Technology and consolidation improve productivity, reduce costs.

With increasing costs for traditional healthcare and a greater life expectancy rate due to medical and technological advancements, the trend toward quality home healthcare is on the rise. Although the expenditures for home healthcare services have dipped recently in response to Medicare reimbursement cuts enacted under the Balanced Budget Act of 1997, home health's cost-effectiveness and demographics clearly support the trend.

Home healthcare provides solutions to several problems facing today's healthcare industry, yet there are still many basic issues concerning the quality and integrity of patient care. Nevertheless, major advancements in information technology are enabling IT managers to address the significant issues.

Need for IT Systems

The expected climb in expenditures over the next few years has created a need for significant investments in both clinical and financial systems. It has also dictated an improved level of productivity for the healthcare professional. In order to minimize the economic impact incurred by home healthcare agencies (HHA), many are consolidating into larger, more efficient organizations covering expansive geographical areas.

The major factors contributing to the need for more advanced technological information systems are the new set of data collection requirements called OASIS, or the Outcome and Assessment Information Set, and the increased demands on the healthcare professional as a mobile worker. OASIS, sponsored by the Health Care Financing Administration (HCFA), is a group of data elements that represent core items in the assessment of an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

HCFA, in accordance with OASIS, has finalized two rules relating to home health agencies. One rule revises the existing HHA Conditions of Participation by requiring that HHAs begin collecting OASIS data. The other expands those new Conditions of Participation by requiring HHAs to report OASIS data to their state survey agencies. HHAs will be required to transmit the data electronically to the standard state system, which has already been installed by HCFA.

The Balanced Budget Act of 1997 includes a Medicare requirement for HHA prospective payment that also depends on the data acquired by the OASIS system. It is anticipated that the provision of the act will not be effective for HHA's cost reporting periods until October 2000--a year behind schedule. Both clinical and financial data are needed to determine the total cost of care delivery, often referred to as activity based costing. In addition, managed care organizations must also have outcome data to support the position that their agencies can get high quality patient outcomes in the fewest possible visits.

Increasing demand for higher productivity of the healthcare professional has dictated that the individual care provider operate in a mobile capacity. The healthcare professional, now potentially removed from the traditional corporate infrastructure, must have easy and convenient access to information, systems, and the breadth of the healthcare community. Such access must accommodate the traditional use of core information systems with a portable-computing device, and it must advance the use of collaboration amongst a distributed community of professionals via voice.

As demonstrated by the need for automation, there is an incredible opportunity for the use of applied technology throughout the healthcare industry. More specifically, within the home healthcare domain, now is the opportune time through effective technology deployment to realize cost savings, productivity gains, regulatory compliance, and more efficient ways of delivering quality patient care.

Using the Internet

In the world of technology, the Internet has become prolific. However, an exaggerated misconception of its value exists among the public--that the only relevant uses of the Internet are within research, marketing, or direct sales to consumers. Furthermore, there are many skeptics as to the safety and security of Internet-based systems.

On the contrary, in the coming years, Internet-based technology will provide the infrastructure for business-to-business relationships and the cornerstone of communications within the distributed staffing model, such as home healthcare.

Internet-based technology will provide the necessary infrastructure for healthcare professionals to access data warehouses, data marts, HEDIS reporting tools, and data mining systems.

User Access

In order to use this Internet-based infrastructure effectively, it is critical to clearly define to whom access is granted and to what level. Patient access via the Internet will become common. Access should be confined to their own patient records or indirectly to consumer-based information in the form of medical record or health record service bureaus.

Healthcare professionals' access to information and the care community via the Internet or intranet will be critical for the successful healthcare provider. Increasingly, healthcare is mobile, thus dictating remote points of access within a safe and secure infrastructure.

Healthcare professionals must be able to access information, capture admissions, assessments and encounters, and collaborate with each other more effectively. Administrators will have access throughout all enterprise levels of information.

Their main objective will be to ensure the integrity of both the clinical and financial information as well as the integrity of the reporting and compliance processes. Institutions must have the ability to exchange sensitive information in order to keep the total cost of ownership down. And supplier management functions will become more streamlined as preferred vendors interact directly with customer-based systems for just-in-time consumables.

Confidentiality and Security

As healthcare continues to move toward automation and Internet-based systems, security issues will continue to gain importance. Patient confidentiality and government regulations (HIPAA among them) will require organizations to implement extensive security systems. Due to increased regulation and heightened consumer awareness, it will be likely that the larger healthcare organizations will employ security directors to ensure the integrity and security of their sensitive data.

The security and confidentiality of information comes to the forefront when addressing enterprise information architecture based on various forms of Internet technology for personal healthcare information. Although breaches of security are often exaggerated in perception, there are several emerging schemes to address the real security of information on an Internet-based infrastructure. One form of safety already implemented by several vendors is the use of digital identification.

The development of the Virtual Private Network (VPN) has also increased the level of confidence for the institutional exchange and access of restricted information through a trusted relationship. Although temporary, the VPN provides a secure connection over a public network such as the Internet.

By leveraging the Internet, the VPN offers significant cost savings, greater flexibility, and easier management relative to traditional inter-networking methods, such as leased lines and dial-up access; however, each potential solution possesses varying degrees of security and performance.

In selecting a VPN strategy, IT managers must identify the institutional business needs for access and protection, and at a minimum, encrypt the data over the dynamic connection on the public network. In the near term, collection points will become available over the public network that will be secure for trusted institutions through an implementation of Digital ID and public/private key encryption.

Mobile Professional Emerging

For years now, the technology sector has focused developments in mobile infrastructure on the sales and service representatives as the mobile professional. Perhaps the most influential component in making home healthcare a success will be for the technology sector to recognize the emergence of the home healthcare professional as a mobile one and support him or her with the appropriate hardware and software systems. As a mobile professional, the home healthcare professional will require several accessibility features for effective operation. These features include:

* Access to the enterprise information systems;

* Access to medical references on both public and private networks;

* Access to the extended community of healthcare providers for collaboration;

* Quality mobile computing and telephony devices for communication.

The central element for all of these access features would be the integration of computer telephony and voice recognition technology for collaboration with the information capture and data reporting requirements of the information systems (CPR for example). Such functionality would allow the mobile healthcare professional to interact seamlessly with the surrounding enterprise infrastructure.

Preferred Interaction

Data capture at point-of-contact has generally been accepted as the preferred method of interaction with data-capture-information systems across any industry. It specifically allows the healthcare professional to verify the information at point of acquisition thus removing the inaccuracy and expense of off-line translation. Data capture, as well as the other forms of data access, would primarily involve the use of hand-held computing devices to connect to the network infrastructure.

The primary drawback to the use of the handheld computing device can be the limits placed on it by bandwidth restrictions and physical access to reliable connection points. Such restrictions have provided the opportunity for a new class of advanced applications based on the technological progress in computer telephony and agent software.

Advanced Applications

Workflow applications streamline the prescribed interaction and/or best practices within an institution, including data capture and regulatory compliance. However, in the past, technology and infrastructure constraints have limited the workflow application to "in-office" staff thus excluding the mobile healthcare professional. Due to the combination of workflow patterns with voice-invoked agents, speech recognition, and text-to-speech functions, these advanced applications are now being made available to the mobile healthcare professional. Applications using voice-command technology could include the capture of OASIS information, scheduling, admission functions, authorizations for referrals, physician orders, and notification of results.

Advances in information technology and the specific application of technology within the home healthcare industry are providing a foundation for managed care to succeed despite rising costs and increased regulation. As our population ages, the continued increase in home healthcare will demand that the technology advocates of the home healthcare enterprise promote the adoption of leading edge information technology systems as an approach to thriving within the new model of operation.

RELATED ARTICLE: Home Care Industry Ponders POC Automation

Interest and need in clinical automation are there, but not resources and payback.

By Thomas D. Williams

It has been nearly 10 years since the first systems automating clinical data capture at the point-of-care were introduced to the home care industry. Nevertheless, after a decade of development and product promotion, fewer than one in four home care clinicians routinely uses a computer to prepare documentation associated with patient care.

Why hasn't POC clinical automation taken off, particularly during a period when virtually every industry has experienced an explosion in information technology use? Aside from the lack of applications software with broad market appeal, the primary reason has been cost.

While interest in clinical automation has grown, few agencies could justify the significant resources required to automate clinical staff, even under cost reimbursement. In today's cost conscious post-IPS environment, POS automation investments need to be evaluated more thoroughly.

Increased Importance Today

Recent interest in clinical automation has been driven largely by demands for increased data on service effectiveness. HCFA's OASIS project and JCAHO's ORYX initiative are prime examples. Unfortunately, at the same time interest and need are increasing, most agencies confront the realities of today's reimbursement climate. Resources are strained for many, and investments will be made only when payback can be clearly documented.

In today's marketplace you will most likely spend more to automate your clinical staff than you will on your back office administrative system. Two years ago the total cost per clinician was typically more than $7,000 on remote data capture investment. Today we see vendor proposals with one-time costs nearing $10,000 per staff person. Clearly the investment required automating clinicians remains among the greatest any agency will ever consider.

Within this context it is imperative that agency executives be able to cost justify POC automation expenditures. One-time and ongoing costs need to be identified over expected system life. Benefits need to be quantified and savings realistically forecasted over a similar timeframe.

Medicare Dollars Not There

Payback scenarios need to be developed and results tracked to assess return on investment. No longer can such decisions be made based on the promise of "better and more timely data" and paid for with plentiful Medicare dollars.

While we've had nearly ten years to prove the efficacy of POC automation, only a handful of agencies have stepped forward to proclaim the benefits of providing clinicians with computers. We've seen improvement of about one-half visit per day after the nursing staff is fully trained and comfortable with a system--not quite what vendors forecast when they present the "business case" for buying their products.

Results from Automation

What results should you expect from automating your clinicians? Improved productivity is one likely benefit, but performance improvement will vary greatly to agency circumstance (current productivity levels, geographic area covered, population served). You will likely be disappointed with the results unless you approach clinical automation decisions with a clear understanding of total system cost and potential benefits.

You can avoid disappointment by developing realistic forecasts of costs and benefits, setting reasonable goals and expectations for management staff, and monitoring performance to make certain results are achieved.

Underestimating cost and overestimating benefits are the primary reasons there have been so few success stories. While vendors bear responsibility for often painting too rosy a picture, agency executives need to recognize the importance of basing decisions on forecasts that account for unique agency circumstance and experience of others.

Thomas D. Williams is editor and publisher of Home Care Automation Report working from Fredonia, WI.

Dempsey Nugent is president and CEO of ObjectRealm Consulting Group, Columbia, S.C.