Bedside computing.

You can take clinical data just as you always did, and your friend the computer will help you

No if, ands, or buts. Nursing homes will be "going electronic." It's only a matter of time before Medicaid, Medicare, HMOs, and other players in the coming managed health care environment require electronic billing and patient records.

But going electronic is a whole lot more than moving billing claims from paper in the mail to electronic data interchange (EDI), or patient records from file drawers to data bases. Those may be the desired results driving the process, but it's a process that doesn't begin and end with a couple of computers in the accounting office and three or four more placed strategically around the building for data entry. It isn't even a computer at every desk.

It's a computer in every hand. That's because the reports you get out of a system are only as good as the data you put in, and the best place and time to record a supply used, a procedure administered, a pharmaceutical issued, is where and when it happens. Computerizing a nursing home starts at the bedside and anywhere else a resident can be found.

There are a number of ways to get that "computer in every hand," and in the end the people holding it may not even think of it as a computer. And that, says Greg Adams, President of Triad Data Resource Systems in New Concord, Ohio, is a good thing.

The less the caregiver thinks of data collection devices as computers, the better," says Adams, whose company offers a bar coding system for use in nursing homes. "The challenge for tech people is to make data collection friendly enough not to get in the way."

Bar coding offers one potential solution to point of care data entry for nursing homes. In its simplest form, a person dispensing a supply would swipe the wand of a portable reader across a bar-code label on that supply. Later the data would be downloaded to a computerized inventory system. However bar codes can be applied to more than supplies. A patient can have a bar code wrist band, a caregiver a coded badge - even medical procedures can be assigned bar codes. In theory anything and everything that is used or done in a nursing home, and anybody who does it, can have a bar code, and that information can be incorporated into the facility's overall management software, whether on a centrally located computer or a satellite network station. The software/hardware combination would record an activity, the person doing it, where and when it occurred, and to whom.

The fact that such systems have been slow to be adopted in nursing homes is something Adams attributes to cost and to a shortcoming on the part of the developers of those systems. "Lay a big part of the blame on we tech people for not having come up with systems tailored to the long-term care environment," he explains. "Bar coding inventory systems have been around for quite a while, but you can't take the same tool designed for a forklift driver in a warehouse and just put it in a nurse's hands and expect it to do the job. It's too big, it's too clumsy. It gets in the way." Another data collection device being used in nursing homes and other health-care environments is the notebook computer. These portable machines, some weighing as little as three pounds, are used by caregivers to input information at the bedside.

Seattle based CARE Computer Systems is one company that makes extensive use of notebooks as part of it's VistaCARE computer system for long-term care facilities. This modular system is a total long-term-care management package covering everything from inventory, to care-plan development, to billing. "A program is installed on a host computer that allows a user to selectively go and download a patient record to a notebook computer," explains Jim Ingalls, Vice President of Sales and Marketing at CARE. "That's done by disc or a direct data link. Then the notebook is taken into the patient's room and treatment, medication records, and plan of care are updated on the spot. The information in the notebook is then uploaded to the host computer." The VistaCARE system also allows for bar-code data entry.

A combination of bar coding and caregiver-controlled data input seems likely for the future of data collection in health-care facilities. However, for systems to function optimally in this (or any) environment, they need to be as user-friendly as possible - and, for many, keyboard entry is simply not user-friendly.

Not to worry: Beginning to make its entry on the data collection stage is the pen-based computer. These systems succeed in conveying the "clipboard-and-paper" feel so familiar to nurses and other caregivers. Electronically, they link into the nursing home computer system and function in the same way as a notebook computer, but the keyboard is replaced by an electronic stylus, or "pen," which is used to "write" on a display screen. The caregiver simply has to check the appropriate box or write out a comment.

Hardware and software for these hand-held, hand-writing-recognition systems is just beginning to come into its own. And that is happening at the same time that yet another technology is reaching health care.

It can be seen being put to use hospitals today. Wireless data communication is being combined with pen-based computers in hospitals to broaden the usage and lower the cost of all inclusive point-of-care computing. CliniCom of Boulder, CO developed a hand-held wireless computer system for health-care facilities in 1991, and Telxon, an Akron, Ohio company that is the world leader in wireless radio communication systems, has established a Health Care Technology Group to market its products to hospitals and other health-care providers.

In 1993, Telxon made West Virginia University Hospitals what it calls the "first totally wireless hospital." The computer system, installed in the ten-story, 750,000-square-foot facility, includes 60 hand-held, pen-based, tablet-size computers and 32 antennas. Telxon says it would have cost about $1 million to hardwire a PC into each of the hospital's 250 rooms. Cost to the hospital for the Telxon system was $167,000, and the antennas also covers an adjacent 250,000-square-foot physician office building.

Obviously, the $167,000 is not reflective of what actual pricing to a customer would be because the hospital was treated as a development partner. Nevertheless, even without the partnership break, it would have been substantially lower than the hard-wired system. And for that, caregivers get to transmit their data to a central location without the necessity of finding, plugging into and uploading into a central unit.

Hospitals, with their acute-care needs, are more able to budget the higher cost of new technology such as wireless. But, as cost drops, that technology will migrate to the long-term-care environment. There is an axiom in computing called Moore's Law, which says that the cost of computer hardware halves itself every 18 months. If that proves to be even close to true for wireless, pen-based systems, they may become the systems of choice for nursing homes as they "go electronic." You really could see a nursing home where there's a "computer in every hand."