Computerization: where do we go from here?

In the March/April issue of NURSING HOMES last year, top executives of three leading software vendors offered advice on how to get started with computerizing OBRA's mandated care planning process. For this issue, three more industry leaders discussed the & lessons that nursing homes have learned from computerizing, and their outlook for the 21st century. Fielding questions from NURSING HOMES Editor Richard L. Peck were: Kathryn Alden, President, Creative Solutions Unlimited, Inc., Dougherty, Iowa Steven Blackford, President, Medical Communication Software, North Kansas City, Missouri. James Ingalls, Vice-president of Sales and Marketing Care Computer Systems, Bellevue, Washington.

What are some of the major lessons that nursing homes that have already computerized learned from this process?

Ingalls: There are a couple of important ones. One is that they've been able to deal much better with a problem that surveyors have typically cited them on: lack of consistency between the resident care flowsheet and the care plan. The convenient updating abilities of the computer have made it much easier to keep them consistent. Computers have also saved time in the sense that facilities can retrieve documentation that surveyors want -- for example, the resident roster (Form 682) and the survey report (Form 672) -- much more rapidly, within minutes rather than hours. Facilities are also able to identify individual resident RAPS within a matter of seconds or minutes, rather than hours, as happens when you're doing this by hand.

Alden: I agree. Our customers have found, too, that they can pull up reports for their own use, as well as surveyors', for their own programs of continuous quality improvement. In fact, once they've seen what computers can do for them, even some of the most "computer-phobic" staffers have ended up wanting to do more and more with them.

Blackford: I remember one facility that was undergoing a Medicaid audit and had top-level staffers running around literally all day collecting information for the surveyors. We figured it had taken them 32 man/hours. After they had computerized, the very same process, involving the same amount of information, took about five minutes.

Kathy's point about quality audits is well-taken, too. Using computers,today's nursing facilities can take snapshots of themselves -- acuity trends, "hot areas" before they become problems -- on a weekly or even daily basis. They can identify and deal with problems before they become an issue for the survey.

If staff turnover is a problem as is so often the case in nursing homes -- what can the nursing home do to maintain the staff's training on use of computers?

Alden: You want to make sure that the initial training is given to a group of people, not just one or two staffers with a particular interest in computers. This decreases the chances that the training walks out the door. User group meetings also help in keeping facilities using the system updated. Also, even if turnover is a problem, the consistency of computerized care planning facilitates an easier transition by maintaining continuity of documentation.

Ingalls: Retraining can sometimes be a difficult problem, from the vendor's standpoint. We've had situations in which retraining needs existed, but we encountered resistance in trying to help with this, due to cost considerations and what have you. Kathy's point about making sure a group of people is trained is definitely the way to go.

Blackford: Other than our normal onsite training program, one way we've approached the training problem is to develop VHS training casettes which can be obtained and used as the need arises. These can also be used for the staff to review skills, as well. We produce a new set of these videos every year.

Alden: That's a really good idea. Also, we have found that in states that mandate computer instruction as part of continuing education for clinical staff, we have been able to develop continuing education seminars combining clinical content and computer content -- for example, use of computers in infection control, behavioral management, psychotropic prescribing, restraint reduction, etc.

Ingalls: Concerning the turnover problem, sometimes just the improvement in the quality of the work environment -- using computers to track RAPs, for example, rather than have to go through the mundane business of tracking these by hand -- may have an impact on reducing turnover.

When care planning with computers, how can staffers avoid the feeling that they are straitjacketed or that the process is somehow "canned"?

Alden: That's a very common question, and a big issue. It is very important that these systems allow for flexibility and accommodation to change.

Ingalls: Most vendors these days are, or should be, providing libraries of problem complexes -- the problems, goals and approaches -- that allow for individualized care. We have, for example, some 1,400 interventions to choose from.

Alden: Once staffers see how they can pull up these libraries, they find they're a marvelous resource. The secret is that the library has to allow you to be very resident-specific. "Give Flora a Milky Way bar twice a week." That's fine; it works for Flora, and can be made part of her care plan.

Blackford: Our industry took something of a bad rap for the software that was put out 10 years ago that wasn't really modifiable and really was "canned," to some extent. There's been a lot of evolution since then, and the vendor today who doesn't build flexibility into his system isn't going anywhere in the marketplace. You've got to have the libraries and the ability to modify them for each resident.

But you have to be a little careful, too. A few years ago we built a library of thousands and thousands of choices -- it got to be like Webster's dictionary. We canvassed our customers and found out that they were actually using only about 10% of this. For them, it was learning to speak English using Webster's dictionary, and using only about 1,000 words. Well, most people can communicate pretty well with a 1,000-word dictionary if it meets their needs. So we've cut our library down to a reasonable size.

Alden: Another trend with these libraries is to include literature references for the options they provide. More and more customers seem to want to know who the experts are behind these recommendations, and this is broadening their knowledge.

There is also increasing flexibility for use of these libraries by non-medical personnel, such as admissions and social services. If, for example, a resident being admitted is grieving for a loved one who recently passed away, these systems will give admissions and social services options to deal with this.

Blackford: These options necessary because OBRA mandates interdisciplinary care plans. Computerized systems these days have to accommodate this.

It is interesting to see how things have changed. It used to be that the front office did the billings and ran the show, and medical records took a back seat. With computerized care planning, that process has totally flip-flopped, and medical records are driving accounts receivable. That trend is continuing, and five years from now we'll all look back and laugh at how rigid and inflexible we were.

What impact has computerization had on time and staff required to assess and manage residents?

Blackford: We once commissioned a time-and-motion study that showed that, once the system was up and running, one facility achieved a 50% time savings in man-hours spent doing paperwork -- a $26,000 savings. That number didn't translate to the bottom line; what it meant was that this facility's staff had that much more time available to carry out its clinical responsibilities.

Alden: To help with the initial time problem involved in adjusting to this, we about a year ago started assisting facilities in keying in their admission records and physicians orders prior to the training process, so that when they're ready to start training on doing the MDS and care planning, the system is already up and running.

Blackmore: We're doing that, too, and it's taken off like a skyrocket. This is a service that wasn't available a year ago. We take two days to load in the demographic data, the mds, and the physician's orders, and the facility can see a statistical picture of itself. After two days of training them how to use the system, they're ready to go with nearly fresh data.

What do you see as important new developments and trends in computer software for the nursing home?

Blackford: I think that everyone, from the Federal government on down, realizes that we have a lot of questions to answer about nursing home care before the explosion really hits. The number of nursing home residents is projected to double by the year 2020. As a result, there is a growing interest in outcome studies for quality assurance. Typical of this is the multi-state case-mix study that HCFA is conducting right now to develop quality-of-care indicators. Someday nursing homes will be able to feed their data into the state programs which will, in turn, offload them to the Federal government, and surveyors will be able to use that data in making judgments about quality of care. Also, as Kathy already suggested, nursing homes themselves will be able to use this data for their own quality improvement programs.

Ingalls: Bar coding is an idea that's catching on and expanding. We're seeing this mostly in central supplies right now, but I think this will be adaptable to clinical documentation, as well. Anything you can quantify, you can scan. This, of course, will produce a major savings of time spent now in keypunching.

Another development I foresee is the use of hand-held computers at the bedside. This isn't happening now because these devices are not cost-effective. But I think that, as is usual with computer technology, prices will come down drastically and facilities will accept this for the convenience this offers, compared to having to write down the notes and keypunch them at a specific terminal.

Alden: Voice recognition is another exciting possibility. Imagine, being able to speak your resident assessment directly into the computer.

Blackford: Yes, we've been playing with that. It's way off in the future, but I think that by the year 2000 it won't be unusual to find a clinician wearing a transmitting device enabling the central computer to record that clinician's spoken observations and recommendations, either directly or from a bedside computer than can be offloaded to the central unit.

Alden: You're talking about the possibilities of cellular telephone technology and wireless transmission.

Blackford: That's right, it'll be RF LANS transmission -- the kind of thing you see right now at rock concerts with transmitting devices right on the instruments. And, as with computers, I see the costs of that coming down, too, and making it affordable for the nursing home.

Alden: Another trend we're seeing is a growing demand for customized assessment systems. Many facilities see the MDS as just that -- minimum data -- and they've used it as the basis to develop their own, more sophisticated assessment tools. Many of them have gone to all the trouble of doing this by hand, and now they want the computerized system to accommodate to this.

Anyone care to offer a final comment?

Ingalls: We like to think of ourselves as selling solutions, but it's important that these be sold to the people who will be implementing them. Selling in the past has been pretty much geared to the administrator and/or the owner, primarily because they are the ones who sign the checks. The staff, though, has frequently not gotten as involved in the process as it should be. In purchasing and developing these systems, the staff should have direct involvement before decisions are made, because it makes the process so much more workable and successful.