Record Keeping on Paper...Why?

Paper... it's been around a really long time. Sure, it's construction has changed but how we use it? Not one fiber. If you are curious, you can read more about paper here. Now here's the thing. While paper may be flexible and easy to use, it can only store data in an imutable fashion. It is this feature, above all else, that makes paper costly and obsolete! It allows for embedded errors, storage issues and reporting.

Why use paper all? There are so many issues with it that you just want to forget it!

But not so fast....

Here's the amazing thing about paper. A large portion of health care information is charted and stored on PAPER! This fact is changing slowly. To top it off high end medical system are replacing skilled technicians. Read about the Radiologists here (don't worry, computer programmers are not far behind).

Let's look at a likely scenario:

Your primary doctor prescribes you a new medication. Your specialist prescribes something else. Two different medications. What happens?

In the best case, the pharmacist or prescriber reviews your medication list and makes sure there are no problems with combining the two drugs.

Remember, you're on paper. With paper, there is no way to compare any of the medications exept by visual inspection and with detailed medical knowledge. If you are taking other medications or if it is new, talk to the pharmacist. What happens when the conversation goes beyond you and your doctor(s)? Care facilities, institutions, and even homeless shelters are getting into the medication and care administration segment.

The worst case? You are living in a care facility of some level and they are managing your medications using paper MARs printed by the Pharmacy. The facility is on paper. "What is the problem here and why is this the worst case" you ask? The Pharmacy is managing the medications and generating the forms.

Setting the stage:

For the purposes of this article here are some definitions of terms:

Healthcare Facility: an institution managed by a team of medical professionals providing long term care for seniors.

The "MAR" (Medical Administration Record): Each medication to be administered is listed with its specific times to be administered. Days of the month go across the top.

Runs on paper: When medications are administered, the administration's date and time are recorded on the MAR. The recordation is achieved by the medical technicians initials being entered into a special box on this document.

The Stage Is Set for the Worst...

Everything was simple until this document showed up. It is an outdated way to manage information. Paper charting suffers from a serious redundancy problem, a high margin of error, and a storage migrain that doesn't quit.

Redundancy problem - translated - you can only use it once. You've spent hours in Excel, transcribing all of your residents medication orders. To save time, you print out three months of blank charts. Halfway through the month, a new medication comes in. Back to Excel you go, editing your patients health record.

"Wait, doesn't the pharmacy generate these forms?" The pharmacy typically only provides forms for the administration of medication. In a Health Care facility, administering medications is only one part of the whole care the facility provides. Recording this additional care is necessary for the facility to get the full reimbursement for the care they provide. Like medications, this additional care is often prescribed and recorded. This means additional forms are needed.

The plot thickens...

The Medication Technician has to visually scan the whole chart in order to determine what medications and care to give at what time.

So at this point, you have one chart, half filled with administered medications and a requirement to add a new medication or treatment to the chart.

What do you do? You made the change in Excel but you have half a chart filled out.

Print out a new chart and mark up both charts appropriately? This is the easiest approach and may be the only method accepted by regulators. The old charts remaining days are "X'd" out and it gets attached to the new form.

Copy the prior administrations onto the new form?

Hand write the new medication on the existing chart?

There are many ways to handle this but remember, your process is to print out three months at a time. If you forget to manage the change on the additional MARs, a error will occur the following month. Any medication error is one too many. So, the last step is to print out the additional months and destroy the prior versions that are no longer correct.

So you can see, even if you are hyper diligent, an error can easily creep in. At the very least, your resident has not received the highest quality care. They've missed a medication or possibly been given the wrong medication.

Electronic Tracking...really?

Yes, to err is human but to really foul things up, a computer is required. Let's face it, computers can be intimidating. They don't smile, laugh or have a real conversation. Siri, et al, you don't count. We talk to our phones, tablets and computers. They will write down what we say or tell us where the closest restaurant is. With modern devices, you can simply dictate your comments instead of typing or hand writing them out. Not only that, that same device can capture an image of the situation you are documenting. Try doing that with paper forms.

Adapting to change is challenging under the best circumstances.  Switching to an electronic system over a paper process can be a frightening and overwhelming proposition. Remaining on paper however, is a dead end. It's very nature has caused it's general use to be reduced to a mere fraction of what it was ten years ago. Regulated industries also are at risk of being forced to change to an electronic system if the Regulators make that a requirement.

How do you choose the right system?

The right system provider?

What about training?

Support?

The list goes on but the process of converting from a manual operation to an automated one brings turmoil, frustration and potential employee turnover. Yet not converting brings its own set of risks including being regulated out of the industry, unable to compete on key features or offer the highest quality care.

Decision Made what's next?

You've decided to put in a system and are faced with many choices ranging from systems that cover all operations of a facility to targeted applications and tools designed for a specific process. How do you choose a solution provider?

Providers; here, there and everywhere...

Conventions, sales calls, demos...you have choices but which system is the "right" system?

No system will be perfect. So stop looking for the perfect match. It does not exist. Close match? You bet.

Maybe you've been through this process before and you are looking for a better match. Maybe its your first trip to the rodeo. Either way here are some things to consider:

All In One or Specialized

At first glance the "All In One" system seems like the best choice. Especially if you are transitioning from a manual to an automated process. While this may seem like the right choice, or indeed is the best choice, it may be too expensive. To help resolve this question, you want to know:

• Buy what you need

Case: Many systems can be sold piecemeal allowing you to use only the feature you need today and potentially add additional features later as you grow. This may be one cost saving strategy if the system is designed around a modular approach.

Case: Most of the features of the All In One work for your business however a different specialized product (like an eMAR) handles a specific aspect of your business in better or more compliant fashion.  

Question: Does the specialized product support standard interfaces? Does the All In One allow for other systems to connect?

If you really like the specialized system or the specialized system is more compliant with regulations then you have to consider the "Two System" option. If the systems can talk to each other already, then this is a small issue. If they cannot, one or both does not have a shared language, then a technical solution may be a possibility. A technical solution however implies delays and the timeframe may be significant.

Case: All In Ones are more complex systems and typically take longer for the company to address a bug or a new feature.

If your industry is in a period of significant changes, especially if industry specific regulations are involved; you want a provider that can quickly address changes in their system. What is their update cycle? Do they practice "Continuous Development" or the more traditional waterfall approach where requests are evaluated periodically then schedule based on perceived size and complexity.

If the process is complex, like medication administration, a product that specifically targets this process is likely the better tool. When a product is focused on a specific niche, it gets all the focus. When the product is part of a suite of features from house keeping to accounts receivable and everything else including medications, focus gets diluted.

Case: While the specialized tool, by its very nature, will often be the best tool for the job it may not be the best tool for the organization.

Choosing systems is often a balance of conflicting features. While one product handles a particular aspect very well, it will not share its information or the all inclusive system doesn't support interfacing.

When facing this situation the choice comes down to implementing a Sneaker Interface or just going with the one system. A sneaker interface? This is a twist on the term "Sneakernet".

Are there interface standards?

In the medical industry, two key standards are Script 10.6 and HL7. Script 10.6 specifically address how Medicare part D drug information can be communicated. Health Level 7 is a more inclusive standard that manages a far greater range of health specific information.

Company size and location is important

Bigger is better right? Not necessarily. As a company size increases, its ability to react quickly becomes impeded.

• A small company typically is more nimble

Fewer employees means a shorter path to decision makers. A small company may be a new entry into the market and is trying to leverage a feature or process that presents a better solution over competitors.

• A large company usually has more industry partners than the small company

A larger company has more customers. This gives the larger company an advantage when attracting partners with complementary products or services.

• What lifecycle stage is the product in (new, early adoption, established, in decline)?

New - if the product is a new entry, what are the key features that make this a consideration? Cost? Critical job functions? Considering a new product brings advantages and risks worth considering. A new product is likely based on the latest technology and can offer significant advantages or improved compliance. At the same time, a new product may have more issues or bugs and does not have a large customer base for referrals.

Early Adoptions - by this stage, the product has gone through revisions and updates. The customer base is growing. 

Key to items to evaluate product in this stage are:

• Customer reviews of the product available?

Are people talking about the product? Recommending the product? Can the potential vendor provide referrals?

• Does the vendor have a backlog of installs?  

It might be worth the wait. Products at this stage are generally offered with incentives to assist potential buyers with system set up, training, and adoption. While this stage is a riskier choice than an established system; cost savings, more support options and a more personal relationship with the vendor can make this a very attractive option.

Established - You know what your are getting. An established system has a large customer base, is usually well documented and often has customer reviews and testimonials. This makes the decision easier. Information and reviews are easy to find and you have a better idea of what your are getting. Established systems however change at a slower place and if they are a market leader, generally the most costly.

Decline - Systems can enter this stage through no fault of their own. Often, the resources available when the system was created may no longer exist or be supported. Regulations can change reducing the systems relevance to the point of obsolescence. You are likely in this situation if your system is old. An older system is unlikely to have the connection points for sharing information that new systems will have. Adherence to new standards may be problematic as well.

A bigger company is likely to be more stable and be around five years from now. A small company presents the risk that it may not survive.

Location, Location, Location...

Not just for real estate, in todays global market place, where the software comes from should be considered. Especially if the country is in a region where trade agreements are being addressed.

Where is the company based? If the software comes from another country, international issues and laws can leave you hanging. How close is the company? Are they local? Can you visit their business location?

All of these factors play a role in selecting a system.

Shiny new tool, what's next? It is training time!

You've waded through the madness of researching, evaluating and finally choosing a system. Now you need to set it up. This is another area where vendors vary greatly. Your team has to be educated on how to use the new system. Proper guidance is often the biggest factor for post installation success. With any system installation, you have some type of training. The variety and cost largely depends on the depth and the number of person hours required.

After the initial training

• What type of support does the vendor offer?
• Is it live support?
• Is there a charge?
• How is it set up?
• What type of information needs to be entered for the system to be functional?

Can the information be transferred electronically or does it have to be entered manually?

Depending on the vendor, each of these services may result in additional charges either as an "Add-On" or billed on a per call basis. Other vendors may include these valuable services at no charge.

The ability to speak with an expert when you need to...

is a critical feature.

After the training is done and you are on your own, what type of support did you get when you bought the system?

• 24 x 7 live support
• Regular and After Hours
• Per call basis
• Online and User forums

When a system is new, you are show how to use the main features for all roles in the organization. It is important to have quick access to support resources. It is a given, not all features are created equal. Some only get used once a month. You've done this process once. It's been a month and it is time to do it again. Your notes from training? Having the ability to make a quick call to get you started saves a tremendous amount of time. Time = Money, yes? Good support saves you money.

Perhaps you can elect to opt out of the support agreement and avoid the charge but in doing so, learning how to use the system is up to you.

When considering a new system or changing to a new vendor, the software is only one part of the equation. Technology constantly changes. Large monolithic systems get buried under their own weight and fall behind the market place. Specialty system can adapt more quickly but if they are isolated and don't share information with other systems, their utility gets limited. Three things to keep in mind:

• Make sure it meets your needs
• You are confident that both the software and vendor are solid
• The path to adoption is clear of weeds and blockers

If you are currently using paper as your means of information storage and tracking, it is not a question of if but when you will switch to a system. Choosing the right system is a challenging but rewarding adventure. You want to choose a system that comes closest to your needs. The system may all be from one vendor or a modular approach combining best of breed. Even with the best of the best software, to be successful, initial training and ongoing support are as important as the software itself. Hard costs are only one aspect of choosing a system and often the least valuable.