Software's new generation.

A Special Product Focus The Vendor's View

There is a saying in the architectural field that "form follows function." This means that the shape and design of a structure reflects (or should reflect) the functions that take place within it. In computerized information management, however, the reverse has been true: functions follows form. The form, in this case is the module - general ledger, accounts payable, physician's orders, MDS, etc. - and the module defines the function. That is, it serves its own purpose very well, but is very difficult to connect with other modules in any meaningful way. Separate (and often redundant) entries, separate reports, these are the order of the day. To "mix and match" these data, to make them all available to all users in whatever way they seem useful, has been all but impossible.

Enter the "relational database." This transforms the capabilities of a computerized information system so that form does indeed follow function. It "integrates" the software. Put simply, a single data entry transforms all related data in the database so that the effects of a single event on an entire operation become immediately clear. Further, these data are made accessible to all appropriate users anywhere at any time. They may also create new patterns of data in relationships that mean something.

Comparing the two approaches, it is the difference between building with blocks, concentrating on one piece at a time, and shaking up a kaleidoscope to produce patterns - except that this kaleidoscope follows orders.

What does integrated software mean, in specific terms, to nursing homes? To fill in some of the details on the concept and early attempts at addressing it, Nursing Homes recently posed a series of questions to there vendors involved in marketing some of the first of these new products. (Nursing Homes does not, of course, endorse specific products, and acknowledges that there are multiple competing vendors in the market.) Those interviewed included:

Zoe M. Bolton Vice-President of Operations, Care Computer Systems, which markets the VistaCARE Clinical Information System

J. Christian Hawver Vice-President and Chief Marketing Officer, Achieve Healthcare Information Systems, which markets Achieve PathLinks[TM]

Eileen Villa, RN, BSN Clinical Applications Specialist, HCS, which markets INTERACTANT Applications and Executive Information Systems.

What is integrated software?

Bolton: It means that different software applications share common data elements. In order to do this, there needs to be a single source, or database, in which the data reside. If designed appropriately, entering data in the system will trigger activity or updates in other applications.

Hawver: For the post-acute market it is a series of applications supporting case management, financial management, clinical management and facility management. That is, data need be entered only once; no rekeying is needed, supporting a tremendous time savings. This should be differentiated from "interfacing," in which data may be transmitted from one application to another, but if either application is changed in any way, the interface disappears. Such changes don't matter with integration.

Villa: Financial management and clinical data integration means that authorized users have access to all data in the form that they are needed regardless of where or when they were entered. Integration occurs within applications as well - for example, daily documentation at the point of care can automatically fill in specific MDS items.

What are the principal advantages of integrated software?

Bolton: It encourages accuracy and consistency within the record and avoids duplication of effort. It automatically notifies other departments of changes in resident status and their impacts on the treatment record or business office record.

Hawver: Though it is not a necessary precondition for an integrated system, a graphic user interface (GUI)-based system (e.g., Windows) works better with integrated software than does a character-based system. The GUI brings with it increased ease of use and a reduction of time-consuming staff training. A GUI-based system also allows the use of "wizards" and "cue cards" for training. "Wizards" automatically take the trainee through a given process step-by-step; "cue cards" spell out the process, and can be called up at any time. Both can be user-defined to set up training for specific operations in a given facility. Appropriately installed, therefore, an integrated system helps from the very start with some of the more difficult aspects of implementation.

Villa: Integrated software decreases redundant keying of information, eliminates transcription errors and saves on data entry time for staff. Meaningful outcome reports linking care, costs and results can be generated automatically. Critical pathways defining multidisciplinary interventions and outcomes for some 200 problems are readily available to increase residents' quality of life.

How does it relate to the financial and clinical software typically used in nursing homes?

Bolton: Basically, this allows accounting applications to keep current with clinical applications. We all know intuitively that changes in a resident's condition can lead to changes in reimbursement, in supplies ordered, and so forth. Now all cost centers are automatically notified of these changes and they're recorded immediately and accurately. All applications and disciplines write to and read from the same database, and everything they do is correlated.

Hawver: Put succinctly, an integrated solution lets post-acute care facilities balance the cost and delivery of care with outcomes data. Shared information between these two key information system components maximizes the usefulness of true integration. Knowledge of the cost of care coupled with the course of treatment is what managed care organizations are demanding. Measuring the quality of care with financial and clinical data needs to be a priority for providers across the continuum of care.

Villa: This approach eliminates the costs and errors involved in rekeying data. Because the data are more accurate and timely, they can be used to make clinical and management decisions for individual residents or for the entire nursing home.

What are its uses vis-a-vis managed care?

Bolton: Managed care significantly increases the need for cross-disciplinary communication so that everyone is keeping track of a situation. For example, the nurse coordinator needs to monitor service authorizations in terms of coverage, and the billing office needs to be aware of coverage to properly bill. Clinicians need to review outcomes in terms of quality care, while management needs to review outcomes in terms of profitability. All are reviewing such matters as length-of-stay and service delivery, with corresponding revenue and expense figures.

Hawver: Case management can be integrated with financial information to establish user-defined pathways defining quality and cost-effectiveness of care. These pathways can serve as a standard for any managed care contract negotiation. The facility can also track how well the contract is performing for any given resident or patient in terms of coverage vs. cost vs. reimbursement. With this information, the facility can optimize reimbursement by revising the care plan where appropriate. Other reports are readily available in the form of spreadsheets, which allow "what if?" analyses - by changing the data in one area and seeing how this affects the others, one can see whether the facility is on-track for capitated rates.

Villa: There are two basic functions the software can perform with respect to managed care: (1)to coordinate care with contract requirements (i.e., coverage, authorization, utilization), and (2)to evaluate proposed contracts by running them against the facility's population.

What are the basic challenges administration faces in getting staff up-to-speed for the new challenge in computerization?

Bolton: An important consideration is to develop a team mentality among staff, to arrive at common definitions and concepts so that all are using and interpreting the data in the same way. This avoids conflicts and misunderstandings upfront and allows integration to work. This presupposes open access to the data by all staff involved. This means that, rather than a single workstation, there should be a workstation at every nurses' station at a minimum. There should also be access to use of various bedside computing devices to expedite data entry. Finally, staff should be cross-trained so that staffers on every shift are knowledgeable and comfortable with the system. The "MDS nurse" concept that many facilities use will not work with this system.

Hawver: Computerization or software changes are often perceived as causing changes in user behavior and a disruption of workflow. To help get past staff reluctance, avoid having them get too deeply involved with the need to sit in front of a computer to do a task. There are various data collection devices available that limit face-to-screen computer time and still allow quick collection of resident/patient information. Such devices include a scanable form used at the bedside, bar code wands, wireless personal data assistants and wireless portable terminals. All of these bypass being tied to a mouse or a keyboard. For the administrator or director of nursing, there are management-specific modules that dissect the myriad of data collected for each resident. These executive information system modules allow management to define exactly what data they want to see and how they want to view them. They simply have to log on to get these data. In short, computerization should adapt to the user and to the facility's workflow, and it should be able to adapt to changes as the organization evolves.

Villa: Challenges include some health care providers' fear of using computers and an extreme learning curve. Until some staff develop confidence, the first few hours can be a living hell. There are various outside sources to turn to for help such as vendor training, on-line help text, point of care pen-based terminals and a user-friendly system with a graphic user interface.

What are the minimum hardware needs?

Bolton: Among the minimums for a workstation would be a 486 DX2 processor, a DOS Win 3.1 operating system, and 8 megabytes of RAM; for a network, the basic operating system would be Netware/NT, along with 16 megabytes of RAM and a minimum 2 gigabyte hard drive. We recommend, however, a Pentium processor, Windows '95 operating system, 16-20 megabytes of RAM and a 2 gigabyte hard drive for a workstation, and for a network, a Pentium Pro/Dual Processor, Netware/NT operating system, 32-64 megabytes of RAM and possibly more than a 2 gigabyte hard drive.

Hawver: Very simply, we recommend purchasing as much hard drive and power as you can afford. And don't skimp on RAM; 8 megabytes is a "barebones" product, and you will pay for it in lost time and productivity. We also recommend purchasing the fastest modem you can afford, because sooner or later, you'll want to be on the Internet or Intranet. A system needs to be configured to meet the amount of usage. Speed and increased productivity are the key.

Villa: At a minimum, the IBM AS 400, with sufficient PCs to give staff needed access. Various bedside devices and Windows solutions are options - but they are options to very seriously consider to get maximum benefit from integrated software.

Any final words of advice?

Bolton: I would reiterate the need for common definitions among staff using the system. This is necessary, because staff may have differing interpretations of such issues as a resident's range of motion or ability to self-feed and record these in different ways. Use of diagnostic codes may vary, as well, with one being reimbursable and the other not. To avoid ongoing disagreements or reimbursement shortfalls, the facility's policy on data values must be clearly defined.

Hawver: Managed care is coming, and its arrival for facilities is only a matter of time. Facilities should start gathering data now, because the more data they have, the more statistically significant they will be, and the more useful in contract negotiations. Unfortunately, managed care has the "mystique" of having a wealth of data. In fact it doesn't, though it's trying to get it. The bottom line is, he who has the data wins.

Villa: Cost is always the biggest fear for long-term care facilities looking at information systems. Being frugal, they often buy systems that don't quite work for them and they end up paying in other ways. So spend the money - hopefully, with an experienced, financially stable vendor - to get something that really works for you. Don't be penny-wise and pound-foolish with something as important as an information system.