Can we talk? Communications made possible through computer technology.

We're a long way from the day when a "computer" was a machine that enabled you to perform mathematical wonders at prodigious rates of speed. Today's computers are parts of systems that enable people, of diverse descriptions, and at great distances, to communicate with one another as if they were in the same room. All hardware "pieces and parts" other than the computer--the connections, the wiring, the wireless devices--are available now to make this miracle come true. In the long-term carefield, this concept is meeting its acid test with new installations in two major organizations: the 1,630-bed Jewish Home and Hospital in New York City, and the 240-facility, 28,000-resident Evangelical Lutheran Good Samaritan Society (the largest not-for-profit long-term care organization in the United States), based in Sioux Falls, South Dakota. Obviously, these organizations are working with technologies (and budgets) scaled to their size. So what possible relevance would their experiences have for the smaller facility? Only this: If organizations this size can improve internal communication using information technology, smaller ones might find their own answers in the same technologies sized to their needs. You be the judge.

The Jewish Home and Hospital--Everyone Gets Into the Caregiving Act

The Jewish Home and Hospital (JHH) is big--in fact, it is three large facilities: the 816-bed Bronx division, the 514-bed Manhattan division and the 300-bed Sarah Neuman Center for Healthcare and Rehabilitation in Mamaroneck, New York. It employs more than 4,000 staff, including physicians, nurses, dietitians, social workers, rehabilitation therapists, housekeeping and security. And, as does any healthcare organization, it generates paper--lots of it. Until recently, it was estimated that nurses were spending three or four hours a day--half their shifts-- completing paperwork. Although JHH has been better than average in retaining staff (see "Keys to Retaining Staff: The Jewish Home & Hospital Experience," May 2000, p. 24), staff is still a precious commodity there, and President and CEO Sheldon Goldberg thought there had to be a better way for caregiving professionals to spend their time than writing on paper.

The $7 million answer was the clinical information system (CIS), which JHH began activating this past November after three years of planning. Using special "workflow-based" software developed by Per-Se Technologies, a Georgia-based vendor, the CIS makes sure that a complete and updated clinical picture of every patient is available at all times to every caregiver involved, at the appropriate "need to know" level, no matter where in the organization he or she might be. As soon as a patient is admitted, the CIS alerts a staff physician that a history and physical must be performed within 48 hours. The resulting data, plus medication orders, care plans and referrals to other departments, are entered into the system, and these entries themselves generate updated information and prompts of specific interest to specific caregivers.

For example, the pharmacist will see the physician's medication order, to which the CIS might have added specific needs or risks of that medication for the patient, leaving it up to the pharmacist to either approve the order or get back to the physician with further suggestions. Nurses, meanwhile, will have the patient's medication administration record (MAR) updated continually on their own particular computers. Social work's computer terminal might list family issues pertaining to the patient, while the beautician learns that a biweekly hairdressing appointment will be important to her, and will see a specific reminder about that appointment a week later.

As the CIS updates, it actually follows the caregivers about. Handheld notebook computers using wireless technology are mounted on medication and treatment carts throughout the facility, giving nearby staff immediate access to the patient data they need to know and, if necessary, prompts about tasks that have to be done at that point. The staff can also enter their own updates, which will go to the central database and be accessible to relevant terminals.

Needless to say, a communications network of this magnitude will take some time developing. JHH went online with two nursing units last November, anticipates adding four more by the end of this month and then plans to have all three facilities on board by the end of this year. "We want to make sure we take our time and get it right," says Chief Information Officer Kristine Cerchiara. Staff training alone, she notes, has been a major project, with staff from nurses through CNAs through housekeeping spending hours using the 18 basic modules, with written examinations, and follow-up specialized training offered by Per-Se.

Getting even to the basic level of training was a leap, says Cerchiara, because fully 350 of the Bronx division's 800+ staff had never even touched a computer before the move to CIS was announced. "We had a lot of shaking and crying that first day," she says, "but it got better the second day." The situation was no doubt helped by JHH's unusual approach to the situation--setting up seven computer stations in the staff dining area, loading them with computer games and mandating the inexperienced staffers to play the games for a total of two hours during regular shifts.

As more and more staff come on board, more and more will get done. For instance, the network will be set up so that all relevant assessment data will flow automatically to the Minimum Data Set (MDS), completing that crucial piece of paperwork without a hand being laid upon it. "This and the medication administration system are the big-ticket items," says Cerchiara. "This is where we expect to make our greatest return on investment."

Evangelical Lutheran Good Samaritan Society (GSS)--1 for 240, 240 for 1

To understand the organizational change that GSS has gone through, imagine if you were a business with 240 branches in 25 states. Each branch has its own information management system, with its own way of keeping updated, and with personal computers (PCs) susceptible to disk drive failures and bugs, each costing around $6,000 a year according to industry analysts, just to keep running. Suppose you could set it up so that you could get all of those branches on the same information system, speaking the same language, having updates taken care of for them and replacing those high-maintenance PCs with network "shell" terminals requiring relatively little support.

What would you do?

Which explains why GSS has taken upon itself the large task of becoming its own application service provider (ASP). An ASP uses large servers to provide needed computer programs to far-flung facilities and offices, providing all necessary maintenance, backup and updating, and freeing those facilities to focus on providing service--in this case, resident care--without the burden of keeping their information systems running. According to GSS Chief Information officer Rustan Williams, the switch has enabled GSS to increase efficiency to the point that the organization's technical support requires only one-and-a-half full-time equivalents (FTEs) for more than 2,000 PCs, compared with the industry average of one FTE for every 75 PCs.

For its clinical and accounts receivable software, GSS has selected the Health Care Software (HCS) INTERACTANT programs, which have been designed for use on a high-speed server from IBM (the eServer iSeries, for the technologically literate, which has a reputation for being virtually virus-proof). Consolidating GSS's mission-critical applications on one server, Williams notes, "is what has made this approach so cost-effective for us."

Training for the system is Web-based, with modules set up to allow each trainee to learn interactively at his/her own pace.

Of course, no adaptation of a new technology infrastructure goes seamlessly. GSS has had to work through particular challenges, such as the logging of keystrokes that "slowed everything to a crawl," says Williams, until GSS was able to localize the function, and the structuring of a "single sign-on" security system that would work efficiently. And commenting on the long-term care industry in general, HCS's Vice-President of Marketing Tom Fahey adds that for multi-facility long-term care providers, overall technologic improvements are still needed to "consolidate facility information for use in facility, regional and corporate-wide analysis in a real-time environment"--the in-depth reporting function that is a major promise of the ASP approach.

For now, though, both GSS and JHH have made sufficient progress to document the basic value of the new information technology: (with apologies to Hillary Clinton) "it makes a village," no matter how big you might be.