How can hospice enter the information age?
How can hospice enter the information age?
Inflated claims, uncertainties, and new initiatives
As the new millennium approaches, many hospice managers wonder how they can take advantage of the explosion in information technology to obtain the clinical and financial information they need to effectively manage their agencies. Several ambitious initiatives are now under way to advance the state of the art in hospice information management, but there are things that even managers of small hospices can start doing today to make better use of what's already out there. (See list of expert recommendations on p. 56.)
Unfortunately, there are few areas of hospice management that generate as much hype and as many unfulfilled hopes as information management. Some of the claims made at booths at hospice conferences may be inflated by software developers, who have an interest in increasing their customer base. Hospice leaders on the cutting edge of product development express high hopes for computerization, but so far delivery on this promise has been slow.
A number of software vendors, including several affiliated with large hospice programs, already serve the hospice and home care markets. Although hospice managers often express dissatisfaction with their current software systems, vendors respond that most hospices are not using them to their full capacity. The use of laptops and other portable computers also holds tremendous potential for the two-way exchange of essential data between professional staff in the field and their offices. Some hospices are already utilizing this technology to vastly decrease paperwork steps, while others have spent thousands of dollars without being able to incorporate the technology into daily practice.
"One thing I have discovered about hospice people is that when it comes to technology, they're pretty gullible," observes Kit Stroup, chief information officer for Hospice of Michigan. "There are good information system consultants throughout the industry who have no vested interests and will come in for a reasonable cost to help define your needs. If hospice people feel they don't know what they're doing, get somebody who does," he says.
Jan Cetti, BSN, MS, CEO of San Diego Hospice, worries that a "do-it-yourself" impulse may lead the industry astray. "I fear where other hospices are going with software self-development," she warns. Based on her experience in other health care settings, Cetti prefers to work with larger, well-established vendors - which in this case means hospital information system vendors.
"A lot of systems demo really well, but what if the company goes out of business? A lot of great-looking demos at the front end have no integrated engine driving them," she says. "What you often see in the information services market is, yeah, you get a typed patient record you can call up to the screen, or a progress note you can print out. But if you want to do research or work with the data in any way, it's as though you're working from a word processor. How is the data coded? Where does it go? Can it be pulled out in different ways? Has anybody really seen where the system is up and running in actual practice? Go and talk to the people who are using it. See it in use without a salesperson present."
Cetti's hospice is now working with Shared Medical Systems (SMS), a huge hospital information system vendor, to develop a hospice information system that SMS may eventually sell to other hospices. Even Cetti's own staff reacted negatively when SMS representatives used hospital terminology in presenting the system to the hospice.
"We believe that the proven hospital system can be adapted to a hospice environment, but you have to get beyond the terminology" and see that different informational fields from the home setting can be substituted for the hospital, she says. "We have found effective ways of making the hospital system work for us," adds Jim Johnson, the hospice's director of information technologies.
San Diego Hospice hopes to implement its system later this year, using laptops and wireless technology. "The goal is to eliminate paper and develop an integrated data repository, enabled by e-mail fed from all clinicians, where staff can have instantaneous access to the data," Cetti says. "It can be done and it will revolutionize hospice." For San Diego Hospice, the estimated investment will be $1.2 million.
What are other hospices doing?"When I arrived here five years ago, there were four stand-alone computers, and none could talk to each other," recalls Joe Bach, manager of information systems for Hospice Association of Western New York, Cheektowaga. "Now we have 135 computer work stations with a LAN [local area network] server" on the agency's main campus, with plans to develop a wide area network reaching alternate sites and even referring community hospitals. "The technology is there to share information and to tie in with the hospital systems to facilitate admissions," and possibly even affect length of stay, he says.
"We use information systems here to a very high degree, such as bar code scanning for our medical supplies. We have reduced paperwork for nurses by 80% with the use of electronic care plans. We now have a high degree of integration of data, but even for us, we still come up against the challenge of how to turn data into information," Bach says.
Stroup describes an even bigger challenge of bringing together 15 hospice offices in the merger that created statewide Hospice of Michigan (HOM), in settings ranging from rural to urban, each with its own small information system vendor. "It took me an entire year just to learn what was already here, and what was going on," Stroup says. He has succeeded in constructing a statewide information system and standardizing work stations with the same e-mail, word processing, and spreadsheet systems. His next step is to replace the current patient registry and clinical software with something closer to the health care industry standard.
HOM's subsidiary BEP Software System is too small to meet that standard, and the hospice will likely be divesting itself of this software vendor and looking for large hospital vendors, following the path of San Diego Hospice. "We hope to choose the vendor by June, building on specifications developed by San Diego Hospice," Stroup says.
An electronic record is easier to achieve in the hospital setting, "where you can rigorously control electronic charting. In the home setting, you need something that's convenient, bulletproof, and easy to carry into the field," he says. "My goal is to provide whatever information system is necessary to allow Hospice of Michigan to provide quality palliative care." When everything is standardized, he adds, the hospice will even have the option of divesting itself of information services and contracting them out to a third party.
The next generation of hospice softwareDavid English, president and CEO of Hospice of Northern Virginia (HNV) in Falls Church, has gathered a loose coalition of 12 large hospices to push for "the next generation" of hospice MIS. This group last year put out a request for proposals, and then realized after reviewing the responses that it needed to go back and develop a more detailed needs requirement statement. In late February, patient care and financial managers from the 12 hospices gathered at HNV to work on the requirements.
"The bottom line is it should be user-friendly, easy to use, and highly flexible," he says. "Our goal is to move forward and quickly make a choice. If we find what we're looking for we'll being working with that vendor. If not, we'll find one to start from scratch. All of us are still searching for the same goal: a system we can use that combines both clinical and business data in the same configuration."
Hospice of the Florida Suncoast, Largo, in association with Suncoast Solutions of Metairie, LA, is now working on refining its own software package. Beta testing of the software system will soon begin at three hospice sites, and Suncoast Solutions staff are demonstrating the product at hospice conferences. "We wanted to get the information system down the chain, closer and closer to the patient's bedside, so nursing staff can input data, gain access to information, and reduce charting time," says Kevin Rick, CPA, Hospice of the Florida Suncoast's chief financial officer.
Two years ago, the Vitas Healthcare Corporation hospice chain was actively soliciting interest from the industry for its highly touted Vx integrated patient management system. Vitas representatives gave demonstrations to selected hospice executives and discussed the possibility of sharing Vx through unspecified "partnerships," lease arrangements or management contracts. However, all of this was put on hold by the announcement that Apria Healthcare Group of Costa Mesa, CA, would purchase Vitas - a purchase that was later aborted when Apria stock prices fell.
Some in the industry have wondered what would happen to access to Vx now that Vitas is back on its own. "It's on the table," says the company's chief patient care officer, J.R. Williams, MD. "We are talking about a set of services best characterized as management services. We are interested in the future - but not the immediate future - in offering management services to other hospices, including information management, outcomes measurement, the whole gamut, although it's not yet clearly defined," Williams says. "We're also willing to talk to anybody who's interested in talking to us."
In upstate New York, an alliance of 10 hospice programs with a combined census of 250 patients has come together to pursue common interests, says Peter Moberg-Sarver, president and CEO of Hospice of Central New York in Syracuse, the largest of the 10 hospices. "We have all come to appreciate the mutuality of our situation. We are banding together to pursue common interests, and information systems is one of them. We have found a very receptive software vendor that is giving us a discount on a package deal for 10 sets of integrated software," with the cost allocated according to the programs' size.
What's unique to this program is that the Syracuse hospice's information system manager will act as a "service bureau" for the other nine hospices, offering on-line technical assistance and in-person training, while allowing the Syracuse hospice to help subsidize his salary. "There are other residual benefits to this arrangement. We'll all be working with a common language, so we'll be able to give back managerial reports to each hospice on its costs relative to network benchmarks. Eventually, it will give us the database to do higher-level cost analysis required for managed care, and conceivably enter into some partial capitation arrangements," Moberg-Sarver says.
This goal of amassing basic cost and utilization data between hospices in order to better argue the industry's needs to payers has continued to bedevil hospices. Most previous efforts, including initiatives by the National Hospice Organization and Hospice Association of America, have failed to even generate agreement on data elements, let alone comparable data on a large scale.
"I feel strongly that we don't have a choice. We have to know this information," Bach says. "One thing that has held back the setting of standards for information is that there are so many varying sizes and models of hospice. It's a struggle for us to all do business in the same way. There needs to be some structure - some way to collect data using an industry electronic standard."
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