monthly conference calls, or video status reports [Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA Intern Med 2020 Aug 01;180(8):1070-1078 [FREE Full text] [CrossRef] [Medline]35,Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017 Apr;14(2):140-151 [FREE Full text] [CrossRef] [Medline]37] to determine the effect and use of the intervention [Alexander G. A descriptive analysis of a nursing home clinical information system with decision support. Perspect Health Inf Manag 2008 Sep 02;5:12 [FREE Full text] [Medline]46]. Receiving feedback can also motivate care home participation, with an absence of evaluative feedback leading to a feeling of being short-changed [Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia (London) 2020 Jul;19(5):1604-1620 [FREE Full text] [CrossRef] [Medline]43].


Principal Findings

This review investigated the key facilitators and barriers that influence the implementation of eHealth interventions to support comprehensive assessment and decision-making for people with dementia in care homes. Our findings inform a model of eHealth implementation in long-term care for people with dementia (Figure 2). We identified 4 novel subconstructs (denoted in the figure by an asterisk) required to adapt the CFIR to the care home context and use of eHealth to enhance integrated care for people with dementia. This modification enables the framework to accommodate the context-specific findings identified in this review and enhances its use when applied to implement eHealth in the care home context.

The 3 novel subconstructs—resident experience, clinical benefit, and person-centered care—were identified within the patient needs construct. No subconstructs have previously been delineated here, and the framework was previously not nuanced enough to capture the data and implementation requirements for this population. Clinical benefit was the most commonly identified theme, with the capacity to minimize burdensome transition between care settings as a key facilitator of implementation. This is echoed in the literature that highlights the adverse impact of burdensome care transitions, both on the resident [Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014 Nov;43(6):759-766. [CrossRef] [Medline]61] and on costs [Wolters A, Santos F, Lloyd T, Lilburne C, Steventon A. Emergency admissions to hospital from care homes: how often and what for? The Health Foundation. 2019.   URL: https://www.health.org.uk/publications/reports/emergency-admissions-to-hospital-from-care-homes [accessed 2021-12-11] 62]. Although outcomes were not the focus of this review, eHealth interventions are more likely to be embedded if they can improve the delivery of integrated health care where it is required, enhance integrated care, and improve cost-effectiveness in the National Health Service [Delivering the benefits of digital health care. Nuffield Trust. 2016.   URL: https:/​/www.​nuffieldtrust.org.uk/​files/​2017-01/​delivering-the-benefits-of-digital-technology-web-final.​pdf [accessed 2021-12-11] 63].

Findings around the potential dehumanization of care reiterate a concern raised previously in relation to eHealth implementation [Bailey J. Does health information technology dehumanize health care? Virtual Mentor 2011 Mar 01;13(3):181-185 [FREE Full text] [CrossRef] [Medline]64]. Although the aim of eHealth is to enhance care delivery, entirely omitting in-person contact has clear disadvantages. Striking the right balance between delivering care face to face and virtually is crucial. Future research should focus on delineating the components of health care that must be delivered in person and identifying those that are more amenable to remote delivery to ensure that care quality is not compromised.

Figure 2. A model of factors that influence the implementation of eHealth in care for people with dementia.
View this figure

The engaging subconstruct of the implementation process was also modified for the purpose of this review. None of the proposed subcategories of engaging (opinion leaders, formally appointed internal implementation leaders, champions, and external change leaders) were suitable for capturing data around engaging end users. The importance of involving end users throughout the implementation process is a key finding and is consistently advocated in the literature to help close the gap between research production and clinical practice [Versluis A, van Luenen S, Meijer E, Honkoop PJ, Pinnock H, Mohr DC, et al. SERIES: eHealth in primary care. Part 4: addressing the challenges of implementation. Eur J Gen Pract 2020 Dec;26(1):140-145 [FREE Full text] [CrossRef] [Medline]65,Slattery P, Saeri AK, Bragge P. Research co-design in health: a rapid overview of reviews. Health Res Policy Syst 2020 Feb 11;18(1):17 [FREE Full text] [CrossRef] [Medline]66]. Therefore, a novel subcategory titled end users was added to the CFIR. Contradictory findings regarding staff and resident preferences on the design and use of eHealth devices are an important indication that there is no one-size-fits-all approach to eHealth implementation. This inconsistency in preferences highlights the critical need to involve end users during intervention development to accommodate a range of requirements and enhance the likelihood of sustained implementation. Progressing the CFIR to include a subcategory suitable for data pertaining to all stakeholders’ input increases its relevance and applicability for this context.

The most salient construct identified in this review was inner setting of the implementing organization. This is concurrent with the existing research on care homes. A systematic review by Goodman et al [Goodman C, Sharpe R, Russell C, Meyer J, Gordon A, Dening T. Care home readiness: a rapid review and consensus workshops on how organisational context affects care home engagement with health care innovation. University of Hertfordshire Research Archive. 2017.   URL: https://uhra.herts.ac.uk/handle/2299/18200 [accessed 2021-12-11] 67] identified many of the same factors that influence the readiness of care homes to participate in change. These include ensuring compatibility between the intervention and existing care home routine, providing sufficient training and resources, and engaging care home leaders. Both reviews highlight the significance of the organizational context on implementation success and the need to consider context in the planning stage to inform study design rather than retrospectively. This is contrary to a review of determinants for eHealth implementation with informal caregivers in the community [Christie HL, Bartels SL, Boots LM, Tange HJ, Verhey FR, de Vugt ME. A systematic review on the implementation of eHealth interventions for informal caregivers of people with dementia. Internet Interv 2018 Sep;13:51-59 [FREE Full text] [CrossRef] [Medline]68], where few factors relating to context were identified as important. This indicates that factors influencing implementation may not be consistent across health care settings and stresses the importance of understanding specific contextual factors and tailoring implementation strategies accordingly.

One of the most prominent determinants of implementation identified in this review was the complexity of the intervention, consistent with previous findings highlighting ease of use as the most important facilitator of eHealth adoption. The nonadoption, abandonment, scale-up, spread, and sustainability framework [Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res 2017 Nov 01;19(11):e367 [FREE Full text] [CrossRef] [Medline]69] was developed specifically in response to the finding that eHealth, which is categorized as complex is rarely, if ever, successfully embedded in mainstream care. It aims to help innovators and implementers measure and minimize complexity in eHealth and scale-up and sustain innovation, and therefore, it could helpfully be used in this context.

Implications for Policy and Clinical Practice

Using the most salient subconstructs of the framework, a conceptual model was developed to highlight the most important factors that influence the implementation of eHealth interventions to enhance integrated care focusing on care processes of comprehensive assessment and decision-making about care and treatment (Figure 2). The findings can be translated into practical recommendations for organizations aiming to embed eHealth within long-term care settings for people with dementia (Textbox 2). The model indicates that for implementation to be successful, eHealth devices must be low cost, simple to use, and tailored to the care home setting and residents. It must be clinically beneficial to the residents, with special consideration of changing, multimorbid dementia-specific needs. Extensive planning and engagement of care home leaders, end users, and champions in the development and implementation process are key to ensuring successful execution. Providing sufficient training and resources to ensure that care home staff feel valued, motivated, and optimistic about a change in practice is crucial to fostering a positive implementation climate.

Practical recommendation for implementation of eHealth in long-term care for residents with dementia.

Consolidated Framework for Implementation Research constructs and practical recommendations for eHealth implementation

Patient needs

  • eHealth should be tailored to the individual resident and accommodate changing and complex needs.
  • It should be unobtrusive and not replace in-person contact or compromise care quality.
  • eHealth must not just streamline workload but clinically benefit the resident and improve outcomes.

Intervention characteristics

  • eHealth should be user-friendly and accessible to increase sustainability.
  • eHealth that is interoperable with current systems is advisable to minimize installation cost and complex new learning for end users.
  • Technical support should be easily attainable and readily available.

Outer setting

  • Policies that endorse eHealth use in care homes ease implementation, for example, rapid policy-driven implementation of remote consultations during the COVID-19 pandemic.

Inner setting

  • eHealth tools should be tailored to care home settings to fit with existing workflow and care home values.
  • Engaging care home leaders in the intervention is key to promoting enthusiasm and a cohesive working environment.
  • Staff participation and learning about eHealth should be encouraged.
  • Sufficient training should be provided for end users, which should be tailored to individual requirements.
  • Additional resources need to be allocated to accommodate a change in practice. These include technological requirements such as bandwidth and equipment and extra staff time.

Individual characteristics

  • Fostering a positive staff attitude toward eHealth is essential for uptake.
  • The tool should benefit staff by easing workload, increasing knowledge, and improving job satisfaction.

Implementation process

  • Preparation for change and consideration of implementation timelines, strategies, and contingency plans in advance is crucial.
  • Champions should be designated in each care home to drive and support implementation.
  • End users and other stakeholders should be engaged from an early point and consulted in the implementation process to accommodate individual requirements.
  • Ongoing evaluation and reflection on uptake and adherence to eHealth should occur to inform any necessary developments and improvements.
Textbox 2. Practical recommendation for implementation of eHealth in long-term care for residents with dementia.

CFIR Framework

The CFIR is a comprehensive determinant framework and is chosen to guide analysis owing to its previous application with eHealth interventions [Christie HL, Bartels SL, Boots LM, Tange HJ, Verhey FR, de Vugt ME. A systematic review on the implementation of eHealth interventions for informal caregivers of people with dementia. Internet Interv 2018 Sep;13:51-59 [FREE Full text] [CrossRef] [Medline]68,Ross J, Stevenson F, Lau R, Murray E. Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update). Implement Sci 2016 Oct 26;11(1):146 [FREE Full text] [CrossRef] [Medline]70,Ware P, Ross HJ, Cafazzo JA, Laporte A, Gordon K, Seto E. Evaluating the implementation of a mobile phone-based telemonitoring program: longitudinal study guided by the consolidated framework for implementation research. JMIR Mhealth Uhealth 2018 Jul 31;6(7):e10768 [FREE Full text] [CrossRef] [Medline]71]. Generally, the extracted data were amenable to the CFIR, with no data left uncoded. However, 33% (13/39) of the subconstructs had no associated data (Table 2), concurrent with findings from a previous review of eHealth implementation across health care settings [Ross J, Stevenson F, Lau R, Murray E. Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update). Implement Sci 2016 Oct 26;11(1):146 [FREE Full text] [CrossRef] [Medline]70]. This consistency either suggests that some subconstructs are not relevant to implementing eHealth or highlights a limitation of the evidence base and lack of existing literature for this setting and population. These areas of uncertainty are important for informing future research, which should focus on identifying barriers to and facilitators of the implementation of these underresearched constructs.

Strengths and Limitations

A systematic approach to this review allowed for the rigorous and thorough identification of the relevant literature. Evidence synthesis was theory driven and guided by the CFIR, which has been built upon here to increase its relevance in eHealth and long-term care contexts.

Although this review specifies care home residents with dementia as its population of interest, only 38% (11/29) of the included studies had an exclusive dementia population. This was to reflect the real-world heterogeneous populations in care homes and include interventions that were suitable at an organizational level rather than the individual level. Although there was no real difference in factors that influence implementation between dementia-specific and mixed populations, caution must be exercised when extrapolating these findings to homogeneous dementia populations.

Gray literature was not included in this review. This was because, when identified, it provided little data on the factors that influence implementation. This could have excluded relevant data on the eHealth interventions used in care homes. A recent scoping review on telehealth during the COVID-19 pandemic reported a rapid rise in eHealth during the pandemic [Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of telehealth during the COVID-19 pandemic: scoping review. J Med Internet Res 2020 Dec 01;22(12):e24087 [FREE Full text] [CrossRef] [Medline]72].

Conclusions

To our knowledge, this is the first review to synthesize evidence on the implementation of eHealth interventions focusing specifically on improving assessment and decision-making in care homes for people with dementia. We adapted the CFIR and progressed its applicability for use in this context. We developed a conceptual model to demonstrate the most important factors to consider when designing and implementing an eHealth intervention and translated it into 18 practical recommendations for implementers, innovators, and organizations to implement eHealth for people with dementia in long-term care. Particular focus should be placed on the individual care home setting and on the consideration of resident and end-user needs when developing an implementation strategy for use in this context.

Acknowledgments

The authors would like to thank Adam Garside, an information support specialist at King’s College London, who helped with the development of the search strategy. This project was funded by the Economic and Social Research Council (ESRC), National Institute for Health Research (NIHR), and ESRC/NIHR Dementia Initiative 2018 (grant reference number ES/S010327/1). CE is funded by a Health Education England/NIHR Senior Clinical Lectureship (ICA-SCL-2015-01-001). ND was supported by a fellowship from the Alzheimer’s Society, United Kingdom (grant number AS-JF-16b-012). The views expressed are those of the authors and not necessarily those of the ESRC, NIHR, or the Department of Health and Social Care.

Authors' Contributions

JG, CE, ND, and JEA designed the study. JG, EY, and JA contributed to data screening, extraction, and analysis. JG wrote the manuscript. The authors contributed to revisions and read and approved the final manuscript.

Conflicts of Interest

None declared.

Multimedia Appendix 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

PDF File (Adobe PDF File), 96 KB

Multimedia Appendix 2

Search strategy.

DOCX File , 18 KB

Multimedia Appendix 3

Quality appraisal summary table.

DOCX File , 16 KB

Multimedia Appendix 4

Differences in implementation requirements.

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CASP: Critical Appraisal Skills Program
CFIR: Consolidated Framework for Implementation Research
ESRC: Economic and Social Research Council
JBI: Joanna Briggs Institute
MMAT: Mixed Methods Appraisal Tool
NIHR: National Institute for Health Research
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analyses
PROSPERO: International Prospective Register of Systematic Reviews


Edited by R Kukafka; submitted 23.04.21; peer-reviewed by D Valdes, S Lundell; comments to author 20.07.21; revised version received 29.10.21; accepted 02.11.21; published 03.02.22

Copyright

©Juliet Gillam, Nathan Davies, Jesutofunmi Aworinde, Emel Yorganci, Janet E Anderson, Catherine Evans. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 03.02.2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.


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