Core Technologies

From Paper to Electronic in multiple Skilled Nursing Facilities (SNF)


This article reflects my team’s journey through transition from paper records to fully paperless records across multiple Skilled Nursing Facilities (SNF).


Our journey began before we even started looking for a true electronic medical record product. In the SNF setting, the Minimum Data Set (MDS) drives payment and historically the MDS nurse has been the only nurse using a computer. As the MDS Consultant for the organization, I became “the computer nurse”.

We went through many various MDS software applications and point of care documentation (POCD) applications during my thirty years. We had one failed attempt at an electronic medication administration system, multiple successful implementations of MDS software, a failed POCD implementation and a successful POCD implementation. Through the experiences, we learned many lessons.

Pre-vendor Selection

Drawing upon our history, we knew the journey towards a fully paperless system required extensive planning prior to even beginning the vendor selection process. Working with IT, we began having discussions around what it would take to bring up sixty centers on an electronic record, just from a technical needs standpoint. All of our centers are in rural areas with limited connection options and centers are all of various ages, both presenting opportunities.

Workflow assessments began at this point establishing data flows both within the individual centers and outside the center to partners such as pharmacy, lab, radiology, and others. Using this work, we identified key stakeholders, core team members and extended team members to participate in a vendor selection project. We then began making decisions about goals for an electronic health record. This core team identified the minimum needs requirements of an electronic record, and established long term and short-term goals. This team also identified the infrastructure projects required to support any electronic system.These discussions and decisions guided the next step of our process, which was vendor selection.

Vendor Selection

Expanding upon the core team’s work, we determined additional features needed to help us obtain our strategic goals over the next five to ten years. This same group established not just product needs but requirements for a vendor partner. This group felt very strongly that we needed a vendor partner who shared the same vision as our organization and would work alongside the organization to help achieve not just implementation, but growth toward a shared vision. Once we had this information, we utilized resources available through Caring for Aging Services (CAST)(Leading Age , n.d.), such as vendor comparison and planning tools to assist in vendor product comparisons and planning. Once we identified vendors that met the minimum needs we began comparing products.

Using a short list of products that could meet our need requirements we had center users begin logging into “training/sample” sites to review the products. During this process, users determined ease of navigation throughout the application with little to no instruction or guidance.

We also brought vendors onsite for product demonstration with both the core and extended team.  During the process, the team compared and evaluated products to verify whether products actually delivered necessary features. Following the onsite demonstrations, the core team visited centers that used the final two products on our list. During these site visits, team members ranked each product based on predetermined criteria.

Taking needs assessment into account plus site visit results, ease of navigation reports from test users, references, KLAS rankings, and vendor interviews, the core and extended team identified the best application and vendor for our needs.  KLAS Research is a healthcare IT data and insights company providing the industry with accurate, honest, and impartial research on the software and services used by providers and payers worldwide (KLAS, n.d.).


We now began the hard work, spending the next several months reviewing every piece of paper utilized within the centers as well as every clinical process with the vendor to establish best practices within the electronic record system. This collaborative team started with the end goal in mind and then mapped the process of how to successfully reach this goal. The team in collaboration with the vendor then established workflows, documentation tools, and processes within the application to both ensure patient safety and gain efficiencies with the end goal in mind. Next, we developed training tools and training plans collaboratively with the vendor to train users not just on how the application works, but how the established processes work within the application. The team then identified an interdisciplinary implementation team to provide onsite and offsite support, as well as a post go-live support plan.

The criteria for selection in the pilot included center size and leadership style, acuity of patients, the average length of stay for patients, and geography. The team determined we wanted two very different centers versus two similar centers for this pilot. We also chose one center who had not historically embraced technology and one who has so that we could assess usability in both situations. The centers selected had to volunteer to participate versus mandating participation in the pilot.

The team scheduled regular stop points throughout the pilot to evaluate the following: what worked, what did not work, duplication, redundancy, how are the end users responding to the application, and how can we improve as we go. Throughout this process, the team identified many opportunities for improvement.


Once the pilot was completed, we began working on a collaborative implementation plan.  This implementation plan included revision of training tools, training super users or champions for each location, implementation schedules and selection of the implementation team. Our original implementation plan included an eighteen-month implementation from start to finish for fifty-three centers. Our final schedule, based on requirements of the executive team, required us to shorten this period by six months. This required an implementation in two to three centers weekly throughout the process. We have successfully completed implementation in all but one center at this time and have had good feedback from these centers.

Next Steps

Now we are ready to transition to the next phase of this project, which will include establishment of an interoperable system, utilization of clinical pathways, reduction or elimination of risk areas, and continual improvement of workflows and efficiencies.

Citation: Rowe, S. (Winter 2019). From Paper to Electronic in multiple Skilled Nursing Facilities (SNF). Online Journal of Nursing Informatics (OJNI), 23(1). Available at

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Leading Age . (n.d.). Electronic Health Records (EHRs) for Long-Term and Post-Acute Care A Primer on Planning and Vendor Selection. Retrieved from…

Taylor & Francis Group, an Informa business. (2013). HIMSS Dictionary of Healthcare Information Tehcnology Term, Acronyms and Organizations, Third Edition . Boca Raton: CRC Press.