Integration now, integration forever.

A seamless flow of information can cut costs, paperwork, and error rates

THE PROS AND CONS OF LONG TERM CARE'S SHIFT TO A prospective payment system will be debated well into the next millennium, but its effects have already been profound. Not least has been the role PPS has played in dragging providers into the information age. Providers who were once steadfast in their refusal to participate in the computer revolution are now eager converts, implementing innovative information and clinical technologies to operate more efficiently and improve quality of care.

Major changes rarely happen overnight. The long process of upgrading information systems and integrating new clinical technologies will remain arduous for years to come. But innovative technologies (including non-computerized devices and equipment ranging from lift systems to weightlifting equipment) will play an ever-increasing role as the industry takes a more consumer-driven approach to delivery of care.

While some providers complain that vendors have been slow to develop the level of sophisticated, integrative systems they require, vendors fault providers for not being able or willing to invest the capital necessary to upgrade their platforms to support state-of-the-art software. But partnering rather than finger-pointing appears to be winning the day as facilities and vendors intensify their efforts to create more and better technology for long term care.

In the following pages, we look at a number of innovative providers--from Bronx, New York, to Oshkosh, Wisconsin, from big chains to mom-and-pops--who have come up with creative solutions to common problems.

TO MANAGE COSTS AND REMAIN COMPETItive in today's risk-based environment, most long term care facilities are replacing and/or upgrading their information management systems. Hampered by limited resources and a tendency to see information systems as a one-time investment, providers have been slow to embrace advances in information technology. As a result, they are discovering that their "legacy" (i.e., existing) technology is ill-equipped to meet the demands of managed care payors or PPS and MDS reporting requirements.

An effective information management system ideally creates a seamless flow of information between core systems (clinical, accounting, and marketing), minimizing staff time required to enter data, streamlining the often complicated process of billing, and maximizing management's ability to use captured data for better and more cost-effective care or to document outcomes.

To achieve that goal, some providers have purchased integrated information management systems. Others are partnering with a software vendor to develop a customized information system, implementing a "best of breed" purchasing approach (shopping around for the best software components, then integrating them in-house), or both. The strategy a provider takes depends on the type of care the facility provides, its level of complexity, and its size--not to mention the size of its budget.

"Freestanding facilities and small chains do better with one integrated package," says Jan Huttner, senior management consultant for information systems at Chicago-based Superior Consulting Company Inc. Most of these packages are equipped to handle the core needs of a smaller facility: resident assessments, reimbursement, clinical documentation, and basic management reporting.

Some systems can do more complex operations. These are better suited for facilities with multiple levels of care. Such systems can include property management software, financial applications that can calculate amortization rates for owned units, and sophisticated billing programs that accommodate multiple payor classes.

Two years ago, Fairview Ministries, a Downers Grove, Illinois-based not-for-profit continuing care retirement community (CCRC), invested in an integrated management system specializing in continuum of care solutions. Fairview needed to track residents as they transitioned to various levels of care during the course of their stay.

With the package, notes Stephen Stewart, Fairview's chief financial officer, information provided by a prospective resident will automatically transfer to admission software when the resident moves in. If and when a resident moves from independent or assisted living to skilled nursing care, the resident's file will automatically flow into the appropriate software--including the MDS, care plans, and billing--for efficient care and data management.

Additional modules, such as, property management, fund-raising, and preventive maintenance, are included in the package.

Yet Fairview's system is far from perfect. Though it is highly integrative, it is not very user-friendly. First, the system is character-based as opposed to the more graphic, Windows-based systems that are becoming more commonplace. Second, because the system is character-based, customizing management reports is a huge programming endeavor. In fact, it's easier and more time-efficient for Stewart to have the vendor write customized reports, but these are costly and inconvenient. Stewart hopes that these issues will be remedied when Fairfield upgrades its system to Windows technology next year.

Software shortcomings are endemic throughout long term care. These are the cause of much consternation, especially among larger and more complex enterprises, whose managers often complain of the slow rate of software development and note that available packaged systems are not sophisticated enough to meet their needs. In fact, many of the better capitalized providers have addressed the problem in-house, creating sophisticated information systems (IS) departments.

The Jewish Home and Hospital, a 1,600-bed not-for-profit institution with three SNFs and about 500 units of housing in the New York City area, initiated two strategies to overcome such hurdles. First, the company partnered with a vendor to customize an information system that will meet its unique needs. Then it implemented a best-of-breed approach, buying the best software components on the market and integrating them into its system. By shopping around, JHH has, for example, been able to acquire state-of-the-art dietary and materials management systems.

The dietary module manages diet orders and food allergens, identifies food preferences, and assesses nutritional data. A production database contains inventory, recipes, and menus for managing kitchen activities. And because the module is integrated with clinical systems, any change in a resident's location or dietary requirements is updated and automatically passed along to the dietary module.

Meanwhile, a recently acquired marketing system helps JHH keep tabs on prospective residents from their very first inquiry. After the initial contact, the system automatically sends case-specific brochures to the prospective resident with periodic follow-ups, ensuring that a potential source of revenue doesn't fall through the cracks. The program is integrated with admissions software to reduce duplication of data entry and create a seamless flow of information.

JHH recently implemented an enterprise-wide systems management program that monitors the routine functioning of the JHH network, freeing up the IS department to work strategically. The system automatically inventories hardware and software, detects viruses and hardware/software tampering, ensures productive deployment of computer assets, and promotes enterprise-wide software delivery.

Ultimately, the IS team's sights are set on developing a central databank that will allow them to collect and analyze the patient care data flowing through its network. But it's one step at a time. "Our strategy is to support operations first," says JHH's information systems director Kris Cerchiara. "Once all systems are fully integrated, we will be ready to work on a central repository."

Evergreen Retirement Community, a not-for-profit CCRC in Oshkosh, Wisconsin, recently installed a software program that automates the complicated and labor-intensive task of scheduling employees. With linkages to the payroll department, the system also provides health services scheduler Sara Scherer with the financial information she needs to make overtime assignments. And the software is such a time saver that Scherer is doing less overtime herself.

Maintaining West Point, Pennsylvania-based, ACTS Retirement-Life Communities' 15 CCRCs is the daunting task of maintenance systems manager Scott Rohrer. How does he do it? With a lot of help from his network-based preventive maintenance software program. Each week the system identifies, prompts, and tracks routinely scheduled maintenance tasks and provides detailed job plans on how to complete a complex assignment. Work orders are also posted to the system and can be easily monitored for quality control. ACTS is currently integrating the program with its accounting software for automatic amortization of core assets such as refrigerators, air conditioners, and generators.

Having quality indicators at your fingertips will become a premium in the future. Beverly Enterprises, the giant Fort Smith, Arkansas-based nursing home chain, is nearing the completion of an outcomes database that will allow data to be pulled daily, as opposed to the current weekly capability. According to Ron Litke, business solutions manager, the database will be able to integrate multiple systems, from employee turnover to clinical data, and will interface with a user-friendly, graphic-based front-end program.

For smaller, less well-capitalized providers, many vendors provide outcomes database software. So do HCFA and the American Health Care Association.

Before a facility can pull reports daily, however, it has to be able to enter data daily. Many data-capturing tools can make this possible, including handheld computers, wireless devices, and touch screens. Unfortunately, they are cost-prohibitive for most providers, says Heath Odom, president of Integrity Group, a Minneapolis-based information systems consulting firm. "Once data-capturing tools become more readily available and cost-effective, you'll begin to see real improvement in care," Odom predicts.

Pharmacy companies tend to be ahead of the technological curve in long term care, giving providers greater flexibility to meet the challenges of capitated funding and a higher acuity population.

For instance, many providers are contracting with pharmacies for automatically dispensed, multi-dose-packaging medications (also known as automated compliance packaging). These resident-specific, bar-coded packages help providers "improve patient compliance, dramatically reduce the potential for medication errors, significantly cut med pass time, and provide vital inventory controls to reduce waste," writes Dana Saffel in the June issue of Consultant Pharmacist.

Rich Williams, operations manager for Chapel Hill, North Carolina-based Southern Assisted Living, echoes these sentiments. Southern recently implemented multi-dose packaging in one of its thirteen assisted living communities and already, the benefits are apparent. "We expect to see a savings in pass time of about thirty to forty percent, if not fifty percent," says Williams. And with a 7-day drug exchange, rather than the standard 30 days, Williams says he's noticed a significant reduction in waste.

Automated medication dispensing systems are another significant advance. As facilities accept more acutely ill people, their need for immediate access to medications increases. Automated medication dispensing systems, common in acute care facilities, are making inroads into subacute care and skilled nursing, as states start to allow these devices to be used in emergencies. Operating like ATM machines, automated dispensing systems offer providers secure, on-demand, computer-controlled access to emergency medications.