Information systems: gearing up for the new generation.

An interview with Deborah L. Roland, President, Care Information Technologies, Inc.

Having just gotten comfortable with installing clinical, MDS-related software to accompany their older financial information systems, long-term care providers are now being asked to consider "stepping up" once again - this time toward integrated, managed care-type systems for tomorrow's health care. There is no escaping it: Information management has become a major responsibility for administrators and DONs, requiring them to exhibit knowledge and skills never demanded of them before. In what way? At the recent annual meeting of the American Association of Homes and Services for the Aging, computer consultant Deborah L. Roland offered to a "packed house" of attendees a global view of the new challenges. Nursing Homes Editor Richard L. Peck asked her subsequently to zero in on the issues confronting nursing home managers in getting from Point A - today's financial/clinical systems - to Point B - the next generation of computerization.

Peck: What should nursing home management think about doing to computerize their facilities beyond what they're doing now?

Roland: The key issue to start with is connecting up areas and departments within the facility. All should be operating from the same database, and any authorized person should be able to enter and access all needed data at any point in the system. We have to recognize that we are not just "number crunching" any more; this is about information sharing. With the MDS, for example, the only way to get full value from it is to open it up to access by everyone on the clinical staff.

"Openness" is the key word - the system must have an "open architecture" to allow for this sort of sharing. Every vendor knows enough to say that his or her product is "open," but this may or may not be true for your particular needs. You have to find out whether the product will allow for the kinds of information sharing you want.

This is, in large measure, a hardware issue - the installation of the necessary cabling and appropriate operating systems. These are available from local computer vendors - they are not necessarily specific to the nursing home industry.

The other important point here is to "go with the flow" - to acquire equipment that is prevalent in your marketplace, rather than something that is esoteric and untested. And, to all intents and purposes, it is a Microsoft Windows world out there today. Hardware has to be able to handle it.

Peck: What, then, are the basic types of computer equipment that you'd want for this?

Roland: I would say Windows capability and a 486 at the minimum. And they don't even manufacture 486s anymore - today's standard computers are the Pentiums. These do cost money, but today's facilities have to be prepared to make these sorts of expenditures regularly; it is important to devote a proportion of the facility's annual budget to this on an ongoing basis.

Peck: Would leasing or purchase be preferable?

Roland: It depends on how much one wants to purchase at one time. If the purchases are to be made gradually, it might be preferable to go with a line of credit.

Peck: You also mentioned, at your AAHSA presentation, the idea of using multiple vendors to build these new systems. Would you elaborate?

Roland: It used to be that people would get everything from a single source - for example, "Big Blue", i.e., IBM - whether it was hardware, operating systems maintenance or applications software. Now you might get your hardware from, say, Compaq, operating system from Microsoft, applications software from Lotus and networking from Novell. The marketplace has become segmented, and that's the main reason we've seen such dramatic reductions in prices over the years; in fact, these price drops would never have occurred otherwise.

It is also important to recognize that, for several specific functions, there are vendors specializing in applications software that will work on lots of computers for lots of different businesses. Obviously you stick with the nursing home vendors for the applications that are unique to our industry, most particularly in the billing and clinical areas. But you don't need an industry solution for such applications as staff scheduling, facility maintenance or even general ledger and accounts payable. As your "Computer Advisory" columnist David Patterson pointed out recently ("Get Ready for Special Purpose Software," Nursing Homes, October 1997, p. 65), you can save lots of money by looking for generic - i.e., across-industry - solutions in these areas. And nursing homes these days are a lot about saving money.

Peck: Integrated delivery systems - with hospitals, other nursing homes and/or other levels of long-term care - are all the talk these days. What are some considerations nursing homes would face in computerizing for this?

Roland: First of all, it is interesting to observe the consolidation that is going on among long-term care software vendors these days. They're beginning to mimic what happened in the hospital marketplace - i.e., becoming involved in affiliations, acquisitions and mergers, because that's what their clients are becoming.

There are several pointers I'd suggest in planning for multi-facility integration, whether with hospitals or with other nursing facilities or levels of care. Any investment you are making now toward a network connecting the PCs in your organization will probably be justified in the long run, because that is where we are going. Also, you can't go wrong buying an MDS system now, no matter what's going on with HCFA or Medicaid in your state. Almost no hospital software vendor has anything resembling an MDS application in its software line, and this is something you will need in any event.

If you are unsatisfied with your financial system for any reason, and partnership with a hospital is a distinct possibility, I would wait until that partnership occurred before deciding on a change. In all likelihood the hospital will want you to use its high-end, multi-million dollar financial system, and while that may be a bit of overkill, it probably won't be too bad a fit. The same is true with subacute care-type systems; you may want to bill your managed care patients through the hospital's patient accounting and managed care contracting system. If, however, a hospital partnership is not a prospect, you may want to start looking for the specialized clinical and financial systems you'll need.

If you are planning a horizontally integrated system with other nursing homes or with such providers as assisted living or home health care, you will want to add a network referrals system and an outcomes management system to your software arsenal. No stand-alone facility is going to have these right now, obviously.

In short, your computer decisions will - or should - be guided by your specific plans for your marketplace.

Peck: What are the particular administrative challenges in gearing staff up for the new generation of software?

Roland: As always, there is the issue of training. Interestingly, as younger staffers come on board, this might not be so much of a challenge. As anyone with even young children knows, all of this seems to come naturally to them. Until these younger staffers predominate, though, computer training is a responsibility that administration must assume.

As things stand now in our typical facilities, if we're using 10 to 20% of our computer systems' capabilities, we're lucky. I've seen staffs that didn't know how to do spreadsheets or even word processing - they were essentially using their computers as typewriters, simply entering information that was stored but not shared. To me, that approach to a major investment offering so many possibilities is a crime.

There is an important distinction, though: To get the full benefit of a computer system, we don't need staff training so much as we need staff education. We shouldn't emphasize only how to perform a specific function over and over again, but rather how to think using computers - to understand what they mean to operations, and how their uses might be modified to meet specific goals.

That is why I contend that the best computer trainers are not systems people, but educators. I have seen first grade teachers do abetter job of this, compared to "techies." In the nursing home, the teachers are often the inservice coordinators. Education is what they do, and given a chance with computerization, they can do it very well.

Peck: Some in nursing home administration have developed a reputation for hanging back, for not wanting to get involved with computerization and preferring to leave it up to someone else on staff, if possible. Are there resources available to help administrators get past this reluctance and take charge of this important function?

Roland: There are several possible resources. A growing source of independent information and advice is the Health Information Management Systems Society (HIMSS). Some of us recently started a constituency group in HIMSS to get the organization to address the unique field of long-term care, and for the first time the organization is developing a core body of knowledge in this area. HIMSS can be accessed at (312)664-HIMS or on the Internet at WWW.HIMSS.ORG. There is also a growing role for technology managers (I/T professionals) in this field. The rule of thumb is that you should have one I/T professional for every 25-40 users in the system. Multi-facility chains have, of course, taken the lead so far in hiring these specialists, but individual facilities are reaching the point where the investment is justified. Finally, a particular source of guidance and support for the not-for-profit facility is the agency's board of directors. There is a good chance that someone on that board has gone through this, or perhaps knows someone in the computer industry who would be willing to volunteer some assistance.

Certainly administration should reach out for all the help it can get in making this transition. It will make it easier even to think about, not to mention accomplish.