Information Systems & Long Term Care Possibilities and Pitfalls

by Richard H. Irving, Karim Munjee, Peggy Ng

The Long-Term Care sector along with the rest of the Canadian health care community is actively involved in the adoption and use of information technology to facilitate operations and improve the collection, reporting and use of resident care data. A recent article by Hirdes describes the potential for LTC to adopt MDS. Zidenberg reported on a program to connect seniors living in a care facility to the Internet.

Clearly, there is interest in the potential of information technology to transform LTC and action to adopt IT. However, the process of using modern IT is less straightforward than one might think. Irving has argued that effective strategic planning is a key element in the successful adoption of IT in LTC.

Adopting information technology becomes a more serious issue when an organization moves from having a few stand-alone PCs to running an integrated network that ties systems together. Obtaining and using a few personal computers to perform isolated functions (e.g. administrative functions such as managing trust funds or dietary management) has localized benefits, but has little impact on other aspects of daily operations.

With a network-based enterprise-wide system, the situation is quite different. For example, adopting a clinical reporting system such as MDS or even adopting a facility-wide scheduling system may require significant job and work redesign before the organization can obtain real benefits. This is due to the increased need for coordination between previously separate organizational units and the need to adapt the organization's systems to the peculiarities of the software and vice versa.

These efforts can be time-consuming and costly. Clearly, understanding the ability of the LTC sector to successfully adopt IT is a useful first step in the road to an integrated health information system for long-term care. In the fall of 1998, Dr. R.H. Irving and Dr. K. Macdonald, collected data on IT Use, IT Management, IT Infrastructure, IT Investment and attitudes to IT in LTC. Descriptive data were also obtained on individual facilities and on the individuals (senior administrators mostly) who filled out the questionnaire. This exploratory study was grounded in a practical concern for the ability of the LTC sector in Ontario to adopt information technology successfully. In the following paragraphs we describe, briefly, the results of the study and present the conclusions and recommendations we derived from it.

People

The respondents were largely middle-aged female administrators with between 2-10 years experience in their current job and with 6-15 years experience in the LTC field. They are knowledgeable and experienced in their profession.

Over half have a college diploma and about 30% have a university degree. They clearly know their facility and their industry. The respondents are also professionally active with 36% belonging to three or more professional organizations and over half attend professional conferences and training seminars. While 58% of respondents subscribe to three or more professional journals or magazines, only 30% read them for more than one hr/week.

Given the demands of these senior administrative positions this is not unexpected, but it may indicate that they have trouble keeping up on developments in the LTC field. It also may indicate that they do not have enough time to learn the planning and management skills required to adopt complex IT systems. Their IT knowledge is largely limited to the use of standard desktop software, e-mail, Internet browsers and fax. Though 66% indicate they have between 2-10 years experience with IT, this experience alone does not prepare them well for the adoption of integrative IT technology.

Facilities

The facilities in the survey were evenly divided among communities ranging from small to large. Forty-seven percent (47%) have been in business 20-30 years. This implies that significant physical redesign of the space will be necessary in many facilities to accommodate extensive use of IT. For example, simply finding a secure space in which to place a workstation has engendered a major effort at some physically older facilities. In some cases, infirmary rooms and storage closets have been brought into use as office workspaces. Installing a complete enterprise-wide system will require a significant physical redesign project in many facilities. The facilities represent all types of ownership and orientation . Slightly more than half were private (For-Profit) and the rest were various forms of Not-for-Profit facilities. The median home had about 100 beds, 50 volunteers, 90 paid staff and a total operating budget of between $3 and $4 million.

Technology

As of the fall of 1998 there were a number of Pentiums; however, many still had 486s or lower as their desktop machine. Most had three or four machines, and used W3.1 or W95 as their desktop operating system. Those that had a network generally preferred Windows NT as their operating system though other systems were in use. Generally, the level of computerization is low and focussed on administrative computing using stand-alone PC applications. While a number of networks are in use, most of the use is for entry-level applications such as e-mail, fax, etc. Little use was made of networked enterprise-wide software, though some use was made of local area networks to connect individual PCs together for e-mail and file sharing.

Little use is made of electronic ordering at present. 37% do no electronic ordering and 41% use only one type of E-ordering. This provides additional evidence for the fact that IT is mainly used for administrative purposes. Use of software application packages is largely confined to administrative packages such as Payroll (72%) or resident billing (52%) with little use of software for other activities such as housekeeping (4%), dietary care plans (10%) or medical records management (4%). About 45% of our sample had an Internet connection and about 15% had a facility web page. However, few facilities have IT committees (32%). Those IT committees that exist do not represent all stakeholders (including experienced IT professionals, enduser staff and resident/family members) and are likely to be dominated by administrative and financial types.

For example, only 28% of Facility level committees and 11% of Group/Chain (multiple facility organizations) level committees report that staff are represented.

We developed a predictive model of the probability of a facility having an IT Committee on the basis of the number of beds (facility size), whether the facility was independently owned and its use of related technology (e.g. a facility web page, etc.). Based on this model, we concluded that smaller sized, independently owned facilities are much less likely to have an IT committee than are facilities with other demographics. This means that when these facilities adopt integrative IT such as a clinical reporting system, they are at risk of having an unsuccessful implementation.

Having an effective, representative IT committee is an essential component of good IT planning and implementation, especially for enterprise-wide IT systems. One administrator from a municipal/regional public home recounted how an external Board dominated by accountants insisted that it would be cheaper to hire a programmer rather than buy software. Two years and thousands of dollars later they realized their mistake.

Attitudes to IT and LTC

Most respondents (82%) believed that IT could have a positive effect in the LTC sector, though some (10%) believed that it has not yet affected patient care outcomes.

Clearly, there was a willingness to consider the potential of IT for the LTC sector. Many respondents (59%) indicated that time, cost and learning how to use the technology were holding back IT adoption. These views indicate that there was a real awareness of potential roadblocks to IT adoption in the LTC sector.

Conclusions & Recommendations

If an integrated seamless Information System for LTC facilities is to be successfully developed and deployed, the following actions must be taken.

Facility operators must learn how to deal with integrated technology that changes work processes and communication patterns. This learning includes:

Industry Associations must:

Provincial Governments must:

The Federal Government can facilitate the process of IT adoption by:

These conclusions lead us to recommend that the federal government create a coordinating body for IT and LTC that includes provincial governments, provincial industry associations, major vendors, and others such as consultants and academics that work in the LTC field. This body would have the mandate of recommending an integrated LTC architecture and standards for IT as well as facilitating the development of appropriate nation-wide training programs for LTC administrators. It could also work to establish an effective national LTC association that could eventually coordinate these efforts at the industry level.

The implications of inaction are significant. If LTC facilities, particularly the smaller independently owned facilities, attempt to adopt a major IT system such as a clinical reporting system without a thorough understanding of the processes, time and costs involved, the adoption is unlikely to be effective. Some small public and private sector facilities will likely suffer severe financial hardships as a result.

In the rush to build a health information highway, we must allow the LTC industry time to purchase vehicles and to learn the rules of the road.