Lessons from computerizing a facility.

With the inauguration of OBRA, the push for greater computerization in American long-term care facilities has begun in earnest. Traditionally having less capital than hospitals for all types of capital improvement, nursing homes have lagged behind their acute-care counterparts in the development and use of rather pricey electronic charting systems. Many nursing homes have not been able to spend relatively large sums of money on big-ticket items like computer systems, or else they have had to spend their limited capital budgets on other requisites.

The pressure is on, however, to implement computer systems in long-term care. Because of the increased demand for additional data, different forms of data (MDS, etc.), the need to make staff more efficient, and ready access to data for a number of purposes, it is no longer a question of if a facility will implement a clinical computer system, but when.

Our "when" occurred not long ago. Here's what we learned, and are learning.

Getting Started

The implementation of a computer system in a nursing home is not as scary as it used to be. But, before you jump into the fray of deciding the nuts-and-bolts technical issues, you should first assess the need in your organization by talking and listening:

Talk to yourself. I'm sometimes criticized for talking to myself My staff, my family, and my friends think that I'm maybe a couple of sandwiches short of a picnic when I talk with nobody else in the room! But, look, I get answers!!

When you're considering investing time and money into a computer system, ask yourself what you want to accomplish with this system. Decide if the potential gain is worth the price. After you've convinced yourself that you want to proceed, it's time to talk to others.

Organize a meeting of people who would use the computer system. Don't just include the supervisory staff, but everyone who will use it. Introduce the facts about the system as you know them. You may even want to include a software manufacturer in your meeting as a resource person to answer technical questions about systems in general. Use real participatory management techniques during this meeting. Tell your employees that their feelings about a computer system will have an effect on whether or not you proceed with implementation, and how the system will be organized. Then ask for their questions.

Whatever questions arise during your staff meeting, offer your employees the opportunity to put their thoughts and feelings about the system down on paper. A good way to proceed is to create a survey in such a way to permit measurement of the results. Finally, report your results to the employees.

If they support the implementation of a computer system, you've overcome the single greatest hurdle in this process.

What happens if they don't support the concept? I suggest you don't implement it until you obtain their support. Do not attempt to force a computer system down their throats. The bottom line is, it will never be successful if your employees don't support it.

Selecting Hardware

The variety of hardware systems has increased significantly in number in the last few years. What's more, if the downward spiral in pricing that has occurred for hardware occurred in the stock market, it would be disastrous. For computer hardware buyers, it is an excellent time to buy. Computers that cost $5,000 five years ago are being practically given away today.

Personal computers are attractive to companies and individuals on tight budgets because of their competitive pricing. Previous problems because of their limited capacity have been eliminated. Five years ago, affordable hard drives had a 40 to 60 megabyte capacity ceiling. Now it's common to find PC hard drives of 200 megabytes or more storage costing a few hundred dollars.

To coordinate the PCs in a computer system, it is common to find CPU's (central processing units) with RAM (random access memory) of 2 or 4 megabytes standard and options to 8 meg or higher. In short, their power is phenomonal, comparable to the much more expensive mainframes of not so many years ago.

Speed has improved radically, as well. In technical terms, "old" PC's (5 years ago) operated around 8 to 12 megahertz. Now, the "486" PC's typically advertise 25 to 33 megahertz. Speed is as important a consideration in nursing homes as in any other business, because time is money.

Apple vs. IBM-Compatible

The incompatability problems of the two major PC manufacturers are part of computer lore, known to anyone with only a passing acquaintance with this field. PC users who had exclusive experience with only Apples or IBMS may have had trouble making the jump to the other type of system. This is no longer a serious problem. Many computer software manufacturers sell their products for use in both systems. There are software packages that permit the operation of either type of software in either type of computer, and the newest "Mac" technology permits the operation of IBM-compatible software in the Mac.

Printers

A critical facet in a computer system is the printer. It provides the final and often the working copy of the report that your computer generates. While there are many inexpensive dot matrix printers, laser printers offer a far superior print appearance and more flexibility. The MDS (Minimum Data Set) as defined by OBRA must be in a form acceptable to the government regulator. The laser printer can duplicate this form to the government's specifications and eliminates the need for buying MDS forms. Duplexing, or printing on both sides of the paper, is also available on laser printers, and will help to keep the size of the medical record smaller.

Networks

In a clinical computer system, you will most likely want the ability for nurses stations to communicate with the main system. The investment into a LAN (local area network) or other type of network can be expensive. A network should be investigated carefully, keeping in mind the desired results.

If data collection only is going to be provided at the "remote" locations (nurses stations), a "tennis shoe" network may be appropriate, i.e., an employee running from station to station with a floppy disk, transferring the information at each station to the floppy, and then downloading it to the main system. The only expense is the occasional replacement of the employee's tennis shoes.

The bottom line in choosing networks is to try the least expensive option first. You can always add a real network later.

When buying hardware, though, buy the most computer that you can afford. Technology advances so quickly, that if you buy a bargain, you may be getting "old" technology and may hasten the obsolescence of your purchase.

To choose appropriate hardware, you must match it to the software which you are going to use. Each software manufacturer can either make recommendations as to the specifications of the hardware you will need, or else they can sell it to you directly. The brand name of hardware is not critical. Instead, once you have decided on specifications, concentrate on the following when choosing hardware:

Product Reputation

Service Availability

Maintenance Agreement

Price

And probably in that order.

Choosing Software

Software is the actual program that you are choosing, and it must reflect or accomplish the various goals that you and your staff decided upon. In choosing a software program for our facility, we wanted to accomplish the following goals:

Make the nursing department more efficient by spending less time on charting and more on patient care.

Have access to better and more data regarding our resident population.

Recruit nursing staff because of our obvious commitment to higher technology.

Select a system flexible enough to reflect our care policies and procedures instead of trying to fit your operation into a "canned" system.

We then had to make perhaps the most crucial decision of all: choosing a software company. You are not only choosing a product, you are entering into a long-range service contract. It is a lot like a marriage, and probably should be thought of that way.

Involved in this is the realization that periodic updates to the product will be required over time. Make sure you understand the financial arrangement for these updates. It is important that the research and development department of the software company can remain abreast of changes in the long-term care industry.

At our facility, we chose Data Med Clinical Support Services for our clinical computer system. We found a match between Data Med and our goals. We also were offered the opportunity to become a beta test site for the development of our clinical package. So far the marriage is working, and working well.

Our Experience To Date

With our open approach to the staff, and with myself and our director of medical records serving as local resource people and troubleshooters, we found that it took only a couple of months for the staff to adapt to use of the system.

The most rewarding aspect, personally, has been the flexibility we have had to customize the system to reflect our facility's care. We are able to get more data more quickly to track trends in our care so that, if need be, we can make adjustments. Our nurses are spending more time on patient care, less on paperwork. We have found, for example, that generating our nine-page MDS takes only a few minutes, rather than the hours required manually.

In fact, we have gone counter to a trend. Many facilities have found that compliance with OBRA has required them to add staff. We are in compliance, and have not added one staffer, and we credit that to our computer system.

No doubt there will be more developments down the road -- but isn't that enough of a recommendation already?

Jerry L. Hoganson, is the administrator/CEO of St. Paul's Church Home, Saint Paul, MN. He is past President of the Minnesota Chapter of the American College of Health Care Administrators and the Member Participation Chairperson of Care Providers of Minnesota.