No time to stand still.

In today's sea of information, facilities that don't keep moving will sink, says this computer consultant

Information management is a growth field in today's long-term care - so much so that facilities that don't grow with it put their survival at risk. Increased pressures from payment sources, government and management for more information make information systems mandatory for all nursing homes. Yet many facilities have yet to computerize - and many of those that have are reluctant to confront the prospect of spending thousands of dollars more to upgrade to more capable systems.

This is understandable. Over-reliance on Medicaid, the rise of managed care contracting for service at the lowest prices and the growth of competing levels of care, such as assisted living and home health care, have put nursing homes under financial pressure. Even so, as the nursing home industry moves from the cottage industry of the past to being a major player in networks of care, information is the key to success.

Computers represent a major change in the ways facilities conduct business. Competent systems can help care providers plan care, document it and provide sound information to administration for decisionmaking. Computer systems are increasingly necessary to bill for services. And the integration of these clinical and administrative functions is a major reason to upgrade systems.

While not yet mandated by the Health Care Financing Administration (HCFA) (the long-awaited Final Rule is expected this summer), several states have already mandated computerization of MDS 2.0, examples being Texas, Washington, Mississippi and Nebraska. In addition, HCFA's Nursing Home Case Mix and Quality Demonstration already mandates computer program support for MDS and billing as a condition of participation in the Medical Prospective Payment demonstration. Other states are testing the University of Wisconsin's "Quality Indicators," having facilities electronically transmit clinical data to a central repository which in turn transmits data back to the facilities. South Dakota, Kansas, Maine and Ohio are examples here. In short, depending on where you are located in the United States, computerization may already be a very live issue.

Even in those states where it is not, however, facilities have run out of time to wait. As is becoming clear to anyone who follows the trends in long-term care, some very profound changes - having nothing to do with HCFA or its plans - lie ahead. Managed care is increasingly becoming a presence, and those facilities that are starting to feel the heat are also feeling the necessity to start thinking about networking - networking with each other, with hospitals and with other levels of care. And they're finding that information management is a crucial facet of the game.

Let's say that a facility already has computerized its basic functions, so that it has a program for financials and an MDS-based clinical program, and feels that it is at least "up-and-running." Where does it go from there? A good place to start is to review the lessons learned in what got it there.

In facilities I have observed over the years, I have noticed an astonishingly low level of attention paid to planning the implementation of an information system. Management frequently just doesn't see this as a part of its "core business." Now that we're learning otherwise, what can we do better? For one thing, we can start budgeting for this appropriately. Nursing homes devote less than 0.3% of gross revenue to information systems. The hospital industry, by comparison, typically sets aside 2 to 3% of its gross revenues for information systems, an investment that is growing by about 20% a year. One of the offshoots of the long-term care industry's "low-dollar" philosophy is that many vendors have not felt incentivized to offer much more than minimal systems to this market. This is changing as the industry becomes more savvy about health care's "real world," but it's not changing fast enough.

Facilities already computerized should take time to assess what they already have and how well they are using it. Investing in the people who use the systems, whether through additional training or improved process design, can be a more important investment than faster hardware or fancier programs (although newer software is - or should be - easier to use). Selecting the "perfect" software is only part of the problem. Planning, implementing and paying continuous attention to operations are essential to maximize the benefit of any new system.

For facilities considering a new system, would-be purchasers should make a point of visiting other facilities using systems in which they are interested, to actually see these systems in action. The importance of this can't be over-emphasized. I wouldn't want to "bet the business" on an unknown quantity - unknown, that is, as to its impact on day-to-day operations like yours.

Beyond this, though, there is some good news: I submit that the MDS software that many facilities have acquired by now has already given them a leg up in moving to the next generation of managed care, network-oriented software. MDS 2.0 should be looked at as your most important information component. Admittedly, there remain facilities where it is still viewed as a paperwork exercise, where staffs simply don't understand how it relates to clinical care and how it can be used as a tool for improvement.

The fact is, though, that the MDS with its RAPs and triggers is one of the best assessment instruments devised for any clinical environment. (Just because it was devised by government doesn't mean it is bad!) The MDS can also be used as a quality assurance tool and a cost identification tool. By applying RUGS III values to MDS-documented staff time for clinical functions, the facility can come up with an excellent picture of its cost situation. This is an absolute necessity for being able to cope with the demands of managed care. Don't forget, RUGS III is based on very extensive time studies of staff clinical care. When connected with MDS documentation, this can give the facility a better understanding of its costs and cost variances than hospitals can get from their DRGs.

It is also worth mentioning that RUGS III may very well serve as the basis for any prospective payment system (PPS) Congress may enact (as many anticipate will happen soon). In short, RUGS III capability should be part of any software system purchasing agreement.

It has been pointed out that the MDS is actually a "minimum" assessment and may not have global application to everything found in a nursing home. This is true and, although the RAPs and triggers provide an effective mechanism for narrowing the assessment down, there is probably room for new clinical software addressing these specialized areas of care. But for an initial assessment, I would be hard-pressed to come up with a more effective instrument than the MDS.

All in all, a solid MDS 2.0 software system should be a "hot item" on any facility's capital purchasing list right now. Beyond this, though, there is another specific concern to keep in mind. Particularly if the facility has any prospect of integrating its information system with that of other providers of long-term care services in a so-called integrated delivery system (IDS), it should start thinking "connectivity." And the specific term to keep in mind here is HL-7.

HL-7 is the now commonly accepted standard for allowing different information systems to communicate with each other. This not only expedites intra-net-work transfers of data, but allows the facility, if it is so inclined, to use multiple vendors to supply a variety of operational needs, all operating on the same database. Though there are so-called "interface engines" that allow this to occur, one has to have a very cooperative vendor to make this work. Better to have HL-7 adaptability built into the software you obtain, and this should be specifically written into the contract of purchase.

In sum, planning and investment in people and systems are necessary to get maximum benefit from existing and new information systems. There is no longer time to wait, or "sit on" a computer investment that threatens to soon become obsolete. When it comes to information management systems, facilities have to move and keep moving.

David Oatway, RN, is President of Chesapeake Applied Technology, Bethesda, MD. He consults on several major clinical software systems and has helped many nursing homes implement such systems. He has worked with HCFA's Nursing Home Case Mix and Quality demonstration, the MDS 2.0 data specification project and with several states.