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How to computerize: tips from software makers.

When nursing homes enter the wonderful -- and scary -- world of computers, what do the experts think they should know? Recently top executives of three of the leading computer software houses in the long-term care field had an informal conversation about that. NURSING HOMES Editor Richard L Peck posed the questions and eavesdropped on the answers.

For the administrator contemplating computerizing his or her facility, what is a good way to get started?

Seel: I have about a half-dozen suggestions I'd like to make on that one.

First, in trying to size up what your facility needs, do your own research. No one knows better than the administrator what the specific facility's overall needs might be.

Second, look for customer support first and price second. IBM once did a survey of some 1,500 customers on what they considered to be most important in selecting a system. The first time around, price came out first, and support ranked about seventh or eighth. Five years later they repeated the survey; support ranked first and price last.

You are, in effect, in a marriage with the vendor. The vendor must be committed to maintaining your programs in the light of changing rules and regulations. The initial programming involves only about 10% of your total system cost; 90% is involved in system maintenance over time, and that is where so many software houses fail.

Third, when you do market research, get all the literature you can -- from the vendors, periodicals and so forth.

Fourth, make sure that the vendor you choose has a specific commitment to the long-term care industry. This industry is second only to atomic energy in regulation, and has 50 Medicaid programs and numerous Medicare intermediaries, among others, to deal with. This requires a commitment to addressing these complex issues.

Fifth, beware of the new kids on the block. Ninety percent of all software vendors fail within two years. I'm not saying do not patronize start-up companies, because we were all new ourselves once. Just, be careful.

Sixth, be decisive. Your search for a vendor shouldn't take more than two or three months.

Furst: A big problem that I see is that a lot of facilities will not follow up on the reference lists we provide them. They're thinking of spending perhaps tens of thousands of dollars on a new system, but they won't spend $300 to get on a plane and visit someone who's using it. They'll call someone on the phone and hear how pleased everyone is, but they don't go to see how, or in fact whether, the system operates for that facility.

Wolf: I agree with Russ that the administrator should do the market search himself or herself. The administrator and his or her staff should draw up a list of the facility's specific needs, because this will guide the questions to be asked of the vendors. Then the administrator should touch base with trade associations, trade magazines, friends in the business, etc., to narrow down the list to a few potential vendors. Finally, look for vendors who have the commitment to and the track record in regards to long-term care.

What particular functions might the administrator wish to think about computerizing to start with?

Furst: By now most businesses have probably automated their front offices, but according to the Health Care Financing Administration, only 10% of nursing homes had computerized systems for MDS. This is an area about which they should all be thinking about seriously.

Seel: Still, for those facilities that are thinking in general terms, I think the areas where you get the most bang for the buck are billing, medical records, employee scheduling and dietary. Billing, of course, involves your revenue stream, and eventually Medicaid and Medicare will mandate automated billing. Medical records, especially because of OBRA, are now seen to be a wasteful use of manpower when done manually, with highly trained professionals doing paperwork when they really want to be doing patient care. Employee scheduling is important to consider for computerization because, in the nursing home, labor is the biggest expense item; a 10% savings there can double or triple the bottom line. Dietary is important because it is the second-biggest expense item.

Wolf: Both financials and clinical are important. You need good financial reporting systems these days, and if this function hasn't been automated yet, it should be strongly considered. Each facility, however, should start with the functions it feels are most important. Each facility's needs are different.

Does computerization have to be expensive?

Wolf: There is no question that computers are a significant capital investment, but the appropriate system should yield benefits well in excess of its cost amortized over five years, and the cost should be less than 10 cents per patient day.

Furst: The average, adequate computer system should save a 100-bed skilled facility anywhere from 2,000 to 8,000 professional hours a year.

Does this translate to staff reductions? I don't think so. First of all, I don't know of any facilities in this business that are overstaffed. Rather, what happens is that the staff finds more time for the work that they want to do and were trained to perform. They are caring people who want to take care of people, and the more paperwork that is imposed upon them, the less satisfied they are. It can lead to high rates of burnout and staff turnover, and a properly implemented computer system can help reduce these problems.

Seel: Our rule-of-thumb is that, depending on the software module involved, a facility can save as much as 5 cents a patient day.

Is expense the biggest hurdle that new customers face?

Wolf: No! The two biggest problems, in my view, are top-down implementation (insufficient involvement of staff) and lack of planning or thinking through just what is wanted. The list of facility needs I referred to earlier is critical.

Furst: That's true, the biggest problem is not the expense of the system -- budgets are all over the place, and things can be worked out so that the system is affordable. The biggest problem is implementation. The best way to solve it is to see how others are doing it. One should not only ask other administrators how they like a system, but see how they're implementing it. If they tell you the system is "just great," but you go and see that no one in particular is making much use of it, try to figure out why. The problem may be with the facility, rather than the product, but you should analyze what's going on.

Seel: In my opinion, the biggest problem is customers' failure to commit to training. This commitment is absolutely essential. For our core modules -- the financials, the medical records, the care planning and so forth -- we look at training as a 3- to 6-month process. If you're doing it any faster than that, you're probably shooting from the hip and making decisions sooner than you should; if it's any longer, there may be something slowing the process down, such as a lack of commitment by the staff or even staff turnover.

Furst: I agree, and would add that training should in fact be an ongoing process, in view of the continual updates that will be needed in this field.

Wolf: A significant training period should be budgeted in the start-up costs for any computer system.

Will new staff have to be hired to implement and run the new system?

Seel: This can be done with existing staff, but what we look for is someone to "lead the parade," someone who is enthusiastic and willing to put in the time and effort needed. It has a lot to do with how the administrator handles it; if it's just a matter of the financial department dumping something into the RNs' laps, it just won't fly.

Furst: We look for what we call the "product champions." This could be anyone, from a nurse's aide to the DON. If you can't find someone like this on the existing staff, you're going to have a tough time implementing the system.

In fact, I would go so far as to say -- and this won't make me any friends in the software industry -- that if the entire staff seems strongly opposed to computerizing, don't buy a system. It will never be properly implemented or used. And, to tell you the truth, there are installations out there that are in just that circumstance.

Wolf: Management has to be committed to the new system, too, in the sense of being willing to budget the hours needed to implement the system and train people properly. A facility may not need added staff for implementation, but it will need extra hours, and the willingness to provide the time has to be there.

We, the software manufacturers, can provide the facility with excellent tools, but we won't be there to use the computers for them.

Should administrators make use of outside consultants to determine what's best?

Furst: A good consultant, in my opinion, is one who recommends my software.

Seriously, I would be very careful about this if I were an administrator. Almost anyone can call himself a consultant; you just have to make up the right business cards. The first test is, does he or she come in with a preconceived notion about what is "the best system"? What you want is someone who will help determine what is the best particular system for the particular facility, based on its real needs.

Wolf: I go along with Russ Seel's earlier comment that the best way to go about researching systems is to do it yourself A consultant will not have all the answers for your facility. In the real world, unfortunately, some people are spending more for a consultant than they are for the system.

Seel: You really have to watch out for consultants who, in fact, have dual agendas. Sometimes they're just trying to get their foot in the door, and they'll be with you, or after you, forever. A consultant, if used, should be project-oriented only, and once you're done with it, they should be gone.

In trying to decide on a new system,

what assurance will the administrator have that the system he or she selects won't be outmoded in a couple of years?

Wolf: Technologically speaking, the system will be outmoded before the administrator even puts his signature on the contract. Somebody somewhere (be it IBM or whomever) has developed a technology that is better than what is on the marketplace, but just hasn't developed it to the point that it can be released yet. In this industry, that is a situation that will never end, at least not in our lifetimes.

But this is not something for the new customer to concern himself with, because waiting only ends up costing many lost opportunities. In today's business, every day you function without a computer, you are costing yourself somehow in some way.

From a practical perspective, as long as your system is doing the job and is being appropriately updated, it will never be outmoded.

Furst: I think Russ Seel hit the nail on the head when he said that the best way to keep your system current is to find a vendor with 100% commitment to the field. There are no guarantees in this world. Yes, we guarantee our customers that we will keep their systems current with all regulatory changes within 30 days. But that guarantee isn't worth much if we go out of business.

Wolf: I have been in this business since 1974, and have seen a lot of companies come and go. When MDS hit a couple of years ago, it was so adaptable to computerization that an awful lot of companies got started. How many will still be here three years from now...

Furst: Or are still here?

Seel: A lot of people look at the financial strength of an organization rather than its commitment to long-term care. Since 1975 I've seen a number of companies with deep pockets get involved in this as a new business, but when something went wrong, someone in an ivory tower pulled the plug. In this field, it is reassuring to find a vendor who has survived all the changes that the legislative arena imposes.

Yes, the explosion of technology is fantastic, but as Steve Wolf said, that doesn't mean that current systems aren't useful and doing the job. However, when maintaining the old system becomes more expensive than acquiring the new equipment available, that's when to look at your vendor to see if he has kept up and may have something worthwhile to offer.

No doubt an administrator checking around will hear a number of computer "horror stories." How about some success stories?

Seel: One I remember involved a small chain of seven 100-bed facilities in about a 50-mile radius. After installing one of our systems, they had one person doing all the billing, all the payroll, all the general ledger work and, after a few years, were asking if we had a clinical module they could install so she'd have something to do with her spare time. An operation of that size doing this manually would probably have a dedicated staff of 10 to 14 people.

Furst: Our largest client has 240 work stations on a five-server network and a 2.2 gigabyte drive. Using our software, the entire system costs about one-third of the cost for a mainframe doing all this.

Another example: the state of Nebraska announced this past November 25 that it was changing the format of the quarterly MDS as of December 1, and nothing would be reimbursed on the old MDS thereafter. Our customers were up and running on the conversion by December 6.

Wolf: One of my favorite success stories involved a county facility that had spent $40,000 on its hardware-software system. The administrator didn't have to try hard to justify the expense to the county commissioners. Through the use of just one of our modules, the county made over $40,000 and paid for the entire system in less than four months!

Without giving away any trade secrets, what sort of technological advance do you foresee in long-term care systems in coming years?

Seel: All I can say is, Wow! Technology is exploding, and no one person can keep track of it all.

Artificial intelligence is coming into its own. I can foresee care planning based on automatic sensors implanted on or in the resident. Diagnosis and treatment will be based on what the sensors pick up. Miniaturization is the key.

We will also see systems talking with one another, and in essence the whole world of nursing home care connecting up. Picture this: Susie in Room 101 is playing chess with Fred in Room 312 in a facility three states away. Based on ongoing monitoring of her vital signs, an order for new medication is automatically placed with a pharmacy across town, while the appropriate billing is recorded at the Medicaid office in the state capitol. Meanwhile, she has checkmated Fred, and he sends her congratulations via an implant in her inner ear. This delivers it in the preferred voice she has selected, that of Cary Grant.

Furst: I see myself as visionary, but maybe not that visionary!

To begin with, there are a lot of unknowns -- for example, after the next couple of general elections, I'm not sure whether Medicare or Medicaid will be here anymore.

I do see the interconnectivity Russ mentions, though, and the bedside monitoring and charting. I can see the resident, the physician, the pharmacy, the lab and dietary all being on-line with one another. I also see computers being used to help upgrade nurses' training in geriatric care and in other forms of staff training. I also think computers will be used more and more in the entertainment of residents who may not wish to socialize that much; there are some old Commodores and computer games already being used for just that purpose.

Maybe, too, we'll finally achieve the paperless office that has been promised so long. I'll FAX you a memo on that.

Wolf: To me, the biggest impact -- probably before the year 2000 -- will come from voice recognition. There are still people out there who are terrified of keyboards; those young people who grew up with computers and are comfortable with them still haven't quite become nursing home staff yet. Voice recognition will be a major step forward here, and the past two years have seen unbelievable advances in this technology. The predictions made only three years ago have already been far exceeded.

Seel: Before we get ahead of ourselves, though, let's deliver the real message for today: Computers are no longer a plaything of the well-to-do. They have become absolutely essential to doing business in the nursing home field as we approach the next century.
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Title Annotation:nursing home computerization
Author:Peck, Richard L.
Publication:Nursing Homes
Date:Mar 1, 1992
Previous Article:Getting computerized: what will it take?
Next Article:Lessons from computerizing a facility.

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