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alk of computer systems, data, reports, hand-held technology, staff compliance, external review, and accuracy of data permeates our conversation no matter what the topic—whether it is clinical, operational, marketing, or regulatory compliance. The post-acute care facility needs to consider the impact of technology and the value of quality information systems to function in the current regulatory, payment, and operational environment. You do not have to go any further than the current periodicals, trade shows, or educational events to hear about the impact of data collection and integration of clinical and financial systems as well as the importance regulators place on the data facilities transmit to their servers. Although all of the facilities I work with have computers and access to the Web, and some have information systems departments, the problems with data remain significant. This article will take you on a journey to a time and place where information systems play a key role in smooth operations and assist the facility to deliver quality care to its customers.

System Integration

       The first quality that needs to be discussed is integration. The system must combine clinical and business management functions within the entire operation, which would not be exclusive to the long-term care facility if other levels of service are present in the operation. You need 1 system to track the resident wherever he or she is in your service delivery platform. To do this, the system will probably be Web-based, have significant security at the user level, be Health Insurance Portability and Accountability Act (HIPAA) compliant, and have a broad range of reporting capabilities—clinical, financial, and management. Many facilities are currently operating with 2 or 3 focused systems that do not integrate data for billing and management purposes. The Minimum Data Set (MDS) software frequently runs on its own, and integrated reports are frequently lost or need to be produced by hand. Electronic records are positive. The move from paper to electronic formats need not stop the wheels of the operation or be excessively costly. An open electronic platform for all data is the goal, so reports can be customized, and realtime monitoring of data for all departments and functions is part of daily operations. Each part of the system must be designed carefully to meet quality and regulatory requirements as well as standards of practice in all areas.

Implementation

       Implementation is by far the most difficult step in this process of change. The expense of implementation must be part of the cost consideration and regarded as a long-term investment in operational quality. The standards, policies, and processes as well as the use of good business rules must be the foundation of the implementation. For example, a program should include current ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) information, care plan libraries, care plan templates, MDS manuals, risk assessments, clinical and financial assessments, event reporting, and financial management reports. Hardware and software considerations must be addressed, and the economies of a Web-based program can lower these costs. Training must be specific, and outcomes from training must be measured. On-site training is important and must be adapted to the learner groups participating. A system is only as good as the training for the facility staff that will be using the program. Staff members need to understand the flow of data into the system and the use of the data within the operational structure of the facility and company. Implementation has become friendlier, as software providers offer more services on-site at the beginning of the process. Systems need to be practical and user friendly because of the variety of people that participate in data collection across all involved departments. The schedule of implementation needs to be developed with consideration of the uniqueness of the facility and its staff.
       An electronic system should produce an integrated documentation and communication process throughout the operation. Single point-of-data entry shares information across all applications and users. This includes demographic, MDS, financial, and risk management as well as census and service delivery reporting data. An integrated system provides realtime reporting to professionals, managers, and financial departments as well as interdepartmental communication. Some current systems also provide physician, pharmacy, lab, and radiology paging and faxing. This gives the facility a realtime notification and response system that is time-dated and provides a consistent record of all contacts. Internal forms and formats become standardized and available in many platforms, work stations, hand- held devices, and central kiosks. Results of testing, assessments, care delivery, and professional evaluations are instantly communicated to all interested parties, keeping all informed of the issues and changes in service delivery or condition of the resident. Realtime data entry, point-of-care data entry, and event reporting create a complete record that can be communicated accurately within the facility and to related professionals by fax or page notification. Assessment data is collected in formats reflecting best practice standards, and event reporting stimulates follow-up actions and progress notes. Vital sign parameters can be established with automatic alerts and messaging, including e-mail notification processes. This may sound like a futuristic system to some, but this type of system is available now—and the technology is improving each day.

The Benefits of Electronic Documentation

       If the documentation system provides accurate, realtime data created to the current regulatory and practice standards, we will reduce legal risk, improve outcomes, and maximize payment. Point-of-care data collection is the key to accuracy, and accuracy of reporting has been proven to support proper payment. Accuracy of reporting also improves the quality of the MDS database to create better plans of care and regulatory compliance. Remember, this is not a clinical system; this is an operational system, so it should make the connection to financial services for billing data, collections information, and service identification. Many facilities are now using “pasted” programs that lose data on a regular basis or manual processes that produce no usable data at all. Operational reporting and management require clinical and financial data flow. Lowering risk in this area is very important to maintain a healthy financial picture and comply with the federal billing requirements.
       One of the most positive outcomes of an integrated information system is its potential for reporting. Realtime data gives the facility the flexibility to evaluate issues and events soon after they occur. An open system with clinical, financial, and management data flow can create reports in a time frame that stimulates problem-solving and notification processes. Reports must be easy to create and disseminate. Make sure that systems do not require the use of their reports only. Having standard reports available can be helpful, but custom reports in all departments should be available. If the system has an open architecture, your ability to create reports improves. Some current systems let you create PDF files, HTML files for viewing, or Excel files for spreadsheet flexibility. This is an important feature.
       Information systems should be able to report the results of notification or event reporting or messages with color coding, so that a manager or clinician can quickly scan a report to find priority issues. Financial reports can also be established this way to locate types of files that need immediate attention or reporting. The resident information section is where the facility establishes the resident’s data, demographics, care delivery process, and care delivery documentation as well as professional notes, orders, assessments, events, and regulatory documents (ie, certifications). This can now include uploaded lab and x-ray results, vital signs and resident-specific reports, realtime notification information, and message history related to the care. Once this database is established, it can then be used for billing and management. This requires no duplicative processes that frequently produce errors. Accountability is a very important benefit of this record-keeping process. The Resident Assessment Instrument function of an electronic system not only collects resident-specific data but assists in the management of the schedule, validation, edits, and transmission to the state database as well as the billing department when appropriate. The system should be able to produce Resource Utilization Group levels, activities of daily living scores, Resident Assessment Protocol data, quality indicator statistics, and quality measures. Reports of MDS activity and status of documents are an important management tool as well as an internal audit. Some current systems will even prevent fatal error transmission because of enhanced internal pretransmission audit programs. Managers should check with their MDS coordinators to question how much time is spent with MDS validation. Their answers may be surprising.

Conclusion

       This may sound like a dream world for the average facility, but it is available today. Conversion to an electronic system is a significant step with many long-term benefits. This is a strategic decision that involves the entire team. The entire team will benefit from better accuracy, realtime reporting, and accountability. Management with an integrated electronic system is more effective, because it is based on facts, time lines, specific formats, and complete data evaluation. I am excited about the systems I see in place today; they are the future for our industry, but we must stand back and consider the value of an integrated system that permits us to use our data and interact with data flow when required to other systems for clinical and financial reporting. Creating an accurate internal medical and financial record requires that our systems use the current clinical and financial standards as well as comply with regulatory standards that change. Flexibility is important, which requires software vendors to be members of the facility team who listen to concerns and needs for the database to grow and change as necessary. The benefits are great, the investment long-term. A fully integrated system is a primary management solution.