Bringing LTC up to Internet speed.

E-commerce goes beyond buying and selling online

E-COMMERCE IS IN ITS INFANCY IN LONG term care. The delay in adopting e-commerce technologies is because of the many challenges that face the industry. Long term care providers need to define the roles that e-commerce will play and understand the preparations necessary to utilize e-commerce in their field.

Numerous financial challenges must be overcome before the long term care industry can take full advantage of e-commerce technologies. Pricewater-houseCoopers reported in August 2000 that health care supply chain automation would take several years to be fully implemented unless providers are willing to spend more than 3.5 percent of their total budgeted annual sales on information technology. However, few long term care providers currently are positioned to support such a significant allocation of resources.

The long term care industry recently has emerged from a "cost plus" world. In the past, the industry has been mainly financially focused. Automation had been primarily limited to "score keeping" and reporting information, which was usually stale and outdated by the time it was gathered and examined. It was generally used to understand, not shape, the business. The net effect of this delayed information was a "chain saw" versus "pruning" style of management.

Other challenges that have slowed the adoption of these technologies are record litigation expenses, adjusting from a cost-based to a margin-driven business model, a full-employment economy that supports high rates of turnover, and increasingly complex regulations. It becomes difficult to utilize e-commerce technology in an industry that must implement survival tactics constantly.

Another issue affecting long term care is the absence of a nationally implemented product-classification system for standardized universal-product and health-information numbers. As providers buy many different products from many different vendors who may not barcode all products, it becomes difficult to make all of these purchases through an e-commerce or an e-procurement model. Some vendors may be slow to adopt e-commerce because of the niche markets that they occupy--and the long term care industry uses many niche-market providers.

Long term care also lacks competent technology staff. Recruiting and retaining employees that have both long term care experience and the necessary technical expertise is a significant challenge. Offering pay rates and compensation packages for technology talent is difficult when providers are competing with other industries that have larger budgets.

Roles of e-commerce

E-commerce plays two basic roles in long term care: tactical and strategic. The tactical role is to facilitate or enhance cost control while staying in compliance with rapidly changing rules and regulations through timely, accurate, complete, and relevant information. The strategic role is fundamental. It must support core clinical programs, monitor systemic failures in care and cost, and help providers acclimate to the changing regulatory environment. If e-commerce strategies can accomplish these tasks, then there is a very good chance of a successful implementation of e-commerce within the industry.

What can providers do to better position themselves for this brave new world of e-commerce? To begin, they must invest in infrastructure, such as developing a technology management team. While not every member of the team has to be a star, they should work well together, which provides stability to the organization. Senior management must actively support the technology initiatives that are deployed and focus on developing a concrete business plan that contains an operational and capital budget.

Technology products and vendors

Providers must utilize mainstream technology products and vendors. These are the players who are going to be in this market from an e-commerce perspective over the long term. They will adopt the standards that will be necessary for better implementation of e-commerce in long term care, such as Web-enabled or Web-based technologies. By focusing on Web-enabled applications, providers are able to offer training and manuals over an Intranet or Extranet. (An Intranet is a network linking employees within a company; an Extranet links companies that work together.) This would enable a new clinician to access the company's standards manuals, clinical programs manual, or the nursing practice manual directly from his or her workstation. Web-enabling provides access to regulations, forms that can be filled out and submitted electronically, policies, company news, and compliance updates through the Intranet.

Another example of Web-enabling documents is to have the human resources policy and procedure manuals accessible on the Intranet. This facilitates quick reference to specific processes such as employment application and screening, non-discrimination, offensive-behavior policy, and checking references on new employees. Government-regulations updates can also be provided via the Intranet. With the click of a mouse, employees can access information on current congressional sessions, actions expected on specific long term care-related bills, and pending legislation.

Online access for all

Providers should encourage all staff members to use e-commerce technology by providing Internet access from every workstation. This will help in developing the competencies and skill sets necessary to use these technologies long term. Providers should also encourage dial-up from the road or from home. An 800 number can offer remote access to the Internet and Intranet.

One national long term care chain offers employees a PC-purchase program to help them buy their own personal computers for home. By negotiating with local hardware vendors, risk for the provider is avoided and the debt remains external through deducting a monthly payment from the employee's paycheck. This extra benefit could help facilities retain CNAs and other staff members.

E-commerce encourages financial and clinical staff members to use the Intranet by providing information systems with leading business indicators such as clinical outcomes, labor hour utilization, and census on a daily basis. A variety of other indicators can be monitored as well, such as weight changes, returns to hospital, leaves of absence, and restraint utilization, with the ability to point and click into a specific analysis. This assists in analyzing the financial and clinical performance of each grouping, region, or building.

The goal is to have individuals focus on current information on a current basis, rather than reacting to outdated data, a practice that has been typical of the long term care industry. In the future, much of this information may be collected via wireless hand-held technology, thus supporting clinical initiatives through low-cost data-collection devices. Ideally, providers will offer all facilities secure Internet access and educate employees on company policies regarding e-mail and the appropriate use of the Internet. (See "SNF of the future," facing page.)

Some providers are also starting initiatives to provide personal computers with Internet access and e-mail to their residents. This can be a good way to provide additional mental stimulation and social interaction for residents, especially those who might otherwise experience cognitive deterioration. Such services can also enhance facility marketing programs by letting family members know that their loved ones will be accessible in an electronic forum.

E-procurement and online training

Long term care facilities can also utilize e-commerce by starting e-procurement initiatives through contracts with group purchasing organizations (GPOs). By creating electronic formularies to achieve compliance with the purchasing contracts, providers can interface the back-end transactions through the GPO with their accounts-payable system to minimize paperwork. Developing a Web-based training program is a cost-effective way to train facility personnel in the e-procurement process.

Vendors and suppliers that employ e-strategies include DSSI, Click2Learn, Mindleaders, Microsoft, Virtual Care Provider Inc., and Sysco Foods, These companies work closely with organizations to help develop new "e-solutions" for common problems. For instance, one large long term care provider offers training on computer applications via the Internet and Intranet by using Click2Learn, a Web-based authoring tool that enables customers to author their own industry-specific training material.

Through Mindleaders computer-based training (CBT) services, users receive instruction at their own pace on applications such as Excel, Word, and PowerPoint, without having to leave their workstation for outside training. Similarly, Placeware.com provides Web-based conferencing so groups of individuals can be trained simultaneously with live demonstrations on their workstations, thus eliminating travel and the deployment of trainers.

Affordability from Extranets and ASPs

It is important to build an Extranet to enhance relations with suppliers and particularly Web-based referral sources such as discharge planners. By interfacing with hospital information systems, long term care providers and discharge planners minimize the process of faxing and telephone calls. Discharge planners will want to do business with those who make their jobs easier.

One of the best ways to implement e-commerce affordably is through outsourcing information technology to an application service provider (ASP), such as Virtual Care Provider Inc., Trizetto.com, and Ultrabridge.com. Such companies can provide an array of telecommunication, transitional, and professional services, by hosting, managing, and deploying access to packaged software applications from centrally managed data centers for a fixed fee on a subscription basis. ASPs reduce the total cost of ownership of technology and provide greater access to technology at a lower cost.

Setting specific goals

Long term care providers must determine their own goals for implementing e-commerce in their organization. They must identify how much they plan on saving and where they want to be in terms of compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA).

Numerous intangible and tangible benefits exist through the implementation of e-commerce. By focusing on the tangible benefits first, providers can roll out simple initiatives that can be mastered successfully. This can provide the necessary momentum for tackling more complicated tasks down the road. Providers must define their tactics clearly and make sure that everyone understands the potential return on the investment. E-commerce is a vital survival tactic, a part of our future business that is here to stay.

SNF of the future?

Howard Lange

Rand Johnson

"Smart rooms" may be on the horizon

Mrs. Jean Jones, an 89-year-old retired biomedical engineer recovering from a stroke with right-side hemiplegia, has been in her bed for 1 hour and 45 minutes. She is unable to turn herself, but a microchip timer in her bed has been set to signal her CNA's hand-held computer (a personal data assistant, or PDA) 10 minutes before it's time to turn her. However, sensors in the bed, measuring specific matrices of comfort, alert the CNA that the patient needs to be turned immediately.

Upon entering the room, the CNA turns Mrs. Jones to the new position in bed as displayed on her PDA's screen. The bed, sensing the new position, automatically adjusts its head and foot according to the positioning requirements entered into its software, specific to the resident's weight, height, and musculo-skeletal characteristics. The CNA then offers a drink of water dispensed according to the hydration needs of the patient. The e-chart notes the intake through fluid-intake sensors.

Later, Mr. Murray Smith suddenly spikes a temperature of 103. Immediately, an alarm sounds on the PDA carried by the charge nurse. Using the PDA, the nurse confirms that the sensor's information has been recorded in the e-chart, noting the corresponding treatment and medications ordered for such an episode by Mr. Smith's physician. As the charge nurse heads to the room, he uses the PDA to check the inventory of medication stored securely in a wall unit next to Mr. Smith's bed.

The nurse swipes his ID card against the electronic reader next to the medication storage unit. Once he has placed his thumb on the reader to confirm his identity, the lock securing the storage unit door hums briefly and the door opens. A small, removable drawer, containing the proper medication and dosage is sitting on the dispensing tray ready for the nurse to administer to Mr. Smith. The lock on the storage unit automatically resets when the door is closed.

Meanwhile, the unit's sensors and inventory software collect the information, noting date, time, and dosage, combined with the nurse's ID information, recording it in the e-chart. The software further notes the change in inventory and communicates it over wireless connections to the central supply storage application and Mr. Smith's pharmacy. Eventually, when the medication reaches predetermined par levels, set specifically for Mr. Smith, the pharmacy's computer will automatically prepare the refill and will communicate the information to the physician for her approval prior to sending the order to the facility.

THESE "SMART ROOM" SCENARIOS REPresent only a small fraction of the possibilities that e-commerce and information technology may bring to reality 30 to 50 years from now. With a Star Trek vision of the future and the emerging technologies of today, long term care and its vendors may enjoy seamless communication while its residents enjoy enhanced care.

Virtual reality designed specifically for dementia patients may be able to stimulate their minds with "real" images of people, objects, sights, experiences, sounds, and smells, recommended by the team of geriatricians.

Resident admissions will proceed smoothly, with the information automatically recorded during the hospital stay immediately accessible through the technology of Universal Application Architecture (UAA)--the way computers with disparate operating systems and software share and exchange information. This will enable the secure flow of comprehensive biographical, medical, and financial information, dating back to the birth of the patient, throughout the entire continuum of care.

Rapid advances in technology will greatly improve the devices--such as hand-held computers and smart cards--that monitor and communicate resident care needs. Such technology will create smart rooms that will constantly monitor the resident's vital signs and behavior, measure intake and outflow, and alert nursing staff of any change in condition or steps to be taken as a result of the information gathered.

Ordering the needed products and pharmaceuticals by way of a wireless, seamlessly integrated Internet will ensure accuracy and timeliness, while reducing costs. Hand-held devices, carried by physicians and nurses, will be used to gather the information required to determine the types and amounts of products to be ordered.

Of course, bringing these dreams to fruition will be expensive. Improved payment rates for resident care, the affordability of these technologies, the leadership needed for their implementation, and the regulatory environment will all influence whether they will become reality.

Howard Lange is vice president, information technology, at Extendicare Health Services Inc., Milwaukee. Rand Johnson is supervisor of sales and marketing for Milwaukee-based Virtual Care Provider Inc.