Electronic documentation comes to the fore. (Computer Quarterly Update).
Electronic documentation should not be confused with existing MDS and related clinical software programs; it cannot, at present, replace these applications. Instead, electronic documentation provides support for information gathered by existing applications and provides major improvements in documentation accuracy, staff efficiency and real-time resident information availability. Its major benefits include improved reimbursement, staffing efficiency, resident clinical care and resident outcomes.
Currently available electronic documentation systems use hand-held, wall-mounted (touch screen) or other portable devices to record resident data such as assessment information, acuity, vitals, fluid intake/output, bowel/bladder, pain, medications, etc. Because of these devices, information can be continually updated and accessed by multiple treating staff on a real-time basis.
In some cases electronic documentation systems are linked to broader facility information system applications to permit both greater access to resident data and more detailed and effective management reporting.
In general, this technology is not very costly--usually $15,000 to 40,000, depending on the size and requirements of the facility. While ROI can vary according to multiple factors, full amortization of the cost can often be expected within a year or less.
While there are approximately 50 software vendors providing clinical management software for long-term care, not all currently have portable electronic documentation support technology available. As a first step, ask your clinical software vendor whether it offers this capability. Other steps include consulting the Nursing Homes/Long Term Care Management 2002 Buyers Guide, published in July, and the Health Care Software Sourcebook 2002 (Aspen Publishers), to identify vendors offering electronic documentation software. As with all software purchases, obtaining information directly from users of the product and determining the capabilities of vendors are very important steps to take before any purchase or leasing decision is made. Perhaps even more important is determining your staff's level of knowledge regarding assessment, coding and documentation procedures, and completing any training that might be required.
Now that Medicare PPS payment for skilled nursing and tightened Medicaid reimbursement for long-term care have created a need for improved patient assessment, documentation and coding procedures, it is fortunate that electronic documentation technology is now available at relatively reasonable cost. Now is the time for skilled nursing facilities to give it serious evaluation.
Malcolm H. Morrison, PhD, is president and CEO of Morrison Informatics, Inc., an information technology and data analysis consulting company in Mechanicsburg, Pennsylvania. For further information, phone (800) 559-8410. To comment on this article, please send e-mail to firstname.lastname@example.org.