The second time around.

If, as the song says, "love is lovelier the second time around," what is choosing a computer system? "Smarter," according both to administrators who have done it and the experts who advise on selecting information management systems. That's the positive side. The negative, of course, is that you are smarter at choosing your second system because of the shortcomings you experienced with your first.

"The system we had prior to our new one was never fully up and running," says Diane Richardson, a Senior Administrator for Prestige Care who manages their Cascade Terrace facility in' Portland, OR. With a little more reflection she adds, "It was almost completely nonfunctional for us."

You can learn a lot from your failures, but first you have to admit that they are just that - your failures. Even if you aren't the person who purchased that flawed first system, the result of that failure is still yours. Admitting to failure allows you to analyze what went wrong. So, whether you or a predecessor purchased the system, to avoid making the same or maybe even worse mistakes, you need to look at how the system was bought, what the expectations for it were, how it was used and who used it, compared to what you plan now. That means you need to determine what you want your new system to do and who will be doing it.

Unfortunately, Cascade Terrace's experience is common to a surprisingly large number of first-time buyers. Outright failure of a system to meet a nursing home's basic information management needs is a realistic concern, according to David Oatway, president of Chesapeake Applied Technology of Bethesda, MD and a consultant to HCFA'S Nursing Home Case Mix and Quality demonstration. "I think one of the biggest problems in the industry, "says Oatway, "is the over-selling of systems. Vendors point to things that aren't real, things that in the end their systems just can't do or aren't really prepared to do, such as working with HCFA's quality indicators which aren't even finalized yet."

Vendors are packing their products with all sorts of ancillary features. They may be useful, but Oatway notes that they can complicate a system, lessening its ease of adaptability and use and steepening the learning curve. If the first time around you bought a system that claimed to do everything but take out the trash and found it so hard to operate that it sat virtually unused, then you are likely to have developed an appreciation for simplicity.

"Look at the minimum requirements your facility needs," says Oatway, "and then find a system that works best to meet those requirements. Don't get caught up in all the whiz-bang features the sales person is selling. Don't let someone tell you what you need."

Buying a computer system is a process, and that process begins by putting together a team. "You need to include all of the departments that are impacted," says Douglas High, MIS Director of Keswick Multi-Care Center in Baltimore, MD. "If you don't include them in the process, they won't embrace it. When we chose our new system we did it as a team and we voted on it as a team."

Many of the systems that fail to do the job their buyers expected are systems that were purchased by one person researching them, making the decision to buy, and then decreeing how and by whom they would be used. That process sets up failure in two ways: First, no one person is likely to be able to ask all the right questions of vendors or have all the right answers as to how a system can fit into a facility's procedures. Secondly, as Douglas High says, people won't "embrace" a system if they aren't involved in its selection.

When it came time for Cascade Terrace to replace its "non-functioning" system, Diane Richardson brought together the people who were going to use it and had them evaluate their facility's needs. She was also fortunate in that Cascade Terrace had been selected as a beta test site by the vendor. That meant they were able to try the system for three months before committing to purchase it.

While a 90-day on-site trial is a luxury that few nursing homes are likely to get, the concept of trying before you buy is crucial to the selection process. It is the best way to prove what a system can and can't do and to determine whether you need or even want all the extras it comes with. If you have been stung once - bought a system that didn't deliver - you are much more likely to ask the hard questions when you are told that a feature "is planned for the next release in just a couple of months" or that "we have a function that works just like that, don't worry."

"Buy what is actually there, not something that is being promised for the future," says Oatway. "See it in operation. Talk to people who are actually using it. Once you have narrowed the choice down to two or three systems, I would first make phone calls to nursing homes using them. Then before buying, I would go out and see them in operation. I would go through the whole process of entering an MDS to see how easy the system is to use. I would ask the people who operate it what works and what doesn't, which features they actually use and which are needless bells and whistles."

Ease of use is at the center of what Oatway identifies as the crucial core of what a system needs to be. "Systems have to be very competent, very easy to use, and very easy to train someone on," he says.

"A system should not be so difficult that it requires two or three days of training to do initial entry," states Oatway. "There is nothing about computers that is as complicated as what nurses and administrators do every day. A system that is not easy to use is, by that definition, a bad system."

A corollary is that the company selling a system offers good support - another lesson learned by those who have owned a sub-par system. Readily available, high-quality support, both technical and training, is critical - and you should expect to pay for it. Remember the old saw "you get what you pay for"? Don't count on your sales person to be a free, all-purpose repair person/instructor. It's the rare sales person who is technically competent to take you through and fix the glitches and bugs, or is qualified to train people in anything more than rudimentary usage. Sales people are neither technicians nor teachers.

Put succinctly, if you have a system that is not meeting expectations, a large part of the problem is almost certainly misunderstood assurances or overblown selling combined with less than adequate support. Knowledgeable second-time buyers will have learned how to recognize the former and protect themselves from getting stuck with the latter. Seeing a system in actual operation and using it yourself will take care of over-stated claims, and quality of support is easily checked.

"Call a company's support line," says Oatway. "Do it with the sales person in the room. How quickly do you get through? Ask other nursing homes that are using the system what their experience with the company's technical support has been, and how good the training was."

Another mistake often made in purchasing first systems is underbuying hardware. By the time you are ready to purchase your second system, you are likely to have learned the truth of the statement that hardware is the least expensive part of your system. That's because hardware generally requires little training to use and minimal support to maintain.

"There was some work done by IBM several years ago looking at people who have made multiple purchases of systems," explains Oatway. "The first time someone purchases a system, their highest interest is in price. Next time around they realize that cost is more important, and cost is determined by things like training and support time."

Since hardware is the smallest part of the real expense of installing an information management system, buying enough hardware to ensure that the people who will be putting data into a system will be able to do so quickly and conveniently is in itself an ease-of-use concern. If ease-of-use is at the core of your system's value, as already suggested, then investment in convenient-to-use hardware is a small price to pay. Buy enough hard drive, power and RAM to serve your facility conveniently now and into the foreseeable future (see also my recent Computer Advisory "Throw Those Old Computers Away," Nursing Homes, November/December 1996 for specific suggestions). It will make all the difference as to whether the system is not only used well, but used at all.

One possible complication that could come as a nasty shock to the second-time purchaser is the "ownership of data" question. "There are companies whose contracts specify that they 'own' the data you put in," explains Oatway. "That means essentially that the data, once in the system, are part of the software, and cannot be copied - to your new system, for example - without the vendor's permission." An uncooperative vendor could mean lots of keyboarding time for your staff in this situation. Seems unlikely? Perhaps. But just to be prepared, ask your vendor about data ownership before you purchase a system, and get a definitive answer in writing.

Also to be remembered in purchasing new software, the installed base - i.e., the size of market share - a program has is of major concern. Many first-timers purchase programs with a very small installed base either because the program seemed to be far better than its more widely accepted competitors or (more likely) had a substantially lower price. Choose software that has few users, and you take a risk in any case. For better or worse, companies in the computer industry whose products are not widely used have historically fallen by the wayside. Even though the product may be very good, the company often lacks the resources to continuously upgrade it, provide adequate support for it or successfully continue to market it. If the company goes out of business, you will find yourself stuck with an "orphan." The unwitting "foster parents" seldom choose a system with a small base of installed users the second time around.

Another important factor is how "open" a system is. "Open" in this context, refers to its ability to transfer data seamlessly with standard word processing, spreadsheet and data base management programs. Systems that are open are flexible. They allow you to use off-the-shelf software which may be more economical, and which new workers may already have encountered and become experienced with at previous places of employment. By contrast, non-open systems have a proprietary data storage system that either prevents the transfer of information or requires a special translation process. Perhaps the best way to assure that the system you get is truly open is to choose one that is Windows-based.

Another reason for choosing a Windows-based system is that Windows has become the operating environment of choice for the foreseeable future. Non-Windows-based programs have died out in nearly all areas of the personal computer industry, and it won't be long before they have disappeared from the product lines of vendors selling to nursing homes as well.

All nursing homes need to computerize now, if they haven't already, and make sure that their systems can do at least one thing successfully - format and send MDS 2.0 records. Stresses Oatway, "Nursing homes need a good MDS system that complies with HCFA's requirements and is designed so that it can be upgraded as necessary as those requirements evolve. And, it should be linked into a care planning system that minimizes data reentry and facilitates the clinical staff's efforts to come up with good care plans. It is crucial that a system be able to function in this way, because this is how nursing homes are going to be surveyed, how quality is going to be assessed, and how nursing homes will get paid in the very near future."

Cascade Terrace's Diane Richardson agrees: "Handling the requirements for electronic data interface was a crucial concern in choosing our new system," she says.

In fact, though, there are benefits other than HCFA-related ones to be had by improving your system now. Keswick's Douglas High describes some of them: "The computer is part of the checks and balances that enable us to give the best care possible. It lets us analyze data and find solutions to problems. Why does one floor need more overtime than any other? Why is it that a certain patient tends to fall down on Sundays? Is high absenteeism linked to an event or a day? Are staffing patterns optimal? All of these questions can be examined at our facility because we have the data and are able to organize them to see patterns."

The pioneers in nursing home computerization may have been looking for these benefits when they bought early, and hopefully many began to experience them. Some are now choosing their second or even third system, though, in many cases because they've learned a few lessons. The mistakes they made and the disappointments they experienced have made them better buyers of hardware and software. Perhaps the foremost lesson on which they all agree is this: It's got to be a team effort. Those who will actually use the system must have a major say in picking it.

David Patterson is a Contributing Editor to Nursing Homes.