Judging computer systems for case management

Fully automated paths still on the horizon

Case managers are gaining increased responsibility for helping evaluate health infor-mation systems (HIS). The reason: Hospital administrators want computerized patient records that incorporate critical paths, as well as the technology to measure, report, and manage outcomes.

That means case managers need to become more savvy about computer hardware and software technology, warns Sherry D. Lee, RN, BSN, MEd, an informatics and case management consultant based in Matthews, NC. Lee, along with Jay E. Toole, national director of health care information technology consulting for Ernst & Young Limited Liability Partnership in Atlanta, presented a session on evaluating information systems for case management at the First Annual Hospital Case Management Conference.

Case management lags behind

Innovative HIS programs have quickly emerged in the health care arena, but applications addressing case management issues have not met market demands, Toole says. Newer systems, however, are beginning to offer some case management functions and "are leading to the evolution of the computerized patient record," continues Toole. For example, many case managers are starting to use master patient indexes, clinical workstations, clinical databases, and clinical decision support systems to expedite patient care documentation.

Lee recommends that case managers evaluating HIS vendors look at these seven key areas:

* company stability, including history, how long the company has been operational, headquarters, and financial status;

* expertise in system development;

* customer involvement in new development or products;

* customer references;

* product's ease of use;

* ability to meet needs rather than impress with superficial glitz;

* analysis of your organization's "must have" features.

As case managers begin to maneuver through this new, and to many, unfamiliar, computer maze, Toole and Lee recommend keeping the following strategies in mind:

* Do not simply automate what you currently are doing on paper.

That approach "limits your ability to improve," Toole says. "Look at your current state and ways you can improve."

Lee adds that case managers need to be open to new ideas regarding automating their case management system. "Don't say, 'Here is my template. It must look like this. If your system doesn't look like this, we don't want to talk to you.' There will be some things that you will probably need to change from your original manual system," she says.

* Determine how the system will interface with the hospital's existing information system.

"You must have communication between different systems," Lee says. Consider how you want to be able to retrieve data from admitting, pharmacy, lab, and all other areas of the facility. If the system is health level seven (HL7)-compliant, then it can be easily posted to your existing HIS, but if not, be wary, says Lee.

The HL7 standard was established by a seven-member group, known as HL7, located in Ann Arbor, MI. HL7 compliant means that the software follows a standard communication protocol that allows a facility to exchange data among different systems.

Open-architecture-based systems that integrate information from various software and programs are most effective for information systems.

* Consider building an order set.

An order set can be built for various DRGs. For example, if a physician admits a congestive heart failure patient, many systems will allow case managers to simply enter "congestive heart failure pathway" to instantaneously retrieve the orders.

"This was one of the easiest things I have done, and one of the things the physicians raved about," Lee says. For physicians who do not do their own order entry, that function allows the case manager to provide an order set, which allows them to check off which procedures or care plan physicians want for a particular patient on a particular day.

* Determine if you want a Windows-based or a Windows front-end system.

For many, having a Windows-based system is extremely important. Therefore, beware that a Windows front-end package is not going to give you a Windows environment. "I have seen some software packages that look like Windows, come up like Windows, but once you click on the [icon], you go into the age-old typing," Lee warns.

* Don't forget to consider and evaluate hand-held devices.

Vendors can dream up wonderful solutions for you, but case managers must "think through how you will use them. For example, is the device one that you can't use unless you turn the lights on in the room? What if the device is dropped? How much does it weigh? You may run into problems like these," Lee says.

* Ensure the system will help you make decisions.

You also will need to know if this is a system that will only allow you to enter data, or if it will help you make decisions by analyzing that data for you. A good case management system should crunch the data for you, providing ideas to help you set up your pathways rather than providing information that you will spend hours trying to decipher.

"Ideally, we would like to have artificial intelligence so that it can come back and give you specific information. For example, for a congestive heart failure patient between the ages of 64 and 65, you could retrieve data that say, 'This patient is also diabetic. Typically, this is a high-risk patient, and you need to be doing X.' The data tells you instantly what you need to be planning for that patient," Lee explains.

* Beware of being sold on products not yet installed or fine-tuned.

Lee and Toole warn against being swept away by innovative, cutting-edge presentations on products that may not yet live up to their promises. Once you get to the point in your evaluation process of reviewing demos, ask for the names of hospitals currently using that specific system.

Lee recalls a presentation in which the vendor demonstrated on the screen a physician dialing into the system from a car phone to obtain reports. The system also was integrated with an imaging component. After the demonstration, Lee inquired where this system was installed and what imaging software was being used. She was told the remote system was not yet available, nor had the vendor even selected an imaging system.

"I knew right then they were showing us something of the future. Those are the type of questions you should be asking," Lee says.

Evaluate with a wish list

When working with your hospital administration and staff on selecting a computer system, have your interdisciplinary team make a wish list, says Lee. "Think outside the park. Don't think in terms of what you can afford or only what you've seen before. Think of anything in the world that you ever wanted in an automated case management system."

Sherri Stevens, MSN, RN, a clinical nurse specialist and case manager at St. Thomas Hospital in Nashville, TN, is one step ahead of the evaluation process and is planning to automate her hospital's care maps, or critical pathways, in May, although she admits, "We're still very fragmented at best.

"Nobody has anything in place that does the job 100%. Our HIS department is working closely with medical records and trying to put together a way of tracking data.

They have an idea of the direction they want to go, but we don't know yet if it will work," says Stevens. "We're going to use their idea for about six months and see how they do it."

For this stage, staff at Saint Thomas will use their existing information system vendor, Malvern, PA-based Shared Medical Systems, to automate the pathways. The facility recently installed Tucson, AZ-based EMTEK Healthcare Systems' information system in its critical care areas for patient care. *