Pennsylvania ACEP -- ED Computer Conference
Tracking Component

Keith Conover, M.D., Section Coordinator

What's a . . . eunuch's wizard?

Goal: Learn the essential features of computer systems and software for the ED.

How do you calculate the cost-benefit ratio of a system? You must understand that costs include money, manpower, and mental energy and frustration, and that benefits include money, efficiency, quality of patient care and quality of work environment for staff.

I will provide you with four resources for learning about computers in the ED, from most basic and general to .most complex and ED-specific.

The first (attached) is "Keith and Betty's Idiosyncratic Recommendations" The cover sheet describes this basic introduction to personal computing.

Second: after my first-night semi-humorous introduction to computer technology, I will distribute a printed Glossary for you to keep as a reference. No, it isn't attached because (1) I don't want you to sit in the audience and read off all the answers, and (2) it isn't done in time for this Syllabus.

Third, I am attaching a copy of a computer specification for a tracking system that I made up for our hospital a long time ago. At the end of it are several memos about what I learned during subsequent visits to various Emergency Departments to look at tracking systems.

Fourth, you will find a detailed checklist for analyzing tracking systems.

What's a Tracking System Worth?

(Cost-Benefit Analysis)

Goal: Understand the principles of cost-benefit analysis of a computer system including cash outlay, cost savings, improved efficiency, quality of information, and medico-legal benefits.

Simple Cost-Benefit Analysis

The decision whether to set up a compute tracking system is relatively complex. Nonetheless, it is amenable to a relatively straightforward cost-benefit analysis. The details of basic cost-benefit analysis are available in management and cost-benefit analysis texts, magazines and courses. I've attached three sections for your reference: Internet World-Wide Web (WWW) information for one book, one magazine, and one course offering on standard cost-benefit analysis.

As a tool for making the decision whether to, or which tracking system to install, this analysis is useful. But as a tool for ferreting out hidden costs, it is irreplaceable.

There are two general things worth keeping in mind as you consider the costs and benefits of a computer tracking system for your Emergency Department. First, for most costs, calculate both startup and maintenance costs. Second, put dollar figures on intangibles. Even if very rough estimates, do this, as intangibles are very important in cost-benefit analysis for computer systems. (More below on this topic.)

Also attached you will find a series of articles on "Successfully Managing Custom Software Projects" by Marshall Brain, reproduced with his permission. This excellent series provides succinct practical advice for anyone considering a computer tracking system. After reading it all I can say is "what he said." Keep it with you as you plan, and as you install.

The following outline gives you an idea of how to use standard cost-benefit analysis to look at a potential tracking system.

Cost Breakdown

Tangible (Monetary) Costs

Hardware

• Get an initial estimate from vendor.
• Get an estimate from local PC store or hospital MIS department on ongoing hardware support costs.
• Expect to replace all of your PCs on the average of once every 2-3 years, regardless of what vendors may say.
• New features will make new hardware irresistible even if for reasons other than tracking system, e.g., multimedia medical teaching tools that require CD-ROM formats and special CPU capabilities that are not yet available. You might as well budget for it because you won't be able to resist it. Trust me on this.
• Consider if the vendor's hardware is compatible with what your hospital uses. For instance, most network hardware is based on "Ethernet," developed by AT&T Bell Labs (I think). But some hospitals use the rival, and basically incompatible "Token Ring" network hardware supplied by IBM. A tracking system that is designed to run over an Ethernet system can be run over Token Ring hardware, but it's harder and takes more tweaking to work right; and time is money.

Software

• Ensure that your vendor's maintenance fee includes free updates when they come out with a new improved version. (Actually, it's more of a "technical support fee." But it's still often called a "maintenance fee" in a holdover from the bad old mainframe days when lots of computer geeks were kept busy rewriting "C" or "COBOL" code (programming) to keep the system from breaking down.) If your fee doesn't include free updates, add in the cost of updates, and find out from your vendor their estimated cost and schedule of updates.
• Also figure in cost of switching to another software system ($$$!, even more in intangibles than in tangibles) should the vendor go out of business. (Or out of the business of making charting and tracking systems, as with Ventech's ProTouch systems at Mercy Pittsburgh and the University of Maryland -- and no we haven't figured out how much it'll cost us yet! But a lot.)
  • This is more likely with firms with small market share are relative to the entire market.
  • You should figure "entire market" in relative terms, i.e., compare whole-hospital system vendors to whole-hospital system vendor market, and ED-specific vendors to ED-specific market.
  • As with Token Ring vs. Ethernet hardware (vide supra), software compatibility makes a difference, in time (which again is money) if not in actual dollars. For instance, a tracking system designed to run on Macs will be hard to adapt if you already have a big investment in IBM PC-compatibles and DOS-Windows software.

Personnel

If it takes more time than what you do now, you must either have spare time, or add more staff, or decrease throughput.

If it takes more time only for an interim period, you must cover that interim period with more staff.

• Figure an extra FTE (Full Time Equivalent; full or fractional) for liaison with vendor or MIS department during the startup period.
  • The startup period will run, depending on your situation, roughly 3 months to 1-2 years.
  • Not providing adequately for such a staff position, or overload a staff person by assigning an impossibly small portion of the person's time for computer-related tasks, can cause implementation to fail, possibly due to overloaded staff quitting.
  • If you plan to continue adding functions to system until ED "paperwork" is completely computer-based, may need to hire or assign staff to this function over a longer term.
  • Extra FTEs (full or fractional) or overtime for nursing and physicians staff due to inefficiency during transition to new system (don't believe vendors who tell you otherwise)
  • An extra FTE (full or fractional) for ongoing system software maintenance. Possibly this can be divided between ED and MIS departments at the hospital. By system software maintenance, I mean solving conflicts between the network software that connects all the computers together, the operating systems on the individual PCs (e.g., DOS and Windows), video drivers, sound card drivers, CD-ROM drivers, tape backup software -- you get the idea. In larger hospitals your MIS department may take care of this. But with the squeeze on healthcare dollars, you may find that your hospital's top management wants to cut back on MIS people just as you will be needing them the most.
  • You may need extra FTEs (full or fractional) for the increased work of data entry (some simple systems may decrease FTEs for data entry slightly but complex systems, or systems with poorly designed or just simply less-advanced user interfaces will increase FTEs while providing other benefits, often intangible but very worthwhile)

Intangible (Non-Monetary) Costs

Time cost in waiting for the computer to do something is simply and totally unacceptable. Psychologically if not in reality, staff will not tolerate waiting for computers to "do their thing." There must be rapid realtime response to all staff interactions related to ED patient care.

• Decreased efficiency during startup period due to interruption of normal procedures and patient flow.
  • more frequent backup call-ins
  • more frequent "closure" or "reroute"
  • measure also in terms ofworsening of relationship with prehospital providers, which may mean decreased emergency admissions
  • consider decreased satisfaction of other departments, medical staff, and administrators
• Decreased staff satisfaction due to change in procedures (measure in terms of worse staff retention, difficulties in recruiting).
  • generic computer-phobia of a few staff members may be insurmountable
  • shift of responsibilities from one staff category to another (e.g., from secretaries to nurses) may cause friction between staff categories
• Loss of writing space due to new equipment (estimate in terms of cost of renovating facility to provide more writing space earlier than otherwise; may be minimal to critical depending on current ED status).
• Loss of storage space due to new equipment.

Benefits Analysis

You should analyze the benefits you expect from a tracking system in a manner similar to what I provide above for costs. Benefits depend on your ED, which is unique. You shold review the attachments, listen to the lectures, visit the vendors, and talk with others at the conference. This will give you some idea of what is possible. Then put a dollar vallue on it.

Remember that many of the "intangible" benefits add up to effeciency that will, eventually:

• allow you to recruit and retain better staff at the same salary and benefits
• allow you to expand your services and volume without adding additional staff
• allow your ED to better serve its customers, particularly other staff and administration at the hospital.

Thank you for reading this far, and as you enter cyberspace -- good luck!