Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
UBCV
Lindstrom, Ronald Raymond
Master of Science - MSc
University of British Columbia
Hospital decision-makers face several uncertainties during evaluation and selection of computerized hospital information systems. Cost-benefit analysis is one method of predictive economic evaluation and is particularly important from the perspective of the hospital. Unless hospitals can economically justify such systems, it makes little sense to pursue them unless there are over-riding political or qualitative reasons. This thesis discusses the principles of cost-benefit analysis and a general framework for such analysis from the perspective of the hospital, in order to answer the question of whether a proposed hospital information system is justifiable on cost-benefit grounds relative to the status quo method of handling information. Three dominant approaches to planning for such systems in British Columbia and Ministry of Health funding guidelines and policies are discussed in relation to the framework. An application of the framework is made to a community general hospital in British Columbia using actual data obtained during the complete planning process for a proposed system. The analysis demonstrates that over the expected duration of the project, the sample hospital will experience net costs, as opposed to net savings for the proposed system, even if all one-time capital costs are funded by others. It is unlikely that this finding is unique to this single hospital; thus, there are broader implications for other hospitals considering such systems, especially in the face of recently published expenditure limits and priorities in British Columbia.
A GENERAL FRAMEWORK FOR PREDICTIVE ECONOMIC EVALUATION OF COMPUTERIZED HOSPITAL INFORMATION SYSTEMS AND AN APPLICATION TO A BRITISH COLUMBIA HOSPITAL by RONALD RAYMOND LINDSTROM B . S c , The U n i v e r s i t y of B r i t i s h Columbia, 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology (Health S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n Programme We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA APRIL 1986 © R O N A L D RAYMOND LINDSTROM, 1986 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department O f Health Care and Epidemiology The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 ^ 29 A p r i l 1986 Date DE-6 (2/79) ABSTRACT H o s p i t a l d e c i s i o n - m a k e r s f a c e s e v e r a l u n c e r t a i n t i e s d u r i n g e v a l u a t i o n a n d s e l e c t i o n o f c o m p u t e r i z e d h o s p i t a l i n f o r m a t i o n s y s t e m s . C o s t - b e n e f i t a n a l y s i s i s one m e t h o d o f p r e d i c t i v e e c o n o m i c e v a l u a t i o n a n d i s p a r t i c u l a r l y i m -p o r t a n t f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l . U n l e s s h o s p i t a l s c a n e c o n o m i c a l l y j u s t i f y s u c h s y s t e m s , i t makes l i t t l e s e n s e t o p u r s u e them u n l e s s t h e r e a r e o v e r - r i d i n g p o l i t i c a l o r q u a l -i t a t i v e r e a s o n s . T h i s t h e s i s d i s c u s s e s t h e p r i n c i p l e s o f c o s t - b e n e f i t a n a l y s i s a n d a g e n e r a l f r a m e w o r k f o r s u c h a n a l y s i s f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l , i n o r d e r t o a n s w e r t h e q u e s t i o n o f w h e t h e r a p r o p o s e d h o s p i t a l i n f o r m a t i o n s y s t e m i s j u s t i f i a b l e on c o s t - b e n e f i t g r o u n d s r e l a t i v e t o t h e s t a t u s quo method o f h a n d l i n g i n f o r m a t i o n . T h r e e d o m i n a n t a p p r o a c h e s t o p l a n n i n g f o r s u c h s y s t e m s i n B r i t i s h C o l u m b i a a n d M i n i s t r y o f H e a l t h f u n d i n g g u i d e l i n e s a n d p o l i c i e s a r e d i s c u s s e d i n r e l a t i o n t o t h e f r a m e w o r k . An a p p l i c a t i o n o f t h e f r a m e w o r k i s made t o a c o m m u n i t y g e n e r a l h o s p i t a l i n B r i t i s h C o l u m b i a u s i n g a c t u a l d a t a o b t a i n e d d u r i n g t h e c o m p l e t e p l a n n i n g p r o c e s s f o r a p r o p o s e d s y s t e m . The a n a l y s i s d e m o n s t r a t e s t h a t o v e r t h e e x p e c t e d d u r -a t i o n o f t h e p r o j e c t , t h e s a m p l e h o s p i t a l w i l l e x p e r i e n c e n e t c o s t s , a s o p p o s e d t o n e t s a v i n g s f o r t h e p r o p o s e d s y s t e m , e v e n i f a l l o n e - t i m e c a p i t a l c o s t s a r e f u n d e d b y o t h e r s . I t i s u n l i k e l y t h a t t h i s f i n d i n g i s u n i q u e t o t h i s s i n g l e h o s p i t a l ; t h u s , t h e r e a r e b r o a d e r i m p l i c a t i o n s f o r o t h e r h o s p i t a l s c o n -s i d e r i n g s u c h s y s t e m s , e s p e c i a l l y i n t h e f a c e o f r e c e n t l y p u b l i s h e d e x p e n d i t u r e l i m i t s a n d p r i o r i t i e s i n B r i t i s h C o l u m b i v TABLE OF CONTENTS ABSTRACT . . . . . . . . . . . . . . . i i TABLE OF CONTENTS . . . . . .' . . . . . . .' . . . . . i v LIST OF TABLES v i i LIST OF FIGURES . . . . . . . . . . . i x ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . x QUOTATION . . . . . . . . . . . . . x i Chapter I . LITERATURE REVIEW 1 I s s u e s i n P l a n n i n g f o r H o s p i t a l I n f o r m a t i o n Systems 1 S o f t Systems A n a l y s i s 2 H o s p i t a l I n f o r m a t i o n Systems P l a n n i n g Methodology 3 From HIS P l a n n i n g t o Economic E v a l u a t i o n . . g D e f i n i t i o n and D i s c u s s i o n of the Methodology 6 Advantages and Importance g D i s a d v a n t a g e s and L i m i t a t i o n s g I m p l i c a t i o n s and Use as a D e c i s i o n - M a k i n g T ° o 1 13 J u s t i f i c a t i o n f o r Government Fun d i n g . . . . ^4 T h e s i s Road Map .^6 F o o t n o t e s ^ 9 I I . APPROACHES TO INFORMATION SYSTEMS PLANNING IN THE BRITISH COLUMBIA HOSPITAL ENVIRONMENT . 2 4 B r i t i s h Columbia H o s p i t a l Shared Systems S o c i e t y 2 5 R o l e 2 5 Changing P l a n s 2 ^ Systems A r c h i t e c t u r e P l a n 27 I n f o r m a t i o n Systems P l a n 2 ^ Economic P e r s p e c t i v e 2 ^ B r i t i s h Columbia H e a l t h A s s o c i a t i o n . . . . 3 u" Ro l e 3 0 Economic P e r s p e c t i v e 3 3 F u t u r e R o l e 3 ^ H o s p i t a l s 3 6 G e n e r a l D i f f i c u l t i e s ' E n c o u n t e r e d by H o s p i t a l s i n P l a n n i n g f o r Computerized I n f o r m a t i o n Systems 3 ^ I V S p e c i f i c D i f f i c u l t i e s E n c o untered i n the Face of BCHSSS' and BCHA's C u r r e n t R o l e s 37 I m p l i c a t i o n s o f t h e Economic: P e r s p e c t i v e . . . 40 A p p r o v a l and Funding::Processes from' the P e r s p e c t i v e ^ f . t h e : H o s p i t a l . 41 F o o t n o t e s ' ' ' 4 5 I I I . A GENERAL FRAMEWORK FOR PREDICTIVE ECONOMIC EVALUATION . . . . . . . . . . . . . . 47 G e n e r a l C o n s i d e r a t i o n s and the Reasons f o r S e l e c t i n g C o s t - B e n e f i t A n a l y s i s . . . . 47 P r i n c i p l e s o f C o s t - B e n e f i t A n a l y s i s A p p l i e d t o H o s p i t a l I n f o r m a t i o n Systems . . . . . . 49 D e f i n i n g the Q u e s t i o n 4 9 D e l i n e a t i o n o f O b j e c t i v e s and I d e n t i f i c a t i o n and S e l e c t i o n o f A l t e r n a t i v e s 50 Enumeration o f R e l e v a n t C o s t s and B e n e f i t s . 50 Q u a n t i f i c a t i o n o f C o s t s and B e n e f i t s . . . . 62 V a l u a t i o n o f C o s t s and B e n e f i t s 63 D i s c o u n t i n g o f C o s t s and B e n e f i t s 65 S e n s i t i v i t y A n a l y s i s 68 I n t e r p r e t a t i o n and P r e s e n t a t i o n o f F i n d i n g s 69 F o o t n o t e s 74 IV. THE CHILLIWACK GENERAL HOSPITAL'S EXPERIENCE . . 78 D e s c r i p t i o n o f t h e H o s p i t a l , 78 D e s c r i p t i o n o f t h e H o s p i t a l ' s P l a n n i n g Methodology 80 D e s c r i p t i o n of t h e H o s p i t a l ' s O p t i o n s . . . . 84 F o o t n o t e s . . . 87 V. ECONOMIC EVALUATION OF A HOSPITAL INFORMATION SYSTEM FOR THE CHILLIWACK GENERAL HOSPITAL . . . 88 D e f i n i n g t h e Q u e s t i o n 88 D e l i n e a t i o n o f O b j e c t i v e s and I d e n t i f i c a i t o n o f A l t e r n a t i v e s 90 Enumeration o f R e l e v a n t C o s t s and B e n e f i t s . . 91 Q u a n t i f i c a t i o n and V a l u a t i o n o f C o s t s and B e n e f i t s 1°° D i s c o u n t i n g o f C o s t s and B e n e f i t s 101 S e n s i t i v i t y A n a l y s i s 101 I n t e r p r e t a t i o n and P r e s e n t a t i o n o f F i n d i n g s . . m F o o t n o t e s 118 v i V I . GUIDELINES FOR GENERAL. USE BY BRITISH COLUMBIA HOSPITALS 119 I d e n t i f i c a t i o n o f Problems 122 I d e n t i f i c a t i o n o f B e n e f i t s 123 I d e n t i f i c a t i o n o f P r i o r i t i e s 124 Request f o r I n f o r m a t i o n P r o c e s s 125 Request: f o r P r o p o s a l P r o c e s s . . . 126 C o s t - B e n e f i t A n a l y s i s 128 D e c i s i o n - M a k i n g P r o c e s s 129 Government A p p r o v a l and F u n d i n g P r o p o s a l . . . 130. F o o t n o t e s 133 V I I . SUMMARY AND CONCLUSIONS 134 F o r The C h i l l i w a c k G e n e r a l H o s p i t a l 134 P o l i c y and Broader I m p l i c a t i o n s f o r B r i t i s h Columbia H o s p i t a l s 137 SELECTED BIBLIOGRAPHY 14 2 Appendices APPENDIX 1. M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h C o lumbia, G u i d e l i n e s f o r Computer Fund i n g P r o p o s a l s 14 8 APPENDIX 2. M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h Columbia, Computer P o l i c i e s 167 APPENDIX 3. C h i l l i w a c k G e n e r a l H o s p i t a l , Systems P l a n n i n g P r o j e c t , Two-dimensional P r o c e s s M a t r i x 173 APPENDIX 4. C h i l l i w a c k G e n e r a l H o s p i t a l , Systems P l a n n i n g P r o j e c t , P r o c e s s D e f i n i t i o n s 174 APPENDIX 5. C h i l l i w a c k G e n e r a l H o s p i t a l , Summary of Problems I d e n t i f i e d Through HSP Study . . . 183 APPENDIX 6. C h i l l i w a c k G e n e r a l H o s p i t a l , Summary of B e n e f i t s ( T a n g i b l e and I n t a n g i b l e ) I d e n t i f i e d Through HSP Study . . . . 194 APPENDIX 7. C h i l l i w a c k G e n e r a l H o s p i t a l , Systems P l a n n i n g P r o j e c t , Request f o r P r o p o s a l 202 v i i LIST OF TABLES 1. Enumeration, Q u a n t i f i c a t i o n and V a l u a t i o n of T a n g i b l e One-Time C o s t s of HIS Over E i g h t Year P e r i o d f o r The C h i l l i w a c k G e n e r a l H o s p i t a l . . . 92 2. Enumeration, Q u a n t i f i c a t i o n and V a l u a t i o n o f T a n g i b l e On-Going C o s t s o f HIS Over E i g h t Year P e r i o d f o r The C h i l l i w a c k G e n e r a l H o s p i t a l . . . 94 3. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s of HIS Over E i g h t Year P e r i o d Assuming 100% Funded by The C h i l l i w a c k G e n e r a l H o s p i t a l . . . . . . . 95 4. Summary o f N o n - I n f l a t e d , Non-Discounted E s t i m a t e d S a v i n g s (Labor and Non-Labor) Over E i g h t Year P e r i o d f o r The C h i l l i w a c k G e n e r a l H o s p i t a l . . . 98 5. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s and B e n e f i t s o f HIS Over E i g h t Year P e r i o d f o r The C h i l l i w a c k G e n e r a l H o s p i t a l 102 6. P r e s e n t D i s c o u n t e d V a l u e s ( C a l c u l a t e d a t 3% D i s c o u n t Rate) f o r E n t i r e Stream o f C o s t s and B e n e f i t s f o r The C h i l l i w a c k G e n e r a l H o s p i t a l . . 103 7. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s and B e n e f i t s o f HIS.Over E i g h t Year P e r i o d Assuming A l l C o s t s 100% Funded by The C h i l l i w a c k G e n e r a l H o s p i t a l (1.4 U.S. Exchange Rate) 104 8. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s and B e n e f i t s o f HIS Over E i g h t Year P e r i o d Assuming One-Time C a p i t a l C o s t s 100% Funded by Othe r s (1.4 U.S. Exchange Rate) 105 9. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s and B e n e f i t s o f HIS Over E i g h t Year P e r i o d Assuming A l l C o s t s 100% Funded by The C h i l l i w a c k G e n e r a l H o s p i t a l (1.3 U.S. Exchange Rate) 106 10. Summary o f N o n - I n f l a t e d , Non-Discounted C o s t s and B e n e f i t s o f HIS Over E i g h t Year P e r i o d Assuming A l l One-Time C a p i t a l C o s t s 100% Funded by O t h e r s (1.3 U.S. Exchange Rate) . . . . . . . . . . . . 107 11. Summary o f P r e s e n t V a l u e C o s t s and B e n e f i t s a t V a r i o u s P r e s e n t D i s c o u n t e d V a l u e s (1.4 U.S. Exchange Rate) 108 12. Summary o f P r e s e n t V a l u e C o s t s and B e n e f i t s a t V a r i o u s P r e s e n t D i s c o u n t e d V a l u e s (1.3 U.S. Exchange Rate) . . . 109 v i i i 13. Summary of N o n - I n f l a t e d , Non-Discounted Net C o s t s of HIS Over E i g h t Year P e r i o d as P e r c e n t a g e of N o n - I n f l a t e d , Non-Discounted Gross Annual Oper-a t i n g Budgets f o r The C h i l l i w a c k G e n e r a l H o s p i t a l 1 1 0 i x LIST OF FIGURES 1. Enumeration o f C o s t s 54 2. Enumeration o f B e n e f i t s 61 3. I m p l e m e n t a t i o n , C o s t s and T a n g i b l e B e n e f i t s Streams o f a Proposed HIS f o r The C h i l l i w a c k G e n e r a l H o s p i t a l , . 8 9 4. F l o w c h a r t D e m o n s t r a t i n g P l a n n i n g , C o s t - B e n e f i t . A n a l y s i s and D e c i s i o n - M a k i n g P r o c e s s e s 120 X ACKNOWLEDGEMENTS I owe many p e o p l e t h a n k s f o r t h e i r h e l p , e n c o u r a g e m e n t a n d f o r b e a r a n c e a s I e n d e a v o u r e d t o c o m p l e t e t h i s t h e s i s , b u t my e v e r - p a t i e n t w i f e , K a t h l e e n , a n d o u r f i v e c h i l d r e n , M a r c u s , J a r e d , J o s h u a , M i c h a e l a n d B r e a n n e d e s e r v e , w i t h o u t a d o u b t , a v e r y s p e c i a l t h a n k y o u f o r t h e i r u n f a i l i n g p a t i e n c e . To D r . M o r r i s B a r e r , D r . A l b e r t D e x t e r and Mr. Norman B a r t h o f my T h e s i s C o m m i t t e e , t h a n k y o u f o r s u c c e s s f u l l y n a v i g a t i n g me t h r o u g h t h i s s t u d y w h i c h , I t r u s t , w i l l p r o v e t o be o f u s e t o o t h e r s . F i n a l l y , I w o u l d l i k e t o t h a n k M a r i a V a n d e n B e r g e a nd V a l e r i e Edmondson f o r t h e i r t y p i n g p a r e x c e l l e n c e , i n s p i t e o f a d e m a n d i n g s c h e d u l e . x i " I t i s b e s t t o t h i n k o f the c o s t - b e n e f i t approach as a way of o r g a n i z i n g thought r a t h e r t h a n as a s u b s t i t u t e f o r i t . " M.F. Drummond, 1980 1 CHAPTER I LITERATURE REVIEW I s s u e s i n P l a n n i n g f o r H o s p i t a l I n f o r m a t i o n Systems There i s a growing body o f e v i d e n c e i n t h e c u r r e n t l i t e r a t u r e d e m o n s t r a t i n g t h e n e c e s s i t y o f e f f e c t i v e p l a n n i n g f o r a c o m p u t e r i z e d h o s p i t a l i n f o r m a t i o n system (HIS) . C o l l e c t i v e l y , t h e s e s o u r c e s u n d e r s c o r e t h e im p o r t a n c e o f t h e HIS p l a n n i n g p r o c e s s as w e l l as t h e p l a n produced by t h e p r o c e s s . As A u s t i n and Greene"'"''" have r e p o r t e d w i t h r e s p e c t t o system d e s i g n approaches, t h e 1950s saw i n d i v i d u a l d e p a r t -m e n t a l systems and no i n t e g r a t i o n ; t h e 1960s saw p r e d o m i n a n t l y b a t c h p r o c e s s i n g w i t h a t t e m p t s t o i n t e g r a t e systems; and t h e 1970s saw s h i f t s t o o n - l i n e a p p l i c a t i o n s w i t h an i n t e r e s t i n f u l l y i n t e g r a t e d systems. Indeed, t h e 1980s a r e s e e i n g development o f f u l l y i n t e g r a t e d systems as e x e m p l i f i e d by hundreds o f i n s t a l l a t i o n s i n h o s p i t a l s t h r o u g h o u t the w o r l d . T h i s t h e s i s w i l l f o c u s on such i n t e g r a t e d systems i n c l u d i n g 12 such elements as d e f i n e d by A u s t i n and Greene: o n - l i n e e n t r y , r e t r i e v a l and d i s p l a y o f i n f o r m a t i o n v i a s p e c i a l i z e d t e r m i n a l s ; a u t o m a t i c message s w i t c h i n g f o r communicating i n f o r m a t i o n t h r o u g h o u t t h e h o s p i t a l ; - f a c i l i t a t i o n o f d a y - t o -day o p e r a t i o n s ; and, employment o f a f u l l y i n t e g r a t e d d e s i g n approach i n c l u d i n g common d a t a d e f i n i t i o n s , e s s e n t i a l d a t a f i l e s and a u t o m a t i c communication o f d a t a from one f u n c t i o n a l subsystem t o a n o t h e r as needed. The " f u l l y i n t e g r a t e d " 2 system may v a r y from h o s p i t a l t o h o s p i t a l ; however, f u l l i n t e g r a t i o n i m p l i e s a c a p a b i l i t y o f p r o v i d i n g comprehensive and c o o r d i n a t e d i n f o r m a t i o n t h r o u g h o u t t h e h o s p i t a l as r e -q u i r e d . T h i s i s p a r t i c u l a r l y i m p o r t a n t i n t h e h o s p i t a l s e t t i n g because of t h e h i g h l y i n t e r r e l a t e d and i n t e r d e p e n d e n t n a t u r e o f a l l i n f o r m a t i o n r e q u i r e d t o admit, d i a g n o s e , t r e a t , s u p p o r t and b i l l t h e a c t i v i t i e s r e l a t e d t o t h e c a r e , t r a n s f e r and d i s c h a r g e o f each p a t i e n t . T h i s i s one r e a s o n why s t a n d -a l o n e , n o n - i n t e g r a t e d systems have been l a r g e l y d e s t i n e d t o f a i l . I n t h i s e r a o f comprehensive, h o s p i t a l - w i d e systems, t h e r e has been an a t t empt t o i n t e g r a t e t h e a d m i n i s t r a t i v e a c t i v i t i e s r e l a t e d t o p r o v i s i o n o f h e a l t h c a r e s e r v i c e s i n -c l u d i n g such t h i n g s as o p e r a t i n g and c a p i t a l b u d g ets, a d m i n i s t r a t i v e s u p p o r t and r e p o r t i n g mechanisms. Computerized i n t e g r a t i o n o f such f i s c a l and s t a t i s t i c a l i n f o r m a t i o n i s v e r y i m p o r t a n t i n terms of p r o s p e c t i v e reimbursements f o r h o s p i t a l s as D i a g n o s i s R e l a t e d Groups (DRGs) o r Case Mix Groups (CMGs) a r e becoming a f a c t o f h o s p i t a l l i f e i n t h e U n i t e d S t a t e s and Canadian s e t t i n g s , r e s p e c t i v e l y . The need f o r i n t e g r a t i o n of such i n f o r m a t i o n i s e x t e n s i v e l y s u p p o r t e d '• 4-K i 4- 13-20 i n t h e l i t e r a t u r e . S o f t Systems A n a l y s i s HIS p l a n n i n g and, i n d e e d , d e s i g n and i m p l e m e n t a t i o n , i s . v e r y much p a r t of g e n e r a l systems t h e o r y . Even t h e c o ncept o f an HIS, by d e f i n i t i o n , r e f e r s t o systems c o n c e p t s . T h i s i s a v e r y u s e f u l p e r s p e c t i v e from w h i c h t o examine 3 p l a n n i n g s i n c e i t f o r c e s t h e a n a l y s t t o v i e w t h e h o s p i t a l s y s t e m a s a c o m p l e x s e t o f i n t e r r e l a t i o n s h i p s c o m p r i s e d o f s u b - s y s t e m s , t h e h o s p i t a l i t s e l f b e i n g p a r t o f a l a r g e r s y s t e m i n t h e e n v i r o n m e n t w i t h i n w h i c h i t f u n c t i o n s . S y s t e m s t h e o r y a s i t a p p l i e s t o t h e h o s p i t a l s e t t i n g w i l l n o t be e x -p l o r e d h e r e ; h o w e v e r , i n t e r e s t e d r e a d e r s a r e d i r e c t e d t o 21 22 t e x t s by A u s t i n a n d R e i s m a n f o r more c o m p l e t e d i s c u s s i o n s . W i t h r e s p e c t t o p l a n n i n g f o r s u c h s y s t e m s , i t i s i m p o r t a n t t h a t t h e s y s t e m s c o n c e p t be b o r n e i n m i n d e s p e c i a l l y f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l . As A u s t i n n o t e s : H o s p i t a l f u n c t i o n s v i e w e d i n a s y s t e m s c o n t e x t a r e i n f o r m a t i o n - d e p e n d e n t . E f f e c t i v e i n f o r m a t i o n f o r management c o n t r o l p u r p o s e s h a s s e v e r a l i m p o r t a n t c h a r a c t e r i s t i c s , i n c l u d i n g r e l e v a n c e , t i m e l i n e s s , s e n s i t i v i t y , c o m p r e h e n s i v e n e s s , o b j e c t i v i t y , a c t i o n -o r i e n t a t i o n , u n i f o r m i t y , p e r f o r m a n c e - t a r g e t i n g , a n d c o s t - e f f e c t i v e n e s s . Good i n f o r m a t i o n s y s t e m s w i l l be d e v e l o p e d w i t h t h e s e c h a r a c t e r i s t i c s c o n s t a n t l y i n v i e w o f t h o s e c h a r g e d w i t h d e s i g n a n d i m p l e m e n t a t i o n . I n p a r t i c u l a r , t h e c h a r a c t e r i s t i c s o f c o s t - e f f e c t i v e n e s s o f i n f o r m a t i o n w i l l be t h e s u b j e c t o f t h i s p a p e r . T h i s i s o n l y one c h a r a c t e r i s t i c o f e f f e c t i v e i n f o r m a t i o n i n t h e h o s p i t a l s y s t e m , b u t f o r p u r p o s e s o f p l a n n i n g s u c h s y s t e m s , i t i s v i t a l t h a t t h i s be l o g i c a l l y a d d r e s s e d . H o s p i t a l I n f o r m a t i o n S y s t e m s P l a n n i n g M e t h o d o l o g y 24 As K o l e n a t y h a s p o i n t e d o u t : "The p u r p o s e o f t h e HIS p l a n n i n g a c t i v i t i e s i s t o o u t l i n e a l o n g - t e r m s t r a t e g y f o r t h e i m p r o v e m e n t and d e v e l o p m e n t o f i n f o r m a t i o n s y s t e m s 4 i n t he a r e a o f p a t i e n t c a r e , t e a c h i n g , and r e s e a r c h as w e l l as i n t h e a d m i n i s t r a t i o n o f t h e s e a r e a s . " I t f o l l o w s , t h e n , t h a t t h e h o s p i t a l ' s p l a n n i n g methodology and t h e a c t i v i t i e s t h a t c o m p r i s e such a methodology must be c o n s i s t e n t w i t h and f u r t h e r t h e aims o f t h e l o n g - t e r m s t r a t e g y . W h i l e t h e s p e c i f i c o b j e c t i v e s o f t h e i n f o r m a t i o n p l a n n i n g p r o c e s s may v a r y from h o s p i t a l t o h o s p i t a l , i t i s g e n e r a l l y a c c e p t e d t h a t h o s p i t a l s must f i r s t i d e n t i f y t h e i r c u r r e n t i n f o r m a t i o n h a n d l i n g p roblems, t h e i r needs, t h e b e n e f i t s t o be a c h i e v e d by a c o m p u t e r i z e d i n f o r m a t i o n system and t h e s o l u t i o n p r i o r i t i e s . The l i t e r a t u r e c o n t a i n s s e v e r a l approaches t o t h e p l a n n i n g , e v a l u a t i o n and i m p l e m e n t a t i o n of HISs. The concept of p a r t i c i p a t o r y management r e f e r s t o o r g a n i z i n g t h e h o s p i t a l ' s human r e s o u r c e s t o ensure needs a r e met and a system i s 25 s e l e c t e d wrhich a d d r e s s e s such d e f i n e d needs. A n o t h e r t e c h n i q u e c a l l e d t h e Needs Assessment Report (NAR) r e f l e c t s the needs t h a t have been a s s e s s e d by s t a f f and management of the h o s p i t a l , t h u s becoming t h e b a s i s f o r s p e c i f y i n g t h e 2 6 system needs o f the o r g a n i z a t i o n . T h i s approach emphasizes t h e i m p o r t a n c e o f t h e p l a n n i n g p r o c e s s as opposed t o a c h i e v i n g d o c u m e n t a t i o n o n l y . Other t e c h n i q u e s i n c l u d e "bottom-up p l a n n i n g " e m p h a s i z i n g u s e r i n p u t , b u t m i n i m i z i n g t h e o v e r a l l 27 28 systems p e r s p e c t i v e . ' T h i s can be c o n t r a s t e d w i t h t h e "top-down p l a n n i n g " approach w h i c h emphasizes m a n a g e r i a l 0 5 i n p u t , presumably from a more g e n e r a l systems p e r s p e c t i v e 29 30 w h i l e , a t the same t i m e , l i m i t i n g d e t a i l e d u s e r i n p u t . 7 A n o t h e r concept i s t h a t o f " o u t s i d e - i n " systems p l a n n i n g whereby o u t s i d e c o n s u l t a n t s p l a n t h e system, as opposed t o " i n s i d e - o u t " p l a n n i n g i n wh i c h managers a t a l l l e v e l s and p a r t s o f t h e o r g a n i z a t i o n p a r t i c i p a t e i n d e v e l o p i n g t h e 31 o v e r a l l systems p l a n . W h i l e t h e m e t h o d o l o g i e s d i f f e r , i t i s the p r o c e s s o f p l a n n i n g t h a t i s as i m p o r t a n t as t h e u l t i m a t e p l a n produced. F i n a l l y , t h e r e i s t h e con c e p t o f lo n g - r a n g e o r s t r a t e g i c i n f o r m a t i o n systems p l a n n i n g w h i c h p r o v i d e s t h e means f o r e n s u r i n g t h a t t h e h o s p i t a l ' s i n f o r m a t i o n p r o c e s s i n g r e q u i r e m e n t s o f t h e f u t u r e a r e met and a r e congrue n t 3 2 - 3 5 w i t h t h e h o s p i t a l ' s p h i l o s o p h y and g o a l s . A major t h r u s t o f t h i s approach i s t o p l a n i n f o r m a t i o n systems i n c o n j u n c t i o n w i t h the h o s p i t a l ' s l o n g - r a n g e p l a n , t h u s a t t e m p t i n g t o ensure t h a t t h e h o s p i t a l ' s needs i n p r o v i d i n g h e a l t h c a r e s e r v i c e s can and w i l l be met e f f e c t i v e l y and e f f i c i e n t l y . 3 6 On a c a u t i o n a r y n o t e , D a v i s warns t h a t s i m p l y a s k i n g p r o s p e c t i v e systems u s e r s t o s p e c i f y t h e i r r e q u i r e m e n t s w i l l n o t u s u a l l y s u f f i c e because o f t h e d i f f i c u l t i e s i n o b t a i n i n g a c o r r e c t and complete s e t o f r e q u i r e m e n t s . These d i f f i c u l t i e s i n c l u d e human c o n s t r a i n t s , v a r i e t y and c o m p l e x i t y o f i n f o r m a t i o n r e q u i r e m e n t s and t h e complex p a t t e r n s o f i n t e r -a c t i o n among u s e r s and a n a l y s t s . He s u g g e s t s t h a t : . . . t h e r e s h o u l d n o t be a s i n g l e approach t o 6 r e q u i r e m e n t s d e t e r m i n a t i o n t h a t i s a p p l i e d t o a l l p r o j e c t s . I n s t e a d , t h e r e s h o u l d be s e v e r a l g e n e r a l approaches o r s t r a t e g i e s t h a t may be used. These s t r a t e g i e s r e f l e c t t h e b e s t approaches t o use c o n s i d e r i n g the a l t e r n a t i v e s e t o f c o n d i t i o n s t h a t may apply.37 Undoubtedly, f u r t h e r i n n o v a t i v e p l a n n i n g m e t h o d o l o g i e s w i l l p e r i o d i c a l l y appear i n t h e l i t e r a t u r e ; however, t h e p r i n c i p a l r e a s o n s f o r u n d e r t a k i n g HIS p l a n n i n g i n c l u d e : a p p r o p r i a t e l y i d e n t i f y i n g c u r r e n t i n f o r m a t i o n h a n d l i n g p r oblems, needs t h a t a r i s e as a r e s u l t o f t h e s e problems, b e n e f i t s t h a t s h o u l d a c c r u e by m e e t i n g t h e s e needs and t h e s o l u t i o n p r i o r i t i e s . From HIS P l a n n i n g t o Economic E v a l u a t i o n Moving from t h e p l a n n i n g t o e v a l u a t i o n a s p e c t s o f HIS development i s a l a r g e s t e p w h i c h r e q u i r e s t h e a n a l y s t t o ". . . i d e n t i f y , measure, and compare a l l o f t h e s i g n i f i c a n t c o s t s and d e s i r a b l e consequences o f a l t e r n a t i v e means o f 38 a d d r e s s i n g a g i v e n problem." Such c o s t s and consequences 39 40 a r e v a l u e d i n monetary u n i t s , t h a t i s , d o l l a r s ' and CBA i s the method o f c h o i c e when a d d r e s s i n g t h e economic f e a s i b i l i t y o f an HIS.'*"'' T h i s i s t h e approach t h a t i s used t h r o u g h o u t t h i s t h e s i s and t h e f o l l o w i n g d i s c u s s i o n more c l o s e l y d e f i n e s and d i s c u s s e s t h e methodology. D e f i n i t i o n and D i s c u s s i o n . o f "the Methodology CBA i s not a new t h e o r y t o economics; i n f a c t , c o s t -b e n e f i t t h e o r y can be t r a c e d back t o w e l f a r e economics o f 7 t h e 19th c e n t u r y w i t h i t f i r s t b e i n g made p r a c t i c a l i n t h e 42 U n i t e d S t a t e s i n t h e 1930s. The l i t e r a t u r e seems t o i n d i -c a t e t h a t CBA has been r o o t e d i n a p r e d o m i n a n t l y s o c i a l 4 3 44 p e r s p e c t i v e f o r a m y r i a d o f a p p l i c a t i o n s . ' W h i l e e a r l y a p p l i c a t i o n s were concerned w i t h s o c i e t y , i t s economy, and t h e w e l f a r e o f such a d e f i n e d s o c i e t y , t h e p r i n c i p l e s o f CBA can be t r a n s l a t e d t o and used i n s p e c i f i c programs o r p r o j e c t s w i t h d i f f e r e n t and narrower p e r s p e c t i v e s , such as computer a p p l i c a t i o n s i n h o s p i t a l s . Of c o u r s e , CBA i s o n l y one o f s e v e r a l t o o l s a v a i l a b l e t o d e c i s i o n - m a k e r s . I t i s w i t h t h i s i n mind t h a t t h i s t h e s i s i s w r i t t e n . As much as CBA, i n t h e e a r l y and t r a d i t i o n a l s ense, i s concerned w i t h t h e o v e r a l l economy and s o c i e t y as a whole and n o t any s m a l l e r p a r t of i t , CBA i n a h o s p i t a l s e t t i n g , t h e p e r s p e c t i v e t a k e n i n t h i s t h e s i s , i s on a more m i c r o l e v e l , c o n c erned w i t h a h o s p i t a l ' s " s o c i e t y " and economy as a whole. T r a d i t i o n a l l y , CBA a t t e m p t s t o d e s c r i b e and q u a n t i f y t h e s o c i a l advantages ( b e n e f i t s o r n e g a t i v e c o s t s ) and d i s -advantages ( c o s t s o r n e g a t i v e b e n e f i t s ) o f t h e v a r i o u s p o l i c i e s , programs o r p r o j e c t s i n terms o f common monetary 4 5 4 6 u n i t s ( u s u a l l y d o l l a r s ) . ' T h i s same d e f i n i t i o n can be t r a n s l a t e d d i r e c t l y t o t h e h o s p i t a l s e t t i n g i n terms o f a n a l y z i n g t h e advantages ( b e n e f i t s ) and d i s a d v a n t a g e s ( c o s t s ) o f an HIS. L e t us now examine t h e importance and advantages of t h i s economic e v a l u a t i o n methodology i n a p r e d i c t i v e (as 8 o p p o s e d t o r e t r o s p e c t i v e ) . f a s h i o n . W h i l e t h e r e i s a p l a c e f o r r e t r o s p e c t i v e CBA, i n an HIS c o n t e x t , d e c i s i o n - m a k e r s c a n more a p p r o p r i a t e l y u s e CBA b e f o r e and d u r i n g t h e HIS d e c i s i o n - m a k i n g p r o c e s s . A d v a n t a g e s a nd I m p o r t a n c e I t i s g e n e r a l l y a g r e e d t h a t t h e r e a r e s e v e r a l a d v a n t a g e s t o p e r f o r m i n g CBA and t h a t i t i s an i m p o r t a n t t o o l , b u t t h e r e h a v e b e e n v e r y few c o m p r e h e n s i v e e v a l u a t i o n s a n d s t u d i e s com-47 p l e t e d i n C a n a d i a n h o s p i t a l s . F l e t t n o t e s t h a t a 1981 s u r v e y b y t h e O n t a r i o H o s p i t a l A s s o c i a t i o n d e m o n s t r a t e d t h a t o n l y t w e n t y - t h r e e p e r c e n t o f O n t a r i o h o s p i t a l s w i t h i n s t a l l e d s y s t e m s w ere a b l e t o q u a n t i f y s a v i n g s . A g a i n , t h i s u n d e r -s c o r e s t h e i m p o r t a n c e o f a c o m p r e h e n s i v e CBA. W h i l e t h i s d o e s n o t n e c e s s a r i l y g u a r a n t e e r e a l i z a t i o n o f t h e p r o j e c t e d b e n e f i t s , i t d o e s o f f e r management t h e a b i l i t y t o p r e d i c t s a v i n g s . A m a j o r a d v a n t a g e o f CBA i s t h e p r o c e s s o f p e r f o r m i n g i t . An a n a l y s i s o f f e r s t h e a n a l y s t , i n c o n c e r t w i t h a l l u s e r p e r s o n n e l a n d management, an o p p o r t u n i t y t o s t r u c t u r e w h a t e a s i l y c o u l d become a f o r m i d a b l e u n d e r t a k i n g . The c o n c e p t o f CBA i s r e l a t i v e l y s i m p l e i n t h a t i t m e r e l y w e i g h s a d v a n t a g e s and d i s a d v a n t a g e s o f a l t e r n a t i v e ways o f m a n a g i n g i n f o r m a t i o n i n t h e h o s p i t a l ; t r a n s l a t i o n o f t h i s c o n c e p t t o a p r a c t i c a l , w o r k a b l e m e t h o d o l o g y t o a s s i s t i n d e c i s i o n - m a k i n g a n d t o a s s i s t d e c i s i o n - m a k e r s i n t h e i r u n d e r -s t a n d i n g o f t h e s o l u t i o n i s , h o w e v e r , t i m e - c o n s u m i n g a nd 9 t a x i n g e v e n t o a n a l y s t s who p o s s e s s a c o n c e p t u a l b a c k g r o u n d an d e x p e r i e n c e i n t h i s a r e a . D i s a d v a n t a g e s and L i m i t a t i o n s T h e r e i s more e v i d e n c e o f d i s a d v a n t a g e s and l i m i t a t i o n s o f CBA t h a n i d e n t i f i c a t i o n o f a d v a n t a g e s i n t h e l i t e r a t u r e . I n a more g l o b a l s e n s e , t h e i d e n t i f i c a t i o n and a c q u i s i t i o n o f 48 a p p r o p r i a t e d a t a a r e commonly d i f f i c u l t , i f n o t i m p o s s i b l e . 49 W a r n e r and L u c e n o t e t h a t t h e a p p l i c a t i o n o f CBA t o h e a l t h c a r e r e s o u r c e a l l o c a t i o n i s r e l a t i v e l y new a n d , a s a r e s u l t , a n a l y s e s h a v e n o t t a k e n i n t o a c c o u n t c o n c e r n s f o r p r a c t i c a l i m p l e m e n t a t i o n . T h i s c a n e a s i l y , be t r a n s l a t e d t o CBA o f H I S s w h i c h i s i t s e l f a l s o r e l a t i v e l y new. W h i l e r e f e r r i n g t o t h e more g e n e r a l e c o n o m i c e v a l u a t i o n o f a t o t a l m e d i c a l i n f o r m a t i o n s y s t e m i n a h o s p i t a l , Norwood"*^ and G a l l ^ " * " e m p h a s i z e t h a t t h e m a j o r d i f f i c u l t y l i e s i n q u a n t i f i c a t i o n o f b e n e f i t s r a t h e r t h a n d o c u m e n t a t i o n o f c o s t s . T h i s i s f u r t h e r c o m p l i c a t e d by t h e e v e n t u a l n e e d t o make r e a l i z a b l e t h e p o t e n t i a l b e n e f i t s ; t h a t i s , t h e t r a n s l a t i o n o f p o t e n t i a l b e n e f i t s i n t o r e a l i z a b l e ( t y p i c a l l y l a b o r ) s a v i n g s . T h e s e c o n c e r n s a r e f o u n d e d on a c t u a l e x p e r i e n c e a t t h e E l Camino H o s p i t a l p r o j e c t s i n c e t h e e a r l y 1 9 7 0 s . P e r h a p s one o f t h e g r e a t e s t d i s a d v a n t a g e s and l i m i t a t i o n s o f CBA i s i t s p r o n e n e s s t o m i s i n t e r p r e t a t i o n by 1 0 t h e a n a l y s t a n d d e c i s i o n - m a k e r s . R e s u l t s t e n d t o be o v e r l y r e l i e d upon a s i f a s i n g l e o p t i o n o r t h e " t r u t h " . I t i s n o t a c a s e o f m e r e l y d e c i d i n g i f c o s t s a r e l e s s t h a n b e n e f i t s a n d t h e n g o i n g a h e a d w i t h t h e p r o j e c t . On t h e c o n t r a r y , CBA i s o n l y one o f s e v e r a l a v a i l a b l e d e c i s i o n - m a k i n g t o o l s . A s 52 R o t h e m p h a s i z e s : "The c h o i c e i s n e v e r a l l t h a t c l e a r . " 53 R o t h a l s o b r i n g s t o l i g h t o t h e r l i m i t a t i o n s o f t h e t e c h n i q u e w i t h r e s p e c t t o a l t e r n a t i v e s e n t e r t a i n e d by t h e CBA. An o b v i o u s l i m i t a t i o n i s t h e p o s s i b i l i t y o f m i s s i n g a l t e r n a t i v e s o r , r e a l i s t i c a l l y , a l t e r n a t i v e s t h a t w e r e t h o u g h t o f b u t n e v e r g i v e n a c h a n c e t o p r o v e t h e i r p r a c t i c a b i l i t y due t o t i m e c o n s t r a i n t s o r undue c o m p l e x i t y . W i t h r e s p e c t t o v a l u a t i o n o f c o s t s a n d b e n e f i t s , R o t h r e i t e r a t e s t h e d i f f i c u l t y o r i m -p o s s i b i l i t y o f v a l u i n g i m m e a s u r a b l e s s u c h a s s o c i a l i n t e -g r a t i o n , h a p p i n e s s , work s a t i s f a c t i o n , p r i d e a n d o t h e r f a c t o r s w h i c h may be j u s t a s i m p o r t a n t o r , i n f a c t , more i m p o r t a n t t h a n t h e d o l l a r b e n e f i t s . T h u s , by r e d u c i n g m e r e l y t o d o l l a r s , some o f t h e most i m p o r t a n t a s p e c t s o f t h e HIS b e n e f i t s may be m i s s e d , i g n o r e d o r r e l e g a t e d t o s e c o n d a r y i m p o r t a n c e . U n f o r t u n a t e l y , some d e c i s i o n s a r e made, s o l e l y on t h e b a s i s o f one p a r a m e t e r , c o s t . He a l s o n o t e s a n o t h e r p r o b l e m w i t h t h e u n m e a s u r a b l e s ; i t i s p o s s i b l e t o i n c l u d e so 54 many o f them. F i n a l l y , R o t h w a r n s t h a t ". . . c o s t - b e n e f i t a n a l y s i s i s n o t a s c i e n c e : I t i s a r a t i o n a l , e t h i c a l c a l c u l u s . " I t may be a r g u e d t h a t t h i s : c r e a t e s a c a s e f o r CEA a s o p p o s e d t o CBA; h o w e v e r , CEA s h o u l d be u s e d when t h e p u r p o s e i s t o compare o n l y t h o s e p r o g r a m s t h a t show s i m i l a r 55-57 o b j e c t i v e s . I f t h e s t a t u s quo m a n u a l s y s t e m i s one o f t h e a l t e r n a t i v e s , t h e o b j e c t i v e s a r e n o t s i m i l a r t o an HIS b e c a u s e t h e l a t t e r c a r r i e s a w h o l e new l e v e l o f o b j e c t i v e s c h a r a c t e r i z e d b y : o n - l i n e e n t r y , r e t r i e v a l and d i s p l a y o f i n f o r m a t i o n v i a s p e c i a l i z e d t e r m i n a l s ; a u t o m a t i c message s w i t c h i n g f o r c o m m u n i c a t i n g i n f o r m a t i o n t h r o u g h o u t t h e h o s p i t a l ; f a c i l i t a t i o n o f d a y - t o - d a y o p e r a t i o n s ; a n d , e m p l o y ment o f a f u l l y i n t e g r a t e d d e s i g n a p p r o a c h i n c l u d i n g common d a t a d e f i n i t i o n s , e s s e n t i a l d a t a f i l e s , a n d a u t o m a t i c c o m m u n i c a t i o n o f d a t a f r o m one f u n c t i o n a l s u b s y s t e m t o a n o t h e r a s n e e d e d . T h i s i s i m p o s s i b l e w i t h m a n u a l m e t h o d s . T h i s t h e s i s e x a m i n e s o n l y t h o s e f a c t o r s t h a t a r e q u a n t i f i a b l h e n c e CBA was c h o s e n . I n t e r e s t i n g l y , a t l e a s t one s o u r c e i n d i c a t e s t h a t when s u c h c o m p a r a b l e H I S s compete i n t h i s d e c a d e , t h e e v a l u a t i o n i s s u e f o r h o s p i t a l s w i l l be more i n 5 8 t e r m s o f CEA a s o p p o s e d t o CBA. P r e s u m a b l y , a s t e c h n o l o g y r e n d e r s H I S s more and more i d e n t i c a l , e v a l u a t i o n w i l l be i n 59 t e r m s o f c o s t - m i n i m i z a t i o n a n a l y s i s (CMA). I n t i m e , t h i s c o u l d be t h e s u b j e c t o f f u r t h e r i n t e r e s t i n g r e s e a r c h . 6 0 D r a z e n i d e n t i f i e s two m a j o r p r o b l e m s w i t h CBA a s a p l a n n i n g t o o l . F i r s t , e v a l u a t i o n o f c o s t i m p a c t s i s a v e r y c o m p l e x p r o c e s s . She n o t e s t h a t t h e r e a r e no v a l i d a t e d , 12 p r a c t i c a l m e t h o d o l o g i e s w i t h i n t h e p u b l i c d o m a i n w h i c h c a n be u s e d as g u i d e l i n e s i n c o n d u c t i n g s u c h an a n a l y s i s . She n o t e s t h a t many o f t h e m e t h o d o l o g i e s u s e d h a v e s u b s e q u e n t l y b e e n shown t o be b a s e d on f a u l t y a s s u m p t i o n s . S e c o n d , she f e e l s t h a t d i r e c t c o s t s a v i n g s , n o t a b l y l a b o r r e d u c t i o n s , h a v e n o t b e e n a m a j o r b e n e f i t o f H I S s . On t h e o t h e r h a n d , i n c r e a s e d t i m e l i n e s s , a c c u r a c y , c o m p l e t e n e s s and a c c e s s i b i l i t y o f i n f o r m a t i o n u s e d i n p a t i e n t c a r e d e l i v e r y a nd management o f t h e d e l i v e r y p r o c r e s s a r e t h e m a j o r b e n e f i t s . T h i s o p i n i o n , a l t h o u g h a r g u a b l e and c o n t r o v e r s i a l , a g a i n u n d e r s c o r e s t h e f a c t t h a t CBA i s o n l y one o f s e v e r a l t o o l s a v a i l a b l e t o t h e d e c i s i o n - m a k e r . P a r a d o x i c a l l y , D r a z e n f e e l s t h a t , w h e r e a s t h e q u a l i t y o f c a r e b e n e f i t i s p r o b a b l y t h e m o s t i m p o r t a n t o n e , i t r e m a i n s d i f f i c u l t t o q u a n t i f y i n d o l l a r s a nd l i k e l y w i l l c o n t i n u e t o be e l u s i v e u n t i l c a s e m i x a n a l y s i s becomes an a c c e p t a b l e m e a s u r e o f h o s p i t a l p a t i e n t c a r e a c t i v i t i e s . F i n a l l y , F e n n a ^ h a s w r i t t e n a n i n t e r e s t i n g r e v i e w o f t h e h i s t o r y o f e v a l u a t i o n w h i c h w i l l n o t be r e i t e r a t e d h e r e . I n e s s e n c e , he n o t e s t h a t e v a l u a t i o n o f c o m p u t e r s y s t e m s h a s b e e n a ' p o o r s i s t e r ' , s k i m p e d o f s u p p o r t and p e r s i s t e n t l y d e f e r r e d . He s u g g e s t s t h a t " l a c k o f s i g n i f i c a n t n e e d h a s b e e n one r e a s o n f o r t h e i n a c t i v i t y , a n d l a c k o f p r i o r i t y h a s ft "7 b e e n one r e a s o n f o r d e f e r m e n t and n o n - c o m p l e t i o n . " F i n a l l y , 6 3 a s F e n n a r e p o r t s , " l i t t l e p r o p e r e v a l u a t i o n h a s t h u s b e e n d o n e , b u t l i t t l e h a s b e e n m i s s e d . " U n d o u b t e d l y , t h i s r e f e r s 13 t o t h e m y r i a d o f a r t i c l e s p u r p o r t i n g " p r o p e r " e v a l u a t i o n ; h o w e v e r , t h e r e i s l i t t l e t o c o n v i n c e t h e r e a d e r s t h a t one b e s t and a c c u r a t e m e thod e x i s t s . H o p e f u l l y , t h i s t h e s i s w i l l c o n t r i b u t e t o t h e p r o v i s i o n o f " p r o p e r " e v a l u a t i o n and l e s s e n c o n f u s i o n i n t h i s a r e a . I m p l i c a t i o n s a n d Use a s a D e c i s i o n s - m a k i n g T o o l The l i t e r a t u r e g e n e r a l l y s u p p o r t s t h e u s e o f CBA a s a 64 d e c i s i o n - m a k i n g t o o l . K i n g a n d S c h r e m s , w h i l e f o c u s s i n g p r i m a r i l y on CBA and p u b l i c o r g a n i z a t i o n s , n o t s p e c i f i c a l l y h o s p i t a l s , e m p h a s i z e t h a t m o s t o r g a n i z a t i o n s p r e f e r t o c o n d u c t a CBA b e f o r e m a k i n g a m a j o r d e c i s i o n r e g a r d i n g i n f o r m a t i o n s y s t e m s i m p l e m e n t a t i o n . They s t a t e t h a t , w h i l e t h i s s h o u l d g u i d e d e c i s i o n - m a k i n g , i t s u s e must be w e i g h e d a g a i n s t t h e d i f f i c u l t y i n p e r f o r m i n g a CBA. A f u r t h e r r i s k l i e s i n t h e u s e o f a n a l y s e s w r o n g l y r e g a r d e d a s good o n e s . They e m p h a s i z e t h a t CBA i s a p l a n n i n g t o o l o n l y t o be u s e d i n a s s i s t i n g d e c i s i o n - m a k e r s i n c h o o s i n g among a l t e r n a t i v e s i n t h e i r a t t e m p t t o a l l o c a t e s c a r c e r e s o u r c e s among c o m p e t i n g demands. S c h a u f f l e r and K o r a n ^ e m p h a s i z e t h e i m p o r t a n c e o f CBA t o d e c i s i o n - m a k e r s i n t e r m s o f a c c u r a t e a n d t i m e l y i n f o r m a t i o n i n t h e p l a n n i n g p r o c e s s . 6 6 A u s t i n c o r r e c t l y p l a c e s t h e c o s t a n a l y s i s s t e p w i t h i n t h e l a r g e r m e t h o d o l o g y o f d e v e l o p m e n t o f a m a s t e r p l a n . E m p h a s i z e d a g a i n i s t h e f a c t t h a t CBA i s p a r t o f t h e o v e r a l l p r o c e s s o f p l a n n i n g f o r i n f o r m a t i o n s y s t e m s and i s n o t an 14 e n d i n and o f i t s e l f . When d e c i s i o n - m a k e r s u s e c o s t (as o p p o s e d t o i n c l u d i n g b e n e f i t s ) a s t h e s o l e c r i t e r i o n f o r p l a n n i n g , i m p l e m e n t i n g and e v a l u a t i n g s u c h s y s t e m s , t h e y do s o w i t h o u t t h e s u p p o r t o f t h e l i t e r a t u r e o f t h o s e who h a v e a c t u a l l y i m p l e m e n t e d s u c h s y s t e m s and h a v e d i s c o v e r e d t h a t t h i s was o n l y one a s p e c t o f t h e e n d e a v o u r . T h o s e who d e c i d e d t o i m p l e m e n t i n s u c h a manner w i l l l i k e l y p a y t h e p r i c e o f n o t r e a l i z i n g s i g n i f i c a n t t a n g i b l e b e n e f i t s . J u s t i f i c a t i o n f o r G o v e r n m e n t F u n d i n g W h i l e n o t a p r i m a r y r a t i o n a l e , CBA h a s a r o l e i n p r e p a r a t i o n f o r s e e k i n g g o v e r n m e n t f u n d i n g f o r an HIS i n B r i t i s h C o l u m b i a . A t t h e t i m e o f w r i t i n g , G u i d e l i n e s f o r C o m p u t e r F u n d i n g P r o p o s a l s , p u b l i s h e d December, 1984 a r e i n e f f e c t ( A p p e n d i x 1 ) . T h e s e g u i d e l i n e s w i l l be d i s c u s s e d i n g r e a t e r d e t a i l i n C h a p t e r I I ; h o w e v e r , a t t h i s j u n c t u r e i t s h o u l d be e m p h a s i z e d t h a t t h e y a r e i n t e n d e d t o a s s i s t t h e f u n d i n g a g e n c i e s i n t h e i r d e c i s i o n t o c o s t - s h a r e i n c o m p u t e r a c q u i s i t i o n s i n h o s p i t a l s i n B r i t i s h C o l u m b i a ; m o r e v e r , t h e g u i d e l i n e s a r e i n t e n d e d t o a s s i s t h o s p i t a l s i n c o m p l e t i n g a CBA a s p a r t o f t h e i r HIS s u b m i s s i o n . Of g r e a t e r i m p o r t , h o w e v e r , a r e t h e c o m p u t e r p o l i c y g u i d e l i n e s r e c e n t l y r e l e a s e d by t h e P r o v i n c i a l M i n i s t r y o f H e a l t h (MOH) S e p t e m b e r , 1985 ( A p p e n d i x 2 ) . A g a i n , t h e s e w i l l be d i s c u s s e d i n more d e t a i l i n C h a p t e r . I I ; h o w e v e r , 15 somewhat i n c o n t r a d i c t i o n o f t h e December, 1984 g u i d e l i n e s , t h e s e g u i d e l i n e s d i c t a t e t h e p r i o r i t i e s t h a t t h e h o s p i t a l i s s u p p o s e d t o p u r s u e . I n e s s e n c e , t h i s n e g a t e s t h e e n t i r e p l a n n i n g p r o c e s s s i n c e t h e p o l i c i e s a r e c l e a r i n s t a t i n g t h a t ". . . t h e M i n i s t r y may n o t be i n a p o s i t i o n t o p r o v i d e c a p i t a l f u n d i n g f o r s y s t e m s o t h e r t h a n t h o s e o f h i g h e s t [ t h e 6 7 M i n i s t r y ' s ] p r i o r i t y . " The maximum a c c e p t a b l e e x p e n d i t u r e l e v e l d i c t a t e d by t h e p o l i c y f o r t h e c o m m u n i t y h o s p i t a l e n v i r o n m e n t o f B r i t i s h C o l u m b i a i s c a p p e d a t 0.5% o f g r o s s a n n u a l o p e r a t i n g i n c o m e ( e x c l u s i v e o f s a v i n g s a c h i e v e d t h r o u g h b e n e f i t r e a l i z a t i o n ) . T h u s , i n a d d i t i o n t o n e g a t i n g t h e e n t i r e p l a n n i n g p r o c e s s , t h e e n t i r e CBA m e t h o d o l o g y i s n e g a t e d by w h a t a p p e a r s t o be an a r b i t r a r y c a p p i n g o f t h e e x p e n d i t u r e l e v e l . T h i s p u t s B r i t i s h C o l u m b i a h o s p i t a l s i n an i n t e r e s t i n g d i l e m m a . On t h e one h a n d , s o u n d r a t i o n a l p l a n n i n g b a s e d on i d e n t i f i e d n e e d s s h o u l d p r e v a i l f o l l o w e d b y c o m p r e h e n s i v e CBA t o d e t e r m i n e e c o n o m i c w o r t h i n e s s o f t h e p r o p o s e d s y s t e m . On t h e o t h e r h a n d , t h e MOH i s c l e a r l y s t a t i n g t h a t i t h a s a l r e a d y d e t e r m i n e d t h e s y s t e m s a p p l i c a t i o n p r i o r i t i e s a n d t h e maximum e x p e n d i t u r e l e v e l . W h i l e CBA s h o u l d a s s i s t t h e h o s p i t a l i n j u s t i f y i n g p r o p o s e d i n f o r m a t i o n s y s t e m s , b e c a u s e o f t h e f u n d i n g m e c h a n i s m s i n B r i t i s h C o l u m b i a , t h e e n t i r e e x e r c i s e becomes a c a d e m i c , a t l e a s t f o r t h e p u r p o s e s o f o b t a i n i n g f u n d i n g . 16 T h e s i s Road Map The l i t e r a t u r e d e m o n s t r a t e s t h a t t h e r e a r e s t i l l s e v e r a l u n c e r t a i n t i e s i n d e a l i n g w i t h t h i s t o o l and t h a t i t i s n o t an e x a c t s c i e n c e . A g r e a t o n u s i s p l a c e d on t h e a n a l y s t ' s d e c i s i o n t o i n c l u d e o r e x c l u d e v a r i a b l e s and w h a t a s s u m p t i o n s a r e made t h r o u g h o u t t h e a n a l y s i s . I t i s c l e a r t h a t CBA d o e s h a v e an i m p o r t a n t a p p l i c a t i o n i n p l a n n i n g f o r H I S s . W h i l e i t d o e s h a v e s e v e r a l a d v a n t a g e s t h e r e a r e s e v e r a l d i s a d v a n t a g e s and l i m i t a t i o n s t o b e a r i n m i n d . U s e d w i s e l y , i t c a n be an i m p o r t a n t d e c i s i o n - m a k i n g t o o l f o r p r i o r i t y s e t t i n g and b e n e f i t i d e n t i f i c a t i o n . C h a p t e r I I e x a m i n e s t h r e e d o m i n a n t s t r e a m s o f h o s p i t a l i n f o r m a t i o n s y s t e m s d e v e l o p m e n t i n t h e B r i t i s h C o l u m b i a h o s p i t a l e n v i r o n m e n t . The B r i t i s h C o l u m b i a H o s p i t a l s S h a r e d S y s t e m s S o c i e t y (BCHSSS), B r i t i s h C o l u m b i a H e a l t h A s s o c i a t i o n (BCHA) and t h e i n d i v i d u a l h o s p i t a l p e r s p e c t i v e w i l l be d i s -c u s s e d . I n p a r t i c u l a r , t h e r o l e o f t h e e c o n o m i c p e r s p e c t i v e w i l l be e x a m i n e d i n e a c h o f t h e s e t h r e e s t r e a m s . The i m p l i -c a t i o n s o f t h i s r o l e i n e a c h w i l l be d i s c u s s e d and a n a l y z e d . C h a p t e r I I I e x a m i n e s i n d e t a i l t h e g e n e r a l f r a m e w o r k f o r e c o n o m i c e v a l u a t i o n , f o c u s s i n g on t h e m a j o r p r i n c i p l e s o f CBA. S e v e r a l p r a c t i c a l l i m i t a t i o n s o f CBA a r e d i s c u s s e d and p r a c t i c a l a s p e c t s o f f u n d i n g and a p p r o v a l f r o m t h e p e r s p e c t i v e o f t h e P r o v i n c i a l M i n i s t r y o f H e a l t h a r e a l s o a d d r e s s e d . F o l l o w i n g t h e d i s c u s s i o n o f p r i n c i p l e s i n C h a p t e r I I I , 17 o p t i o n s f o r a t y p i c a l B r i t i s h C o l u m b i a c o m m u n i t y g e n e r a l h o s p i t a l , t h e C h i l l i w a c k G e n e r a l , a r e d e s c r i b e d i n C h a p t e r I V . A f t e r a b r i e f d e s c r i p t i o n o f t h e h o s p i t a l a n d t h e s y s t e m s p l a n n i n g m e t h o d o l o g y u s e d f o r i n f o r m a t i o n s y s t e m s p l a n n i n g i n t h i s h o s p i t a l , o p t i o n s a v a i l a b l e a r e d e t a i l e d , i n c l u d i n g t h e s t a t u s quo v e r s u s a p r o p o s e d h o s p i t a l - w i d e i n f o r m a t i o n s y s t e m . The a u t h o r i s c u r r e n t l y e m p l o y e d a s t h e A s s i s t a n t A d m i n i s t r a t o r a t C h i l l i w a c k G e n e r a l H o s p i t a l (CGH) and h a s b e e n a b l e t o a p p l y and t e s t t h e p r i n c i p l e s d i s c u s s e d t h r o u g h -o u t t h i s t h e s i s . C h a p t e r V t h e n a p p l i e s t h e p r i n c i p l e s d i s c u s s e d i n C h a p t e r I I I t o CGH's p r o p o s e d H I S . T h i s i n c l u d e s d e f i n i n g t h e q u e s t i o n , t h e a l t e r n a t i v e s c o n s i d e r e d , i d e n t i f i c a t i o n , m e a s u r e m e n t , a n d v a l u a t i o n o f a l l c o s t s and b e n e f i t s o f t h e a l t e r n a t i v e s . D i s c o u n t i n g o f c o s t s a n d b e n e f i t s i s p e r f o r m e d a s a r e s e n s i t i v i t y a n a l y s e s . F o l l o w i n g t h i s , p r a c t i c a l g u i d e l i n e s a r e d i s c u s s e d f o r g e n e r a l u s e by o t h e r h o s p i t a l s i n B r i t i s h C o l u m b i a i n C h a p t e r V I . S p e c i f i c a l l y , a h o s p i t a l s y s t e m s p l a n n i n g m e t h o d o l o g y i s d i s c u s s e d ( t h e one u s e d a t CGH). A s t e p - b y - s t e p f r a m e w o r k i s t h e n d e v e l o p e d t a k i n g t h e r e a d e r t h r o u g h t h e R e q u e s t f o r I n f o r m a t i o n (RFI) p r o c e s s , t h e R e q u e s t f o r P r o p o s a l (RFP) p r o c e s s , CBA, d e c i s i o n - m a k i n g p r o c e s s a n d s e l e c t i o n o f f i n a l i s t , a n d s e e k i n g g o v e r n m e n t a p p r o v a l and f u n d i n g f o r t h e p r o p o s a l . F i n a l l y , C h a p t e r V I I s u m m a r i z e s t h e f i n d i n g s o f t h e 1 8 t h e s i s , r e f e r e n c i n g , i n p a r t i c u l a r , the e x p e r i e n c e a t CGH i n an attempt t o g e n e r a l i z e the f i n d i n g s f o r use by o t h e r h o s p i t a l s i n B r i t i s h Columbia. 19 F o o t n o t e s . "'"Paul W o l o t s k y and Americo J . Varone, " H o s p i t a l I n f o r m a t i o n Systems P l a n n i n g , " J o u r n a l o f M e d i c a l Systems 7 (August 1983) :379-86 . 2 George K o l e n a t y , " H o s p i t a l I n f o r m a t i o n Systems P l a n n i n g , " i n I n f o r m a t i o n Systems f o r P a t i e n t Care, Bruce I . Blum, ed. (New York: S p r i n g e r - V e r l a g , 1984), pp. 147-64. 3 Thomas G. Roovers, " E v a l u a t i n g Computer Systems — Which Approach, th e RFP, t h e RFI o r t h e NAR?" Computers i n H e a l t h c a r e 5 (March 1984):54. , 4 Homer H. 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CHAPTER I I APPROACHES TO INFORMATION SYSTEMS PLANNING IN THE BRITISH COLUMBIA HOSPITAL ENVIRONMENT C u r r e n t l y , t h e r e a r e t h r e e dominant groups p l a n n i n g HISs i n B r i t i s h Columbia — BCHSSS, BCHA and i n d i v i d u a l h o s p i t a l s . The f a c t t h a t t h e s e r e p r e s e n t t h r e e d i s t i n c t approaches i s r e f l e c t i v e o f where B r i t i s h Columbia s i t s i n r e l a t i o n t o p o l i t i c a l , economic and s t a t e - o f - t h e - a r t t e c h n o -l o g i c a l f a c t o r s i n f l u e n c i n g development o f such systems. Perhaps t h e r e s h o u l d be o n l y one c o r r e c t approach; on t h e o t h e r hand, t h e r e i s l i k e l y n o t one c o r r e c t approach o r s o l u t i o n s i n c e t e c h n o l o g y i s i t s e l f e v e r - c h a n g i n g . Such change w i l l l e a d t o even f u r t h e r d i r e c t i o n s and c h o i c e s t o be i n f l u e n c e d a l s o by p o l i t i c a l and economic c l i m a t e s o f t h e day. I n o r d e r t o g a i n an u n d e r s t a n d i n g o f the c u r r e n t c l i m a t e f a c i n g h o s p i t a l s p l a n n i n g such systems i t i s n e c e s s a r y t o a d d r e s s , d i s c u s s and a n a l y z e t h e s e t h r e e approaches, each o f which has been s u b j e c t t o s c r u t i n y by v a r i o u s c r i t i c s . T h i s t r i p a r t i t e p u r s u i t o f t h e " r i g h t " s o l u t i o n i s under-m i n i n g r a t i o n a l , e f f e c t i v e and e f f i c i e n t s t r a t e g i c p l a n n i n g endeavours by h o s p i t a l s who f a u t e de mieux a r e a l i g n i n g t h e m s e l v e s w i t h w h i c h e v e r s o l u t i o n seems a p p r o p r i a t e a t the t i m e . I n e f f e c t , w h i l e some c o m p e t i t i o n may be h e a l t h y , any o v e r a l l good seems t o be overwhelmed by 25 t h e c o s t s o f r e d u n d a n c y i n a n d d i v e r g e n c e o f p l a n n i n g f o r s u c h s y s t e m s . B r i t i s h C o l u m b i a H o s p i t a l s S h a r e d S y s t e m s S o c i e t y BCHSSS was f o r m e d a nd l e g a l l y i n c o r p o r a t e d a s a S o c i e t y i n November, 1982 a n d c o n t i n u e s t o be p r o v i d e d w i t h 1 2 a b u d g e t b y t h e B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h (MOH). ' The o r i g i n a l p u r p o s e o f t h e S o c i e t y was t o c o o r d i n a t e p o l i c y , d e v e l o p p l a n s , e s t a b l i s h p r i o r i t i e s a n d a i d h o s p i t a l s i n a c q u i r i n g c o m p u t e r s y s t e m s . By d e f i n i t i o n , t h e s h a r e d s y s t e m s a p p r o a c h was t h e b a c k b o n e o f t h e S o c i e t y ' s p u r p o s e ; h o w e v e r , i t was a m p l y c l e a r t h a t h o s p i t a l s p l a n n i n g f o r H I S s were e x p e c t e d t o m a n d a t o r i l y p a r t i c i p a t e i n s h a r e d s y s t e m s d e v e l o p -ment by v i r t u e o f t h e w a r n i n g t h a t " h o s p i t a l s w h i c h c h o o s e t o a c t w i t h o u t c o n s u l t a t i o n o r d i s r e g a r d o f [ s i c ] t h e d e c i s i o n s o f t h e S o c i e t y w i l l do so w i t h t h e f u l l u n d e r s t a n d i n g t h a t t h e c a p i t a l a n d / o r o p e r a t i n g f u n d s a s s o c i a t e d w i l l n o t be f u n d e d 3 by H o s p i t a l P r o g r a m s i n any f o r m w h a t s o e v e r . " R o l e 4 November, 1983 saw BCHSSS u n d e r t a k e a new i n i t i a t i v e w h e r e i n t h e n e e d s o f i n t e r m e d i a t e a n d s m a l l s i z e d h o s p i t a l s i n B r i t i s h C o l u m b i a w o u l d be a d d r e s s e d . T h i s was a s i g n i f i -c a n t d e p a r t u r e f r o m t h e o r i g i n a l r o l e o f t h i s S o c i e t y w h i c h , f o r t h e mos t p a r t , e m p h a s i z e d l a r g e h o s p i t a l s y s t e m s . : T h e n , i n J a n u a r y , 1984 t h e S o c i e t y n e w s l e t t e r a n n o u n c e d t h a t t h e i r ". . . p r i o r i t y was t o d e s i g n a n d i m p l e m e n t s y s t e m s , . . ." 26 T h i s was an i n t e r e s t i n g p e r s p e c t i v e g i v e n t h e i n i t i a l r e a s o n s f o r f o r m i n g t h e S o c i e t y . By t h i s e a r l y d a t e , i t became r e a d i l y a p p a r e n t t h a t t h e r o l e o f t h e BCHSSS was c h a n g i n g f r o m t h a t o f c o o r d i n a t i n g p o l i c y a n d d e v e l o p i n g p l a n s a n d p r i o r i t i e s f o r h o s p i t a l s i n B r i t i s h C o l u m b i a t o d e s i g n i n g a n d i m p l e m e n t i n g s y s t e m s . A t t h e p r e s e n t t i m e t h e l a t t e r seems t o be t h e d o m i n a t i n g f o c u s o f t h e S o c i e t y . I n e s s e n c e , BCHSSS h a s become a n o t h e r , a l b e i t MOH-backed, c o m p e t i t o r i n t h e B.C. HIS m a r k e t p l a c e . The S e p t e m b e r , 1985 n e w s l e t t e r f o r m a l l y a n n o u n c e d BCHSSS' m i s s i o n s t a t e m e n t i n r e p l y t o t h e o f t e n - a s k e d q u e s t i o n o f t h e i r r o l e : T h e . m i s s i o n Of t h e B.C. H o s p i t a l s S h a r e d S y s t e m s S o c i e t y e n c o m p a s s e s two d i s t i n c t b u t r e l a t e d a r e a s : 1. D e v e l o p m e n t , i n s t a l l a t i o n , a n d o n - g o i n g s u p p o r t o f q u a l i t y i n t e g r a t e d c o m p u t e r s y s t e m s f o r B.C. h o s p i t a l s . 2. P r o v i s i o n o f management c o n s u l t i n g , s y s t e m s p l a n n i n g , a n d i n d u s t r i a l e n g i n e e r i n g s e r v i c e s , t o a s s i s t h o s p i t a l s i n t h e p l a n n i n g , i m p l e m e n t a t i o n , a n d u t i l i z a t i o n o f management i n f o r m a t i o n s y s t e m s and i n t h e s o l u t i o n o f management a n d o p e r a t i o n a l p r o b l e m s . 6 I t i s r e a d i l y apparent t h a t BCHSSS' r o l e i s a g a i n c h a n g i n g t o i n c l u d e t h e e x p a n s i o n , d i v e r s i f i c a t i o n and i n t e -g r a t i o n o f s e v e r a l s e r v i c e s . G e n e r a l l y , t h i s may be a g o o d s t r a t e g y t o p u r s u e i n an a t t e m p t t o f u r t h e r p e n e t r a t e a n d co m p e t e i n t h e B.C. h o s p i t a l m a r k e t p l a c e . One e x a m p l e o f m a r k e t p e n e t r a t i o n i s t h e r e c e n t l y a n n o u n c e d P e r s o n n e l / T i m e -7 k e e p i n g / P a y r o l l P r o j e c t w h i c h a p p e a r s t o be h e a d - o n com-27 p e t i t i o n w i t h BCHA's H o s p i t a l P e r s o n n e l Management System (HPMS) and o t h e r o f f e r i n g s from p r i v a t e v e n d o r s . The system w i l l p u r p o r t e d l y reduce the c o s t p e r cheque v e r y s i g n i f i c a n t l y . The t a r g e t date f o r f i r s t i n s t a l l a t i o n i s J a n u a r y , 1987. Changing P l a n s Systems A r c h i t e c t u r e P l a n J a n u a r y , 1984 saw t h e p u b l i c a t i o n o f a Systems A r c h -8 i t e c t u r e P l a n f o r S m a l l H o s p i t a l s the o b j e c t i v e s o f wh i c h a r e t o a s s i s t s m a l l h o s p i t a l s i n e s t a b l i s h i n g b o t h computer-i z e d and manual systems. The major r e c o g n i z e d c h a l l e n g e was how t o meet the d i v e r s e needs o f s m a l l e r h o s p i t a l s w h i l e k e e p i n g w i t h i n t h e i r b udgets. The proposed a r c h i t e c t u r e c o n s i s t e d o f networked IBM microcomputers s u p p o r t i n g canned and custom-developed a p p l i c a t i o n s o f t w a r e . Recent S o c i e t y p u b l i c a t i o n s i n d i c a t e t h a t t h e L o c a l A r e a Network (LAN) s o l u t i o n i s v i a b l e ; however, t e c h n i c a l problems due t o h i g h 9 volumes o f d a t a n e c e s s i t a t e a r e - e x a m i n a t i o n o f t h i s c o n c e p t . I n f o r m a t i o n Systems P l a n In A p r i l , 1984 BCHSSS p u b l i s h e d A G u i d e l i n e f o r the P l a n n i n g o f H o s p i t a l I n f o r m a t i o n S y s t e m s ^ which emphasized: The d e c i s i o n s made i n d e v e l o p i n g the S t r a t e g i c I n f o r m a t i o n Systems P l a n w i l l s e r v e as t h e g u i d e t o a l l subsequent s t e p s i n t h e development o f i n f o r m a t i o n systems. I t i s the framework w i t h i n ^ which a l l i n f o r m a t i o n systems a c t i v i t y w i l l o c c u r . I n v i ew o f t h e r e c e n t l y p u b l i s h e d MOH p o l i c y g u i d e -l i n e s w hich s e t out the M i n i s t r y ' s HIS s o l u t i o n s and 28 p r i o r i t i e s , t h i s i s an i n t e r e s t i n g s t a t e m e n t . (See A p p e n d i x 2 ) . I t w o u l d a p p e a r t h a t e a r l i e r a t t e m p t s a t r a t i o n a l p l a n n i n g h a v e now g i v e n way t o a more p o l i t i c a l and n o n -r a t i o n a l o r i e n t a t i o n , a t l e a s t f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l . 12 The J a n u a r y , 1986 n e w s l e t t e r a n n o u n c e d t h a t a l o n g -r a n g e p l a n was f o r t h c o m i n g w h i c h w o u l d i n c l u d e a p p l i c a t i o n d e v e l o p m e n t d i r e c t i o n s , i n t e g r a t i o n , i n t e r f a c e s t a n d a r d s a nd i m p l e m e n t a t i o n p l a n n i n g . T h i s p l a n ' s r e l a t i o n s h i p t o t h e M i n i s t r y 1 s p o l i c y g u i d e l i n e s w i l l a l s o be an i n t e r e s t i n g c o m p a r i s o n a nd s u b j e c t t o c r i t i c a l e x a m i n a t i o n b y t h e h o s p i t a l s e c t o r . E c o n o m i c P e r s p e c t i v e W h i l e BCHSSS o f t e n r e f e r s t o c o s t s a n d b e n e f i t s o f p r o p o s e d H I S s , a f o c u s on t h e e c o n o m i c p e r s p e c t i v e h a s b e e n c o n s p i c u o u s b y i t s a b s e n c e . One w o u l d e x p e c t t h a t BCHSSS, by v i r t u e o f i t s i m p l i c i t r o l e a s a h o s p i t a l a d v o c a t e f o r and e x p e r t on H I S s , s h o u l d p r o v i d e s t r o n g l e a d e r s h i p a n d h a n d s - o n a s s i s t a n c e i n t h e a r e a o f e c o n o m i c e v a l u a t i o n , e s p e c i a l l y CBA, w i t h a n d f o r h o s p i t a l s . I n s t e a d , i t a p p e a r s t h a t BCHSSS i s p l a c i n g t h e onus o f r e s p o n s i b i l i t y on t h e h o s p i t a l . T h i s i s n o t i n c o r r e c t ; h o w e v e r , a l a r g e a n d i m p o r t a n t c omponent o f t h e p l a n n i n g e x e r c i s e i s p r e d i c t i v e e c o n o m i c e v a l u a t i o n a n d , i f i g n o r e d o r r e l e g a t e d t o s e c o n d a r y i m p o r t a n c e by s u c h a g e n c i e s , w i l l l i k e l y be i n t e r p r e t e d as s u c h b y s u b -29 s c r i b i n g h o s p i t a l s and o t h e r s . I t appears t h a t BCHSSS c o n t i n u e s t o e n j o y a budget from the MOH and i s c o n t e n t on c o n t i n u i n g i t s r o l e i n t h e c o s t l y development and i m p l e m e n t a t i o n o f systems f o r B r i t i s h Columbia h o s p i t a l s . The r e a s o n s f o r the MOH's c o n t i n u e d s u p p o r t and p u r s u i t o f t h i s avenue remain u n c l e a r s i n c e t h e r e a r e rumours t h a t BCHSSS w i l l be p r i v a t i z e d w i t h i n a few y e a r s . From the p e r s p e c t i v e o f the h o s p i t a l , what was o r i g i n a l l y c a l l e d " f r e e " s o f t w a r e has now g i v e n way t o , i n some c a s e s , c o s t l y s o f t w a r e , c o s t l y from t h e p e r s p e c t i v e o f the h o s p i t a l and BCHSSS i n terms o f development. C l e a r l y , t h e r e i s d u p l i c a t i o n o f e f f o r t i n a p p l i c a t i o n s o f t w a r e development c a r r i e d o u t i n t h e name o f " h e a l t h y c o m p e t i t i o n " i n t h e B.C. m a r k e t p l a c e . W h i l e f u r t h e r development i s s t i l l o c c u r r i n g i n the p r i v a t e s e c t o r , f u l l y - i n t e g r a t e d , h o s p i t a l -wide systems are now a v a i l a b l e , i n s t a l l e d and r u n n i n g w e l l i n h o s p i t a l s w o r l d - w i d e . The e f f o r t s o f BCHSSS are l a u d a b l e , but how much redevelopment i s r e a l l y n e c e s s a r y ? The c o s t o f s u p p o r t and development must be weighed a g a i n s t t h e p e r c e i v e d b e n e f i t s when compared t o the a l t e r n a t i v e o f p u r c h a s i n g proven systems from t h e p r i v a t e s e c t o r . Of p a r t i c u l a r n o te i s the c u r r e n t t r e n d i n t h e h o s p i t a l i n d u s t r y towards i n t e g r a t e d systems. A t t h e time o f w r i t i n g , BCHSSS cannot o f f e r an i n t e g r a t e d s o l u t i o n because a major component i s n o t y e t a v a i l a b l e and w i l l n o t be f o r some t i m e . Thus, h o s p i t a l s 30 c o n t e m p l a t i n g the BCHSSS s o l u t i o n a r e p l a g u e d by t h e un-c e r t a i n t y o f e v e n t u a l i n t e g r a t i o n . Compared t o what i s a v a i l a b l e i n t h e i n d u s t r y , t h i s may be a r e l a t i v e l y r i s k y a l t e r n a t i v e t o p u r s u e . B r i t i s h Columbia H e a l t h A s s o c i a t i o n R o l e BCHA p r o v i d e s e x t e n s i v e computer s e r v i c e s t o member 13 i n s t i t u t i o n s . C u r r e n t l y i n c l u d e d a r e such a p p l i c a t i o n s as Ac c o u n t s P a y a b l e , G e n e r a l Ledger and A n c i l l a r y R e p o r t i n g , O u t p a t i e n t s A c c o u n t s R e c e i v a b l e , P a y r o l l and P e r s o n n e l R e p o r t i n g , I n v e n t o r y I s s u e s A n a l y s i s , C a p i t a l I n v e n t o r y , Combined H o s p i t a l R e p o r t i n g and M e d i c a l A b s t r a c t i n g . Other a p p l i c a t i o n s a r e under development. I n March, 1981 t h e BCHA Board a u t h o r i z e d t h e d e v e l o p -ment o f a l o n g - r a n g e computer p l a n , which was c a r r i e d out by P r i c e , Waterhouse and A s s o c i a t e s . The l o n g - r a n g e p l a n f o c u s s e d on t h e concept BCHA termed " b a l a n c e d computing" w h i c h , s i m p l y p u t , means b a l a n c i n g t h e computer work done w i t h i n h o s p i t a l s w i t h t h a t done on BCHA p r e m i s e s . I n p r a c t i c e , t h i s means a c e n t r a l IBM 4300 S e r i e s mainframe s u p p o r t i n g r e -mote t e r m i n a l s v i a d i r e c t communication w i t h i n t h e sh a r e d s e r v i c e system. One o f the keys t o o p e r a t i o n a l i z i n g t h e lo n g - r a n g e p l a n was t h e advent o f IBM P e r s o n a l Computers and network systems. A n o t h e r p r o v i s i o n o f t h e l o n g - t e r m p l a n was the e s t a b l i s h m e n t o f an " I n f o r m a t i o n C e n t r e " p e r m i t t i n g sub-31 s c r i b i n g h o s p i t a l s t o a c c e s s t h e i r own d a t a f i l e s a s s o c i a t e d w i t h the r e s p e c t i v e a p p l i c a t i o n s . I n t e r e s t i n g l y , as t h i s was b e i n g implemented t h e MOH c r e a t e d the p r e v i o u s l y d i s c u s s e d BCHSSS. From t h e h o s p i t a l p e r s p e c t i v e , t h i s i n i t i a t e d what appears t o be two d i v e r g e n t streams of p l a n n i n g . On t h e one hand t h e r e was BCHSSS i n an app a r e n t c o n f l i c t o f i n t e r e s t p o s i t i o n , o v e r s e e i n g and c o o r d i n a t i n g p o l i c y and p l a n n i n g i s s u e s and a t the same time p o s t u r i n g i t s e l f t o be a systems d e v e l o p e r f o r l a r g e h o s p i t a l s , and p r o m o t i n g i n - h o u s e , networked microcomputers f o r t h e s m a l l e r h o s p i t a l s . On the o t h e r hand, BCHA was p r o m o t i n g s h a r e d systems o r f a c i l i t i e s management s o l u t i o n s u s i n g a c e n t r a l mainframe c o n f i g u r a t i o n i n Vancouver w i t h a s p i r a t i o n s t o network microcomputers and/or t e r m i n a l s t h r o u g h o u t B r i t i s h Columbia. The l a t t e r i s not s t r a n g e , however, s i n c e BCHA a l r e a d y p r o v i d e s P a y r o l l s e r v i c e s t o a p p r o x i m a t e l y one hundred and t h i r t y member i n s t i t u t i o n s . N o n e t h e l e s s , t h e l e a p from a c e n t r a l i z e d P a y r o l l system t o h o s p i t a l - w i d e i n t e g r a t e d systems i s a major one. In June, 1984 BCHA"''4 announced a v a i l a b i l i t y o f t h e IBM P a t i e n t Care System (PCS) o r i g i n a l l y d e v e l o p e d a t Duke U n i v e r s i t y M e d i c a l C e n t e r i n N o r t h C a r o l i n a . T h i s p a r t i c u l a r s o l u t i o n p e r m i t t e d h o s p i t a l s t o automate m o d u l a r l y a t t h e i r own speed. F u r t h e r a p p l i c a t i o n s o f the PCS have now been C a n a d i a n i z e d and i n t e g r a t e d w i t h t h i s system by BCHA. A t 32 the t i me o f w r i t i n g , o n l y t h r e e Lower M a i n l a n d h o s p i t a l s have p a r t i c i p a t e d . Of i n t e r e s t i s t h e d i f f e r e n c e i n p h i l o s o p h y i n mee t i n g the needs o f h o s p i t a l s . BCHSSS was and c o n t i n u e s t o be i n t e n t on b e i n g a d e v e l o p e r o f systems and t h e i r a c t u a l e x p e r i e n c e i s p r o v i n g t h i s o u t . They e i t h e r buy and sub-s t a n t i a l l y m o d i f y s o f t w a r e a p p l i c a t i o n s o r d e v e l o p t h e i r own. BCHA, on the o t h e r hand, emphasizes s t a n d a r d s o f t w a r e and 15 IBM-backed s u p p o r t and maintenance o f such s o f t w a r e . A major d i f f e r e n c e i s t h a t BCHA's PCS approach f a c i l i t a t e s development o f a c e n t r a l p a t i e n t d a t a base on t h e i r c e n t r a l mainframe; i n c o n t r a s t , BCHSSS c o n t i n u e s t o d e v e l o p s t a n d -a l o n e systems w i t h a view t o i n t e g r a t i n g t h e s e systems on an in-h o u s e b a s i s . H i s t o r i c a l l y , t he l a t t e r has been p l a g u e d w i t h major d i f f i c u l t i e s and, hence, t h e r e i s guarded o p t i m i s m i n t h e h o s p i t a l i n d u s t r y as t o whether o r n o t t h i s can be e f f e c t i v e l y and e f f i c i e n t l y a c c o m p l i s h e d , i f t e c h n i c a l l y f e a s i b l e a t a l l . More i m p o r t a n t , however, a r e the two approaches t o systems p l a n n i n g . Whereas BCHSSS has p r o v i d e d g u i d e l i n e s , i t i s l e f t e n t i r e l y t o h o s p i t a l s t o a v a i l t hemselves o f and f o l l o w t h e g u i d e l i n e s . BCHA, on t h e o t h e r hand, o f f e r s and, f o r a f e e , a s s i s t s h o s p i t a l s i n systems p l a n n i n g u s i n g a s t a n d a r d i z e d H o s p i t a l Systems P l a n n i n g (HSP) methodology. The HSP methodology i s based on IBM's B u s i n e s s Systems 33 P l a n n i n g Methodology and has been adapted t o t h e h o s p i t a l s e t t i n g by BCHA. The two major o b j e c t i v e s o f BCHA's l o n g - r a n g e computer p l a n a r e : To p r o v i d e and implement a p p l i c a t i o n s t h a t f o r m u l a t e a h e a l t h c a r e d a t a base t h a t l i n k s p a t i e n t s , f i n a n c i a l and p e r s o n n e l i n f o r m a t i o n i n o r d e r t o support, the o p e r a t i o n a l and p l a n n i n g r e q u i r e m e n t s o f h e a l t h c a r e p r o v i d e r s i n B.C. To p r o v i d e and implement a p p l i c a t i o n s t h a t formu-l a t e a d a t a base t h a t s u p p o r t the o p e r a t i o n a l and p l a n n i n g r e q u i r e m e n t s of t h e a s s o c i a t i o n and r e l a t e d o r g a n i z a t i o n s . 1 7 To d a t e , i t appears t h a t BCHA has l a r g e l y met t h e s e two major o b j e c t i v e s ; however, i t s g a i n i n g of o n l y t h r e e s u b s c r i b e r s t o dat e i s , p e r h a p s , i n d i c a t i v e o f o n l y m i n i m a l s u c c e s s . T h i s may p o i n t t o u n c e r t a i n t y i n t h e h o s p i t a l community. The f a c t t h a t the H e a l t h Labour R e l a t i o n s A s s o c i a t i o n (HLRA) uses t h e d a t a base f o r i t s f o r e c a s t i n g model f o r b a r g a i n i n g may p o i n t t o a d d i t i o n a l s u c c e s s . Economic P e r s p e c t i v e BCHA expends s i g n i f i c a n t f i s c a l and human r e s o u r c e s on r u n n i n g i t s IBM 4300 S e r i e s mainframe. W h i l e i t does n o t f a c e t h e same development expenses t h a t BCHSSS f a c e s , i t i s r e l a t i v e l y c o s t l y t o run the c u r r e n t c o n f i g u r a t i o n . Lack o f s u b s c r i b e r s d u r i n g t h e m a j o r i t y of 1984 p l a c e d BCHA's system i n some f i n a n c i a l j e o p a r d y . Some c r i t i c i s m was a l s o l e v e l l e d a t BCHA f o r the P a y r o l l System s u r c h a r g e w h i c h was used t o d e v e l o p the computer system; however, t h e s u r c h a r g e was b e i n g 34 used f o r u p g r a d i n g t h e system o r f o r new a p p l i c a t i o n s . One of t h e main f e a t u r e s o f BCHA's PCS shared systems approach i s the o p p o r t u n i t y f o r h o s p i t a l s t o " q u i c k - s t a r t " , w h i c h would o t h e r w i s e be a r e l a t i v e l y c o s t l y and c o m p l i c a t e d endeavour, as w i l l become c l e a r t h r o u g h t h e remainder o f t h i s t h e s i s . BCHA argues t h a t Order E n t r y and R e s u l t s R e p o r t i n g a p p l i c a t i o n s i n t h e system f a c i l i t a t e a r e d u c t i o n i n l e n g t h o f s t a y and improved p r o d u c t i v i t y o f n u r s i n g s t a f f t h r o u g h t i m e - s a v i n g s i n i n f o r m a t i o n - h a n d l i n g a c t i v i t i e s such as t e l e p h o n e c a l l s , t r a n s c r i p t i o n s and communications a t 19 s h i f t change. A c c o u n t i n g a c t i v i t i e s a r e a l s o i n c l u d e d . R e f e r e n c e i s f u r t h e r made t o t h e n a t i o n a l Management I n f o r m a t i o n Systems (MIS) P r o j e c t , t h e chairman o f whi c h i s the P r e s i d e n t of BCHA, Mr. Herman Crewson. Thus, w h i l e t h e r e i s r e c o g n i t i o n o f the p o t e n t i a l f o r c o s t - s a v i n g s i n i m p l e -m enting t h e i r s o l u t i o n , BCHA, as does BCHSSS, r e l i e s on i n d i v i d u a l h o s p i t a l s t o examine t h e advantages and d i s a d v a n -t a g e s , economic and o t h e r w i s e , f o r t h e m s e l v e s . T h i s i s not s u p r i s i n g nor u n u s u a l , g i v e n t h e l i m i t e d i m p l e m e n t a t i o n e x p e r i e n c e o f b o t h t h e s e o r g a n i z a t i o n s t o d a t e . No doubt, once s e v e r a l h o s p i t a l s have t h e i r r e s p e c t i v e systems i n p l a c e , economic a n a l y s e s w i l l shed l i g h t on wh i c h of t h e s e d i f f e r e n t approaches and s o l u t i o n s i s t h e most c o s t -e f f e c t i v e from t h e p e r s p e c t i v e of h o s p i t a l s , t h e MOH and the o r g a n i z a t i o n s . 35 F u t u r e R o l e The f u t u r e o f BCHA's computer s e r v i c e s w i l l undoubted-l y r e s t on i t s a b i l i t y t o g a i n and r e t a i n s u b s t a n t i a l l y more s u b s c r i b e r s . T h i s , i n t u r n , i s dependent on t h e e x p e r i e n c e s of t h e t h r e e r e c e n t l y s u b s c r i b e d h o s p i t a l s . I n t e r e s t i n g l y , 1985 saw a f l u r r y o f a c t i v i t y r e l a t e d t o merging the computer a c t i v i t i e s o f BCHSSS and t h e Computer S e r v i c e s s e c t i o n o f BCHA. U l t i m a t e l y , w i t h the a s s i s t a n c e o f a management c o n s u l t i n g f i r m , t h i s was deemed not t o be f e a s i b l e a t t h i s t i m e ; however, the p o s s i b i l i t y presumably s t i l l e x i s t s and may be an i m p o r t a n t f u t u r e c o n s i d e r a t i o n f o r h o s p i t a l s . Of f u r t h e r i n t e r e s t i s a j o i n t v e n t u r e systems development i n i t i a t i v e between BCHA and t h e A l b e r t a H o s p i t a l 20 A s s o c i a t i o n . Moreover, the r o l e o f Mr. Crewson, as C h a i r -man o f the n a t i o n a l MIS p r o j e c t , w i l l be s i g n i f i c a n t i n e n s u r i n g t h a t the economic p e r s p e c t i v e i s a d d r e s s e d more s u b s t a n t i a l l y t h a n i t has been. D i s c u s s i o n s a r e a l s o t a k i n g p l a c e w i t h a v i e w t o making the Computer S e r v i c e s a s u b s i d i a r y o f BCHA s i m i l a r t o P u r c h a s i n g and I n s u r a n c e such t h a t t h e s e f e e f o r s e r v i c e a c t i v i t i e s c o u l d pay f o r t hemselves and not r e q u i r e s u p p o r t by membership dues. BCHA i s a l s o f o r m i n g a Computer S e r v i c e s S t e e r i n g Committee w h i c h , i f t h e Computer S e r v i c e s D i v i s i o n u l t i m a t e l y becomes a s e p a r a t e s u b s i d i a r y component of BCHA, w i l l become 21 x t s Board of Management. BCHA r e c o g n i z e s t h a t the Computer 36 S e r v i c e s o p e r a t i o n i s i n c o m p e t i t i o n w i t h o t h e r vendors and t h i s move o b v i o u s l y i s an attempt t o ". . . m a i n t a i n c u r r e n t 22 u s e r s o f [ t h e i r ] systems, as w e l l as a t t r a c t new ones." H o s p i t a l s G e n e r a l D i f f i c u l t i e s E n c o u n t e r e d by H o s p i t a l s i n P l a n n i n g f o r C o m p u t e r i z e d I n f o r m a t i o n Systems B r i t i s h Columbia h o s p i t a l s , l i k e most, f a c e d i f f i c u l t i e s as c o m p u t e r i z e d i n f o r m a t i o n systems a r e p l a n n e d , d e v e l o p e d , implemented and e v a l u a t e d . G e n e r a l l y , t h i s i s due t o the l a c k o f a s t a n d a r d i z e d and proven methodology. A u s t i n and 23 Greene r e p o r t t h a t t h e main r e a s o n f o r h o s p i t a l s l a g g i n g b e h i n d t h e i r c o u n t e r p a r t s i n o t h e r i n d u s t r i e s i s because many h o s p i t a l a d m i n i s t r a t o r s l a c k the t e c h n i c a l knowledge and s k i l l s r e q u i r e d t o u n d e r s t a n d such p r o c e s s e s and, t h u s , a r e not i n v o l v e d enough i n t h e d e s i g n o f i n f o r m a t i o n systems f o r t h e i r r e s p e c t i v e o r g a n i z a t i o n s . They s t a t e t h a t t h i s u l t i -m a t e l y l e a d s t o l a c k o f use by top management, t h e r e b y c o n -t r i b u t i n g t o i t s f a i l u r e . W h i l e t h i s may be so, e q u a l l y t r u e would be the f a i l u r e o f some a d m i n i s t r a t o r s t o t a k e advantage o f s t a f f and o u t s i d e a g e n c i e s who can o f f e r a s s i s t a n c e . I n a d d i t i o n t o t h i s m a n a g e r i a l p a s s i v e n e s s , 24 A u s t i n and Greene a l s o p o i n t o u t the importance o f p h y s i c i a n i n p u t i n t h e system development p r o c e s s , something which i s l e s s than a d e q u a t e l y tapped. One major Canadian h o s p i t a l , n o t a b l y t h e V i c t o r i a 37 G e n e r a l H o s p i t a l (VGH) i n H a l i f a x , r e c e n t l y came t o g r i p s 25 w i t h some o f i t s e m e r g i n g p r o b l e m s i n c l u d i n g : u n p l a n n e d s y s t e m s p r o l i f e r a t i o n ; n o n - r e c o g n i t i o n o f h o s p i t a l g o a l s a n d p r i o r i t i e s ; l a c k o f f i s c a l p l a n n i n g f o c u s ; no l o g i c a l b a s i s f o r e s t a b l i s h i n g s y s t e m s p r i o r i t i e s a n d no i n - h o u s e t e c h n i c a l g r o u p t o c o o r d i n a t e i n f o r m a t i o n s y s t e m s . T h e s e d i f f i c u l t i e s w o u l d a p p e a r t o be f a i r l y c ommonplace i n mos t h o s p i t a l s a n d m o s t c e r t a i n l y a p p l y t o h o s p i t a l s g e n e r a l l y i n B r i t i s h 2 6 C o l u m b i a . One s o u r c e p l a c e s t h e l a c k o f s t a b l e a n d l o n g r a n g e d i r e c t i o n f o r d a t a p r o c e s s i n g s q u a r e l y i n t h e l a p o f 2 7 h o s p i t a l e x e c u t i v e s . J o h n s o n n o t e s t h a t h o s p i t a l e x e c u t i v e s a r e v i t a l i n d e v e l o p i n g t h e d a t a p r o c e s s i n g s t r a t e g y . 28 S u l k e r s a l s o s i n g l e s o u t s e n i o r management by v i r t u e o f t h e i r l i m i t e d u n d e r s t a n d i n g o f t h e r o l e o f i n f o r m a t i o n s y s t e m s i n a d d r e s s i n g o b j e c t i v e s o f t h e o r g a n i z a t i o n . He f e e l s t h a t t h i s r e s u l t s i n i n a d e q u a t e s u p p o r t ,and d i r e c t i o n 2 9 by s e n i o r management. Hammon a l s o p o i n t s t o c h a n g i n g g o v e r n m e n t a l r e g u l a t i o n s a s a r o a d b l o c k t o a c h i e v i n g a c o s t -e f f e c t i v e h o s p i t a l i n f o r m a t i o n s y s t e m . S p e c i f i c D i f f i c u l t i e s E n c o u n t e r e d i n t h e F a c e o f BCHSSS' a n d BCHA's C u r r e n t R o l e s A l t h o u g h l i k e l y n o t f u l l y a p p r e c i a t e d by e i t h e r o f t h e s e two o r g a n i z a t i o n s , BCHSSS and BCHA h a v e i n a d v e r t e n t l y , b y v i r t u e o f t h e i r c o n f l i c t s i n p l a n n i n g d i r e c t i o n , p l a c e d B r i t i s h C o l u m b i a h o s p i t a l s i n a p l a n n i n g d i l e m m a . M o s t 38 h o s p i t a l s a r e members o f BCHA and as such, owe some a l l e g i a n c e t o t h e i r own a s s o c i a t i o n . As s t a t e d e a r l i e r , most h o s p i t a l s p a r t i c i p a t e i n the P a y r o l l system and, i n f a c t , have been p a y i n g a systems development s u r c h a r g e as p a r t o f t h e sub-s c r i p t i o n r a t e . Thus, t h e s e h o s p i t a l s have i n a d v e r t e n t l y s u p p o r t e d a s p e c i f i c d i r e c t i o n f o r c o m p u t e r i z a t i o n on a sha r e d mainframe b a s i s . I f t h e m a j o r i t y o f h o s p i t a l s wanted t h i s a t once, i t i s u n l i k e l y t h a t t h e r e would be the t e c h n i c a l c a p a b i l i t y o r manpower f o r BCHA t o handle t h e i n f l u x o f a c t i v i t y . On the o t h e r hand, i f t h e r e a r e t o o few s u b s c r i b e r s , BCHA would be unable t o c o n t i n u e t o s u p p o r t the system f o r any l e n g t h o f t i m e . From t h e economic p e r s p e c t i v e , t h i s a l l o w s h o s p i t a l s t o s t a r t up r e l a t i v e l y i n e x p e n s i v e l y a c c o r d i n g t o BCHA; however, t h i s has not been v a l i d a t e d i n any a c t u a l i n s t a l l a t i o n . W h i l e i t i s t r u e t h a t i t o b v i a t e s a need f o r p u r c h a s i n g e x p e n s i v e o n - s i t e hardware, i t i s e q u a l l y t r u e t h a t h o s p i t a l s , e s p e c i a l l y i f t h e r e a re v e r y few s u b s c r i b e r s , pay a premium f o r use o f a p p l i c a t i o n s s o f t w a r e . I t i s a l s o c o r r e c t l y argued t h a t a major d i s a d v a n t a g e o f the system i s l a c k of h o s p i t a l c o n t r o l o f the d i r e c t i o n and m o d i f i c a t i o n s / enhancements t o t h e system. W i t h r e s p e c t t o BCHSSS, h o s p i t a l s a re n o t n e c e s s a r i l y members o f t h e o r g a n i z a t i o n . However, BCHSSS p r i d e s i t s e l f on the f a c t t h a t i t s Board o f D i r e c t o r s i s o f and by a d m i n i s t r a t o r s o f h o s p i t a l s i n B r i t i s h Columbia and, t h e r e f o r e , 39 can f o r m u l a t e the p o l i c y d i r e c t i o n o f t h e S o c i e t y . I n t e r e s t -i n g l y , however, a t l e a s t two o f the r e c e n t d i r e c t o r s a r e s e n i o r a d m i n i s t r a t o r s o f h o s p i t a l s who have e l e c t e d t o p r o c e e d w i t h non-BCHSSS s o l u t i o n s . A major d i f f i c u l t y w i t h the BCHSSS s o l u t i o n i s the f a c t t h a t t hey have become l a r g e l y d e v e l o p m e n t a l and cannot y e t o f f e r an i n t e g r a t e d system. C u r r e n t a c t i v i t i e s a r e c o m p r i s e d m a i n l y o f s e v e r a l p i l o t p r o j e c t s and i n t e g r a t i o n o f s p e c i f i c a p p l i c a t i o n s has not y e t been completed. The BCHSSS s o l u t i o n a l s o r e q u i r e s h o s p i t a l s t o p u r c h a s e r e l a t i v e l y e x p e n s i v e hardware w i t h the agreement t h a t s o f t w a r e w i l l be p r o v i d e d r e l a t i v e l y i n e x p e n s i v e l y . E x p e r i e n c e t o dat e shows t h a t t h i s i s more c o s t l y t h a n a n t i -c i p a t e d . As s t a t e d e a r l i e r , t h e g u i d e l i n e s p u b l i s h e d by BCHSSS do not prove t h a t t h e r e a r e economic b e n e f i t s i n im-p l e m e n t i n g t h e systems, m e r e l y t h a t h o s p i t a l s a r e e x p e c t e d t o d e v e l o p t h e i r own c o s t - j u s t i f i c a t i o n . Because the MOH has a v e s t e d i n t e r e s t i n t h e S o c i e t y , and i s i n e f f e c t a " s i l e n t " p a r t n e r , t h e a p p r o v a l process, f o r h o s p i t a l p r o p o s a l s may be s u b j e c t t o b i a s depending on wh i c h s o l u t i o n s and p r i o r i t i e s a r e i d e n t i f i e d . I n s h o r t , t h e economic p e r s p e c t i v e i s not e v i d e n t i n the r o l e s o f BCHSSS nor BCHA. N e i t h e r o f t h e s e o r g a n i z a t i o n s has made an attempt a t p r e d i c t i v e CBA o f t h e i r systems, a l t h o u g h h o s p i t a l s t h a t a r e a t t e m p t i n g t o purchase t h e s e systems are o b l i g a t e d t o p r o v i d e such an a n a l y s i s by MOH 40 p o l i c y . A c o l l a b o r a t i v e e f f o r t would be i n o r d e r ; however, no attempt has y e t been made. The MOH c o u l d make a sub-s t a n t i a l c o n t r i b u t i o n by p r o v i d i n g some l e a d e r s h i p and c a t a l y t i c a c t i v i t y i n t h i s a r e a by i n s i s t i n g t h a t t h e BCHSSS and.BCHA approaches a r e v a l i d a t e d by comprehensive p r e d i c t i v e and r e t r o s p e c t i v e economic e v a l u a t i o n s . I n t e r e s t i n g l y , the MOH has r e c e n t l y formed a Computer 30 A d v i s o r y Committee w h i c h has j u s t u n d e r t a k e n a su r v e y (December, 1985) t o de t e r m i n e c u r r e n t e x p e n d i t u r e t r e n d s i n l i g h t o f r e c e n t l y p u b l i s h e d M i n i s t r y g u i d e l i n e s (Appendix 2) r e g a r d i n g a c c e p t a b l e e x p e n d i t u r e l e v e l s . The f i n d i n g s w i l l l i k e l y cause the M i n i s t r y t o r e v i e w the e x p e n d i t u r e l e v e l s s i n c e many h o s p i t a l s a r e a l r e a d y s pending c l o s e t o o r a r e e x c e e d i n g the g u i d e l i n e s w i t h o n l y m i n i m a l c o m p u t e r i z a t i o n . I m p l i c a t i o n s o f the Economic P e r s p e c t i v e The g e n e r a l l a c k of an economic f o c u s i n any of the c u r r e n t approaches and p r o c e s s e s a t t e s t s t o the need f o r a s t a n d a r d i z e d approach t o u n d e r t a k i n g p r e d i c t i v e economic e v a l u a t i o n o f HISs. I t i s mandatory t h a t each h o s p i t a l i n -d e p e n d e n t l y p e r f o r m t h i s e x e r c i s e because h o s p i t a l needs, s o l u t i o n s and p r i o r i t i e s a r e unique and t h e p r o c e s s i s as i m p o r t a n t as the r e s u l t s t h a t i t p r o d u c e s . U n f o r t u n a t e l y , a s t a n d a r d i z e d and r e l i a b l e framework f o r h o s p i t a l s does n ot y e t e x i s t . BCHA does n ot o f f e r such a framework; BCHSSS su g g e s t s t h a t one i s n e c e s s a r y , b u t throws the onus on the 41 h o s p i t a l f o r i t s u n d e r t a k i n g ; t h e M i n i s t r y i n s i s t s on one and goes so f a r as t o p r o v i d e a v e r y g e n e r a l economic e v a l u a t i o n framework f o r h o s p i t a l use. I t does n o t , however, o f f e r any i n s t r u c t i o n s as t o how one s h o u l d go about g a i n i n g the i n f o r -m a t i o n . T h i s l e a v e s h o s p i t a l s i n a v e r y d i f f i c u l t p o s i t i o n . To d a t e t h e r e has not been enough e x p e r i e n c e i n B r i t i s h Columbia h o s p i t a l s t o use what o t h e r h o s p i t a l s have d e v e l o p e d . V e r y l i t t l e has been done and what has i s not g e n e r a l l y a v a i l a b l e t h r o u g h the l i t e r a t u r e . Moreover, what has been done on a l i m i t e d b a s i s may not be a p p r o p r i a t e f o r use by o t h e r h o s p i -t a l s . F i n a l l y , i n d i v i d u a l s w i t h t h e n e c e s s a r y e x p e r t i s e t o a s s i s t h o s p i t a l s w i t h t h i s t y p e o f a n a l y s i s are themselves as s c a r c e as t h e a n a l y s e s have been t o d a t e . Such a l a c k o f methodology does not i n d i c a t e i t s l a c k o f i m p o r t a n c e . On t h e c o n t r a r y , i t o n l y s e r v e s t o remind us t h a t a v e r y n e c e s s a r y p a r t of the p l a n n i n g p r o c e s s has been n e g l e c t e d . A p p r o v a l and F u n d i n g P r o c e s s e s from the P e r s p e c t i v e o f t h e H o s p i t a l I n December, 1984 C i r c u l a r L e t t e r #84/47 c o n c e r n i n g G u i d e l i n e s f o r Computer Fund i n g P r o p o s a l s by the MOH I n s t i t -u t i o n a l S e r v i c e s (Appendix 1) was p u b l i s h e d i n o r d e r t o a s s i s t , h o s p i t a l s i n d e s c r i b i n g t h e i r proposed system and equipment; p r o v i d i n g c o s t s ; i d e n t i f y i n g t a n g i b l e and i n t a n g i b l e b e n e f i t s and r e l a t i n g t h e i r r e q u e s t t o t h e i r i n f o r m a t i o n systems p l a n . A l o n g - a w a i t e d p o l i c y p o s i t i o n . o f the MOH was r e c e n t l y p u b l i s h e d t o a s s i s t h o s p i t a l s i n p l a n n i n g t h e i r computer a c q u i s i t i o n s (Appendix 2 ) . I n e s s e n c e , i t o u t l i n e s t h e 42 p r i o r i t i e s t h e MOH w i l l c o n s i d e r , maximum a c c e p t a b l e e x p e n d -i t u r e l e v e l s , a c c o u n t i n g t r e a t m e n t , a c q u i s i t i o n a l t e r n a t i v e s a n d m o n t h l y e x p e n d i t u r e r e p o r t i n g . T h e s e p o l i c i e s a r e t o be u s e d i n c o n j u n c t i o n w i t h t h e p r e v i o u s l y r e f e r e n c e d G u i d e l i n e s f o r C o m p u t e r F u n d i n g P r o p o s a l s . I t i s c l e a r t h a t c o m p u t e r i z -a t i o n o f t h e f i n a n c i a l a s p e c t s o f r u n n i n g B r i t i s h C o l u m b i a h o s p i t a l s a r e o f t h e h i g h e s t p r i o r i t y f r o m t h e p e r s p e c t i v e o f t h e MOH. R e l e g a t e d t o a l e s s e r p r i o r i t y a r e c l i n i c a l a r e a s w h i c h w i l l e n h a n c e p a t i e n t s u p p o r t , i n c l u d i n g s u c h d e p a r t m e n t s as L a b o r a t o r y , R a d i o l o g y , P h a r m a c y a n d D i e t a r y . I t i s i n t e r e s t i n g t o n o t e t h a t t h e A d m i t t i n g / D i s c h a r g e / T r a n s f e r a p p l i c a t i o n , w h i c h i s a g e n e r a l l y a c c e p t e d a r e a t o commence s y s t e m s i m p l e m e n t a t i o n , i s r e l e g a t e d t o t w e l f t h p l a c e i n t h e p r i o r i t y l i s t . T h u s , i t i s d i f f i c u l t t o c o m p r e h e n d how t h e L a b o r a t o r y , R a d i o l o g y , P h a r m a c y a nd o t h e r c l i n i c a l a p p l i c a -t i o n s w i l l f u n c t i o n i n an i n t e g r a t e d f a s h i o n ( e s p e c i a l l y w i t h r e s p e c t t o O r d e r P r o c e s s i n g ) w i t h o u t t h e w h e r e a b o u t s o f p a t i e n t s b e i n g known. I t w o u l d seem e i t h e r t h a t a n o n - i n t e g r a t e d a p p r o a c h i s b e i n g s u p p o r t e d , w h i c h i s c o n t r a r y t o t h e d i r e c t i o n m o s t h o s p i t a l s a r e t a k i n g , o r t h e p r i o r i t y l i s t has. b e e n p o o r l y t h o u g h t o u t . W i t h r e s p e c t t o t h e maximum a c c e p t a b l e e x p e n d i t u r e l e v e l f o r c o m p u t e r i z a t i o n , t h e g u i d e l i n e s a r e e x p l i c i t i n i n d i c a t i n g t h a t m a j o r r e f e r r a l h o s p i t a l s may s p e n d a maximum o f 0.75 p e r c e n t o f g r o s s a n n u a l o p e r a t i n g i n c o m e . The g u i d e -l i n e s a r e s i l e n t a s t o w h e t h e r t h e f i g u r e s a r e n e t o f b e n e f i t s ( c o s t - s a v i n g s ) g a i n e d p u r s u a n t t o i m p l e m e n t a t i o n . Compared 43 t o the U.S. h o s p i t a l i n d u s t r y average of 2.0 - 3.0 p e r c e n t 31 f o r d a t a p r o c e s s i n g a c t i v i t i e s t h i s may v e r y w e l l be a g r o s s u n d e r - e s t i m a t i o n o f a c t u a l f u n d i n g r e q u i r e m e n t s . No f u n d i n g f o r m u l a i s g i v e n ; however, e i t h e r t h e r e i s n ' t one and t h i s i s an a r b i t r a r y f i g u r e o r t h e r e i s , b u t w i t h no r a t i o n a l b a s i s f o r i t s employ. I n any e v e n t , i t does n o t appear t o be based on t h e l o g i c o f h o s p i t a l - w i d e systems. There i s o b v i o u s l y an attempt by t h e MOH t o d e v e l o p a sense o f o r d e r and c o n s i s t e n c y i n t h i s d i f f i c u l t a r e a o f needs i d e n t i f i c a t i o n , p r i o r i t y s e t t i n g f o r s o l u t i o n s and f u n d i n g . D i f f i c u l t i e s a r i s e because th e p i c t u r e appears (and, i n f a c t , i s ) d i f f e r e n t depending on t h e p e r s p e c t i v e t a k e n and d e s i r e d outcome. N o n e t h e l e s s , h o s p i t a l s must a n a l y z e c o s t s and b e n e f i t s f o r proposed HISs from t h e i r own p e r s p e c t i v e , p r o v i d e d c o s t - b e n e f i t a n a l y s e s a r e c o m p r e h e n s i v e l y performed, a c c u r a t e l y i n t e r p r e t e d and used c o r r e c t l y i n the d e c i s i o n -making p r o c e s s . P r o v i d e d t h e CBA methodology i s c o n s i s t e n t l y a p p l i e d a c r o s s h o s p i t a l s , the MOH c o u l d p e r f o r m i n t e r - h o s p i t a l comparisons i n o r d e r t o d e t e r m i n e f u n d i n g p r i o r i t i e s based on i d e n t i f i e d problems, needs, s o l u t i o n s and i m p l e m e n t a t i o n p r i o r i t i e s . P o s t - i m p l e m e n t a t i o n e v a l u a t i o n would a l s o be p o s s i b l e . A g a i n , t h e immediate r o a d b l o c k i s t h e p r e s e n t l a c k of an a c c e p t a b l e framework f o r g e n e r a l use by h o s p i t a l s . The r a t i o n a l e f o r t h i s t h e s i s , t h e n , i s c l e a r . A g e n e r a l and g e n e r a l i z a b l e framework f o r p r e d i c t i v e economic e v a l u a t i o n o f h o s p i t a l i n f o r m a t i o n systems, p a r t i c u l a r l y i n B r i t i s h Columbia h o s p i t a l s , seems t o be m i s s i n g from t h e r e p o s i t o r y o f t o o l s n e c e s s a r y t o p l a n i n f o r m a t i o n systems. Thus, i t i s a n t i c i p a t e d t h a t t h e framework d i s c u s s e d i n t h i s t h e s i s w i l l a s s i s t h o s p i t a l s i n B r i t i s h Columbia as they em-b a r k on t h e p l a n n i n g , i m p l e m e n t a t i o n and e v a l u a t i o n o f t h e i r own HIS. 45 F o o t n o t e s "''Province o f B r i t i s h . C olumbia, M i n i s t e r o f H e a l t h , I n s t i t u t i o n a l S e r v i c e s , C i r c u l a r L e t t e r No. 82/65 (December 22, 1982). 2 B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , N e w s l e t t e r (Vancouver: BCHSSS, March 1983). 3 P r o v i n c e o f B r i t i s h C o lumbia, M i n i s t r y o f H e a l t h , I n s t i t u t i o n a l S e r v i c e s , C i r c u l a r L e t t e r No. 82/65 (December 22, 1982), p. 3. 4 B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , N e w s l e t t e r (Vancouver: BCHSSS, November 14, 1983). 5 B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , N e w s l e t t e r (Vancouver: BCHSSS, Ja n u a r y 1984), p. 1. B r i t i s h Columbia H o s p i t a l s ^ S h a r e d Systems S o c i e t y , BCHS Infoshare 1 (Vancouver: BCHS , September 1985), p. 1. 7 3 B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , BCHS I n f o s h a r e 2 (Vancouver: BCHS , Ja n u a r y 1986), p. 1. g M.H. Nusbaum and.R.F. Whitmore, Systems A r c h i t e c t u r e P l a n f o r S m a l l H o s p i t a l s (Vancouver: BCHSSS [January 1 9 8 4 ] ) . 9 Telephone I n t e r v i e w w i t h B. R i t c h i e , B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , Vancouver, B.C. 25 F e b r u a r y 1986. 1 0 B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , A G u i d e l i n e f o r t h e P l a n n i n g o f H o s p i t a l I n f o r m a t i o n Systems (Vancouver: BCHSSS, A p r i l 1984). " ^ I b i d . , p. 3 . 12 . B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , BCHS I n f o s h a r e 2 (Vancouver: BCHS , J a n u a r y 1986), p. 1. 13 . . P.B. M a c A l l e n and.P.R. S u l k e r s , R eaching f o r the F u t u r e : A Case o f B a l a n c e (Vancouver: BCHA News Supplement, November 1982), pp. 24-30. 14 B r i t i s h Columbia H e a l t h A s s o c i a t i o n , Announcement o f New Computer System: P a t i e n t Care Systems (Vancouver: BCHA Computer S e r v i c e s , June 8, 1984). 15 B r i t i s h Columbia H e a l t h A s s o c i a t i o n , BCHA News (Vancouver: BCHA, December 1984), p. 8. 46 16 I n t e r n a t i o n a l B u s i n e s s Machines Corp., I n f o r m a t i o n Systems P l a n n i n g Guide, 3 r d ed. (White P l a i n s : IBM, J u l y 1981), p. 1. 17 B r i t i s h Columbia H e a l t h A s s o c i a t i o n , BCHA News, p. 8. 18 Telephone I n t e r v i e w w i t i i p . M a c A l l e n , B r i t i s h Columbia H e a l t h A s s o c i a t i o n , Vancouver, B.C., 3 March 1986. 19 B r i t i s h Columbia H e a l t h A s s o c i a t i o n , BCHA News, p. 8. 20 H. Crewson, From t h e P r e s i d e n t (Vancouver: BCHA, June 1985), p. 8. 21 Herman A. Crewson, "Computer S e r v i c e s S t e e r i n g Committee," l e t t e r t o C h i e f E x e c u t i v e O f f i c e r s , B.C. H e a l t h A s s o c i a t i o n Member F a c i l i t i e s , Vancouver, December 6, 1985. 22 I b i d . 23 C h a r l e s J . A u s t i n and B a r r y R. Greene, " H o s p i t a l I n f o r m a t i o n Systems: A C u r r e n t P e r s p e c t i v e , " I n q u i r y 15 (June 1978):95. 2 4 I b i d . , p. 107. 25 B r i a n S h o r t e r and I a n F e r g u s o n , " I f You Don't Know Where You're Going ... You 111.Never Get There," COACH I/O 8 ( F a l l 1983):29. 26 ECHO, IBM and N o l a n , N o r t o n and Company, " H o s p i t a l Computing: P r o g n o s i s , " COACH I/O 8 (June 1983):35. 27 Thomas H. Johnson, " T i p s on b r i d g i n g management gap," Modern H e a l t h c a r e 11 (May 1981):104. 28 P a u l S u l k e r s , "The R o l e o f S e n i o r Management," Vancouver, October 1981. ( T y p e w r i t t e n . ) 29 Gary L. Hammon, "The F u t u r e of H o s p i t a l I n f o r m a t i o n Systems: E f f e c t on C o s t of P a t i e n t - C a r e ( S o c i a l , H o s p i t a l and M e d i c a l ) , " i n H o s p i t a l I n f o r m a t i o n Systems - An I n t e r - n a t i o n a l P e r s p e c t i v e on Problems and P r o s p e c t s , R.H. Shannon, ed. (Amsterdam: N o r t h - H o l l a n d P u b l i s h i n g Company, 1979), p. 353. 30 P r o v i n c e - of B r i t i s h C o lumbia, M i n i s t r y ; of Health., Computer A d v i s o r y Committee, Survey, December 30, 1985. 31 Stephen L. P r i e s t , Managing H o s p i t a l I n f o r m a t i o n Systems ( R o c k v i l l e : Aspen System Corp., 1982), p. 186. 47 CHAPTER I I I A GENERAL FRAMEWORK FOR PREDICTIVE ECONOMIC EVALUATION G e n e r a l C o n s i d e r a t i o n s a n d t h e R e a s o n s f o r S e l e c t i n g C o s t - B e n e f i t A n a l y s i s T h e r e a r e many f a c t o r s t h a t h o s p i t a l d e c i s i o n - m a k e r s m u s t c o n s i d e r d u r i n g e v a l u a t i o n a n d p r i o r t o s e l e c t i o n o f an HIS t o meet i t s i d e n t i f i e d n e e d s . I f h o s p i t a l s c a n n o t e c o n o m i c a l l y j u s t i f y H I S s i t makes l i t t l e s e n s e t o p u r s u e s u c h s y s t e m s u n l e s s t h e r e a r e o v e r r i d i n g p o l i t i c a l o r q u a l i t a t i v e r e a s o n s i n w h i c h c a s e s u c h d e c i s i o n s w o u l d be made t h r o u g h d i s r e g a r d i n g t h e r e s u l t s o f t h e CBA i f an u n -f a v o u r a b l e r a t i o i s f o u n d . S u c h r e a s o n s , h o w e v e r , may be more i m p o r t a n t f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l o r t h e f u n d i n g b o d y . CBA i s one a p p l i e d m e thod o f e c o n o m i c e v a l u a t i o n , b u t i s l i k e l y t h e mos t i m p o r t a n t one f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l , p a r t i c u l a r l y f o r d e c i s i o n - m a k i n g d u r i n g t h e p r e s e n t e c o n o m i c c o n s t r a i n t p e r i o d . T h i s t h e s i s f o c u s s e s on p r e d i c t i v e e c o n o m i c e v a l u a t i o n u s i n g t h e p r i n c i p l e s o f CBA. T h u s , q u a l i t a t i v e , n o n -m o n e t a r y b e n e f i t s s u c h a s s t a f f m o r a l e , f r u s t r a t i o n l e v e l a n d so on w i l l n o t be a d d r e s s e d . T h i s i s n o t t o s a y t h a t t h e s e b e n e f i t s a r e u n i m p o r t a n t ; on t h e c o n t r a r y , t h e y c o u l d a n d s h o u l d be t h e s u b j e c t o f f u r t h e r s t u d i e s . H i s t o r i c a l l y , many d e c i s i o n s r e g a r d i n g t h e p u r c h a s e o f H I S s a r e made on t h e b a s i s 48 o f s u c h q u a l i t a t i v e b e n e f i t s w i t h l i m i t e d o r t o t a l d i s r e g a r d o f f o r m a l c o s t - b e n e f i t f i n d i n g s . O f t e n , h o w e v e r , a CBA was n e v e r e v e n c a r r i e d o u t . The c o s t - b e n e f i t a p p r o a c h s h o u l d be u s e d i f t h e r e i s a c o n c e r n f o r t h e e c o n o m i c v i a b i l i t y o f t h e p r o p o s e d s y s t e m . I t f a c i l i t a t e s t h e r e d u c t i o n o f a l l q u a n t i f i a b l e b e n e f i t s t o m o n e t a r y u n i t s so t h a t t h e y c a n be w e i g h e d a g a i n s t i d e n t i f i e d c o s t s o f t h e s y s t e m . B e c a u s e t h e t y p i c a l h o s p i t a l must d e a l w i t h t h e a l l o c a t i o n o f s c a r c e r e s o u r c e s a m i d s t c o m p e t i n g n e e d s , e c o n o m i c e v a l u a t i o n i s a p p r o p r i a t e . The f o l l o w i n g s e c t i o n s d e s c r i b e i n d e t a i l t h e p r i n c i p l e s , f r a m e w o r k a nd p r o c e s s o f p r e d i c t i v e e c o n o m i c e v a l u a t i o n o f p r o p o s e d H I S s . The U n i t e d S t a t e s O f f i c e o f T e c h n o l o g y A s s e s s m e n t (OTA)^ a d v o c a t e s CBA i n b u d g e t - c o n s t r a i n e d d e c i s i o n - m a k i n g i n h e a l t h c a r e . I t f o s t e r s t h e i l l u m i n a t i o n o f d e c i s i o n - m a k i n g p r o c e s s e s a n d n e c e s s i t a t e s t h e m a k i n g o f e x p l i c i t j u d g m e n t s . T h i s f o r c e s e x a m i n a t i o n o f a l l a s s u m p t i o n s a nd v a l u e s p l a c e d o n t h e d e c i s i o n v a r i a b l e s . OTA d e s c r i b e s two g e n e r a l f i n d i n g s : . . . p e r f o r m i n g an a n a l y s i s o f c o s t s a n d b e n e f i t s h a s t h e p o t e n t i a l t o b e . v e r y h e l p f u l t o d e c i s i o n -m a k e r s , b e c a u s e t h e p r o c e s s o f a n a l y s i s s t r u c t u r e s t h e p r o b l e m , a l l o w s an open c o n s i d e r a t i o n o f a l l r e l e v a n t e f f e c t s o f a d e c i s i o n , and f o r c e s t h e e x p l i c i t t r e a t m e n t o f k e y a s s u m p t i o n s . The s e c o n d g e n e r a l f i n d i n g i s t h a t [CBA] e x h i b i t s t o o many m e t h o d o l o g i c a l a n d o t h e r l i m i t a t i o n s t o j u s t i f y r e l y i n g s o l e l y o r t o o h e a v i l y on t h e r e s u l t s . . . T h u s , [CBA] c o u l d be u s e f u l f o r a s s i s t i n g i n many d e c i s i o n s , b u t i s p r o b a b l y n o t a p p r o p r i a t e a s t h e s o l e o r p r i m e d e t e r m i n a n t o f t h e d e c i s i o n . 2 49 P r i n c i p l e s of C o s t - B e r i e f i t A n a l y s i s A p p l i e d to H o s p i t a l Information Systems CBA, i n essence, i s a l o g i c a l e i g h t - s t e p procedure t h a t may be used by an a n a l y s t to a s s i s t i n the d e c i s i o n to purchase or not purchase an HIS. S e v e r a l sources d i s c u s s v a r i a t i o n s of these p r i n c i p l e s ; however, there i s gen e r a l 3 r 8 agreement. (1 (2 (3 (4 (5 (6 (7 (8 The e i g h t g e n e r a l p r i n c i p l e s are: D e f i n i n g the q u e s t i o n D e l i n e a t i o n of o b j e c t i v e s and i d e n t i f i c a t i o n and s e l e c t i o n of a l t e r n a t i v e s Enumeration of r e l e v a n t c o s t s and b e n e f i t s Measurement of c o s t s and b e n e f i t s i n a p p r o p r i a t e u n i t s V a l u a t i o n of c o s t s and b e n e f i t s i n monetary u n i t s D i s c o u n t i n g of c o s t s and b e n e f i t s to t h e i r p r e s e n t v a l u e Performing of s e n s i t i v i t y analyses t o reduce u n c e r t a i n t i e s I n t e r p r e t a t i o n and p r e s e n t a t i o n of f i n d i n g s Each of these p r i n c i p l e s w i l l now be d i s c u s s e d i n d e t a i l . D e f i n i n g the Question C l e a r d e l i n e a t i o n of the q u e s t i o n i s perhaps the most thought-provoking and important p a r t of the a n a l y s i s . T h i s may take the form of attempting to s o l v e a problem a s s o c i a t e d w i t h i n f o r m a t i o n h a n d l i n g w i t h i n a h o s p i t a l and may simply reduce t o the q u e s t i o n — W i l l an HIS w i t h a c l e a r l y i d e n t i -f i e d s et of c h a r a c t e r i s t i c s and c a p a b i l i t i e s (as d e f i n e d i n Chapter I) designed to c o m p u t e r i z e / i n t e g r a t e the s t a t u s quo methods of p r o c e s s i n g i n f o r m a t i o n be a c o s t - b e n e f i c i a l 50 s o l u t i o n r e l a t i v e t o t h e s t a t u s quo? The q u e s t i o n must be 9 10 posed i n answerable form ; i t must be c l e a r and e x p l i c i t and t h e p e r s p e c t i v e o f the analyst"''"'' must a l s o be s t a t e d . D e l i n e a t i o n o f O b j e c t i v e s and I d e n t i f i c a t i o n and S e l e c t i o n o f A l t e r n a t i v e s G e n e r a l l y , t h e o b j e c t i v e s o f i n f o r m a t i o n systems a r e t o e x p e d i t e h o s p i t a l c a r e i n o r d e r t o improve t h e h e a l t h s t a t u s of the p a t i e n t s i t houses. I n f o r m a t i o n p r o c e s s i n g e f f e c t i v e n e s s , b u t not n e c e s s a r i l y e f f i c i e n c y , i s a c c o m p l i s h e d t h r o u g h a f u l l y i n t e g r a t e d system and t h i s i s g e n e r a l l y s u p p o r t e d i n the l i t e r a t u r e . T h i s d i s t i n c t i o n i s i m p o r t a n t 12 because as S t o d d a r t and Drummond n o t e , t h e r e i s no p o i n t i n m e r e l y b r i n g i n g about the e f f i c i e n t p r o v i s i o n o f i n e f f e c t i v e s e r v i c e s . The a l t e r n a t i v e s may s i m p l y be a c o m p u t e r i z e d HIS and t h e s t a t u s quo, the l a t t e r t y p i c a l l y b e i n g a manual system. Where i t may be u s e f u l t o e n t e r t a i n o t h e r a l t e r n a t i v e s , f o r t h e most p a r t , a c l e a r d e l i n e a t i o n o f the manual v e r s u s c o m p u t e r i z e d system u s u a l l y s u f f i c e s . I f a p a r t i a l l y i n t e -g r a t e d HIS i s b e i n g p roposed, f u r t h e r a l t e r n a t i v e s (as d i c t a t e d by t h e e x t e n t o f i n t e g r a t i o n ) s h o u l d be examined. Enumeration of R e l e v a n t C o s t s and B e n e f i t s A t f i r s t g l a n c e , t h i s p r o c e s s appears r e l a t i v e l y s t r a i g h t f o r w a r d ; however, the i d e n t i f i c a t i o n o f a l l r e l e v a n t c o s t s and b e n e f i t s can prove t o be q u i t e onerous. The more comprehensive the a n a l y s t has been i n d e t a i l i n g t h e a l t e r n a -51 t i v e s i n t h e p r e v i o u s s t e p s , t h e e a s i e r i s e n u m e r a t i o n . C o s t s B r e a k i n g down t h e t o t a l c o s t s i n t o a t y p o l o g y m e a n i n g -f u l t o t h e a n a l y s t i s t h e f i r s t t a s k . F o r e x a m p l e , i t c o u l d be by o n e - t i m e s y s t e m c o s t s ( h a r d w a r e , s o f t w a r e , l i c e n s e s a n d c o m m u n i c a t i o n s ) ; c o n v e r s i o n c o s t s ; o n - g o i n g m a i n t e n a n c e ( s o f t w a r e a n d h a r d w a r e ) ; a n d , c o s t s o f f u t u r e m o d i f i c a t i o n s a f t e r i n i t i a l i m p l e m e n t a t i o n . T h e s e c o s t s s h o u l d be c a t e g o r -i z e d i n t o c a p i t a l a n d o p e r a t i n g c o s t s , a commonly u s e d d e m a r c a t i o n i n t h e h o s p i t a l e n v i r o n m e n t . A s much a s p o s s i b l e , t h e a n a l y s t must i d e n t i f y a l l r e l e v a n t c o s t s ; h o w e v e r , t h i s i s l a r g e l y p r e d i c a t e d on t h e a n a l y s t ' s a b i l i t y t o c o n c e p t u a l -i z e t h e p u r c h a s e , i m p l e m e n t a t i o n and o n - g o i n g m a i n t e n a n c e o f t h e H I S . O t h e r c o s t s may i n c l u d e r e s e a r c h a n d d e v e l o p m e n t a nd t h e o p p o r t u n i t y c o s t s o f s p a c e u s e d , f o r e x a m p l e , i n a m a i n -f r a m e s o l u t i o n . The d e g r e e o f a p p l i c a b i l i t y o f t h e s e l a t t e r c o s t s must be c l e a r l y e x p r e s s e d by t h e a n a l y s t who must d e c i d e w h e t h e r o r n o t t o i n c l u d e them. F o r e x a m p l e , r e s e a r c h a n d d e v e l o p m e n t c o s t s w o u l d be a p p l i c a b l e i f t h e h o s p i t a l i n t e n d s t o p u r c h a s e a nd f u r t h e r d e v e l o p a s y s t e m w h i c h p r e s e n t l y m e e t s o n l y a p o r t i o n o f i t s p r e s e n t o r a n t i c i p a t e d n e e d s . T h i s i s commonplace e v e n i n t h e C a n a d i a n e n v i r o n m e n t . O b v i o u s l y , t h i s s i g n i f i c a n t l y i m p a c t s o n - g o i n g o p e r a t i n g c o s t s , e s p e c i a l l y t h r o u g h t h e u s e o f human r e s o u r c e s . I f p h y s i c a l s p a c e i s r e q u i r e d (as i n t h e c a s e o f a m a i n f r a m e s o l u t i o n ) , t h i s w o u l d i n v o l v e s p a c e a l r e a d y u s e d f o r , o r p o t e n t i a l l y u s e a b l e b y , some o t h e r a c t i v i t y . T h i s a s p e c t i s f r e q u e n t l y o v e r l o o k e d i n a n a l y s e s . I f t h e a d d i t i o n a l c o s t s a r e m a r g i n a l t h e a n a l y s t m u s t make e x p l i c i t t h e d e c i s i o n t o i n c l u d e o r e x c l u d e them. G e n e r a l l y , c o s t s c a n be c a t e g o r i z e d i n t o t a n g i b l e o r i n t a n g i b l e . I n t a n g i b l e c o s t s may be u n m e a s u r e d o r , p e r h a p s , a r e u n m e a s u r a b l e , a c c o r d i n g t o A n d e r s o n a nd S e t t l e who s u g g e s t a s k i n g t h e q u e s t i o n : "Does i t a p p e a r l i k e l y i n any p a r t i c u l a r i n s t a n c e t h a t t h e v a l u e s a f f e c t e d b y t h e i n t a n g i b l e e f f e c t s c o u l d h a v e b e e n l a r g e e n o u g h , i f t h e y h a d i n f a c t b e e n q u a n t i f i e d , t o h a v e s u b s t a n t i a l l y a l t e r e d t h e f i n d i n g s o f t h e 13 b e n e f i t - c o s t s t u d y ? " They a l s o n o t e t h a t i n t a n g i b l e e f f e c t s may, u n d e r c e r t a i n c i r c u m s t a n c e s , be r e l a t i v e l y u n i m p o r t a n t t o t h e CBA. M i n i m a l l y , t h e a n a l y s t must a t l e a s t i d e n t i f y s u c h i n t a n g i b l e s . The a n a l y s t s h o u l d n o t be o v e r l y c o n c e r n e d w i t h a b s o -l u t e c o s t s a n d b e n e f i t s b u t , r a t h e r , w i t h t h e d i f f e r e n c e s i n c o s t s a n d b e n e f i t s b e t w e e n t h e s t a t u s quo and t h e p r o p o s e d s y s t e m . T h i s i s p a r t i c u l a r l y t r u e i n t h e e n u m e r a t i o n o f b e n e f i t s s i n c e t h e r e may be l i t t l e p o i n t i n d e l i n e a t i n g a l l t h e e l e m e n t s o f t h e s t a t u s quo. I t i s n e c e s s a r y , h o w e v e r , t o e n u m e r a t e t h e d i f f e r e n c e s i n b e n e f i t s a c c r u i n g t o t h e h o s p i t a l u p o n i n t r o d u c t i o n o f t h e H I S . T h u s , t h e g e n e r a l a p p r o a c h i s t o compare i n c r e m e n t a l c o s t s ( r e l a t i v e t o t h e s t a t u s q u o ) , w i t h i n c r e m e n t a l b e n e f i t s . 53 W h i l e i t i s t i d i e r t o t h i n k o f c o s t s i n t e r m s o f t h e e n t i r e H I S , r e a l i t y o f t e n means i n c r e m e n t a l i m p l e m e n t a t i o n o f s t a g e d m o d u l e s . T h i s b e i n g t h e c a s e , i n c r e m e n t a l ( o r m a r g i n a l ) c o s t s may a l s o n e e d t o be c o n s i d e r e d r e l a t i v e t o 14 t h e i n c r e m e n t a l b e n e f i t s o f e a c h m o d u l e . The m a r g i n a l c o s t s (and c o n s e q u e n t b e n e f i t s ) o f i n c r e m e n t a l l y a d d i n g a p p l i c a t i o n m o d u l e s , b o t h h a r d w a r e and s o f t w a r e , may be as i m p o r t a n t a s t h e t o t a l c o s t s ( o r b e n e f i t s ) o f t h e e n t i r e H I S . The i m p l e m e n t a t i o n s e q u e n c i n g i m p a c t s on s u c h i n c r e m e n t a l c o s t s . Some a p p l i c a t i o n s h a v e more t a n g i b l e b e n e f i t s t h a n o t h e r s ; h o w e v e r , t e c h n i c a l f i t and i m p l e m e n t a t i o n s e q u e n c i n g o f t h e m o d u l e s s o m e t i m e s p r e c l u d e g a i n i n g t h e h i g h - y i e l d b e n e f i t s f i r s t . W h i l e t h e c o n c e p t o f i n c r e m e n t a l c o s t s and b e n e f i t s i s i m p o r t a n t , b o u n d a r i e s must be p l a c e d on t h e s y s t e m ' s u l t i m a t e c o n f i g u r a t i o n i n s t e a d o f a t t e m p t i n g c o s t -b e n e f i t c a s e s f o r e a c h m o d u l e o f an i n c r e m e n t a l l y d e v e l o p e d H I S . I f t h i s i s n o t d o n e , t h e l a t t e r ' s i m p l e m e n t a t i o n s e q u e n c i n g may be l e s s t h a n o p t i m a l b e c a u s e i t i s o f t e n d i f f i -c u l t t o a c h i e v e n e t - b e n e f i t (as o p p o s e d t o n e t c o s t ) c a s e s f o r i n d i v i d u a l m o d u l e s . A t y p o l o g y o f t a n g i b l e and i n t a n g i b l e c o s t s i s g i v e n i n F i g u r e 1. T h e s e c o s t s h a v e b e e n c a t e g o r i z e d f r o m t h e 15 p e r s p e c t i v e o f t h e h o s p i t a l and a r e i n t e n d e d o n l y a s a g u i d e f o r d e t e r m i n i n g r e l e v a n t c o s t e l e m e n t s . T h i s s h o u l d p r o v e t o be a u s e f u l f r a m e w o r k f o r a s s i s t i n g a n a l y s t s i n t h e i d e n t i f i -c a t i o n o f s i m i l a r c o s t s i n t h e t y p i c a l B r i t i s h C o l u m b i a h o s p i t a l e n v i r o n m e n t . 54 FIGURE 1 ENUMERATION OF COSTS •TANGIBLE (QUANTITATIVE) .COSTS. ONE-TIME SYSTEMS (HARDWARE AND SOFTWARE) Hardware - System major components - Uninterruptible power supply (UPS) - Video Display Terminals (VDTs) - P r i n t e r s (fast and moderate speed) - E l e c t r o n i c Embossers - Interfaces to equipment (e.g., Laboratory) - Other Software - Operating Systems - A l l a p p l i c a t i o n systems (by module, i f appropriate) - Interfaces - Other Licenses Communications - Multiplexers ( i f applicable) - Modems - Wiring (includes materials and labour). - Other Other - Analyst and s e c r e t a r i a l support - Sales tax (Provincial) - Freight charges Hardware I n s t a l l a t i o n - B u i l d i n g renovations or space creation, including f i r e extinguisher system - In-house s t a f f support Software Implementation and I n s t a l l a t i o n - This i s vendor-supplied manpower and applies to each purchased systems a p p l i c a t i o n or module St a f f Training (Hardware and Software) .- Including r e l i e f "staff, t r a v e l , manuals and audio v i s u a l aids for implementation of HIS modules Conversion Costs - Conversion from manual and/or status quo to proposed system FIGURE 1-Continued ON-GOING COSTS (HARDWARE AND SOFTWARE) Lease Line(s) ( i f applicable) 1 Telephone - For data transmission, on-line trouble-shooting/repair and voice communications Computer Room Services - Including e l e c t r i c a l , heating, v e n t i l a t i n g , a i r conditioning ( i f applicable) In-house HIS S t a f f Support Vendor and/or Third Party Support (usually by service c o n t r a c t ) ; Spare Equipment/Parts ( i f necessary) [ Supplies (e.g., p r i n t e r ribbons, e t c . ) : Modifications/Enhancements A f t e r I n i t i a l Implementation Other J o i n t I n s t i t u t i o n a l Costs - Includes s e c u r i t y , administrative time, housekeeping ( i f applicable) Research and Development ( i f applicable) Opportunity Costs - Includes Space ( i f applicable) INTANGIBLE (QUALITATIVE) COSTS These are usually NOT included i n the CBA, depending on the preference of the analyst or scope of the study. S t a f f - System-induced f r u s t r a t i o n and str e s s , e s p e c i a l l y during implementation ( i d e n t i f y only)', - Other. 56 B e n e f i t s The e n u m e r a t i o n o f b e n e f i t s i s p e r h a p s more o n e r o u s t h a n t h e c o s t - s i d e o f t h e a n a l y s i s . As W a r n e r and L u c e p o i n t o u t i n t h e b r o a d e r c o n t e x t o f h e a l t h c a r e p r o g r a m s , b e n e f i t s a r e " . . . n u m e r o u s , d i v e r s e , o f t e n o b s c u r e , and o f t e n h a r d t o m e a s u r e , " ^ They f u r t h e r n o t e t h a t " t h e r e i s 17 no s i n g l e ' r i g h t ' way t o c a t e g o r i z e b e n e f i t s . . . " As w i t h c o s t s , e n u m e r a t i o n o f b e n e f i t s may be b e s t c a t e g o r i z e d by t a n g i b l e ( c o s t s a v o i d e d ) ' o r i n t a n g i b l e ( n o n - m o n e t a r y b e n e f i t s ) . B e n e f i t s i n t e r m s o f c o s t - i m p a c t s h a v e b e e n d i s -20-22 c u s s e d a t l e n g t h by D r a z e n . She n o t e s t h a t t h e m e t h o d o l -o g i e s u s e d a r e a f f e c t e d by t h e i n s t i t u t i o n a l s e t t i n g , t h e n a t u r e o f t h e p r o p o s e d c o m p u t e r i z e d s y s t e m and t h e p e r s p e c t i v e o f t h e e v a l u a t o r . She f u r t h e r a r g u e s t h a t : I n some c a s e s , c o s t s a v i n g s a l o n e a r e l i k e l y t o be t h e m a j o r i m p e t u s f o r a d o p t i n g a c o m p u t e r s y s t e m . I n o t h e r s , c o s t c o n s i d e r a t i o n s may be s e c o n d a r y t o o t h e r b e n e f i t s , b u t t h e e v a l u a t o r may w a n t t o know what p o r t i o n o f t h e s y s t e m c o s t s w i l l be o f f s e t by l a b o r s a v i n g s . C o n s i s t e n t w i t h t h e p u r p o s e o f t h e e v a l u a t i o n and t h e o b j e c t i v e s f o r t h e A H I S , s p e c i f i c i m p a c t a r e a s must be i d e n t i f i e d a nd q u e s t i o n s a n d / o r h y p o t h e s e s r e l a t i n g t o t h e i m p a c t s p o s e d . The m o s t common r e a s o n s f o r i m p l e m e n t i n g an AHIS a r e t o i n c r e a s e s t a f f p r o d u c t i v i t y (by r e m o v i n g t i m e -c o n s u m i n g p a p e r w o r k ) and t o make i n f o r m a t i o n f l o w more t i m e l y a n d r e l i a b l e . B e c a u s e o f t h e d i f f i c u l t y o f t r a n s l a t i n g p a t i e n t c a r e b e n e f i t s i n t o d o l l a r s a v i n g s , m o s t c o s t s t u d i e s h a v e b e e n f o c u s e d on c h a n g e s i n man-power p r o d u c t i v i t y and t h e i m p a c t o f t h e s e c h a n g e s on p e r s o n n e l c o s t s . Some s t u d i e s h a v e a l s o a s s e s s e d t h e n a t u r e a n d m a g n i t u d e o f o t h e r i m p a c t s , s u c h a s i n c r e a s e d 57 a c c u r a c y o f c o m m u n i c a t i o n s , b u t n o t t h e c o s t i m p l i c a t i o n s o f t h e s e b e n e f i t s . T h e r e f o r e , m o s t c o s t s t u d i e s c o n d u c t e d t o d a t e h a v e b e e n f o c u s e d on a l i m i t e d number o f t h e p o t e n t i a l c o s t i m p a c t s o f an AHIS.23 24 D r a z e n s u p p o r t s t h e p o s i t i o n t h a t l a b o r s a v i n g s a r e a m a j o r e c o n o m i c r a t i o n a l e f o r p u r s u i n g c o m p u t e r i z e d s y s t e m s . She i d e n t i f i e s f o u r d i f f e r e n t t e c h n i q u e s t h a t h a v e b e e n e m p l o y e d i n v a r i o u s h o s p i t a l s e t t i n g s i n t h e U n i t e d S t a t e s f o r e s t i m a t i n g l a b o r s a v i n g s . T h e s e i n c l u d e t a s k > a n a l y s i s , j o b c o n t e n t a n a l y s i s , w o r k s a m p l i n g and t r e n d a n a l y s i s . T a s k a n a l y s i s i n v o l v e s i d e n t i f i c a t i o n o f a l l w o r k a c t i v i t i e s t h a t w i l l be a f f e c t e d by c o m p u t e r i z a t i o n and m e a s u r i n g t h e t i m e s p e n t i n t h e m a n u a l s y s t e m . T h i s i s t h e n c o m p a r e d t o t h e t i m e s p e n t on t h e same a c t i v i t i e s u s i n g t h e c o m p u t e r i z e d s y s t e m ( e i t h e r m e a s u r e d i f a r e t r o s p e c t i v e s t u d y o r p r e d i c t e d i f a p r o s p e c t i v e s t u d y ) . T h i s m e thod i s d i s -c o u r a g e d b e c a u s e u n r e a l i s t i c a s s u m p t i o n s c a n e a s i l y be made ( s u c h a s u n r e a l i s t i c u p w a r d t r a n s f e r o f t a s k s and u n r e a l i s t i c s u m m a t i o n o f s a v e d s t a f f b e t w e e n d e p a r t m e n t s ) w h i c h c o u l d n e g a t i v e l y a f f e c t p r e d i c t e d l a b o r s a v i n g s . 25 J o b c o n t e n t a n a l y s i s o v e r c o m e s some o f t h e i n h e r e n t p r o b l e m s i n t a s k a n a l y s i s s i n c e i t i s t h e e m p l o y e e , n o t t h e t a s k , w h i c h i s o f i n t e r e s t . T h i s a p p r o a c h i s recommended a s b e i n g m o s t e f f i c i e n t f o r n o n - n u r s i n g l a b o r s u c h a s , f o r e x a m p l e , R a d i o l o g y and L a b o r a t o r y , b e c a u s e i t i s l e s s t i m e c o n s u m i n g t h a n t a s k a n a l y s i s and t h e r e s u l t s c a n be more 58 e a s i l y t r a n s l a t e d i n t o r e a l i s t i c s t a f f r e d u c t i o n s . Work s a m p l i n g (or d i r e c t o b s e r v a t i o n ) i n v o l v e s t h e p e r i o d i c measurement of a c t i v i t i e s o f p e r s o n n e l o ver an extended time p e r i o d . Such d a t a a r e used t o d e s c r i b e how i n d i v i d u a l s o r c a t e g o r i e s o f s t a f f spend t h e i r t i m e . T h i s approach i s p a r t i c u l a r l y u s e f u l f o r a n a l y z i n g l a b o r i m p a c t s i n n u r s i n g u n i t s s i n c e n u r s e s p e r f o r m many i n f o r m a t i o n h a n d l i n g t a s k s d u r i n g t h e i r c a r e o f p a t i e n t s ; however, t h e y do not spend l a r g e b l o c k s o f time s o l e l y on i n f o r m a t i o n h a n d l i n g t a s k s . 27 F i n a l l y , t r e n d a n a l y s i s i n v o l v e s t h e e x a m i n a t i o n o f t r e n d s i n c o s t v a r i a b l e s b e f o r e and a f t e r i m p l e m e n t a t i o n o f a c o m p u t e r i z e d system. T h i s t e c h n i q u e i s more a p p l i c a b l e i n r e t r o s p e c t i v e r a t h e r t h a n p r o s p e c t i v e s t u d i e s and e s s e n t i a l l y i n v o l v e s p l o t t i n g h i s t o r i c a l v e r s u s p r e d i c t e d t r e n d s i n l a b o r p r o d u c t i v i t y . Other b e n e f i t elements t h a t c o u l d be c o n s i d e r e d i n -28 e l u d e : r e s e a r c h and development s p i l l o v e r s , i n c r e a s e i n t h e s t a n d a r d o f q u a l i t y o f w o r k - l i f e , e n v i r o n m e n t a l improvements i n the w o r k p l a c e and o t h e r p o s i t i v e t e c h n o l o g i c a l e x t e r n a l i t i e s . W h i l e t h e s e c o u l d be q u a n t i f i e d , i n p r a c t i c e t h e y o f t e n are n o t depending on t h e r e l a t i v e l i k e l y magnitudes. I t i s i n -cumbent upon the a n a l y s t t o e x p l i c i t l y enumerate them as a m i n i m a l r e q u i r e m e n t o f the. CBA. G a l l r a i s e s an i m p o r t a n t p o i n t w i t h r e s p e c t t o CBA i n 59 a n o n - r e s e a r c h ( f o r e x a m p l e , c o m m u n i t y h o s p i t a l ) s e t t i n g : . . . i t i s o f t e n v e r y d i f f i c u l t t o p r o v e i n a d i r e c t c a u s a l m a n n e r t h a t a p a r t i c u l a r o b s e r v e d e c o n o m i c e f f e c t o c c u r r e d b e c a u s e o f t h e s y s t e m . T h e p r o b l e m e x i s t s i n t r y i n g t o i s o l a t e o r s e p a r a t e t h e c h a n g e i n t h e v a r i a b l e b e i n g s t u d i e d f r o m t h e c h a n g e i n m a n y o t h e r a s s o c i a t e d v a r i a b l e s . . . C a l c u l a t i o n o f b e n e f i t s i s f u r t h e r c o m p l i -c a t e d b y l a c k o f a g r e e m e n t n o t o n l y u p o n t h e e x t e n t o f s a v i n g s d u e t o t h e s y s t e m , b u t a l s o t h e i r p r o p e r v a l u a t i o n f o r t h e h o s p i t a l . O p i n i o n o f w h a t c o n s t i t u t e s a s y s t e m s a v i n g s a n d t h e a p p r o p r i a t e v a l u a t i o n t h a t m a y b e c r e d i t e d t o t h e ^ s y s t e m m a y r a n g e w i d e l y f r o m h o s p i t a l t o h o s p i t a l . R e d u c t i o n i n p a t i e n t l e n g t h o f s t a y ( L O S ) i s a n o t h e r p o t e n t i a l b e n e f i t w h i c h m e r i t s c o n s i d e r a t i o n ; h o w e v e r , i t i s o n l y s i g n i f i c a n t i f m a t c h e d w i t h e x c e s s d e m a n d f o r b e d s o r , a s a r e s u l t o f i m p l e m e n t a t i o n , b e d s a r e c l o s e d . T h e l a t t e r s h o u l d t h e n t r a n s l a t e t o l a b o r a n d n o n - l a b o r s a v i n g s . M o r e -o v e r , t h e c a u s a l l i n k b e t w e e n s y s t e m i n t r o d u c t i o n a n d r e d u c e d 3 0 3 1 L O S i s v e r y d i f f i c u l t , i f n o t i m p o s s i b l e , t o d e m o n s t r a t e . ' P e r h a p s t h e a d v e n t o f a D R G - b a s e d p r o s p e c t i v e r e i m b u r s e m e n t m e t h o d o l o g y w i l l m o r e c l e a r l y s h o w a c a u s e - e f f e c t r e l a t i o n s h i p ; h o w e v e r , a t t h e p r e s e n t t i m e t h e a n n u a l o p e r a t i n g g r a n t s y s t e m p r e c l u d e s p r o v i n g a n y d i r e c t r e l a t i o n s h i p b e t w e e n t h e i n t r o -d u c t i o n o f a n H I S a n d r e d u c e d L O S . T h u s , t h i s b e n e f i t i s a d i f f i c u l t o n e t o p u r s u e . . \ A s w i t h t h e c o s t - s i d e o f t h e a n a l y s i s a n d c o n d i t i o n a l o n t h e i n i t i a l q u e s t i o n , i t i s t h e i d e n t i f i c a t i o n o f d i f f e r e n c e s o r c h a n g e s i n b e n e f i t s , n o t t h e d e t e r m i n a t i o n o f t h e i r a b s o l u t e v a l u e s t h a t i s i m p o r t a n t u n l e s s o n e i s i n d e p e n d e n t l y i n t e r e s t e d 60 i n t h e a c t u a l c o s t s o f r u n n i n g e i t h e r s y s t e m . I t i s n o t n e c e s s a r y t o f u l l y e n u m e r a t e a l l t h e b e n e f i t s o f t h e s t a t u s quo a n d a l l t h e b e n e f i t s o f t h e p r o p o s e d s y s t e m . I t i s n e c e s s a r y t o i d e n t i f y c h a n g e s i n b e n e f i t s a c c r u i n g s o l e l y a s t h e r e s u l t o f i m p l e m e n t a t i o n o f t h e c o m p u t e r i z e d s y s t e m . I n t a n g i b l e , b e n e f i t s a l s o d e s e r v e s p e c i a l c o n s i d e r a t i o n by t h e a n a l y s t , who s h o u l d a g a i n a s k : "Does i t a p p e a r l i k e l y i n any p a r t i c u l a r i n s t a n c e t h a t t h e v a l u e s a f f e c t e d by t h e i n t a n g i b l e e f f e c t s c o u l d h a v e b e e n l a r g e e n o u g h , i f t h e y h a d i n f a c t b e e n q u a n t i f i e d , t o h a v e s u b s t a n t i a l l y a l t e r e d t h e 32 f i n d i n g s o f t h e b e n e f i t - c o s t s t u d y ? " S u c h i n t a n g i b l e e f f e c t s , t h e r e f o r e , may be r e l a t i v e l y u n i m p o r t a n t u n d e r c e r t a i n c i r c u m s t a n c e s s u c h a s t h e w i l l i n g n e s s o f d e c i s i o n -m a k e r s t o p r o c e e d w i t h t h e p r o g r a m f o r p o l i t i c a l r e a s o n s o n l y o r i f t h e r e i s a h i g h p r o b a b i l i t y t h a t t h e i n t a n g i b l e e f f e c t s 33 34 w i l l n o t o c c u r . H a m i l t o n a n d C h e r v a n y n o t e t h a t s u c h i n t a n g i b l e , q u a l i t a t i v e e f f e c t s t e n d t o be i g n o r e d i n many 35 36 c a s e s . D i t t m a n a n d S m i t h a nd S t o d d a r t a n d Drummond i n d i -c a t e t h a t t h e y a r e o f t e n e x c l u d e d f r o m t h e a n a l y s i s . A s u g g e s t e d c a t e g o r i z a t i o n o f b e n e f i t s i s d e m o n s t r a t e d i n F i g u r e 2 f o r u s e a s a f r a m e w o r k i n e n u m e r a t i n g b e n e f i t s . A s w i t h c o s t s , e x p l i c i t i d e n t i f i c a t i o n i s c r i t i c a l t o a g o o d a n a l y s i s s i n c e t h e n e x t s t e p s , q u a n t i f i c a t i o n a n d v a l u a t i o n , w i l l o n l y be a s c o m p r e h e n s i v e a s a l l o w e d b y t h e i n i t i a l e n u -m e r a t i o n o f c o s t s a n d b e n e f i t s . FIGURE 2 ENUMERATION OF BENEFITS TANGIBLE (QUANTIFIABLE IN DOLLARS) BENEFITS ONE-TIME - Status quo equipment no longer required (e.g., resale value) - Status quo forms/printing, etc. no longer required •r Others, e.g., space savings ON-GOING - Increased s t a f f p r o d u c t i v i t y and labor savings calculated by Job Content Analysis (non-nursing departments) and Work Sampling (nursing units) - Reduction of outstanding accounts, e.g., reduction of bad debts (patient accounts) and foregone i n t e r e s t on those accounts - Reduction of l o s t revenue i n Cafet e r i a (st a f f and guests) - Reduction of food wastage - Reduction of misappropriated s t a f f b e n e f i t entitlements - P o s i t i v e technological e x t e r n a l i t i e s , e.g., R & D s p i l l - o v e r s , such as software sales revenue, i f applicable - Reduction i n patient length of stay - Others, depending on modules proposed and HSP study which should precede the CBA stage INTANGIBLE (QUALITATIVE) BENEFITS These are usually NOT included i n the ana l y s i s , depending on the preference of the analyst or scope of the study. Examples include: - Improved s t a f f morale - More timely messages - Patient s a t i s f a c t i o n - Integrated health records r e s u l t i n g i n higher standard of patient care and better analysis of data - Improved i n t r a - and inter-departmental r e l a t i o n s h i p s - Greater consistency i n nursing care - Improved Quality Assurance program - Increase i n standard of q u a l i t y of work-life 62 Q u a n t i f i c a t i o n o f C o s t s a n d B e n e f i t s T a n g i b l e C o s t s Once t h e r e l e v a n t c o s t s h a v e b e e n i d e n t i f i e d , t h e y m u s t be q u a n t i f i e d i n a p p r o p r i a t e p h y s i c a l u n i t s . F o r t a n g i b l e c o s t s t h i s i s f a i r l y s t r a i g h t f o r w a r d a n d may be c o m b i n e d w i t h t h e v a l u a t i o n s t e p . One s p e c i a l s i t u a t i o n p r e s e n t i n g a p r o b l e m i s t h a t o f j o i n t r e s o u r c e u t i l i z a t i o n 37 a n d a l l o c a t i o n . T h i s a p p l i e s t o s h a r e d o v e r h e a d c o s t s s u c h as c o m p u t e r room s e r v i c e s i n c l u d i n g h e a t i n g , l i g h t i n g , t e l e -p h o n e , e t c . I n t h i s c a s e , S t o d d a r t a n d Drummond recommend t h a t " r e a s o n a b l e " c r i t e r i a be u s e d i n t h e d i s t r i b u t i o n o f t h e 38 common c o s t s . W a r n e r a nd L u c e s u g g e s t t h a t s u c h m e a s u r e -ment commonly c o n s i s t s o f c o u n t i n g t h e number o f h o u r s o r d a y s r e q u i r e d f o r p l a n t m a i n t e n a n c e l a b o r , t h e p h y s i c a l q u a n t i t i e s o f s u p p l i e s , t h e amount and u s e o f c a p i t a l g o o d s and so o n , u s e d s p e c i f i c a l l y by t h e i n f o r m a t i o n s y s t e m a nd r e l a t i v e t o t h e t o t a l s f o r t h e s e c o s t c a t e g o r i e s . I n t a n g i b l e C o s t s I n t a n g i b l e c o s t s , b e c a u s e t h e y a r e d i f f i c u l t t o i n -c l u d e i n t h e CBA and p r o v i d e d t h e y h a v e b e e n i d e n t i f i e d q u a l i t a t i v e l y , c a n be s e t a s i d e f r o m t h e a c t u a l a n a l y s i s ; h o w e v e r , t h e y s h o u l d n o t be d i s m i s s e d c o m p l e t e l y s i n c e t h e y may be o f i m p o r t a n c e d u r i n g t h e i n t e r p r e t a t i o n a n d p r e s e n t a t i o n s t a g e o f t h e a n a l y s i s a n d be u s e f u l d u r i n g t h e d e c i s i o n - m a k i n g p r o c e s s , p a r t i c u l a r l y w h e r e t a n g i b l e c o s t s e x c e e d t a n g i b l e b e n e f i t s . 63 T a n g i b l e B e n e f i t s E f f o r t s t o q u a n t i f y t a n g i b l e b e n e f i t s s h o u l d be d i r e c t e d p r i m a r i l y a t s u c h t h i n g s a s s t a f f l a b o r s a v i n g s , m a j o r e q u i p m e n t , a p p a r a t u s , r e d u c t i o n o f w a s t a g e and t h e l i k e . T h e r e i s an i n h e r e n t d a n g e r i n t h i s s t a g e o f b e i n g t o o o p t i m i s t i c i n t h e q u a n t i f i c a t i o n o f p o t e n t i a l b e n e f i t s w h i c h w a r r a n t s a n o t e o f c a u t i o n -- e r r on t h e s i d e o f m o d e r a t i o n ! I n p r a c t i c e , b e c a u s e s u c h h e a l t h c a r e r e s o u r c e b e n e f i t s a r e commonly m e a s u r e d d i r e c t l y i n m o n e t a r y u n i t s , a 39 b l e n d i n g o f b e n e f i t m e a s u r e m e n t a n d v a l u a t i o n i s p o s s i b l e . I n t a n g i b l e B e n e f i t s A s w i t h q u a n t i f i c a t i o n o f i n t a n g i b l e c o s t s , i n t a n g i b l e b e n e f i t s c a n c r e a t e m a j o r p r o b l e m s . W a r n e r and L u c e n o t e ". . . a n a l y s t s m u s t a c c e p t t h e f a c t t h a t some b e n e f i t s c a n n o t be q u a n t i f i e d a n d f i n d ways t o p r o c e e d w i t h t h e 4 q u a n t i t a t i v e a n a l y s i s w i t h o u t l o s i n g s i g h t o f t h e s e b e n e f i t s . T h u s , i n p r a c t i c e , q u a n t i f i c a t i o n o f t h e i n t a n g i b l e b e n e f i t s i s r a r e l y a t t e m p t e d , b u t s u c h b e n e f i t s s h o u l d a t l e a s t be b r o u g h t t o t h e a t t e n t i o n o f t h e d e c i s i o n - m a k e r s a l o n g w i t h some e s t i m a t e o f t h e i r i m p o r t a n c e a nd b e a r i n g on t h e d e c i s i o n . V a l u a t i o n o f c o s t s and b e n e f i t s T h i s s t e p i n v o l v e s t h e c o n v e r s i o n o f q u a n t i f i e d c o s t s and b e n e f i t s t o m o n e t a r y u n i t s . I t i s i m p o r t a n t t h a t t h e s o u r c e s a n d m e t h o d s o f v a l u a t i o n be c l e a r l y s t a t e d . 64 T a n g i b l e C o s t s T h i s i s f a i r l y s t r a i g h t f o r w a r d and i n v o l v e s a t t a c h i n g d o l l a r v a l u e s t o t h e i d e n t i f i e d a n d q u a n t i f i e d t a n g i b l e c o s t s u s i n g m a r k e t p r i c e s , c u r r e n t wage r a t e s , b e n e f i t e n t i t l e m e n t s and c o s t p e r s q u a r e m e t e r o f s p a c e , i f a p p l i c a b l e . The s p e c i a l p r o b l e m o f i n f l a t i o n o f f u t u r e c o s t s w i l l be d i s c u s s e d l a t e r . Any a s s u m p t i o n s made must be c l e a r l y s t a t e d a s s h o u l d any e x c l u s i o n s f r o m t h i s s t e p . I n t a n g i b l e C o s t s As i n t h e q u a n t i f i c a t i o n s t e p , i n t a n g i b l e c o s t s s h o u l d be s e t a s i d e b u t n o t be d i s m i s s e d c o m p l e t e l y s i n c e t h e y may be o f i m p o r t a n c e d u r i n g t h e d e c i s i o n - m a k i n g s t a g e . T a n g i b l e B e n e f i t s T h i s i s p e r h a p s t h e most d i f f i c u l t s t e p o f t h e CBA. As w i t h c o s t s , m a r k e t p r i c e s s h o u l d be u s e d p a r t i c u l a r l y a s t h e s e r e l a t e t o s t a f f l a b o r s a v i n g s . I n j o b c o n t e n t a n a l y s i s and w ork s a m p l i n g p r e d i c t i o n s , e s t i m a t e s o f t i m e s a v i n g s c a n 4 2 be made a l o n g w i t h j o b r e a l i g n m e n t s a n d s t a f f i n g c h a n g e s . I f m a r k e t p r i c e s a r e d i f f i c u l t t o a s s o c i a t e d i r e c t l y w i t h r e a l i z e d b e n e f i t s , i m p u t e d p r i c e s c a n s e r v e t o v a l u e t h e 43 b e n e f i t s . The u s e o f h o s p i t a l v o l u n t e e r l a b o r i s one e x a m p l e o f s u c h p r o d u c t i v e a c t i v i t y w h i c h c o u l d be a c c o u n t e d f o r a n d v a l u e d . I n t a n g i b l e B e n e f i t s A g a i n , i n t a n g i b l e b e n e f i t s s h o u l d be s e t a s i d e f o r p o s s i b l e u s e l a t e r . D i s c o u n t i n g o f C o s t s and B e n e f i t s B e c a u s e a l l c o s t s and b e n e f i t s a s s o c i a t e d w i t h t h e p u r c h a s e and i m p l e m e n t a t i o n o f an HIS do n o t o c c u r s i m u l t a -n e o u s l y b u t , r a t h e r , a r e t y p i c a l l y s t a g e d o v e r s e v e r a l y e a r s ' d u r a t i o n , i t i s n e c e s s a r y t o a p p l y an a c c o u n t i n g m e thod known as d i s c o u n t i n g i n o r d e r t o compute t h e p r e s e n t v a l u e o f s t r e a m s o f c o s t s and b e n e f i t s . T h i s h a s b e e n c o m p r e h e n -s i v e l y d i s c u s s e d i n t h e c o n t e x t o f h e a l t h c a r e , m e d i c a l 4 4 - 4 8 t e c h n o l o g y and i n f o r m a t i o n s y s t e m s by s e v e r a l a u t h o r s . The b a s i c p r i n c i p l e i n d i s c o u n t i n g i s t h a t , c e t e r i s p a r i b u s , money h a s t i m e v a l u e and i n d i v i d u a l s ( o r h o s p i t a l s ) h a v e t i m e p r e f e r e n c e s . T h u s , f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l , a d o l l a r i n t h e p r e s e n t i s w o r t h more t h a n t h e same d o l l a r i n t h e f u t u r e . T h i s p r i n c i p l e a p p l i e s b o t h t o t h e c o s t - s i d e o f t h e a n a l y s i s a n d t h e q u a n t i f i e d b e n e f i t -s i d e . I n p r i n c i p l e , t h e d i s c o u n t i n g p r o c e s s i s r e l a t i v e l y s i m p l e ; i n p r a c t i c e , i t r e p r e s e n t s a. number o f c a l c u l a t i o n s w h i c h c o u l d be s e t up o n an e l e c t r o n i c s p r e a d s h e e t , a v e r y few l i n e s o f c o d e , o r be h a n d l e d by m o s t h a n d c a l c u l a t o r s w i t h m i n i m a l e f f o r t . Once t h e e n u m e r a t i o n , q u a n t i f i c a t i o n a n d v a l u a t i o n o f c o s t s and b e n e f i t s h a s b e e n a c c o m p l i s h e d , d i s c o u n t i n g c a n p r o c e e d . S i m p l y s t a t e d , t h i s c o n s i s t s o f s e t t i n g o u t .the c o s t t i m e s t r e a m and t h e b e n e f i t t i m e s t r e a m f o r t h e d u r a t i o n o f t h e c o m p u t e r p r o j e c t , s a y , f i v e o r e i g h t y e a r s . 66 The f o r m u l a f o r p r e s e n t d i s c o u n t e d v a l u e (pdv) i s 49 s i m p l y the i n v e r s e o f the compound i n t e r e s t f o r m u l a , t h a t 50 i s , a r e v e r s e i n t e r e s t r a t e . T h i s a p p l i e s t o b o t h t h e c o s t stream and the b e n e f i t stream. I n i t s s i m p l e form, p r e s e n t d i s c o u n t e d v a l u e f o r a s i n g l e y e a r i s t y p i f i e d by t h e f o l l o w i n g e q u a t i o n : pdv = B o r C n (1.0+r) B = amount o f b e n e f i t s C = amount o f c o s t s r = d i s c o u n t r a t e n = y e a r b e n e f i t o r c o s t o c c u r s Thus, f o r t h e e n t i r e t i m e stream t h i s becomes: For C o s t s : pdv Where: + + + n (1+r) (1+r) (i+r) n C , = p r e s e n t d i s c o u n t e d v a l u e f o r e n t i r e p stream o f c o s t s = immediate c o s t s = c o s t s i n y e a r 1 = c o s t s i n y e a r 2 n = c o s t s i n y e a r n Or, more s i m p l y s t a t e d : * - n c. c = > J p d v f=o -(1+r) ^ Where: ^" = summation j = the y e a r from t h e immediate time n the f i n a l y e a r 67 F o r b e n e f i t s , we s i m p l y s u b s t i t u t e B f o r C; t h e c a l c u l a t i o n s a r e i d e n t i c a l . S e l e c t i o n o f an a p p r o p r i a t e d i s c o u n t r a t e p r e s e n t s a p r o b l e m b e c a u s e t h e r e i s l i t t l e o r no c o n s e n s u s r e g a r d i n g t h e r a t e t h a t s h o u l d be u s e d . 5 1 - ^ 4 C h o i c e o f an a p p r o p r i a t e r a t e i s v e r y i m p o r t a n t , h o w e v e r , b e c a u s e o f t h e i m p a c t i t c a n h a v e on t h e a s s e s s m e n t o f t h e a l t e r n a t i v e s u n d e r c o n s i d e r a t i o n . From t h e p e r s p e c t i v e o f t h e h o s p i t a l , 55 A n d e r s o n and S e t t l e c a u t i o n t h a t , i n t h e t e n d e n c y t o d i s -c o u n t a t h i g h e r r a t e s , t h e p r e s e n t v a l u e o f f u t u r e e f f e c t s i s q u i c k l y d i m i n i s h e d , p a r t i c u l a r l y f o r p r o j e c t s t h a t h a v e v e r y l o n g t e r m b e n e f i t s . W i t h r e s p e c t t o h o s p i t a l c o m p u t e r s y s t e m s , t h e y i e l d o f b e n e f i t s i s , r e a l i s t i c a l l y , u n l i k e l y p a s t t h e e i g h t t o t e n y e a r mark. W h i l e t h e d i s c o u n t r a t e i s n o t a f u n c t i o n o f t h e t y p e o f p r o j e c t , t h e r e i s a t e n d e n c y t o u s e h i g h e r d i s c o u n t r a t e s i n o r d e r t o d i m i n i s h t h e s y s t e m c o s t s , a s s u m i n g i m p l e m e n t a t i o n o c c u r s o v e r s e v e r a l y e a r s ; h o w e v e r , b e c a u s e c o s t s g e n e r a l l y t e n d t o p r e c e d e b e n e f i t s , h i g h e r d i s c o u n t r a t e s w o u l d make t h e s y s t e m a p p e a r e c o n o m i c a l l e s s a t t r a c t i v e . I f p o s s i b l e , t h e d i s c o u n t r a t e u s e d by t h e MOH s h o u l d be i n c o r p o r a t e d a s one o f s e v e r a l r a t e s . C h a r a c t e r i s t i c o f g o o d CBAs, s e v e r a l d i s c o u n t r a t e s a r e u s e d i n o r d e r t o t e s t t h e s e n s i t i v i t y o f t h e n e t b e n e f i t s o f t h e p r o j e c t t o a l t e r n a t i v e r a t e s . I n f l a t i o n r a i s e s a s p e c i a l c o n c e r n . W a r n e r and L u c e " ^ 68 a s s e r t t h a t w h i l e n o t a s o u r c e o f t e c h n i c a l d i f f i c u l t y , d o l l a r f i g u r e s s h o u l d be d e f l a t e d t o t h e p r i c e l e v e l o f a s i n g l e y e a r b e f o r e t h e d i s c o u n t i n g p r o c e s s i s a p p l i e d . They s u g g e s t t h a t by b r i n g i n g s u c h d o l l a r v a l u e s t o a s i n g l e y e a r , s a y , t o d a y ' s p r i c e s , t h e m e s s i n e s s o f i n f l a t i o n i s a v o i d a b l e . The p r o b l e m o f i n f l a t i o n h a s a l s o b e e n d i s c u s s e d by A n d e r s o n and S e t t l e who c a u t i o n t h e a n a l y s t t o a v o i d h a v i n g p u r e l y i n f l a t i o n a r y e f f e c t s i n f l u e n c e t h e outcome o f t h e CBA. They c o n c l u d e t h a t i n f l a t i o n i s p r o p e r l y h a n d l e d as f o l l o w s : (1) e s t i m a t e a l l f u t u r e b e n e f i t s a n d c o s t s i n c o n s t a n t p r i c e s ( t h a t i s , s i m p l y assume no i n f l a t i o n ) a n d u s e , a s t h e d i s c o u n t r a t e , an e s t i m a t e o f t h e p r i v a t e o p p o r t u n i t y c o s t o f c a p i t a l i n t h e a b s e n c e o f a n t i c i p a t e d i n f l a t i o n , o r ( 2 ) e s t i m a t e a l l f u t u r e e f f e c t s i n c u r r e n t ( t h a t i s , i n f l a t e d ) p r i c e s a n d u s e a s t h e d i s c o u n t r a t e an e s t i m a t e o f t h e p r i v a t e o p p o r t u n i t y c o s t o f c a p i t a l i n t h e p r e s e n c e o f t h e a n t i c i p a t e d r a t e o f i n f l a t i o n . 5 7 I n p r a c t i c e , t h e y s u g g e s t t h a t m o s t a n a l y s t s p r o b a b l y e s t i m a t e f u t u r e b e n e f i t s a n d c o s t s i n c o n s t a n t p r i c e s a n d t h e r e b y i g n o r e i n f l a t i o n . T h i s p r a c t i c e i s a c c e p t a b l e p r o -v i d i n g t h e i m p l i e d a s s u m p t i o n t h a t a l l c o s t s a n d b e n e f i t s i n f l a t e a t t h e same r a t e o v e r t h e d u r a t i o n o f t h e p r o j e c t i s deemed r e a l i s t i c . As a m a t t e r o f common p r a c t i c e , some l i k e l y t i m e - p r e f e r e n c e r a t e i s a r b i t r a r i l y s e l e c t e d = f o r d i s c o u n t i n g t h e c o s t s a n d b e n e f i t s o f p u b l i c s e c t o r p r o j e c t s . S e n s i t i v i t y A n a l y s i s The i m p o r t a n c e o f s e n s i t i v i t y a n a l y s i s i n o r d e r t o p r o b e t h e i m p a c t o f u n c e r t a i n t i e s i n CBA h a s b e e n d i s c u s s e d e x t e n s i v e l y . E s s e n t i a l l y , t h i s s t e p i n v o l v e s t e s t i n g v a r i o u s a s s u m p t i o n s and v a r i a b l e s a b o u t w h i c h t h e a n a l y s t i s u n c e r t a i n a n d t h a t a r e s i g n i f i c a n t e n o u g h t o a l t e r t h e r e s u l t s i f r e a s o n a b l e s h i f t s i n t h e i r v a l u e o c c u r . One e x a m p l e i s t h e d i s c o u n t r a t e a n d t h e o v e r a l l i m p a c t i t h a s on t h e e c o n o m i c f e a s i b i l i t y o f t h e p r o j e c t . T h i s i n v o l v e s t e s t i n g s e v e r a l p o s s i b l e d i s c o u n t r a t e s , s a y , t h r e e , f i v e a n d s e v e n p e r c e n t . I f t h i s v a l u e i s p r e d e t e r m i n e d by t h e MOH i t may s e r v e t o be more an a c a d e m i c e x e r c i s e t h a n a p r a c t i c a l o n e. As W a r n e r and L u c e e m p h a s i z e w i t h r e s p e c t t o t h e u n c e r t a i n t i e s p o s e d by CBA: R a t h e r t h a n v i e w i n g u n c e r t a i n t y a s a s o u r c e o f d e s p a i r , a n a l y s t s a n d r e a d e r s s h o u l d a c c e p t i t a s a f a c t o f a n a l y t i c a l l i f e a n d a p p r o a c h t h e d e t e r m i n a t i o n o f i t s i m p o r t a n c e as an i n t e r e s t i n g c h a l l e n g e . 6 3 On t h e o t h e r h a n d , t h e a b o v e - n o t e d a u t h o r s e m p h a s i z e t h a t s t u d i e s w h i c h do n o t p r e s e n t some s e n s i t i v i t y t e s t s c a s t c o n s i d e r a b l e d o u b t on t h e m e t h o d o l o g y e m p l o y e d b y t h e a n a l y s t . The r e a l v a l u e o f p e r f o r m i n g s e n s i t i v i t y a n a l y s e s l i e s i n s a t i s f y i n g t h e a n a l y s t a n d d e c i s i o n - m a k e r s t h a t , o v e r r e a s o n -a b l e r a n g e s o f t h e " u n c e r t a i n " v a r i a b l e s , t h e r e s u l t s r e m a i n r e l a t i v e l y u n c h a n g e d . I f t h e y do c h a n g e s i g n i f i c a n t l y , t h e a s s u m p t i o n s a nd d e c i s i o n s made a s a r e s u l t o f t h e s t u d y a r e somewhat t e n u o u s . I n t e r p r e t a t i o n a n d P r e s e n t a t i o n o f F i n d i n g s The f i n a l s t e p i n CBA i s o f t e n o b s c u r e f r o m t h e p e r -s p e c t i v e o f t h e a n a l y s t , e v e n t u a l r e a d e r s and d e c i s i o n -70 m a k e r s . The f o r e g o i n g p r i n c i p l e s c a r r y m a j o r a s s u m p t i o n s , a n d l i m i t a t i o n s o f m e t h o d o l o g y t h a t u l t i m a t e l y i m p a c t on t h e i n t e r p r e t a t i o n a n d p r e s e n t a t i o n o f t h e f i n d i n g s . M o r e o v e r , t h e l i m i t a t i o n s o f CBA i m p a c t s u b s t a n t i a l l y on i t s i n t e r -p r e t a t i o n a n d u s e . T h u s , t h e more p r e c i s e t h e s t u d y a n d t h e more e x p l i c i t l y s t a t e d t h e e n u m e r a t i o n , q u a n t i f i c a t i o n a n d v a l u a t i o n o f c o s t s a n d b e n e f i t s , t h e l e s s s u b j e c t i t i s t o i n t e r p r e t a t i o n . As W a r n e r and L u c e p o i n t o u t a b o u t a n a l y s t s : . . . [They] a r e i n j e o p a r d y o f m i s i n t e r p r e t i n g t h e i r own a n a l y s e s b e c a u s e t h e y may l o s e s i g h t o f , and e v e n t u a l l y i g n o r e , t h e a s s u m p t i o n s a n d u n c e r t a i n t i e s t h a t a r i s e i n t h e c o u r s e o f a n a l y s i s . U n l e s s t h e y h a v e t e s t e d t h e s e w i t h s e n s i t i v i t y a n a l y s i s , t h e y c a n n o t make a j u d g m e n t on t h e u s e f u l n e s s o f t h e i r f i n d i n g s . 6 4 M o r e o v e r , a s S t o d d a r t and Drummond h a v e p o i n t e d o u t : . . . A g o o d s t u d y s h o u l d l e a v e y o u more ( r a t h e r t h a n l e s s ) a w a r e o f t h e v a r i o u s t e c h n i c a l a n d v a l u e j u d g e -m ents n e c e s s a r y t o a r r i v e a t d e c i s i o n s on t h e a l l o c a t i o n o f r e s o u r c e s i n h e a l t h c a r e . 6 5 I t i s b e y o n d t h e s c o p e o f t h i s t h e s i s t o e n u m e r a t e e a c h p o t e n t i a l p i t f a l l i n d o i n g e a c h s t e p o f t h e CBA. S e v e r a l m a j o r m e t h o d o l o g i c p i t f a l l s h a v e b e e n i d e n t i f i e d i n t h e f o r e g o i n g d i s c u s s i o n ; h o w e v e r , t h e r e a d e r i s d i r e c t e d t o t h e l i t e r a t u r e c i t e d f o r more c o m p l e t e d i s c u s s i o n s a n d e l u c i d a t i o n o f p i t f a l l s a n d p r o b l e m s a s s o c i a t e d w i t h t h e m e t h o d o l o g y . On t h e o t h e r h a n d , t h i s i s an a p p r o p r i a t e p l a c e t o i d e n t i f y a n d d i s c u s s i n some d e t a i l t h e g e n e r a l l i m i t a t i o n s o f p r e d i c t i v e e c o n o m i c e v a l u a t i o n t e c h n i q u e s f o r H I S , i n p a r t i c u l a r , CBA. E c o n o m i c e v a l u a t i o n o f t e n a s s u m e s , r a t h e r t h a n e s t a b l i s h e s , 71 6 6 p r o g r a m e f f e c t i v e n e s s . S e c o n d , f r o m a p o l i c y p e r s p e c t i v e , e c o n o m i c e v a l u a t i o n s do n o t u s u a l l y c o n s i d e r t h e d i s t r i b u t i o n 6 7 o f c o s t s a n d b e n e f i t s . T h i r d , i s t h e a s s u m p t i o n t h a t r e s o u r c e s f r e e d up o r s a v e d t h r o u g h b e n e f i t r e a l i z a t i o n w i l l n o t be w a s t e d , b u t w i l l be u s e d i n a l t e r n a t i v e a n d w o r t h w h i l e 6 8 p r o g r a m s . E a c h o f t h e s e a s s u m p t i o n s b e a r s h e a v i l y on i n t e r -p r e t a t i o n o f t h e CBA a n d f r o m i t any r e c o m m e n d a t i o n s made t o t h e d e c i s i o n - m a k e r s . B e c a u s e b e n e f i t s , i n p a r t i c u l a r l a b o r - r e l a t e d b e n e f i t s , w i l l u n d o u b t e d l y c o n s t i t u t e t h e most s i g n i f i c a n t p a r t o f t h e b e n e f i t - s i d e o f an HIS e v a l u a t i o n , i t i s i m p o r t a n t t h a t t h i s be b r o u g h t i n t o t h e i n t e r p r e t a t i o n a n d p r e s e n t a t i o n o f t h e f i n d i n g s . I n p r e d i c t i v e CBAs s u c h a s t h a t s e t o u t a b o v e , a l l p o t e n t i a l b e n e f i t s a r e e n u m e r a t e d . I t f a l l s t o management t o c o n v e r t p o t e n t i a l t o r e a l i t y a n d t o c o n v i n c e f u n d i n g a g e n c i e s t h a t t h i s c a n and w i l l be done. Once t h e n e c e s s a r y o p e r a t i o n a l a d j u s t m e n t s , s a y l a b o r r e d u c t i o n s , h a v e o c c u r r e d , b e n e f i t s h a v e b e e n r e a l i z e d a n d c o s t - s a v i n g s o r c o s t - a v o i d a n c e s a c h i e v e d . ^ 9 70 71 72 Hodge, Norwood a nd G a l l h a v e c a t e g o r i z e d l a b o r b e n e f i t s i n t o t h r e e c l a s s e s : t h o s e w h i c h f o l l o w a u t o m a t i c a l l y ; t h o s e w h i c h r e q u i r e e x p l i c i t e f f o r t ; a n d t h o s e s p i n o f f b e n e f i t s made p o s s i b l e , b u t w h i c h a r e n o t i n t e g r a l t o t h e s y s t e m and t h u s , p r e s u m a b l y , may n o t be t a k e n up. W h i l e t h e e n u m e r a t i o n , q u a n t i f i c a t i o n a n d v a l u a t i o n o f b e n e f i t s i s one t h i n g , i t i s y e t a n o t h e r t o e n s u r e t h a t t h e y become r e a l i z a b l e , r e a l i z e d 72 a n d t r a n s l a t e d t o a c t u a l r e d u c t i o n s i n c o s t s . W h i l e n o t a m a j o r l i m i t a t i o n o f CBA i t s e l f , t h e l a t t e r may v e r y w e l l p r o v e t o be t h e m o s t d i f f i c u l t a n d c r i t i c a l s t e p i n t h e HIS p r o j e c t . I t i s i n c u m b e n t upon d e c i s i o n - m a k e r s a n d p o l i c y - m a k e r s w i t h i n t h e i n s t i t u t i o n a l s e t t i n g ( o r a t t h e g o v e r n m e n t l e v e l f o r t h a t m a t t e r ) t o e n s u r e t h a t , i f d e c i s i o n s a r e made p u r s u a n t t o a f a v o u r a b l e s t u d y , t h e b e n e f i t s a r e u l t i m a t e l y r e a l i z e d a n d t r a n s l a t e d i n t o r e a l d o l l a r s a v i n g s f o r t h e i n s t i t u t i o n s . I f i t i s i n c u m b e n t u p on t h e h o s p i t a l t o g u a r a n t e e s a v i n g s p r i o r t o p r o j e c t a p p r o v a l by t h e MOH, a b u i l t - i n i n -c e n t i v e e x i s t s f o r t h e i n s t i t u t i o n a n d t h e MOH t o e n s u r e t h a t b e n e f i t s w i l l become r e a l i z e d a nd t r a n s l a t e d t o a c t u a l , s a v i n g s i n t h e h o s p i t a l ' s g r o s s o p e r a t i n g b u d g e t . T h i s may be t h e o n l y s i g n i f i c a n t f o r m o f p r e s s u r e t h a t t h e MOH c a n a p p l y t o p r e c l u d e t h e p r o l i f e r a t i o n o f w h a t , f r o m t h e i r p e r s p e c t i v e , may be u n w a r r a n t e d and i n e f f i c i e n t H I S s . T h i s w o u l d a l s o be i n t h e b e s t i n t e r e s t o f h o s p i t a l s t o a v o i d b e i n g s t r a p p e d w i t h t h e u n e x p e c t e d , e x p e n s i v e p r o v i s i o n o f i n e f f i c i e n t c o m p u t e r s e r v i c e s due t o p o o r p l a n n i n g . T h i s a p p e a r s t o be a t o d d s , h o w e v e r , w i t h t h e p r e v i o u s l y d i s c u s s e d MOH's p o l i c i e s b e c a u s e t h e i r a p p l i c a t i o n p r i o r i t i e s f a l l i n a r e a s w h e r e t h e r e a r e f e w r e a l i z a b l e l a b o r - s a v i n g b e n e f i t s . I t i s i n t h e a r e a o f n u r s e l a b o r s a v i n g s , f o r e x a m p l e , o r d e r p r o c e s s i n g a c t i v i t i e s a nd m e s s a g i n g , t h a t s u b -s t a n t i a l b e n e f i t s a r e l i k e l y t o a c c r u e . T h i s a p p a r e n t i n -73 c o n s i s t e n c y i n MOH r e a s o n i n g m u s t be r e e x a m i n e d . A g a i n , t h e CBA p r o c e s s c a n f a c i l i t a t e ' s u c h i n t e r a c t i o n a n d , h o p e -f u l l y , e f f e c t p o l i c y c h a n g e s t o t h e b e n e f i t o f p a r t i c i p a t i n g h o s p i t a l s a n d , u l t i m a t e l y , t h e MOH. 74 F o o t n o t e s "'"U.S., D e p a r t m e n t o f Commerce, O f f i c e o f Technology-A s s e s s m e n t , The I m p l i c a t i o n s o f C o s t - E f f e c t i v e n e s s A n a l y s i s o f M e d i c a l T e c h n o l o g y (Washington,- D.C.: N T I S , A u g u s t 1 9 8 0 ) , p. 20. 2 I b i d . , p. 2 1 . 3 I b i d . , p p . 26-28. 4 C a n a d a , T r e a s u r y B o a r d S e c r e t a r i a t , P l a n n i n g B r a n c h , B e n e f i t - C o s t A n a l y s i s G u i d e ( O t t a w a : S u p p l y a nd S e r v i c e s C a n a d a , M a r c h 19 7 6 ) , p p . 51-5. 5 M.F. Drummond, P r i n c i p l e s o f E c o n o m i c A p p r a i s a l i n H e a l t h C a r e (New Y o r k : O x f o r d U n i v e r s i t y P r e s s , 1 9 8 0 ) , pp. 1 7 - 5 8 . ^ K e n n e t h E. W a r n e r and B r y a n R. L u c e , C o s t - B e n e f i t a n d C o s t - E f f e c t i v e n e s s A n a l y s i s i n H e a l t h C a r e - P r i n c i p l e s , P r a c t i c e , a n d P o t e n t i a l (Ann A r b o r : H e a l t h A d m i n i s t r a t i o n P r e s s , 1 9 8 2 ) , pp. 59 - 1 1 3 . 7 G.L. S t o d d a r t and M.F. Drummond, "How t o r e a d c l i n i c a l j o u r n a l s : V I I . To u n d e r s t a n d an e c o n o m i c e v a l u a t i o n ( p a r t B ) , " C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l 130 (J u n e 15, 1 9 8 4 ) : 1 5 4 2 - 9 . g J o h n L e s l i e K i n g a n d E d w a r d L. S c h r e m s , " C o s t - B e n e f i t A n a l y s i s i n I n f o r m a t i o n S y s t e m s D e v e l o p m e n t a nd O p e r a t i o n , " ACM C o m p u t i n g S u r v e y s 10 ( M a r c h 1, 1 9 7 8 ) : 1 9 - 3 4 . 9 S t o d d a r t a n d brammond, p. 154 2. "'"'"'u.S., D e p a r t m e n t o f Commerce, O f f i c e o f T e c h n o l o g y A s s e s s m e n t , The I m p l i c a t i o n s o f C O s t - E f f e c t i v e n e s s A n a l y s i s o f M e d i c a l T e c h n o l o g y , p. 26. 1 1 S t o d d a r t a n d Drummond, p . 1542. 1 2 I b i d . , p. 1543. 13 L e e G. A n d e r s o n a nd R u s s e l F. S e t t l e , B e n e f i t - C o s t A n a l y s i s : A P r a c t i c a l G u i d e ( L e x i n g t o n : L e x i n g t o n B o o k s , 1 9 7 7 ) , p. 110. 14 Drummond, pp. 20-2. 15 I n t e r v i e w w i t h D. Z i l m , K e l o w n a G e n e r a l H o s p i t a l , K e l o w n a , B r i t i s h C o l u m b i a , May 22, 1985. 75 " ^ Warner a nd L u c e , p. 82. 1 7 X / I b i d . 18 L i o n s G a t e H o s p i t a l , " S t a t e m e n t o f B e n e f i t P o t e n t i a l , " N o r t h V a n c o u v e r , B.C., O c t o b e r 30, 1981 ( T y p e w r i t t e n . ) 19 P a u l R. S u l k e r s , n o t e s , n.d. 20 U.S., D e p a r t m e n t o f H e a l t h a n d Human S e r v i c e s , N a t i o n a l C e n t e r f o r H e a l t h S e r v i c e s R e s e a r c h , M e t h o d s f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s : F i n a l R e p o r t a n d E x e c u t i v e Summary, by E r i c a D r a z e n , A r t h u r D. L i t t l e , I n c . , R e p o r t No. NCHSR 80-36 ( S p r i n g f i e l d , VA: N T I S , M a r c h 14, 1 9 8 0 ) . 21 E r i c a L. D r a z e n , "Methods f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s , " P r o c e e d i n g s - The F o u r t h A n n u a l Symposium on C o m p u t e r A p p l i c a t i o n s i n M e d i c a l C a r e , W a s h i n g t o n , D . C , November 2-5, 1980, J o s e p h T. O ' N e i l l , e d . (New Y o r k : I E E E , November 1 9 8 0 ) , pp. 673-8. 22 E r i c a L. D r a z e n , "Methods f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s , " i n I n f o r m a t i o n S y s t e m s f o r P a t i e n t C a r e , B r u c e I . B l u m , e d . (New Y o r k : S p r i n g e r - V e r l a g , 1 9 8 4 ) , pp. 427- 3 7 . 2 3 I b i d . , p. 428. 2 4 I b i d . , p. 430. 2 5 D r a z e n , "Methods f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s , " P r o c e e d i n g s - The F o u r t h A n n u a l C o n f . on Comp. A p p l i c . i n Med. C a r e , 1 9 8 0 , pp. 69-70. 2 6 I b i d . 27 D r a z e n , "Methods f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s , " i n I n f o r m a t i o n S y s t e m s f o r P a t i e n t C a r e , B l u m , e d . , 1984, p. 432. 2 8 C a n a d a , T r e a s u r y B o a r d S e c r e t a r i a t , P l a n n i n g B r a n c h , B e n e f i t - C O s t A n a l y s i s G u i d e , p . 53. 29 J o h n G a l l , " C o s t - B e n e f i t A n a l y s i s : T o t a l H o s p i t a l . I n f o r m a t i o n S y s t e m s , " P r o c e e d i n g s o f t h e Symposium on H e a l t h I n f o r m a t i o n S y s t e m s E v a l u a t i o n , A s p e n , C o l o r a d o , A u g u s t 1 5 - 1 7 , 1 9 7 3 , R u s s e l l C. K o z a , e d . ( B o u l d e r , C o l o r a d o : C o l o r a d o A s s o c i a t e d U n i v e r s i t y P r e s s , 1 9 7 4 ) ; p p . 304-5. 76 3 0 I b i d . , pp. 303-4. 31 D. Norwood, " E c o n o m i c E v a l u a t i o n o f T o t a l H o s p i t a l I n f o r m a t i o n S y s t e m s , " P r o c e e d i n g s o f t h e F i r s t W o r l d C o n f e r e n c e o f M e d i c a l I n f o r m a t i c s , S t o c k h o l m , A u g u s t 5-10, 1974, J o h n A n d e r s o n and J . M a l c o l u m F o r s y t h e , e d s . (Amsterdam: N o r t h - H o l l a n d P u b l i s h i n g Company, 1 9 7 4 ) , p. 150. 32 A n d e r s o n a nd S e t t l e , p p . 1 1 0 - 1 1 . 33 I b i d . , p. I l l . 34 S c o t t H a m i l t o n and Norman L. C h e r v a n y , " E v a l u a t i n g I n f o r m a t i o n S y s t e m E f f e c t i v e n e s s - P a r t 1 • C o m p a r i n g E v a l u a t i o n A p p r o a c h e s , " MIS Q u a r t e r l y 5 ( S e p t e m b e r 1 9 8 1 ) : 6 1 . 35 " * D a v i d A. D i t t m a n a nd K e n n e t h R. S m i t h , C o n s i d e r a t i o n o f B e n e f i t s a n d C o s t s : A C o n c e p t u a l Framework f o r t h e H e a l t h P l a n n e r , " H e a l t h C a r e Management R e v i e w 4 ( F a l l 1 9 7 9 ) : 5 5 . S t o d d a r t a n d Drummond, p. 154 5. 3 7 I b i d . 38 W a r n e r and L u c e , pp. 79-80. 3 9 I b i d . , p. 85. 4 0 I b i d . 41 S t o d d a r t a n d Drummond, p. 1546. 4 2 U . S . , D e p ' t o f H e a l t h a n d Human S e r v i c e s , NCHSR, M e t h o d s f o r E v a l u a t i n g C o s t s o f A u t o m a t e d H o s p i t a l I n f o r m a t i o n S y s t e m s : F i n a l R e p o r t and E x e c u t i v e Summary, Qxazen,- 1980 -p 50. 4 3 W a r n e r and L u c e , p. 87. 44 L a P l a n t e a n d Durham, p. 40. 45 A n d e r s o n a nd S e t t l e , pp. 77-90. 4 6 W a r n e r a n d L u c e , pp. 93-8. 47 S t o d d a r t a n d Drummond, p. 1547. 48 Drummond, pp. 4 7-5 2. 4 9 L a P l a n t e and Durham, p. 40. U.S., Dep't o f H e a l t h and Human S e r v i c e s , NCHSR, Methods f o r E v a l u a t i n g C o s t s Of Automated H o s p i t a l I n f o r m a t i o n Systems: F i n a l ' Report and E x e c u t i v e Summary, Drazen, 1980, p. 28. 5 1 I b i d . , pp. 96-8. 52 Anderson and S e t t l e , pp. 82-5. 53 L a P l a n t e and Durham, p. 47. 54 Drummond, p. 50. 55 Anderson and S e t t l e , p. 84. ^ W a r n e r and Luce, pp. 95-6. 57 Anderson and S e t t l e , p. 92. 5 8 Warner and Luce, pp. 100-3. 59 Drummond, pp. 52-8. 6 0 L a P l a n t e and Durham, p. 51. 61 Anderson and S e t t l e , pp. 90-1. 6 2 S t o d d a r t and Drummond, pp. 1547-8. 6 3 Warner and Luce, p. 100. 6 4 I b i d . , pp. 105-6. 6 5 S t o d d a r t and Drummond, p. 1548. 6 6 I b i d . 6 7 I b i d . 6 8 I b i d . , p. 1549. 69 M e l v i l l e . A . Hodge, M e d i c a l I n f o r m a t i o n Systems: A Resource f o r H o s p i t a l s (Germantown: Aspen Systems Corp., 1977), p. 170. I b i d . 71 Norwood, p. 152. 7 2 G a l l , p. 306. 78 CHAPTER I V THE CHILLIWACK GENERAL HOSPITAL'S EXPERIENCE D e s c r i p t i o n o f t h e H o s p i t a l The C h i l l i w a c k G e n e r a l H o s p i t a l (CGH), s i t u a t e d one h u n d r e d k i l o m e t r e s e a s t o f V a n c o u v e r , i s a c o m m u n i t y g e n e r a l h o s p i t a l s e r v i n g an a r e a p o p u l a t i o n o f a p p r o x i m a t e l y s i x t y t h o u s a n d i n t h e F r a s e r Cheam R e g i o n a l H o s p i t a l D i s t r i c t (FCRHD). A d d i t i o n a l l y , P a r k h o l m L o d g e (an I n t e r m e d i a t e C a r e F a c i l i t y i n c o r p o r a t e d a s a s e p a r a t e s o c i e t y ) i s p h y s i c a l l y a t t a c h e d t o t h e h o s p i t a l and h o u s e s n i n e t y i n t e r m e d i a t e c a r e b e d s . The h o s p i t a l ' s c u r r e n t r a t e d c a p a c i t y i s 181 a c u t e c a r e b e d s an d 95 e x t e n d e d c a r e b e d s . I t e m p l o y s a p p r o x i m a t e l y 430 f u l l - t i m e e q u i v a l e n t s t a f f and h a s an a n n u a l o p e r a t i n g b u d g e t o f a p p r o x i m a t e l y s e v e n t e e n m i l l i o n d o l l a r s . A p p r o x i -m a t e l y t h i r t y - f i v e t h o u s a n d d o l l a r s ( e x c l u d i n g w o r d p r o c e s s i n g ) i s e x p e n d e d a n n u a l l y on d a t a p r o c e s s i n g a c t i v i t i e s a s s o c i a t e d w i t h t h e C o m p u t e r S e r v i c e s o f BCHA. T h e s e a c t i v i t i e s i n c l u d e P a y r o l l / P e r s o n n e l , D a t a E n t r y p r o g r a m s f o r A c c o u n t s P a y a b l e , G e n e r a l L e d g e r , M e d i c a l S e r v i c e s P l a n - A c c o u n t s R e c e i v a b l e a n d c o n v e r s i o n t o t a p e o f M e d i c a l A b s t r a c t i n g d a t a . The P a y r o l l / P e r s o n n e l D e p a r t m e n t c u r r e n t l y h a s i n -s t a l l e d an A l t e r n a t e Time Code (ATC) D a t a E n t r y S y s t e m and o n - s i t e p a y r o l l c h e q u e p r i n t i n g p r o j e c t u s i n g an IBM P e r s o n a l C o m p u t e r v i a t e l e p h o n e l i n e a n d modem, t h e l a t t e r h a v i n g b e e n r e c e n t l y p i l o t e d f o r BCHA. A P e r s o n n e l M a s t e r F i l e 79 Update p r o j e c t , u s i n g remote t e r m i n a l s and a l e a s e l i n e , was a l s o r e c e n t l y p i l o t e d f o r BCHA but not i n s t a l l e d because t h e h o s p i t a l f e l t i t was not c o s t - j u s t i f i a b l e . The Pharmacy Department uses an IBM P e r s o n a l Computer as t h e b a s i s o f i t s M o d i f i e d U n i t Dose Drug D i s t r i b u t i o n system. The A d m i n i s t r a t i v e Department j u s t r e c e n t l y a c q u i r e d an IBM P e r s o n a l Computer f o r d e c i s i o n - s u p p o r t . Word p r o c e s s i n g ( u s i n g IBM D i s p l a y w r i t e r s ) i s c u r r e n t l y l i m i t e d t o m e d i c a l stenography and A d m i n i s t r a t i o n ; however, the L a b o r a t o r y Department has j u s t a c q u i r e d two IBM p e r s o n a l computers s p e c i f i c a l l y f o r t h i s purpose and more a r e b e i n g c o n s i d e r e d f o r use i n o t h e r departments. I n September, 1985, t h e h o s p i t a l r e c e i v e d a l o n g -a w a i t e d a p p r o v a l from th e MOH t o p r o c e e d w i t h c o n s t r u c t i o n o f a twenty-seven m i l l i o n d o l l a r Phase I Acute Care E x p a n s i o n p r o j e c t . C o n s t r u c t i o n i s s c h e d u l e d t o commence i n May, 1986 and w i l l i n c l u d e r e p l a c i n g t h e m a j o r i t y o f e x i s t i n g a c u t e c a r e beds, O p e r a t i n g Rooms, Recovery Room, D o c t o r s ' Lounge, R a d i o l o g y , Emergency, Ambulatory Care, A d m i t t i n g / S w i t c h b o a r d , P u r c h a s i n g , Supply and D i s t r i b u t i o n and C e n t r a l Supply Departments. There w i l l a l s o be p r o v i s i o n f o r a P h y s i c a l M e d i c i n e S a t e l l i t e a r e a , expanded B o i l e r P l a n t , r e n o v a t e d Food S e r v i c e s Department and o t h e r p l a n t r e n o v a t i o n s . The f o r t u i t o u s t i m i n g o f t h i s b u i l d i n g p r o j e c t was i m p o r t a n t w i t h r e s p e c t t o t h e p l a n n e d HIS, p a r t i c u l a r l y f o r r e a s o n s of 80 p o s s i b l e f u n d i n g a s p a r t o f t h e e x p a n s i o n p r o j e c t , b u i l d i n g s y s t e m s r e q u i r e m e n t s , s t a g i n g o f t h e a p p l i c a t i o n m o d u l e s a nd t h e e v e n t u a l r e l o c a t i o n o f some h a r d w a r e a nd p e r i p h e r a l d e v i c e s f r o m e x i s t i n g t o new a r e a s o f t h e h o s p i t a l . D e s c r i p t i o n Of t h e H o s p i t a l ' s P l a n n i n g M e t h o d o l o g y The s y s t e m s p l a n n i n g m e t h o d o l o g y u s e d a t CGH i s a m o d i f i e d v e r s i o n o f I n t e r n a t i o n a l B u s i n e s s M a c h i n e s (IBM) C o r p . B u s i n e s s S y s t e m s P l a n n i n g (BSP) m e t h o l o g y e s t a b l i s h e d i n 1970."*" T h i s p r o c e s s - o r i e n t e d m e t h o d o l o g y h a s u n d e r g o n e s e v e r a l r e v i s i o n s a n d h a s b e e n s u c c e s s f u l l y u s e d i n s t u d i e s c o n d u c t e d b y p r o f i t a n d n o n - p r o f i t o r g a n i z a t i o n s o f v a r y i n g s i z e i n many i n d u s t r i e s . I t f a c i l i t a t e s a t o p - d o w n a p p r o a c h t o p l a n n i n g by e n g e n d e r i n g commitment and a c t i v e i n v o l v e m e n t s t a r t i n g w i t h s e n i o r manage-ment and w o r k i n g down t h r o u g h t h e o r g a n i z a t i o n w h i l e s i m u l t a -n e o u s l y w o r k i n g f r o m t h e o v e r a l l t o t h e d e t a i l e d l e v e l ; more-o v e r , a b o t t o m - u p a p p r o a c h t o i m p l e m e n t a t i o n i s f a c i l i t a t e d . T h i s s t r u c t u r e d m e t h o d o l o g y , p r o v e n i n h u n d r e d s o f s t u d i e s , a s s i s t s i n t h e t r a n s l a t i o n o f t h e o r g a n i z a t i o n ' s b u s i n e s s o b j e c t i v e s t o i n f o r m a t i o n s y s t e m r e q u i r e m e n t s . The h o s p i t a l , w i t h t h e a s s i s t a n c e o f BCHA, u s e d t h i s a p p r o a c h a s a g u i d e o n l y , r e c o g n i z i n g t h a t i t w o u l d h a v e b e e n t o o c o m p l e x a nd t i m e - c o n s u m i n g t o a d a p t a l l o f i t s c o n c e p t s t o t h e h o s p i t a l e n v i r o n m e n t . N o n e t h e l e s s , i t p r o v e d t o be a u s e f u l way t o f a c i l i t a t e p a r t i c i p a n t u n d e r s t a n d i n g o f t h e s t a t u s quo and a s s o c i a t e d p r o b l e m s . 81 F o l l o w i n g an A u g u s t , 1984 m e e t i n g w i t h s e n i o r management o f t h e h o s p i t a l a n d BCHA, S e p t e m b e r , 1984 saw d e p a r t m e n t h e a d s , h e a d n u r s e s , c a r e c o o r d i n a t o r s , members o f t h e C o m p u t e r A d v i s o r y C o m m i t t e e ( i n c l u d i n g M e d i c a l S t a f f ) a n d t h e C h a i r m a n o f t h e B o a r d a t t e n d a g e n e r a l o r i e n t a t i o n m e e t i n g on t h e p r o p o s e d HSP m e t h o d o l o g y . Q u e s t i o n n a i r e s w e r e d i s t r i b u t e d t o a l l d e p a r t m e n t a l r e p r e s e n t a t i v e s who w e r e a s k e d t o r e t u r n them i n two w e e k s . The i n t e n t was t o u s e t h e q u e s t i o n n a i r e s a s a f r a m e w o r k f o r s t a f f t o c o n s i d e r i n f o r m a t i o n h a n d l i n g i s s u e s a n d f o r t h e p r o j e c t t e am t o u s e as a b a s i s f o r i n t e r v i e w s . The n e x t s t e p c o n s i s t e d o f i n t e r v i e w i n g a r e p r e s e n t a -t i v e number o f h o s p i t a l s t a f f i n c l u d i n g h e a d n u r s e s , d e p a r t -ment h e a d s , m e d i c a l s t a f f , s e n i o r n u r s i n g a n d a d m i n i s t r a t i v e s t a f f . The p u r p o s e o f t h e i n t e r v i e w s was t w o - f o l d . F i r s t , i t a l l o w e d t h e p a r t i c i p a n t s , a s p o t e n t i a l u s e r s o f t h e p r o p o s e d H I S , t o a p p r e c i a t e t h e e x p e c t a t i o n s o f t h e p r o j e c t team. S e c o n d , i t a l l o w e d t h e p r o j e c t team t o l e a r n more a b o u t i n d i v i d u a l a r e a s o f r e s p o n s i b i l i t y , a b o u t i n f o r m a t i o n t h a t t h e p o t e n t i a l u s e r s c o n s i d e r e d e s s e n t i a l t o manage t h e i r a r e a a n d a b o u t t h e p r o b l e m s t h a t t h e y a nd o t h e r s f a c e . D u r i n g t h e i n t e r v i e w s e s s i o n s , t h e p r o j e c t t e a m made a c o n s c i o u s e f f o r t t o p r e s e n t an o v e r v i e w o f t h e h o s p i t a l t o e a c h p a r t i c i p a n t a n d t o e x p l a i n t h e p r e s e n t i n f o r m a t i o n 82 h a n d l i n g a c t i v i t i e s a n d a s s o c i a t e d c o s t s . The u s e o f a p r o c e s s / o r g a n i z a t i o n t w o - d i m e n s i o n a l m a t r i x ( A p p e n d i x 3) a s s i s t e d t h e p a r t i c i p a n t s i n e x a m i n i n g t h e r e l a t i o n s h i p s o f t h e c u r r e n t h o s p i t a l d e p a r t m e n t s , w i t h v a r i o u s p r e - d e f i n e d i n f o r m a t i o n p r o c e s s e s k i n d l y p r o v i d e d by BCHA ( A p p e n d i x 4 ) . The m a t r i x was b a s e d on IBM's BSP m e t h o d o l o g y . The p r o j e c t team i d e n t i f i e d r e l a t i v e l e v e l s o f d e p a r t m e n t a l i n v o l v e m e n t i n i n f o r m a t i o n h a n d l i n g w h i c h a f f o r d e d t h e p a r t i c i p a n t s a n o p p o r t u n i t y t o e x a m i n e t h e i r i n f o r m a t i o n h a n d l i n g a c t i v i t i e s i n c o m p a r i s o n t o o t h e r d e p a r t m e n t s . The p r o j e c t t e am g a i n e d a g e n e r a l i m p r e s s i o n o f t h e a c t i v i t i e s t h a t w o u l d l i k e l y r e -q u i r e t h e g r e a t e s t d e g r e e o f a t t e n t i o n and t h e g r e a t e s t p r i o r i t y . The p r o c e s s o f w o r k i n g t h r o u g h t h e m a t r i x a f f o r d e d t h e p a r t i c i p a n t s an o p p o r t u n i t y t o t h i n k a b o u t t h e f l o w o f i n f o r m a t i o n i n a l o g i c a l f a s h i o n w h i c h , t o many, was a new and e d u c a t i o n a l e x p e r i e n c e . F o l l o w i n g p r o b l e m i d e n t i f i c a t i o n ( A p p e n d i x 5 ), p o t e n t i a l b e n e f i t s w e r e d i s c u s s e d i n o r d e r t o g i v e t h e p a r t i c i p a n t s a g e n e r a l s e n s e o f t h e s c o p e o f t h e p r o j e c t a n d t o p r o v i d e a b a s i s f o r more d e t a i l e d a n a l y s i s . T h i s i n f o r m a t i o n was r e c o r d e d a n d r e t u r n e d t o t h e i n t e r v i e w e e s f o r t h e i r p e r u s a l , v e r i f i c a t i o n a n d s i g n - o f f . U s i n g a m o d i f i c a t i o n o f a c o m p u t e r 3 r a n k i n g m e t h o d o l o g y , i d e n t i f i e d p r i o r i t i e s w e r e r a n k e d . T h i s s i m p l e , g e n e r i c a p p r o a c h a l l o w e d t h e p r o j e c t team t o e s t a b l i s h i t s p r i o r i t i e s b a s e d on u s e r - d e f i n e d p r o b l e m s , n e e d s a nd s o l u t i o n s . 83 T h i s s t a g e was c o n s i d e r e d t o be t h e i n i t i a l s t e p i n i n f o r m a t i o n s y s t e m s d e v e l o p m e n t s i n c e i t was r e c o g n i z e d t h a t more d e t a i l e d a n d s p e c i f i c a n a l y s e s w o u l d be r e q u i r e d i n t h e n e x t s t a g e s o f t h e p r o j e c t . The p r o j e c t team c o n c l u d e d t h a t t h e p l a n n i n g p r o c e s s s u p p o r t e d i t s s u s p i c i o n t h a t t h e p r e -d o m i n a n t l y m a n u a l . m e t h o d s o f h a n d l i n g i n f o r m a t i o n (and n o n -i n t e g r a t e d , s t a n d - a l o n e c o m p u t e r s y s t e m s ) w e r e g e n e r a l l y i n -e f f e c t i v e a n d i n e f f i c i e n t . The team t h u s recommended t h a t a c o m p u t e r i z e d , i n t e g r a t e d s o l u t i o n be p u r s u e d w h i c h w o u l d l i k e l y l e a d t o g r e a t e r e f f e c t i v e n e s s a n d e f f i c i e n c y o f i n f o r m a t i o n p r o c e s s i n g a n d t h e r e a l i z a t i o n o f s i g n i f i c a n t t a n g i b l e and i n t a n g i b l e b e n e f i t s . I t was f e l t t h a t t h e s o l u t i o n s t o t h e s e p r o b l e m s and a t t a i n m e n t o f b e n e f i t s w o u l d be p o s s i b l e t h r o u g h m o d u l a r c o m p u t e r i z a t i o n . B e c a u s e t h e r e was a h i g h l e v e l o f s t a f f p a r t i c i p a t i o n , i t was f e l t t h a t t h e l i k e l i h o o d o f s u c c e s s f u l i m p l e m e n t a t i o n was g r e a t l y e n h a n c e d . The s y s t e m s p l a n n i n g s t u d y a d d r e s s e d p o t e n t i a l b e n e f i t s f r o m t h e p e r s p e c t i v e o f t h e u s e r s . I t was n e v e r meant t o r e p l a c e t h e n e e d f o r a d e t a i l e d CBA. A t t h i s p o i n t i n the. s t u d y t h e d e p a r t m e n t a l r e p r e s e n t a t i v e s w e r e v a g u e l y a w a r e o f t h e p o t e n t i a l b e n e f i t s o f a c o m p u t e r i z e d s o l u t i o n t o t h e i r i d e n t i f i e d p r o b l e m s and n e e d s ; h o w e v e r , t h e y d i d n o t y e t h a v e a w o r k i n g k n o w l e d g e o r h a n d s - o n e x p e r i e n c e w i t h a n y i n s t a l l e d s y s t e m s . T h u s , many o f t h e p e r c e i v e d a d v a n t a g e s t o c o m p u t e r i z a t i o n w e r e q u i t e , s u b j e c t i v e and p o s s i b l y some-84 w h a t i l l o g i c a l , s e v e r a l p e r h a p s u n a t t a i n a b l e . On t h e o t h e r h a n d , d e l i n e a t i o n o f t h e b e n e f i t s f r o m t h e p e r s p e c t i v e o f t h e u s e r s was i m p o r t a n t a t t h i s s t a g e o f t h e s t u d y b e c a u s e t h e s e w o u l d f o r m t h e b a s i s o f e x p e c t e d b e n e f i t s t h a t one w o u l d hope t o r e a l i z e u p o n i m p l e m e n t a t i o n o f an H I S . The m a i n p u r p o s e o f t h i s s t a g e was t o i d e n t i f y and document t h e p e r c e i v e d a d v a n t a g e s and d i s c u s s them w i t h t h e p r o j e c t team a s w e l l a s t o f u l f i l l t h e i m p o r t a n t a s p e c t s o f p a r t i c i p a t i v e p l a n n i n g . W h i l e i d e n t i f i c a t i o n o f t h e s e a d v a n t a g e s was n o t l i m i t e d s o l e l y t o t a n g i b l e b e n e f i t s , a s much as p o s s i b l e , a g r o s s v a l u a t i o n o f them was s o u g h t . Any i d e n t i f i e d , i n t a n g i b l e b e n e f i t s w e r e a l s o d o c u m e n t e d . A p p e n d i x 6 l i s t s t h e i d e n t i f i e d t a n g i b l e a n d i n t a n g i b l e b e n e f i t s i n t h e i r s u m m a r i z e d , r o u g h f o r m a s i n t e r p r e t e d and d o c u m e n t e d by t h e p r o j e c t team. To e n s u r e c o m p l e t e n e s s , t h e s e w e r e l a t e r r e t u r n e d t o t h e p a r t i c i p a n t s f o r t h e i r p e r u s a l and s i g n - o f f . D e s c r i p t i o n o f t h e H o s p i t a l ' s O p t i o n s . The HSP s t u d y b r o u g h t t h e h o s p i t a l t o a m a j o r d e c i s i o n p o i n t . I t c o u l d c o n t i n u e w i t h t h e s t a t u s quo u s i n g a com-b i n a t i o n o f m a n u a l m e t h o d s and n o n - i n t e g r a t e d m i c r o c o m p u t e r s f o r i n f o r m a t i o n h a n d l i n g . I f t h i s was i n d e e d t h e d e c i s i o n , i t w o u l d c l e a r l y mean c o p i n g w i t h t h e p r o b l e m s i d e n t i f i e d i n t h e HSP s t u d y . G i v e n t h e number and s e v e r i t y o f t h e s e p r o b l e m s , t h i s o p t i o n made l i t t l e s e n s e e v e n t h o u g h t h e m a n u a l m e t h o d t y p i f i e s m o s t c o m m u n i t y h o s p i t a l s i n B r i t i s h C o l u m b i a . 85 The second o p t i o n was f o r the h o s p i t a l to c o n s i d e r the implementation of p a r t or a l l of an HIS by r e p l a c i n g the m a j o r i t y of the manual systems and the stand-alone microcom-puter a p p l i c a t i o n s a l r e a d y i n use. A comprehensive p l a n n i n g r e p o r t , along w i t h recommen-ded s t a g i n g of computerized s o l u t i o n s i n c l u d i n g p a t i e n t r e g i s t r a t i o n and t r a c k i n g , f i n a n c i a l and c l i n i c a l a p p l i c a t i o n s as the h i g h e s t p r i o r i t i e s , was r e c e i v e d and approved i n December, 1984. Approval was a l s o given to proceed to the next stages of p l a n n i n g . In January, 1985 i n v i t a t i o n s were sent to twenty-one vendors to respond to a Request f o r Information (RFI) to a s s i s t the h o s p i t a l i n determining which vendors would r e c e i v e a Request f o r P r o p o s a l (RFP). F o l l o w i n g e v a l u a t i o n , nine s u i t a b l e vendors were s e l e c t e d to r e c e i v e RFPs. In May, 1985 a d e t a i l e d RFP was d i s t r i b u t e d , i n c l u d i n g a p r o f i l e of the h o s p i t a l , g e n e r a l requirements f o r the RFP, t e c h n i c a l c a p a b i l i t i e s of proposed systems, c o s t s / b e n e f i t s / f i n a n c i n g , - i n s t a l l a t i o n / i m p l e m e n t a t i o n / l i v e t i m e t a b l e and r e s p o n s i b i l i t i e s , performance bond/warranty/contract, e v a l u a t i o n methodology and t i m e t a b l e , v i d e o d i s p l a y t e r m i n a l s and p r i n t e r s and d e t a i l e d systems a p p l i c a t i o n s b e i n g requested. Appendix 7 r e p r e s e n t s a copy of the RFP to which the reader i s d i r e c t e d f o r a g r e a t e r a p p r e c i a t i o n of the RFP process and f o r a complete d e s c r i p t i o n of the d e t a i l e d systems a p p l i c a t i o n s 86 b e i n g r e q u e s t e d . CGH e n g a g e d t h e e x p e r t i s e o f a HIS d i r e c t o r i n a n o t h e r h o s p i t a l i n o r d e r t o h e l p d e v e l o p a c o m p r e h e n s i v e a p p l i c a t i o n s s e c t i o n . 4 P r i o r t o r e c e i v i n g t h e c o m p l e t e d R F P s , an E v a l u a t i o n S u b c o m m i t t e e o f t h e h o s p i t a l C o m p u t e r A d v i s o r y C o m m i t t e e was s t r u c k c o m p r i s e d o f r e p r e s e n t a t i o n f r o m A d m i n i s t r a t i o n ( t h e a u t h o r ) , M e d i c a l S t a f f ( t h e D i r e c t o r o f L a b o r a t o r y M e d i c i n e ) and B o a r d (a p r o f e s s i o n a l a c c o u n t a n t ) . T h i s S u b c o m m i t t e e was c h a r g e d w i t h e v a l u a t i n g t h e s e v e n r e s p o n d e n t s (two v e n d o r s d e c l i n e d t o r e s p o n d ) , s h o r t - l i s t i n g a n d r e c o m m e n d i n g a f i n a l i s t t o t h e H o s p i t a l B o a r d . T h i s e v a l u a t i o n p r o c e s s c u l m i n a t e d i n a r e c o m m e n d a t i o n t o p r o c e e d w i t h c o s t - j u s t i f y i n g M e d i t e c h ' s (MS/1200) I n t e g r a t e d H o s p i t a l I n f o r m a t i o n S y s t e m u s i n g D a t a G e n e r a l ' s l a t e s t h a r d w a r e (MV4000DC) c o n f i g u r a t i o n . W i t h t h e f o r e g o i n g i n f o r m a t i o n i n h a n d , a d e c i s i o n was made t o p e r f o r m a CBA. The n e x t c h a p t e r r e v i e w s t h e e i g h t p r i n c i p l e s o f CBA d i s c u s s e d i n C h a p t e r I I I a n d a p p l i e s t h e s t e p s t o t h e CGH p r o j e c t . 87 F o o t n o t e s ^ I n t e r n a t i o n a l B u s i n e s s M a c h i n e s C o r p . , I n f o r m a t i o n S y s t e m s P l a n n i n g G u i d e 3 r d e d . , ( W h i t e P l a i n s : IBM, J u l y 1 9 8 1 ) . 2 I b i d . 3 M a r t i n B u s s , "How t o r a n k c o m p u t e r p r o j e c t s , " H a r v a r d B u s i n e s s R e v i e w 61 ( J a n u a r y - F e b r u a r y 1 9 8 3 ) : 1 1 8 - 2 5 . . 4 M e e t i n g w i t h D. Z i l m , K e l o w n a G e n e r a l H o s p i t a l , K e l o w n a , B.C., 22 May 1985. 88 CHAPTER V ECONOMIC EVALUATION OF A HOSPITAL INFORMATION SYSTEM FOR THE CHILLIWACK GENERAL HOSPITAL U s i n g t h e g e n e r a l f r a m e w o r k f o r e c o n o m i c e v a l u a t i o n a s d i s c u s s e d i n C h a p t e r I I I , t h e p u r p o s e o f t h i s c h a p t e r i s t o a p p l y t h e p r i n c i p l e s o f CBA u s i n g d a t a g e n e r a t e d i n p l a n n i n g an HIS f o r CGH a s d i s c u s s e d i n C h a p t e r I V . T h i s a p p r o a c h h a s b e e n t a k e n b y t h e h o s p i t a l b e c a u s e t h e r e i s c o n c e r n f o r t h e e c o n o m i c v i a b i l i t y o f t h e p r o p o s e d s y s t e m . F i g u r e 3 d e m o n s t r a t e s t h e i m p l e m e n t a t i o n , c o s t s a n d t a n g i b l e b e n e f i t s t r e a m s o f t h e h o s p i t a l ' s p r o p o s e d HIS o v e r an e i g h t y e a r p e r i o d . The a p p l i c a t i o n s a r e l i s t e d i n o r d e r o f i m p l e m e n t a t i o n p r i o r i t y c ommencing i n May, 1986. The c o s t s a n d b e n e f i t s o f t h e CBA a r e b a s e d on t h e s e s t r e a m s o f a c t i v i t y . The P r i n c i p l e s o f CBA a r e : (1 (2 (3 (4 (5 (6 D e f i n i n g t h e q u e s t i o n D e l i n e a t i o n o f o b j e c t i v e s a n d i d e n t i f i c a t i o n a n d s e l e c t i o n o f a l t e r n a t i v e s E n u m e r a t i o n o f r e l e v a n t c o s t s a n d b e n e f i t s M e a s u r e m e n t o f c o s t s a n d b e n e f i t s i n a p p r o p r i a t e u n i t s V a l u a t i o n o f c o s t s a n d b e n e f i t s i n m o n e t a r y u n i t s D i s c o u n t i n g o f c o s t s a n d b e n e f i t s t o t h e i r p r e s e n t v a l u e P e r f o r m i n g s e n s i t i v i t y a n a l y s e s t o r e d u c e u n c e r t a i n t i e s I n t e r p r e t a t i o n a n d p r e s e n t a t i o n o f f i n d i n g s (7 (8 T h e s e w i l l now be s p e c i f i c a l l y a p p l i e d t o CGH. D e f i n i n g t h e Q u e s t i o n W i l l an i n t e g r a t e d HIS d e s i g n e d t o c o m p u t e r i z e 89 FIGURE 3 IMPLEMENTATION, COSTS AND TANGIBLE BENEFITS STREAMS OF A PROPOSED HIS FOR THE CHILLIWACK GENERAL HOSPITAL 1 2 3 4 5 6 7 8 YEAR 1986 1987 1988 1989 1990 1991 1992 1993 APPLICATIONS (8mos) Central Registry SO A/D/T I ADMITTING B SWITCHBOAF BOOKING y j. n r-i I N I r a i T DEF >TS N. C Outpatient S)Q Registration I c R B U £ B ADN RSWI B B O C INESS C 11TTING TCHBOAF >FF I CE 2D )KI NG >, BNUF ?S ING X rn S•s NI CAL 1 < -> Health Records SQ HMRI I p „ HEALTH F i n a n c i a l s S,,Q I p RBUS OFF B ADN »I NESS 'ICE 1 1 M 1 C f n J I T I A M > i i t i *J • r w C l i n i c a l Lab .SQ Pathology SQ I C ' LABORATOFfY tfPAi T-> "HO LOGY BNUF ?S I NG Order entry Results reporting S.Q Communications SQ I T-> T—^ BNUF BgkF ?S I NG s NI CAL s »TS s \ s Food Services SQ SQ SQ I Q BNUF nFOC B S E F IS I NG v. in WICES < 1 Pharmacy "SQ SQ SQ" I c BNUF B P W ?S I NG VRMACY . y •s < Radiology SQ SQ SQ I c BNUF B RAI ?SING jiOLOGY < > b e n e f i t streams f o r each a p p l i c a t i o n implementation stage cost stream for each a p p l i c a t i o n t r a n s i t i o n period awaiting t r a n s l a t i o n of p o t e n t i a l benefits to r e a l i z a b l e benefits Status quo systems B = I = C = T = SQ = 90 i n f o r m a t i o n p r o c e s s i n g be c o s t - e f f e c t i v e r e l a t i v e t o t h e c u r r e n t n o n - i n t e g r a t e d manual and s t a n d - a l o n e c o m p u t e r i z e d methods, from t h e p e r s p e c t i v e of t h e C h i l l i w a c k G e n e r a l H o s p i t a l ? D e l i n e a t i o n o f O b j e c t i v e s and I d e n t i f i c a t i o n o f A l t e r n a t i v e s R e c o g n i z i n g t h a t the o b j e c t i v e s a r e t o e x p e d i t e h o s p i t a l c a r e i n o r d e r t o improve t h e h e a l t h s t a t u s o f i t s p a t i e n t s and r e c o g n i z i n g t h a t the HSP st u d y b r o u g h t t o l i g h t s e v e r a l a r e a s o f s u s p e c t e d i n e f f e c t i v e n e s s and i n e f f i c i e n c i e s w i t h r e s p e c t t o the s t a t u s quo methods o f h a n d l i n g i n f o r m a t i o n , a c o m p u t e r i z e d , i n t e g r a t e d s o l u t i o n was pursued. The i d e n t i -f i e d problems and o t h e r u n i d e n t i f i e d problems br o u g h t t o l i g h t t h r o u g h t h e st u d y can be s o l v e d . The h o s p i t a l f e e l s t h a t s o l u t i o n s t o t h e s e problems and t h e a t t a i n m e n t o f i d e n t -i f i e d b e n e f i t s a r e p o s s i b l e t h r o u g h modular c o m p u t e r i z a t i o n o f t h e i d e n t i f i e d manual i n f o r m a t i o n p r o c e s s i n g systems and t h r o u g h i n t e g r a t i o n o r re p l a c e m e n t o f c u r r e n t s t a n d - a l o n e c o m p u t e r i z e d methods o f h a n d l i n g i n f o r m a t i o n . To some e x t e n t t h e r e was a p r e s u p p o s i t i o n t h a t improved c o s t - e f f e c t i v e n e s s would be made p o s s i b l e t h r o u g h the implemented system. The a l t e r n a t i v e s from the p e r s p e c t i v e o f CGH a r e s i m p l y a h o s p i t a l - w i d e c o m p u t e r i z e d system v e r s u s the s t a t u s quo methods o f h a n d l i n g i n f o r m a t i o n . 91 E n u m e r a t i o n o f R e l e v a n t C o s t s and B e n e f i t s W h i l e s e p a r a t e d i n t h e t e x t , i n p r a c t i c e t h e t h r e e d i s t i n c t s t e p s o f e n u m e r a t i o n , q u a n t i f i c a t i o n a n d v a l u a t i o n may o c c u r s i m u l t a n e o u s l y . T a n g i b l e C o s t s U s i n g t h e t y p o l o g y o f F i g u r e I , t h e n o n - i n f l a t e d and n o n - d i s c o u n t e d o n e - t i m e a n d o n - g o i n g c o s t s w e re t a b u l a t e d ( T a b l e s 1 a n d 2) and w e r e s u m m a r i z e d o v e r an e i g h t y e a r p e r i o d a s s u m i n g one h u n d r e d p e r c e n t o f t h e s y s t e m c o s t s w o u l d be b o r n e b y t h e h o s p i t a l ( T a b l e 3 ) . C a r e must be t a k e n t o e n s u r e a l l t a n g i b l e c o s t s a r e i n c l u d e d f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l . W h i l e a s s i s t a n c e f r o m v e n d o r s i s i m p o r t a n t , t h e y h a v e a t e n d e n c y t o m i s s r e l e v a n t c o s t s b e c a u s e o f t h e i r p e r s p e c t i v e a nd d e s i r e t o be c o m p e t i t i v e . T h u s , i n p u t f r o m s e v e r a l v e n d o r s and s y s t e m u s e r s i s h e l p f u l . 92 TABLE 1 ENUMERATION, QUANTIFICATION AND VALUATION OF TANGIBLE ONE-TIME COSTS OF HIS ' OVER EIGHT YEAR PERIOD FOR THE CHILLIWACK GENERAL HOSPITAL ENUMERATED COMPONENTS QUANTITIES VALUES($) HARDWARE System major components, including: - MV/4000DC each with 1 MB Memory, 3 120 MB Disc, IAC-16 - 1600 BPI Streamer Tape Subsystem 3 - Expansion Chassis, Power Supply Bus Repeater 1 - IAC-16 4 - Wall mount 4 - TP2 P r i n t e r Console 1 - CRT Console 2 - DG Band P r i n t e r 1 227,132 Uninterruptible Power Supply (UPS) Video Display Terminals (VDTs), including: - System units - Training/Back-up units P r i n t e r s E l e c t r o n i c Embosser Interfaces ^ Other Sub-total 71 9 30 1 0 0 19,110 36,920 4,680 66,000 20,000 0 0 373,842 SOFTWARE Operating Systems A l l A p p l i c a t i o n Systems, including: . - Admissions and Comprehensive S t a t i s t i c s , Medical Records (including DRG/ Abstracting/CMG) - F i n a n c i a l s (including Billing/Accounts . . Receivable, MSP, General L e d g e r / S t a t i s t i c s Reporting, Accounts Payable, Fixed Assets, Generalized outputs to tape, a c t i v i t y log 57,850 71,500 91,000 93 TABLE 1-Continued - Laboratory (including Microbiology and 1 97,500 Surgical Pathology) - Nurse Station Communications 1 78,000 - Radiology 1 26,000 - Pharmacy 1 32,500 - Food Services (under development) estimate only 1 20,000 Interfaces - Embosser 1 1,300 - Laboratory Equipment 3 7,800 Other - Interprocessor Communications 2 52,000 Sub-total 535,450 OTHER Hardware i n s t a l l a t i o n - Building.renovations or additions 0 0 Software implementation - Out-of-pocket l i v i n g expenses f or - 60,000 vendor personnel . . . 1 Licenses (3 V> Communications - Multiplexers 0 0 - Modems 2 1,000 - Wiring i n s t a l l a t i o n - 20,000 -. Other 0 0 S t a f f t r a i n i n g during implementation period - 64,000 - Travel Expenses, r e l i e f s t a f f , overtime, manuals, A/V aids Conversion costs (status quo to HIS applications) - Health Records index cards 87,000 27,000 Other - Analyst and s e c r e t a r i a l support 0 0 - P r o v i n c i a l sales tax (Hardware only) @ 7% - 26,169 - Freight (Hardware only, FOB Chilliwack) - 2,000 System, P r i n t e r s , VDTs Sub-total 200,169 T o t a l 1,109,461 NOTE: 1.3 U.S. exchange rate used f o r a l l software costs. "*"Not applicable i n C.G.H. pro j e c t . 94 TABLE 2 ENUMERATION, QUANTIFICATION AND VALUATION OF TANGIBLE ON-GOING COSTS OF HIS OVER EIGHT YEAR PERIOD FOR THE CHILLIWACK GENERAL HOSPITAL ENUMERATED COMPONENTS QUANTITIES VALUES($) Lease lines"*" 0 . 0 Telephone - 13,500 Computer room services"'" 0 0 In-house HIS s t a f f support . - 1.0 FTE D i r . of HIS Dept. ( i n c l . benefits) - 360,000 - 1.0 FTE DP s t a f f ( i n c l . benefits) - 216,000 Vendor and t h i r d party support - H/W maintenance, i n c l . system contract - 133,828 - P r i n t e r s (x 30). estimate only - 14,000 - VDTs (x 80) estimate only - 6,000 - S/W Maintenance Contract, i n c l . a l l Applications, Embosser Interface. - 419,761 Spare Equipment Parts (extra VDTs already included) 0 0 Miscellaneous, including: - 7,000 - Supplies - Microfiche - Postage/Courier S/W Enhancements - 15,000 Other J o i n t D i s t r i b u t i o n Costs"'" 0 0 Research and Development"'" 0 0 Opportunity Costs"'" 0 0 . . To t a l 1,185,089 NOTE: 1.3 U.S. exchange rate applies to a l l software costs. "'"Not applicable i n C.G.H. pro j e c t . TABLE 3 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS OF HIS OVER EIGHT YEAR PERIOD ASSUMING 100% FUNDED BY THE 95 CHILLIWACK GENERAL HOSPITAL YEAR COST ELEMENT 0 1986 (1st 4 mos) 1 1986 2 1987 3 1988 4 1989 5 1990 6 1991 7 1992 8 1993 TOTAL ONE-TIME Hardware (H/W) Software (S/W) S/W implementation 2 Communication a^ nd wiring S t a f f t r a i n i n g Conversion PST @ 7% H/W only Freight H/W only h 16,250 0 0 0 0 0 0 223,814 213,850 20,000 21,000 22,000 27,000 15,667 1,000 35,520 183,300 20,000 0 22,000 0 2,486 500 114,508 122,050 20,000 0 20,000 0 8,016 500 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 373,842 535,450 60,000 21,000 64,000 27,000 26,169 2,000 Sub-total 1,10 9,461 ON-GOING 2 Telephone In-house s t a f f support ' H/W support/maintenance S/W support/maintenance Miscellaneous S/W enhancements 0 0 0 0 0 0 900 24,000 4,516 0 0 0 1,800 48,000 15,548 32,675 1,000 5,000 1,800 84,000 20,604 53,306 1,000 5,000 1,800 84,000 22,632 66,756 1,000 5,000 1,800 84,000 22,632 66,756 1,000 0 1,800 84,000 22,632 66,756 1,000 0 1,800 84,000 22,632 66,756 1,000 0 1,800 84,000 22,632 66,756 1,000 0 13,500 576,000 153,828 419,761 7,000 15,000 Sub-total 1,185,089 Tota l @ 1.3 U.S. exch. . 4 16,250 573,747 367,829 450,784 181,188 176,188 176,188 176,188 176,188 2,294,550 Tota l @ 1.4 U.S. exch. 4,5 . 17,501 591,753 386,384 466,211 186,713 181,328 181,328 181,328 181,328 2,373,874 10% deposit for Stage I software a p p l i c a t i o n s upon signing contract with Meditech. "Budgetary estimate. Includes 20% employee ben e f i t s package i n addition to annual remuneration; excludes vacation and sick r e l i e f . 1 Applies to a l l software costs. Some rounding of figures due to conversion. 96 I n t a n g i b l e C o s t s I t i s r e c o g n i z e d t h a t t h e r e w i l l be c o n s i d e r a b l e s y s t e m - i n d u c e d f r u s t r a t i o n a n d s t r e s s , e s p e c i a l l y d u r i n g i m p l e m e n t a t i o n o f t h e H I S ; h o w e v e r , no a t t e m p t was made t o m e a s u r e t h e s e i n t a n g i b l e s . I t was f e l t t h a t b e c a u s e t h e r e was s u c h a h i g h l e v e l o f u s e r p a r t i c i p a t i o n d u r i n g t h e i n i t i a l HSP s t u d y and b e n e f i t i d e n t i f i c a t i o n p h a s e s o f p l a n n i n g t h e l i k e l i h o o d o f s u c c e s s f u l i m p l e m e n t a t i o n w o u l d be g r e a t l y e n h a n c e d . M o r e o v e r , b e c a u s e t h e m o d u l a r a p p r o a c h t o i m p l e -m e n t a t i o n i s b e i n g t a k e n , f r u s t r a t i o n a n d s t r e s s s h o u l d be m i n i m i z e d a s u s e r s i n s u b s e q u e n t a r e a s become c o m f o r t a b l e w i t h t h e s y s t e m a nd a s c h a n g e i s i n c r e m e n t a l l y e f f e c t e d . T a n g i b l e B e n e f i t s W h i l e i d e n t i f i c a t i o n o f t a n g i b l e and i n t a n g i b l e b e n e f i t s f o r m e d p a r t o f t h e HSP s t u d y , i d e n t i f i c a t i o n o f b e n e f i t s was a g a i n a m a j o r e x e r c i s e f o l l o w i n g s e l e c t i o n o f t h e f i n a l i s t v e n d o r . U s i n g J o b C o n t e n t A n a l y s i s , e a c h n o n -N u r s i n g d e p a r t m e n t / a r e a e n u m e r a t e d i t s m a j o r t a n g i b l e b e n e f i t s . The N u r s i n g D e p a r t m e n t u s e d Work S a m p l i n g t e c h n i q u e s t o a n a l y z e l a b o r i m p a c t s o f t h e p r o p o s e d HIS o v e r t h e s t a t u s q u o . O n l y t h e d i f f e r e n c e s o r c h a n g e s i n b e n e f i t s o f t h e p r o p o s e d HIS o v e r t h e s t a t u s quo were e n u m e r a t e d ; t h a t i s , o n l y t h o s e c h a n g e s i n b e n e f i t s a c c r u i n g a s a r e s u l t o f t h e i m p l e m e n t a t i o n o f t h e p r o p o s e d H I S . F o r t h e m o s t p a r t , t h e g r e a t e s t e m p h a s i s was on m a j o r i m p a c t a r e a s s u c h a s 97 l a b o r s i n c e t h i s was t h e m o s t s i g n i f i c a n t p o t e n t i a l o n - g o i n g b e n e f i t . E a c h a f f e c t e d a r e a was a s k e d t o r e v i e w i t s c u r r e n t s t a f f i n g p a t t e r n s , a s c e r t a i n i f t h e p r o p o s e d HIS c o u l d r e d u c e s t a f f i n g l e v e l s i n e a c h p o s i t i o n a n d / o r i f s t a f f i n g c o u l d be r e o r g a n i z e d t o t a k e a d v a n t a g e o f t r a n s f e r s o f t a s k s i f a p p r o p r i a t e . Forms a n d p r i n t i n g c o s t s w e r e g e n e r a l l y i g n o r e d b e c a u s e i t was f e l t t h e y w o u l d l i k e l y be o f f s e t by a s i m i l a r amount r e q u i r e d by t h e H I S . E l i m i n a t i o n o f o u t -s i d e d a t a s e r v i c e s a n d c o u r i e r s e r v i c e s w e r e a l s o i n c l u d e d w h e r e a p p l i c a b l e . P o t e n t i a l l y r e d u c i b l e w a s t a g e u n d e r t h e s t a t u s quo s y s t e m was e s t i m a t e d and i n c o r p o r a t e d , p a r t i c u l a r l y i n t h e F o o d S e r v i c e s D e p a r t m e n t . T a b l e 4 s u m m a r i z e s t h e l a b o r and n o n - l a b o r b e n e f i t s t r e a m s f o r e a c h i m p l e m e n t a t i o n s t a g e o f t h e HIS.. 98; TABLE 4 SUMMARY OF NON-INFLATED, NON-DISCOUNTED ESTIMATED SAVINGS (LABOR & NON-LABOR) OVER EIGHT YEAR PERIOD FOR THE CHILLIWACK GENERAL HOSPITAL LABOR YEAR BENEFITS DEPARTMENT/AREA 1 1986 2 1987 3 1988 STAGE I Admit/Swbd/OP Finance/Bus. Off. Health Records STAGE II Lab/Path Nursing STAGE III Radiology Pharmacy Food Services Sub-total NON-LABOR2 0 0 0 0 0 0 0 0 25,400 13,570 0 0 0 0 0 38,970 25,400 13,570 40,200 0 0 0 79,170 4 1989 0 25,400 13,570 40,200 53,000 0 0 0 132,170 5 1990 25,400 13,570 40,200 53,000 0 0 132,170 6 1991 0 25,400 13,570 40,200 53,000 0 0 0 132,170 7 1992 0 25,400 13,570 40,200 53,000 0 0 132,170 STAGE I Admit/Swbd/OP Finance/Bus. Off. Health Records STAGE II Lab/Path Nursing STAGE III Radiology Pharmacy Food Services Sub-total . . T o t a l 0 0 0 0 0 0 13,000 400 0 J0 0 0 0 13,400 52,370 0 13,000 400 0 0 0 0 0 13,400 92,570 0 13,000 400 0 0 0 31,000 44,400 176,570 0 13,000 400 0 0 0 0 31,000 44,400 0 13,000 400 0 0 0 0 31,000 44,400 0 13,000 400 0 0 0 31,000 44,400 176,570 176,570 176,570 Includes employee benefits @ approx. 23% (average) of gross annual remuneration rounded to nearest .1 FTE and $100. Includes reduction of wastage, elimination of BCHA data services (except f o r Payroll/Personnel), courier service. Only differences r e l a t i v e to the status quo are included i n f i g u r e s . 99 I n t a n g i b l e B e n e f i t s C o n s i d e r a b l e t i m e was s p e n t d u r i n g t h e HSP s t a g e o f p l a n n i n g i n e n u m e r a t i n g i n t a n g i b l e b e n e f i t s and t h e s e w e re n o t r e v i e w e d a t t h i s s t a g e s i n c e t h e CBA f o c u s s e s on t a n g i b l e b e n e f i t s . T h i s d o e s n o t p r e c l u d e e m p h a s i z i n g t h e i r i m p o r t a n c e . On t h e c o n t r a r y , many o f t h e s e i n t a n g i b l e b e n e f i t s may p r o v e t o be m o s t i m p o r t a n t . E x a m p l e s (drawn f r o m A p p e n d i x 6) i n c l u d e t h e f o l l o w i n g : I m p r o v e d p a t i e n t c a r e s e r v i c e s I m p r o v e d p a t i e n t s a t i s f a c t i o n a nd m o r a l e I n c r e a s e d q u a l i t y o f c a r e G r e a t e r c o n t i n u i t y a n d c o n s i s t e n c y o f c a r e I m p r o v e d o r d e r c o m m u n i c a t i o n p r o c e s s I m p r o v e d i n t e r d e p a r t m e n t a l r e l a t i o n s h i p s More t i m e l y d e c i s i o n - m a k i n g I m p r o v e d s t a f f m o r a l e I m p r o v e d r e t r i e v a l o f p a t i e n t r e c o r d s and p r o c e s s i n g o f r e p o r t s I n t e g r a t e d p a t i e n t r e c o r d s I m p r o v e d d e c i s i o n - m a k i n g and c o m m u n i c a t i o n a b i l i t i e s M ore t i m e l y and a c c u r a t e m e s s a g e s 100 Q u a n t i f i c a t i o n arid V a l u a t i o n o f C o s t s a n d B e n e f i t s T a n g i b l e C o s t s T h i s s t e p p r o v e d t o be s t r a i g h t f o r w a r d , t h e i n f o r m a t i o n b e i n g g a i n e d f r o m t h e RFP p r o c e s s , c o m m u n i c a t i o n w i t h t h e v e n d o r , o t h e r s y s t e m u s e r s and p l a i n common s e n s e . I t c a n be c o m b i n e d w i t h t h e e n u m e r a t i o n p r o c e s s . C a r e must be t a k e n a g a i n i n r e l y i n g t o o h e a v i l y on v e n d o r i n p u t b e c a u s e o f t h e i r n o n - h o s p i t a l p e r s p e c t i v e a n d i n h e r e n t d e s i r e t o s e l l t h e i r p r o d u c t . I n t a n g i b l e C o s t s No a t t e m p t was made t o q u a n t i f y and v a l u e t h e i d e n t i f i e d i n t a n g i b l e c o s t s i d e n t i f i e d a s s y s t e m - i n d u c e d f r u s t r a t i o n a n d s t r e s s , p a r t i c u l a r l y d u r i n g t h e i m p l e m e n t a t i o n p e r i o d . T a n g i b l e B e n e f i t s T h i s s t e p was c o m b i n e d w i t h t h e e n u m e r a t i o n o f t a n g i b l e b e n e f i t s a n d was d i r e c t e d p r i m a r i l y a t s t a f f l a b o r s a v i n g s a n d o t h e r m a j o r , n o n - l a b o r b e n e f i t s ( T a b l e 4 ) . T h e r e may be a t e n d e n c y t o o v e r - e s t i m a t e t h e s e b e n e f i t s i n o r d e r t o c r e a t e a b e t t e r b e n e f i t c a s e ; h o w e v e r , i t i s f a r s a f e r t o be c o n s e r v a t i v e i f u n c e r t a i n and p l e a s a n t l y s u r p r i s e d i n a few y e a r s r a t h e r t h a n r e l y i n g on a f a l s e s e n s e o f b e n e f i t s e c u r i t y a n d u n p l e a s a n t s u r p r i s e s i f t h e b e n e f i t s do n o t a c c r u e . 101 I n t a n g i b l e B e n e f i t s I n p r a c t i c e q u a n t i f i c a t i o n o f i n t a n g i b l e b e n e f i t s i s r a r e l y a t t e m p t e d and f o r t h e p u r p o s e s o f CGH's s t u d y t h e y w e r e i d e n t i f i e d o n l y and b r o u g h t t o t h e a t t e n t i o n o f t h e d e c i s i o n - m a k e r s . D i s c o u n t i n g o f C o s t s and B e n e f i t s Once t h e c o s t s and b e n e f i t s h a v e b e e n e n u m e r a t e d , q u a n t i f i e d and v a l u e d , d i s c o u n t i n g c a n be a p p l i e d . F o r e a s e o f d i s c o u n t i n g , t h e n o n - i n f l a t e d , n o n - d i s c o u n t e d c o s t s and b e n e f i t s s h o u l d be t a b u l a t e d i n summary f o r m ( T a b l e 5 ) . I n i t i a l l y , a t h r e e p e r c e n t d i s c o u n t r a t e was a p p l i e d t o t h e s t r e a m s o f c o s t s and b e n e f i t s ( T a b l e 6 ) . P r i o r t o d i s c o u n t i n g , t h e d o l l a r f i g u r e s f o r c o s t s and b e n e f i t s w e r e i n c o n s t a n t ( t o d a y ' s ) p r i c e s a n d t h e t h r e e p e r c e n t r a t e r e p r e s e n t s an e s t i m a t e o f t h e p r i v a t e o p p o r t u n i t y c o s t o f c a p i t a l i n t h e a b s e n c e o f a n t i c i p a t e d i n f l a t i o n . I n f l a t i o n was i g n o r e d t h r o u g h o u t t h e a n a l y s i s . S e n s i t i v i t y A n a l y s i s F i n a l l y , t h e a n a l y s i s was s u b j e c t e d t o v a r i o u s t e s t s i n c l u d i n g U.S. e x c h a n g e r a t e s ( a p p l i c a b l e t o a l l o n e - t i m e and o n - g o i n g s o f t w a r e c o s t s ) , s c e n a r i o s f o r f u n d i n g f r o m t h e MOH a n d / o r R e g i o n a l H o s p i t a l D i s t r i c t , d i s c o u n t r a t e s and s y s t e m c o s t s a s a p e r c e n t a g e o f t h e h o s p i t a l ' s g r o s s a n n u a l o p e r a t i n g b u d g e t ( T a b l e s 7 - 1 3 ) . 102 TABLE 5 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS AND BENEFITS OF HIS OVER EIGHT YEAR PERIOD FOR THE - CHILLIWACK;GENERAL.HOSPITAL. YEAR COSTS (?) BENEFITS!$) 0 1986 ( 1 s t 4 mos) 17,501 0 1 1986 591,753 0 2 1987 386,384 52,370 3 1988 466,211 92,570 4 1989 186,713 176,570 5 1990 181,328 176,570 6 1991 181,328 176,570 7 1992 181,328 176,570 8 1993 181,328 176,570 5 y e a r C u m u l a t i v e T o t a l 1,829,890 498,080 8 y e a r C u m u l a t i v e T o t a l 2,373,874 1,027,790 10% d e p o s i t f o r Stage I s o f t w a r e a p p l i c a t i o n s upon s i g n i n g contract:with.'Meditech-.• - .. 2 1.4 U.S. exchange r a t e a p p l i e s t o a l l s o f t w a r e c o s t s . 103 TABLE 6 PRESENT DISCOUNTED VALUES (CALCULATED AT 3% DISCOUNT RATE) FOR ENTIRE STREAM OF COSTS AND BENEFITS FOR THE . -CHILLIWACK GENERAL HOSPITAL "pdv (1+r) (1+r) (1+r)' B ^ = B o + pdv 1 + + . (1+r) (1+r) B (l+r) J 0 1 2 3 YEAR 1986 1986 1987 1988 1989 1990 COSTS 1,2 (1st 4 mos) 17,501. 574,517 364,204 426,660 165,893 156,412 BENEFITS ' 0 0 49,3'64 84,717 156,881 152,307 6 7 1991 1992 1993-151,853 147,433• 143,139 147,869 143,565 139,383 5 yr. Cumulative T o t a l 1,705,187 443,269 yr. Cumulative T o t a l 2,147,612 874,086 A l l costs and benefits are estimated i n constant p r i c e s ( i . e . , no i n f l a t i o n ) and discount rate i s pri v a t e opportunity cost of c a p i t a l i n the absence of i n f l a t i o n . 1.4 U.S. exchange rate applies to a l l s o f t -ware costs. TABLE 7 104 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS AND BENEFITS OF HIS OVER EIGHT YEAR PERIOD ASSUMING ALL COSTS 100% FUNDED BY THE CHILLIWACK GENERAL HOSPITAL YEAR COSTS BENEFITS NET CUM. COSTS CUM. BENEFITS CUM. NET 0 1986 ( 1 s t 4 mos) 17,501 0 (17,501) 17,501 0 (17,501) 1 1986 591,753 0 (591,753) 609,254 0 (609,254) 2 1987 386,384 52,370 (334,014) 995,638 52,370 (943,268) 3 1988 466,211 92,570 (373,641) 1,461,849 144,940 (1,316,909) 4 1989 186,713 176,570 (10,143) 1,648,562 321,510 (1,327,052) 5 1990 181,328 176,570 (4,758) 1,829,890 498,080 (1,331,810) 6 1991 181,328 176,570 (4,758) 2,011,218 674,650 (1,336,568) 7 1992 181,328 176,570 (4,758) 2,192,546 851,220 (1,341,326) 8 1993 181,328 176,570 (4,758) 2,373,874 1,027,790 (1,346,084) TOTAL 2,373,874 1,027,790 (1,346,084) NOTE: Format adapted from U.S., Department of Health and Human Services, National Center for Health Services Research. Methods f o r Evaluating Costs of Automated Hospital Information Systems: F i n a l Report and Executive Summary, by E r i c a Drazen, Arthur D. L i t t l e , Inc., Report No. NCHSR 80-36 ( S p r i n g f i e l d , VA: NTIS, March 14, 1980), p. 81. 1.4 U.S. exchange rate applies to a l l software costs. TABLE 8 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS AND BENEFITS OF HIS OVER EIGHT YEAR PERIOD ASSUMING ONE-TIME CAPITAL COSTS 100% FUNDED BY OTHERS 105 YEAR COSTS 1 BENEFITS NET CUM. COSTS CUM. BENEFITS CUM. NET 0 1986 ( 1 s t 4 mos) 0 0 0 0 0 0 1 1986 29,416 0 (29,416) 29,416 0 (29,416) 2 1987 106,924 52,370 (54,554) 136,340 52,370 (83,970) 3 1988 170,200 92,570 (77,630) 306,540 144,940 (161,600) 4 1989 186,713 176,570 (10,143) 493,253 321,510 (171,743) 5 1990 181,328 176,570 (4,758) 674,581 498,080 (176,501) 6 1991 181,328 176,570 (4,758) 855,909 674,650 (181,259) 7 1992 181,328 176,570 (4,758) 1,037,237 851,220 (186,017) 8 1993 181,328 176,570 (4,758) 1,218,565 1,027,790 (190,775) TOTAL 1,218,565 1,027,790 (190,775) 1.4 U.S. exchange r a t e a p p l i e s t o a l l s o f t w a r e c o s t s . TABLE 9 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS AND BENEFITS OF HIS OVER EIGHT YEAR PERIOD ASSUMING ALL COSTS 100% FUNDED BY THE CHILLIWACK GENERAL HOSPITAL YEAR COSTS1 BENEFITS NET CUM. COSTS CUM. BENEFITS CUM. NET 0 1986 ( 1 s t 4 mos) 16,250 0 (16,250) 16,250 0 (16,250) 1 1986 573,747 0 (573,747) 589,997 0 (589,997) 2 1987 367,829 52,370 (315,459) 957,826 52,370 (905,456) 3 1988 450,784 92,570 (358,214) 1,408,610 144,940 (1,263,670) 4 1989 181,188 176,570 (4,618) 1,589,798 321,510 (1,268,288) 5 1990 176,188 176,570 382 1,765,986 498,080 (1,267,906) 6 1991 176,188 176,570 382 1,942,174 674,650 (1,267,524) 7 1992 176,188 176,570 382 2,118,362 851,220 (1,267,142) 8 1993 176,188 176,570 382 2,294,550 1,027,790 (1,266,760) " TOTAL 2,294,550 1,027,790 (1,266,760) 1.3 U.S. exchange r a t e a p p l i e s t o a l l s o f t w a r e c o s t s . TABLE 10 107 SUMMARY OF NON-INFLATED, NON-DISCOUNTED COSTS AND BENEFITS OF HIS OVER EIGHT YEAR PERIOD ASSUMING ALL ONE-TIME CAPITAL COSTS 100% FUNDED BY OTHERS YEAR COSTS 1 BENEFITS NET CUM. COSTS CUM. BENEFITS CUM. NET 1986 (1st 4 mos) 0 0 0 0 0 0 1986 29,416 0 (29,416) 29,416 0 (29,416) 1987 104,023 52,370 (51,653) 133,439 52,370 (81,069) 1988 165,710 92,570 (73,140) 299,149 144,940 (154,209) 1989 181,188 176,570 (4,618) 480,337 321,510 (158,827) 1990 176,188 176,570 382 656,525 498,080 (158,445) 1991 176,188 176,570 382 832,713 674,650 (158,063) 1992 176,188 176,570 382 1,008,901 851,220 (157,681) 1993 176,188 176,570 382 1,185,089 1,027,790 (157,299) TOTAL 1,185,089 1,027,790 (157,299) 1.3 U.S. exchange rate applies to a l l software costs. TABLE 11 SUMMARY OF PRESENT VALUE COSTS AND BENEFITS AT VARIOUS PRESENT DISCOUNTED VALUES ONE-TIME CAPITAL COSTS 100% FUNDED BY THE CHILLIWACK GENERAL HOSPITAL 3% DISCOUNT RATE 5% DISCOUNT RATE 7% DISCOUNT RATE YEAR NET CUM. NET NET CUM. NET NET CUM. NET 0 1986 ( 1 s t 4 mos) (17,501) (17,501) (17,501) (17,501) (17,501) (17,501) 1 1986 (574,517) (592,018) (563,574) (581,075) (553,040) (570,541) 2 1987 (314,840) (906,858) (302,961) (884,036) (291,741) (862,282) 3 1988 (341,943) (1,248,801) (322,772) (1,206,808) (305,013) (1,167,295) 4 1989 (9,012) (1,257,813) (8,345) (1,215,513) (7,738) (1,175,033) 5 1990 (4,104) (1,261,917) (3,728) (1,218,881) (3,392) (1,178,425) 6 1991 (3,985) (1,265,902) (3,550) (1,222,431) (3,171) (1,181,596) 7 1992 (3,869) (1,269,771) (3,381) (1,225,812) (2,963) (1,184,559) 8 1993 (3,756) (1,273,527) (3,220) (1,229,032) (2,769) (1,187,328) ONE-TIME CAPITAL COSTS 100% FUNDED BY OTHERS 0 1986 ( 1 s t 4 mos) 0 0 0 0 0 0 1 1986 (28,559) (28,559) (28,015) (28,015) (27,492) (27,492) 2 1987 (51,422) (79,981) (49,482) (77,497) (47,650) (75,142) 3 1988 (71,044) (151,025) (67,061) (144,558) (63,371) (138,513) 4 1989 (9,012) (160,037) (8,345) (152,903) (7,738) (146,251) 5 1990 (4,104) (164,141) (3,728) (156,631) (3,392) (149,643) 6 1991 (3,985) (168,126) (3,550) (160,181) (3,171) (152,814) 7 1992 (3,869) (171,995) (3,381) (163,562) (2,963) (155,777) 8 1993 (3,756) (175,751) (3,220) (166,782) (2,769) (158,546) NOTE: Format adapted from U.S., Department of Health and Human Services, National Center f o r Health Services Research. Methods f or Evaluating Costs of Automated Hospital Information Systems: F i n a l Report and Executive Summary, by E r i c a Drazen, Arthur D. L i t t l e , Inc., Report No. NCHSR 80-36 ( S p r i n g f i e l d , VA: NTIS, March 14, 1980), p. 83. X1.4 U.S. exchange rate applies to a l l software costs. TABLE 12 SUMMARY OF PRESENT VALUE COSTS AND BENEFITS AT VARIOUS PRESENT DISCOUNTED VALUES 1 ONE-TIME CAPITAL COSTS 100% FUNDED BY THE CHILLIWACK GENERAL HOSPITAL YEAR 3% DISCOUNT RATE NET CUM. NET 5% DISCOUNT RATE NET CUM. NET 7% DISCOUNT RATE NET CUM. NET 0 1986 (1st 4 mos) (16,250) (16,250) (16,250) (16,250) (16,250) (16,250) 1 1986 (557,036) (573,286) (546,426) (562,676) (536,212) (552,462) 2 1987 (297,350) (870,636) (286,131) (848,807) (275,534) (827,996) 3 1988 (327,825) (1,198,461) (309,445) (1,158,252) (292,420) (1,120,416) 4 1989 (4,103) (1,202,564) (3,799) (1,162,051) (3,523) (1,123,939) 5 1990 330 (1,202,234) 299 (1,161,752) 272 (1,123,667) 6 1991 320 (1,201,914) 285 (1,161,467) 255 (1,123,412) 7 1992 311 (1,201,603) 271 (1,161,196) 238 (1,123,174) 8 1993 302 (1,201,301) 259 (1,160,937) 222 (1,122,952) ONE-TIME 1 CAPITAL COSTS 100% FUNDED BY OTHERS 0 1986 (1st 4 mos) 0 0 0 0 0 0 1 1986 (28,559) (28,559) (28,015) (28,015) (27,492) (27,492) 2 1987 (48,688) (77,247) (46,851) (74,866) (45,116) (72,608) 3 1988 (66,935) (144,182) (63,182) (138,048) (59,706) (132,314) 4 1989 (4,103) (148,285) (3,799) (141,847) (3,523) (135,837) 5 1990 330 (147,955) 299 (141,548) 272 (135,565) 6 1991 320 (147,635) 285 (141,263) 255 (135,310) 7 1992 311 (147,324) 271 (140,992) 238 (135,072) 8 1993 302 (147,022) 259 (140,733) 222 (134,850) 1.3 U.S. exchange rate applies to a l l software costs. 1 1 0 TABLE 13 SUMMARY OF NON-INFLATED, NON-DISCOUNTED NET COSTS OF HIS OVER EIGHT YEAR PERIOD AS PERCENTAGE OF NON-INFLATED, NON-DISCOUNTED GROSS ANNUAL OPERATING BUDGETS FOR THE CHILLIWACK GENERAL HOSPITAL YEAR 100% FUNDED BY CGH 50% ONE-TIME 0% ONE-TIME CAPITAL COSTS CAPITAL COSTS FUNDED BY CGH FUNDED BY CGH 1 1986 3.455% 1.841% 0.172% 2 1987 1.924% 1.128% 0.319% 3 1988 2.147% 1.308% 0.454% 4 1989 0.060% 0.060% 0.060% 5 1990 0.028% 0.028% 0.028% 6 1991 0.028% 0.028% 0.028% 7 1992 0.028% 0.028% 0.028% 8 , 1993 0.028% 0.028% 0.028% Mean = 0.962% p.a. 0.556% p.a. 0.140% NOTE: 1985/86 approved budget adjusted annually to r e f l e c t a d d i t i o n a l costs incurred .by KIS., "'"Actual costs can be determined from previous tables. I l l I n t e r p r e t a t i o n and P r e s e n t a t i o n of: F i n d i n g s T a b l e s 1 and 2 d e t a i l t h e e n u m e r a t i o n , q u a n t i f i c a t i o n a n d v a l u a t i o n o f o n e - t i m e and o n - g o i n g t a n g i b l e c o s t s f o r CGH 1s p r o p o s e d HIS o v e r an e i g h t y e a r p e r i o d , f o r m i n g t h e b a s i s o f t h e c o s t - s i d e o f t h e CBA. A l l p e r t i n e n t c o s t s w e r e c o n s i d e r e d , b u t n o t a l l w e re i n c l u d e d b e c a u s e t h e y e i t h e r d i d n o t a p p l y t o t h e c u r r e n t CGH p r o p o s a l o r t h e y w e r e i n c o n s e -q u e n t i a l t o t h e a n a l y s i s . T a b l e 3 s u m m a r i z e s t h e n o n - i n f l a t e d , n o n - d i s c o u n t e d c o s t s a s s u m i n g t h a t one h u n d r e d p e r c e n t o f t h e o n e - t i m e and o n - g o i n g c o s t s w o u l d be f u n d e d by t h e h o s p i t a l . Two U.S. e x c h a n g e r a t e s (1.3 and 1.4) a r e s h o w n , a p p l i c a b l e t o a l l o n e -t i m e and o n - g o i n g s o f t w a r e c o s t s . An e i g h t y e a r p e r i o d was u s e d b e c a u s e i t was f e l t t h i s r e p r e s e n t e d a r e a l i s t i c l i f e -s p a n o f t h e s y s t e m , as o p p o s e d t o t h e f i v e y e a r p e r i o d s u p p o r t e d by t h e MOH. N o t s u r p r i s i n g l y , t h e m o s t s i g n i f i c a n t c o s t s ( l a r g e l y due t o o n e - t i m e h a r d w a r e and s o f t w a r e ) o c c u r i n t h e e a r l y y e a r s o f t h e p r o j e c t , d u r i n g t h e i m p l e m e n t a t i o n s t a g i n g . T h u s , one way t o e a s e t h e f r o n t - e n d b u r d e n i s t o s p r e a d o u t t h e s t a g i n g o f a p p l i c a t i o n s ; h o w e v e r , t h e b e n e f i t s t r e a m s w i l l s u f f e r a c c o r d i n g l y . T a b l e 4 s u m m a r i z e s t h e a n t i c i p a t e d s a v i n g s f o r l a b o r and n o n - l a b o r - t a n g i b l e b e n e f i t s a f t e r i m p l e m e n t a t i o n o f e a c h s t a g e o f t h e H I S . B e c a u s e t h e s e f i g u r e s h a v e b e e n g e n e r a t e d b y t h e p o t e n t i a l s y s t e m u s e r s ( p a r t i c i p a n t s i n t h e e n t i r e 112 p l a n n i n g p r o c e s s ) t h e y a r e f e l t t o be c o n s e r v a t i v e , b u t v a l i d , p r e d i c t i o n s . No o n e - t i m e , s a v i n g s a r e shown b e c a u s e i t i s f e l t t h a t any s t a t u s quo m i c r o c o m p u t e r e q u i p m e n t w o u l d be r e - u s e d i n o t h e r d e p a r t m e n t s . N o n - l a b o r s a v i n g s i n c l u d e e l i m i n a t i o n o f BCHA d a t a s e r v i c e s a n d c o u r i e r s e r v i c e s a n d w a s t e . F o r t h e m o s t p a r t , r e d u c t i o n o f f o r m s a n d p r i n t i n g c o s t s w e r e n o t i n c l u d e d b e c a u s e i t was f e l t t h a t t h e s e c o s t s w o u l d l i k e l y be o f f s e t by t h e p r i n t i n g a n d f o r m s c o s t s o f t h e H I S . The g r e a t e s t s a v i n g s a r e i n l a b o r , p a r t i c u l a r l y c l e r i c a l a s o p p o s e d t o p a t i e n t c a r e r e l a t e d s t a f f . F u t u r e l a b o r c o s t - a v o i d a n c e s w e re n o t i n c l u d e d i n t h i s s t u d y due t o i n h e r e n t e x c e s s c a p a c i t y i n t h e s y s t e m a nd m i n i m a l e x p e c t e d g r o w t h i n CGH's s e r v i c e a c t i v i t y . Had a n n u a l i n p a t i e n t a n d o u t p a t i e n t a c t i v i t i e s b e e n i n c r e a s i n g s i g n i f i c a n t l y t h i s w o u l d h a v e b e e n a much g r e a t e r f a c t o r i n t h e b e n e f i t c a s e . The t a b l e a l s o d e m o n s t r a t e s a s i g n i f i c a n t jump i n b e n e f i t s c o mmencing a t Y e a r F o u r , i m m e d i a t e l y f o l l o w i n g t h e i m p l e m e n t a t i o n o f a l l t h r e e s t a g e s . N o t a b l y , b e n e f i t s i n N u r s i n g a r e n o t f u l l y a c h i e v a b l e u n t i l t h e O r d e r P r o c e s s i n g c o mponent becomes f u n c t i o n a l . T h e s e s a v i n g s c a r r y on i n p e r p e t u i t y a n d t h e m s e l v e s a p p r o a c h t h e g e n e r a l o p e r a t i n g c o s t s o f t h e H I S . T a b l e 5 d e m o n s t r a t e s t h e s u m m a r i z e d , n o n - i n f l a t e d , n o n - d i s c o u n t e d c o s t s and b e n e f i t s by y e a r , by t h e f i v e y e a r c u m u l a t i v e t o t a l and by t h e e i g h t y e a r c u m u l a t i v e t o t a l b a s e d on a 1.4 U.S. e x c h a n g e r a t e a s s u m i n g t h e h o s p i t a l 113 f u n d s one h u n d r e d p e r c e n t o f t h e o n e - t i m e c a p i t a l c o s t s . T a b l e 6 shows t h e p r e s e n t d i s c o u n t e d v a l u e s f o r t h e e n t i r e s t r e a m s o f t a n g i b l e c o s t s a n d b e n e f i t s , u s i n g a t h r e e p e r c e n t d i s c o u n t r a t e . The n o n - d i s c o u n t e d s t r e a m s a r e s u m m a r i z e d i n T a b l e s 7-10 i n o r d e r t o t e s t s e n s i t i v i t y a g a i n s t v a r y i n g U.S. e x c h a n g e r a t e s and f u n d i n g s c e n a r i o s . I t i s i m p o r t a n t t h a t t h e d a t a be t a b u l a t e d ' i n t h i s f a s h i o n f o r e a s e o f c a l c u l a t i o n w i t h r e s p e c t t o v a r y i n g t h e d i s c o u n t r a t e . The e f f e c t s o f v a r y i n g t h e d i s c o u n t r a t e a t t h r e e p e r c e n t , f i v e p e r c e n t and s e v e n p e r c e n t b a s e d on two U.S. e x c h a n g e r a t e s a r e shown i n T a b l e s 11 and 12. T a b l e s 7-10 d e m o n s t r a t e t h e e f f e c t t h a t v a r i o u s f u n d i n g s c e n a r i o s h a v e on t h e c u m u l a t i v e t o t a l s f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l and t h e e f f e c t o f t h e U.S. e x c h a n g e r a t e . N o t s u r p r i s i n g l y , t h e a n a l y s i s i s v e r y s e n s i t i v e t o f u n d i n g o f o n e - t i m e c a p i t a l c o s t s . The U.S. e x c h a n g e r a t e , w h i l e i m p o s s i b l e t o p r e d i c t o v e r t h e e i g h t y e a r p e r i o d , c l e a r l y a f f e c t s s o f t w a r e p u r c h a s e and s u p p o r t c a t e g o r i e s . The c o s t - s i d e o f t h e CBA, a p a r t f r o m t h e u n c e r t a i n t i e s o f t h e ^ U . S . e x c h a n g e r a t e s , w o u l d a p p e a r t o be f a i r l y t i g h t . A d e l i b e r a t e e f f o r t was made t o e r r on t h e s i d e o f o v e r - c o s t i n g i f t h e r e was u n -c e r t a i n t y w i t h r e s p e c t t o a c t u a l c o s t s . E x a m p l e s o f t h i s i n -c l u d e d t h e c o n v e r s i o n o f p a t i e n t r e c o r d i n d e x c a r d s , t r a i n i n g c o s t s , and o n - g o i n g s t a f f s u p p o r t . T h e r e a r e a l w a y s u n -c e r t a i n t i e s when c o s t i n g ; h o w e v e r , i t was f e l t t h a t a m a r g i n 114 f o r e r r o r would be a p p r o p r i a t e . From t h e p e r s p e c t i v e o f the h o s p i t a l , the b e s t - c a s e s c e n a r i o would be one hundred p e r c e n t f u n d i n g by o t h e r s o f the one-time c a p i t a l c o s t s . W h i l e a more f a v o u r a b l e c o s t -b e n e f i t r a t i o would be o b t a i n e d by r a i s i n g t he d i s c o u n t r a t e , a t h r e e p e r c e n t d i s c o u n t r a t e p r o v i d e s a margin of s a f e t y i n -terms o f c u m u l a t i v e n e t c o s t s . W h i l e a 1.3 U.S. exchange r a t e o f f e r s a b e t t e r s c e n a r i o , a 1.4 r a t e seems more r e a l i s t i c p r e s e n t l y . Perhaps the most s i g n i f i c a n t f i n d i n g i n CGH's a n a l y s i s i s t h a t even i f a l l one-time c o s t s a r e one hundred' p e r c e n t funded by o t h e r s , c o s t s s t i l l exceed b e n e f i t s o v e r t h e e i g h t y e a r p e r i o d , even from the narrow h o s p i t a l - o n l y p e r s p e c -t i v e . N a t u r a l l y , any b e n e f i t s t h a t do a c c r u e h i n g e on the h o s p i t a l ' s r e a l i z a b i l i t y of the p r e d i c t e d b e n e f i t s t h r o u g h r e d u c t i o n s i n ; s t a f f i n g l e v e l s . The h o s p i t a l took a c o n s e r v a -t i v e e s t i m a t e o f t h e s e p o t e n t i a l l a b o r s a v i n g s . A c t u a l e x p e r -i e n c e may i n c r e a s e t h e s a v i n g s i n t h i s a r e a . As p a r t o f t h e o v e r a l l d e c i s i o n - m a k i n g p r o c e s s , a f u n d i n g p r o p o s a l i s y e t t o be c a r r i e d out u s i n g the p r e v i o u s l y r e f e r e n c e d MOH g u i d e l i n e s . A t t h e time o f w r i t i n g , t h e g u i d e -l i n e s a r e s t i l l c a l l i n g f o r a maximum e x p e n d i t u r e l e v e l o f 0.5 p e r c e n t f o r community g e n e r a l h o s p i t a l s i n t o which c a t e -g ory CGH f a l l s . Based on t h e h o s p i t a l ' s c u r r e n t approved g r o s s a n n u a l o p e r a t i n g budget of a p p r o x i m a t e l y seventeen m i l l i o n d o l l a r s , t h i s upper l i m i t amounts t o a p p r o x i m a t e l y 115 e i g h t y - f i v e t h o u s a n d d o l l a r s p e r annum f o r a l l c o s t s a s s o c i -a t e d w i t h t h e H I S . The maximum e x p e n d i t u r e l e v e l i s a p p a r e n t l y e x c l u s i v e o f any p o t e n t i a l s a v i n g s made p o s s i b l e t h r o u g h t h e b e n e f i t c a s e ; m o r e o v e r , t h e l e v e l i s an a v e r a g e d one o v e r t h e e x p e c t e d l i f e s p a n o f t h e H I S , w h a t e v e r t h a t i s deemed t o be i n t h e e y e s o f t h e MOH. W h i l e n o t s t a t e d e x p l i c i t l y i n t h e g u i d e l i n e s , t h e s e a r e v e r y i m p o r t a n t p r o v i s o s f o r t h e h o s p i t a l . T a b l e 13 shows t h r e e f u n d i n g s c e n a r i o s u s i n g t h e s u m m a r i z e d n o n - i n f l a t e d , n o n - d i s c o u n t e d n e t c o s t s a s a p e r c e n t a g e o f n o n - i n f l a t e d , n o n - d i s c o u n t e d g r o s s a n n u a l o p e r a t i n g b u d g e t , a s s u m i n g t h e l a t t e r r e m a i n s c o n s t a n t o v e r e i g h t y e a r s . Of p a r t i c u l a r i n t e r e s t i s t h e s c e n a r i o d e p i c t i n g f i f t y p e r c e n t o f t h e o n e - t i m e c a p i t a l c o s t s f u n d e d by CGH and f i f t y p e r c e n t by o t h e r s . The a n n u a l c o s t s ( n e t o f b e n e f i t s ) a v e r a g e d o v e r t h e e i g h t y e a r p e r i o d a r e j u s t i n e x c e s s o f t h e 0.5 p e r c e n t l e v e l . W h i l e n o t p r e s e n t l y i n c l u d e d i n t h e h o s p i t a l 1 s HIS p r o p o s a l o t h e r a v a i l a b l e a p p l i c a t i o n m o d u l e s i n c l u d i n g P a y r o l l / P e r s o n n e l , M a t e r i a l s Managements, N u r s e A c u i t y / W o r k l o a d Management a n d O f f i c e A u t o m a t i o n may be i n c o r p o r a t e d . The P a y r o l l / P e r s o n n e l a p p l i c a t i o n h a s b e e n d e l i b e r a t e l y e x c l u d e d due t o t h e u n c e r t a i n t i e s p o s e d by BCHSSS' r e c e n t e n d e a v o u r t o d e v e l o p a P a y r o l l / P e r s o n n e l a p p l i c a t i o n w h i c h i s p u r p o r t e d t o s u b s t a n t i a l l y r e d u c e p a y r o l l p r o c e s s i n g c o s t s t o h o s p i t a l s . M o r e o v e r , j u s t how i t w i l l l i n k t o t h e a c t i v i t i e s o f HLRA ( i f n e c e s s a r y , a t a l l ) i s unknown. The M a t e r i a l s Management 116 m o d u l e was n o t i n c l u d e d l a r g e l y b e c a u s e t h e HSP s t u d y , w h i l e i d e n t i f y i n g c e r t a i n p r o b l e m s and p o t e n t i a l , s o l u t i o n s i n t h i s a r e a , r e l e g a t e d i t t o a l o w p r i o r i t y . I n r e t r o s p e c t , t h i s was l i k e l y an e r r o r ; h o w e v e r , i t i s c o r r e c t a b l e and w i l l l i k e l y be i n c o r p o r a t e d a s t h e p r o j e c t p r o c e e d s . I r o n i c a l l y , i n b o t h t h e P a y r o l l / P e r s o n n e l a n d M a t e r i a l s Management a p p l i c a t i o n s , s u b s t a n t i a l t a n g i b l e b e n e f i t s w i l l a c c r u e , t h u s p l a c i n g t h e h o s p i t a l i n an e v e n b e t t e r c o s t - b e n e f i t p o s i t i o n p r o v i d i n g t h e s e i n c r e m e n t a l b e n e f i t s e x c e e d t h e i n c r e m e n t a l c o s t s o f t h e s e a p p l i c a t i o n m o d u l e s . The a d d i t i o n a l a p p l i c a t i o n c o s t s a r e m a r g i n a l s i n c e t h e r e i s e x c e s s c a p a c i t y i n t h e h a r d -w a r e c o n f i g u r a t i o n . The N u r s e A c u i t y / W o r k l o a d Management a n d O f f i c e A u t o m a t i o n m o d u l e s , w h i l e d e s i r a b l e a p p l i c a t i o n s , h a v e n o t r e c e i v e d h i g h p r i o r i t y t o d a t e . L i k e l y , t h i s w i l l c h a n g e 2 t h r o u g h i t e r a t i v e d i s c o v e r y o n c e s y s t e m u s e r s h a v e h a d some e x p e r i e n c e w i t h t h e i n i t i a l a p p l i c a t i o n s . I n f a c t , t h e y w o u l d be a r e a l b o o n t o a c c e p t a n c e o f t h e H I S . T h u s , w h i l e t h e h o s p i t a l h a s t h e b a s i s f o r i t s l o n g - r a n g e HIS p l a n a n d CBA, t h e s e t o o w i l l e v o l v e a s h o s p i t a l s t a f f a n d o t h e r s d i s c o v e r a d d i t i o n a l r e q u i r e m e n t s . T h i s p o i n t s t o t h e n e e d , as i n any p l a n n i n g p r o c e s s , f o r d e l i b e r a t e , p e r i o d i c r e v i e w a nd r e v i s i o n b a s e d on e v e r - c h a n g i n g p o l i t i c a l , e c o n o m i c , s o c i a l a n d t e c h n o l o g i c a l f a c t o r s . M o r e o v e r , f u t u r e M e d i t e c h d e v e l o p m e n t s i n c l u d e N u r s e C a r e P l a n s , E l i m i n a t i o n o f N u r s e K a r d e x , C o s t - A c c o u n t i n g 1 1 7 M o d u l e and G e n e r a l L e d g e r F o r e c a s t i n g a nd M o d e l l i n g , a l l o f w h i c h a r e o f i n t e r e s t t o t h e h o s p i t a l . E a c h w i l l n e e d t o be e v a l u a t e d f o r i n c r e m e n t a l c o s t s a nd b e n e f i t s . 118 F o o t n o t e s "'"Telephone c o n v e r s a t i o n w i t h W.L. S t a p l e t o n , Computer A d v i s o r y Committee, B.C. M i n i s t r y o f H e a l t h , Vancouver, B.C., (24 March 1986). G.B. D a v i s , . " S t r a t e g i e s f o r i n f o r m a t i o n r e q u i r e m e n t s d e t e r m i n a t i o n , " IBM System J o u r n a l 21 (January 1982):19.. 119 CHAPTER V I GUIDELINES FOR GENERAL USE BY BRITISH COLUMBIA HOSPITALS T h i s c h a p t e r w i l l f o c u s on t h e development o f g e n e r i c g u i d e l i n e s t o a s s i s t o t h e r h o s p i t a l s i n B r i t i s h Columbia i n d e v e l o p i n g t h e i r own comprehensive c o s t - b e n e f i t c a s e s . There are e i g h t g e n e r a l s t e p s t h a t h o s p i t a l s s h o u l d f o l l o w as they c o n s i d e r moving from t h e i r s t a t u s quo' methods of h a n d l i n g i n f o r m a t i o n t o an i n t e g r a t e d HIS. Each o f t h e s e e i g h t s t e p s w i l l be d i s c u s s e d i n o r d e r t o b u i l d a p r a c t i c a l framework, the p r o c e s s e s f o r which a r e d e p i c t e d i n a f l o w c h a r t ( F i g u r e 4). W h i l e i t i s r e c o g n i z e d t h a t i n f o r m a t i o n systems p l a n n i n g i s a complex, t o r t u o u s and d i f f i c u l t p r o c e s s , the d i v e r g e n t d i r e c t i o n s c u r r e n t l y b e i n g t a k e n by BCHSSS and BCHA do not a s s i s t h o s p i t a l s i n p l a n n i n g t h e i r own systems. I t i s i m p o r t a n t t h a t h o s p i t a l s u n d e r s t a n d t h e p l a n n i n g r o l e s o f b o t h t h e s e o r g a n i z a t i o n s as they p e r t a i n t o h o s p i t a l c o m p u t e r i z a t i o n , and the q u e s t i o n a b l e l i k e l i h o o d o f t h e i r u l t i m a t e convergence. Moreover, i t i s i m p o r t a n t t h a t h o s p i t a l s r e c o g n i z e t h e i r own l i m i t a t i o n s and r o l e s i n the o v e r a l l p l a n n i n g p r o c e s s . F a i l u r e t o do so w i l l r e s u l t i n c o s t l y , r e p e t i t i o u s and i n e f f e c t i v e p l a n n i n g on a l l s i d e s . T h i s i s a t l e a s t one r e a s o n why development o f i n f o r m a t i o n systems c o n t i n u e s t o p r o g r e s s c o m p a r a t i v e l y s l o w l y i n B r i t i s h Columbia h o s p i t a l s as opposed t o p r i v a t e i n d u s t r y o r i n o t h e r p r o v i n c e s . Other r e a s o n s a re not e n t i r e l y c l e a r , FIGURE 4 FLOW CHART DEMONSTRATING PLANNING, COST-BENEFIT ANALYSIS AND 120 DECISION-MAKING PROCESSES PLANNING PROCESS COST-BENEFIT ANALYSIS PROCESS DECISION-MAKING PROCESS S T A R T ^ \ Y E S P E R F O R M R F I P R O C E S S B A S E D O N H S P R E S U L T S \ / I O E N T I F Y A N D S E L E C T A L T E R N A T 1 V E S T O M E E T N E E D S \ / P E R F O R M R F P P R O C E S S \ LEFT? 1 DENT1 FY PROBLEMS AND OBJECTIVES \ / oGisTiJH IN ANSWERABLE FORM \ P E p p " sn JDY \ f ANALY ECT ST(S) \ 1 ENUMERATE ALL RELEVANT COSTS AND BENEFITS FOR EACH ALTERNAT1VE \ W | O W A N D L BENEFITS FOR EACH ALTERNAT1VE \ t V A ^ B E i * F ? ? l T S FOR EACH ALTERNAT1VE S E L E C T A P P R Q P R 1 A T E D l g j O j ^ N T \ / C O N D U C T P R E S E N T V A L U E A N A L Y S 1 S / C O N D U C T S E N S I T I V I T Y A N A L Y S E S I N C L U D I N G D I S C O U N T R A T E S \ 1 N T E R P R E T F I N D I N G S O F C B A \ N O 1 N C O R P O R A T E O T H E R D E C I S I O N - M A K I N G C R I T E R I A N / C O M P A R E A L T E R N A T I V E S A C C O R D I N G T O A L L D E C I S I O N - M A K 1 N G C R I T E R I A \ / S E L E C T B E S T A L T E R N A T 1 V E P E R C B A P R E P A R E P R O P O S A L F O R B C H P U S I N G S U B M ( T T O B C H P F O R A P P R O V A L \ Y E S / N E G O T 1 A T E C O N T R A C T W I T H V E N D O R \ 1 S I G N C O N T R A C T W I T H V E N D O R e-1 C NOTE: Adapted from John Leslie King and Edward L. Schrems, "Cost-Benefit Analysis in Information Systems Development and Operation/'. ACM Computing Surveys 10 (March 1978):27. S T A T U S Q U O " B E S T A L T E R N A T I V E ? 121 b u t c o u l d i n c l u d e s u c h f a c t o r s a s t h e l e v e l o f k n o w l e d g e o f t o p management, h o s p i t a l s i z e , d e g r e e o f p a s t e x p e r i e n c e w i t h c o m p u t e r i z a t i o n , a v a i l a b i l i t y o f and c o n f i d e n c e i n o u t s i d e r e s o u r c e e x p e r t s , l e v e l o f u n d e r s t a n d i n g o f m a n u a l i n f o r m a t i o n p r o c e s s e s and how t h e s e may be i m p r o v e d u p o n , i n a d e q u a t e f u n d i n g f o r p l a n n i n g , d e v e l o p i n g , i m p l e m e n t i n g and e v a l u a t i n g s u c h s y s t e m s and t h e e x t e n t o f e v i d e n c e p u r p o r t i n g t o s u p p o r t i n f o r m a t i o n s y s t e m s . E a c h h o s p i t a l w i l l h a v e t o d e c i d e i f i t w a n t s t o u s e t h e s e r v i c e s o f o u t -s i d e i n f o r m a t i o n s y s t e m s c o n s u l t a n t s , t h e e x a m p l e o f H I S s i n o t h e r h o s p i t a l s , a n d / o r v e n d o r s t o a s s i s t i n e a c h s t e p o f t h e p l a n n i n g p r o c e s s . T y p i c a l l y , m o s t h o s p i t a l s i n ' B r i t i s h C o l u m b i a do n o t y e t h a v e a d e q u a t e i n - h o u s e human r e s o u r c e s . The m a i n p u r p o s e b e h i n d u s i n g t h e HSP m e t h o d o l o g y i s i t s s t r u c t u r e / p r o c e s s a p p r o a c h w h i c h p r o v i d e s an e x c e l l e n t f r a m e w o r k t o f a c i l i t a t e management's u n d e r s t a n d i n g o f t h e c u r r e n t i n f o r m a t i o n p r o c e s s e s and a s s o c i a t e d p r o b l e m s . M o r e o v e r , i t p r o v i d e s an o p p o r t u n i t y t o d i s c u s s t h e s e w i t h t h e s t a f f a nd f a c i l i t a t e s i d e n t i f i c a t i o n a nd . d i s c u s s i o n o f b e n e f i t s a s s o c i a t e d w i t h s o l v i n g t h e s e p r o b l e m s t h r o u g h c o m p u t e r i z e d s o l u t i o n s . T h i s a p p r o a c h a l s o f o s t e r s t h e c o n c e p t o f m a n a g i n g i n f o r m a t i o n a s a c o r p o r a t e r e s o u r c e and f u r t h e r f o s t e r s t h e o r i e n t a t i o n o f t h e p r o j e c t a r o u n d t h e h o s p i t a l ' s i n f o r m a t i o n h a n d l i n g p r o c e s s e s . I t d o e s n o t p r e c l u d e t h e u s e o f o t h e r , s t r a t e g i e s f o r d e t e r m i n i n g r e q u i r e -m e n t s ; on t h e o t h e r h a n d , i t accommodates 122 a l t e r n a t i v e a p p r o a c h e s t o i d e n t i f y i n g n e e d s o f r e s p e c t i v e h o s p i t a l s w h i c h , a c c o r d i n g t o D a v i s x i s n e c e s s a r y . HIS p l a n n i n g s h o u l d be an e c l e c t i c e x e r c i s e . I d e n t i f i c a t i o n : o f P r o b l e m s T h i s s t e p c o n s i s t s o f g a i n i n g an u n d e r s t a n d i n g o f how e a c h h o s p i t a l d e p a r t m e n t / a r e a m a n u a l l y p r o c e s s e s i n f o r m a t i o n a n d , f u r t h e r , i d e n t i f y i n g any p r o b l e m s a s s o c i a t e d w i t h s u c h m a n u a l m e t h o d s . T h i s c o u l d t a k e t h e f o r m o f d i r e c t o b s e r v -a t i o n , e x a m i n a t i o n o f e x i s t i n g d o c u m e n t a t i o n , q u e s t i o n n a i r e s , i n t e r v i e w s o r any c o m b i n a t i o n o f s u c h s u r v e y m e t h o d s . E x p e r i e n c e a t CGH, w i t h t h e a s s i s t a n c e o f BCHA, d e m o n s t r a t e d t h a t a c o m b i n a t i o n o f t h e s e m e t h o d s , b u t p r e d o m i n a n t l y q u e s t i o n n a i r e s a n d i n t e r v i e w s , p r o v e d t o be e f f e c t i v e . T h i s a p p r o a c h g a v e t h e p o t e n t i a l u s e r s o f t h e HIS an o p p o r t u n i t y t o p a r t i c i p a t e i n t h e p r o j e c t a n d gave t h e HSP P r o j e c t team an o p p o r t u n i t y f o r f a c e - t o - f a c e d i s c u s s i o n s a n d t h e u s e o f p r o b i n g q u e s t i o n s w h e r e p r o b l e m s , n e e d s , a nd p e r h a p s s o l u t i o n s a n d p r i o r i t i e s , a p p e a r e d u n c l e a r . The u s e r s s h o u l d know b e s t how t h e m a n u a l , o r any o t h e r , s y s t e m w o r k s i n t h e i r r e s p e c t i v e s e t t i n g s . The b e s t t h a t t h e HSP team c a n do i s t o t r y t o u n d e r s t a n d i t i n t h e b r o a d e r c o n t e x t o f t h e h o s p i t a l . To some e x t e n t , i t may be b e n e f i c i a l t o h a v e some members o f t h e HSP team i n i t i a l l y somewhat l i m i t e d i n t h e i r u n d e r s t a n d i n g o f r e s p e c t i v e u s e r d e p a r t m e n t s i n o r d e r t h a t n e c e s s a r y , p e r h a p s n a i v e , q u e s t i o n s c o u l d be a s k e d . I t i s e s s e n t i a l , 123 however, t h a t the team ga i n an understanding of the i n t e g r a t e d flow of i n f o r m a t i o n i n the: broader context of the h o s p i t a l system and i t s e x t e r n a l i n t e r f a c e s . T h i s does not n e c e s s a r i l y mean t h a t a g i g a n t i c f l o w c h a r t must be c o n s t r u c t e d . On the c o n t r a r y , to accommodate d i s c u s s i o n and incremental under-standing of how complex i n f o r m a t i o n i s handled i n the h o s p i t a l , i t behooves the p r o j e c t team t o keep t h i n g s as simple as p o s s i b l e at t h i s stage. Of key importance i s the incr e m e n t a l b u i l d i n g of knowledge, understanding and commit-ment. I d e n t i f i c a t i o n of B e n e f i t s T h i s step r e q u i r e s a gre a t d e a l of involvement by a person knowledgeable i n the concept of automating manual methods and i n t e g r a t e d i n f o r m a t i o n systems. H o s p i t a l s t a f f g e n e r a l l y understand how t h i s r e l a t e s to t h e i r own departments but t y p i c a l l y have t r o u b l e understanding how such i n f o r m a t i o n r e l a t e s to and flows throughout the r e s t of the h o s p i t a l . At t h i s p o i n t , i t would be u s e f u l f o r the s t a f f to attempt to s u b j e c t i v e l y q u a n t i f y b e n e f i t s they, f e e l would accrue to t h e i r r e s p e c t i v e departments. I n t a n g i b l e b e n e f i t s should a l s o be i d e n t i f i e d . These should be recorded and, to some extent, used as the b a s i s f o r a f u t u r e b e n e f i t , study which i s so i n t e g r a l t o the CBA stage of the p l a n n i n g p r o c e s s . E q u a l l y important a t t h i s stage i s the need to l a y the groundwork f o r s t a f f commitment t o these i d e n t i f i e d b e n e f i t s . It. should be 124 e m p h a s i z e d a t t h i s p o i n t t h a t t h e r e m ust be an e v e n t u a l t r a n s l a t i o n o f t h e s e i d e n t i f i e d b e n e f i t s i n t o r e a l i z e d 2 s a v i n g s . Hodge, i n h i s p r o m o t i o n o f i n f o r m a t i o n a s a r e s o u r c e f o r h o s p i t a l s , r e i t e r a t e s t h a t i t i s t h e r e a l i z a t i o n o f p l a n n e d b e n e f i t s w h i c h i s t h e p u r p o s e o f i m p l e m e n t i n g an H I S , a p r o c e s s w h i c h c a n n o t be t a k e n f o r g r a n t e d . He w a r n s t h a t i t i s e a s y t o f o r g e t why t h e HIS was p u t i n p l a c e and t h a t b e n e f i t s do n o t o c c u r a u t o m a t i c a l l y ; r a t h e r , t h e y o c c u r t h r o u g h p l a n n e d a c t i o n . T h u s , w h i l e i d e n t i f i c a t i o n o f p o t e n t i a l l y r e a l i z a b l e b e n e f i t s i s i m p o r t a n t d u r i n g t h e p l a n n i n g s t a g e , i t i s t h e r e a l i z e d b e n e f i t s t o w a r d w h i c h t h e h o s p i t a l m u s t s t r i v e o r t h e i m p l e m e n t e d HIS w i l l be r e n d e r e d p r a c t i c a l l y u s e l e s s . I d e n t i f i c a t i o n o f P r i o r i t i e s The n e x t s t e p c o n s i s t s o f c o n s o l i d a t i n g a l l t h e p r o b l e m s and b e n e f i t s ( t a n g i b l e and i n t a n g i b l e ) i n t o l o g i c a l c a t e g o r i e s by f u n c t i o n a l a r e a . A t t h i s s t a g e o f t h e a n a l y s i s b e n e f i t s , a s p e r c e i v e d by t h e u s e r s , r e p r e s e n t p r e l i m i n a r y e s t i m a t e s b a s e d on a f u l l y - i n t e g r a t e d , h o s p i t a l - w i d e • i n f o r m a t i o n s y s t e m i n f u l l o p e r a t i o n w h i c h , i n a l l l i k e l i h o o d , w o u l d r e q u i r e i m p l e m e n t a t i o n o v e r s e v e r a l y e a r s . T h i s i s n o t g e n e r a l l y e a s y f o r u s e r s t o g r a s p ; h o w e v e r , t h e p r o j e c t team c a n f a c i l i t a t e i t s u n d e r s t a n d i n g . T h i s s t e p a l s o i n c l u d e s t h e 'need f o r u s i n g a s t r u c t u r e d p r i o r i t y r a n k i n g a p p r o a c h , t h e c r i t e r i a f o r w h i c h may i n c l u d e t a n g i b l e b e n e f i t s , i n t a n g i b l e b e n e f i t s , t e c h n i c a l 125 sequencing, and f i t with h o s p i t a l g o als and o b j e c t i v e s . T h i s process i s important and gi v e s the p r o j e c t team an o p p o r t u n i t y to develop a reasonable l i s t of implementation p r i o r i t i e s . The c u r r e n t MOH p o l i c y r e q u i r e s t h a t f i n a n c i a l systems should be h o s p i t a l s ' p r i o r i t i e s when, i n f a c t , h o s p i t a l s , by t h e i r very g o a l s , must c o n s i d e r c l i n i c a l and r e l a t e d systems as the top p r i o r i t y . The importance of t h i s step l i e s i n the h o s p i t a l s ' a b i l i t y to i d e n t i f y and j u s t i f y t h e i r own needs and r e s u l t a n t p r i o r i t i e s . U l t i m a t e l y , t h i s i s important to the CBA because i f a case cannot be made on a f i n a n c i a l b a s i s , and i t becomes the o v e r r i d i n g reason f o r r e j e c t i o n , i t i s e s s e n t i a l t h a t l e s s e r , as opposed to h i g h e r , p r i o r i t i e s be axed. Request f o r Information Process Once the i d e n t i f i c a t i o n of problems, b e n e f i t s and p r i o r i t i e s has been completed, the next step c o n s i s t s of f i n d i n g p o t e n t i a l s o l u t i o n s to the i d e n t i f i e d needs. T h i s Request f o r Information (RFI) stage c o n s i s t s of sur v e y i n g vendors to determine, on a s u b j e c t i v e b a s i s , who c o u l d f u l f i l l the needs of the h o s p i t a l . E s s e n t i a l l y , t h i s c o n s i s t s of s e l e c t e d vendors and the h o s p i t a l exchanging p e r t i n e n t i n f o r m a t i o n i n an attempt t o ga i n s u i t a b l e matches of needs and s o l u t i o n s . Of the twenty-one RFIs sent out i n the CGH context, nine were u l t i m a t e l y s e l e c t e d to r e c e i v e RFPs. At t h i s stage, some vendors w i l l merely t e l l the h o s p i t a l t h a t they cannot or do not wish t o be i n v o l v e d i n s u b m i t t i n g RFPs; 1 2 6 o t h e r s w i l l s t a t e t h a t t h e y c a n , w h i c h may o r may n o t t u r n o u t t o be t h e c a s e . The t u r n - a r o u n d p e r i o d f o r t h i s p r o c e s s s h o u l d be i n t h e o r d e r o f t h r e e t o f o u r w e e k s . R e q u e s t f o r P r o p o s a l P r o c e s s T h i s s t a g e c o n s i s t s o f c h o o s i n g f r o m t h e r e t u r n e d R F I s t h o s e v e n d o r s m o s t l i k e l y a b l e t o meet t h e n e e d s o f t h e h o s p i t a l . T y p i c a l l y , t h i s c o n s i s t s o f s e n d i n g d o c u m e n t a t i o n s i m i l a r t o A p p e n d i x 1. t o s e l e c t e d v e n d o r s . The f o l l o w i n g m a j o r c a t e g o r i e s o f i n f o r m a t i o n s h o u l d be i n c l u d e d i n t h e RFP: I n t r o d u c t i o n H o s p i t a l P r o f i l e G e n e r a l R e q u i r e m e n t s o f t h e RFP - C o n d i t i o n s - C a n a d i a n u s e r s ' l i s t - P r e s e n t a t i o n / s i t e v i s i t s t i m e t a b l e T e c h n i c a l C a p a b i l i t i e s o f P r o p o s e d S y s t e m s - S o f t w a r e - H a r d w a r e - S e c u r i t y - D a t a I n t e g r i t y C o s t / B e n e f i t s / F i n a n c i n g - O n e - t i m e s y s t e m s c o s t s - H a r d w a r e i n s t a l l a t i o n c o s t s - S o f t w a r e i m p l e m e n t a t i o n and i n s t a l l a t i o n c o s t s - T r a i n i n g c o s t s - C o n v e r s i o n c o s t s - O n - g o i n g m a i n t e n a n c e c o s t s - F u t u r e m o d i f i c a t i o n s c o s t s - P r o j e c t e d t a n g i b l e and i n t a n g i b l e b e n e f i t s - F i n a n c i n g o p t i o n s I n s t a l l a t i o n / I m p l e m e n t a t i o n / L i v e T i m e t a b l e and R e s p o n s i b l i t i e s P e r f o r m a n c e B o n d s / W a r r a n t i e s / C o n t r a c t 127 E v a l u a t i o n M e t h o d o l o g y and T i m e t a b l e V i d e o D i s p l a y T e r m i n a l s a n d P r i n t e r R e q u i r e m e n t s D e t a i l e d S y s t e m s A p p l i c a t i o n s - T h e s e a r e a l l o f t h e a p p l i c a t i o n s a s i d e n t i f i e d by t h e HSP i n o r d e r o f p r i o r i t y . The t y p i c a l t u r n - a r o u n d t i m e f o r t h e RFP i s f o u r t o s i x weeks d e p e n d i n g o n t h e c o m p l e x i t y o f t h e p r o p o s a l . I t i s i m p o r t a n t t h a t t h i s p a r t o f t h e p l a n n i n g p r o c e s s be w e l l t h o u g h t o u t b e c a u s e i t w i l l f o r m t h e b a s i s o f t h e c o s t - s i d e o f t h e CBA and w i l l s a v e much r e p e t i t i o u s w ork i f t h e i n s t r u c t i o n s a r e e x p l i c i t l y s t a t e d a n d f o l l o w e d b y t h e r e s p o n d i n g v e n d o r s . Of p a r t i c u l a r v a l u e i s t o r e q u e s t t h e v e n d o r t o p r o v i d e a s p r e a d -s h e e t o f c o s t s , s a y , f o r f i v e o r e i g h t y e a r s . S u c h a b r e a k -down w i l l g r e a t l y a s s i s t i n d e v e l o p i n g t h e c o s t - s i d e o f t h e p r o p o s a l arid s a v e much r e d u n d a n c y o f work d u r i n g t h e CBA. The t r a d e o f f h e r e i s b e t w e e n h a v i n g t h e h o s p i t a l p r o v i d e as much s t r u c t u r e a s p o s s i b l e w i t h i n t h e RFP, a t c o n s i d e r a b l e u p - f r o n t c o s t s b u t s a v i n g s l a t e r , v e r s u s g i v i n g t h e v e n d o r s a f r e e r h a n d , t h u s m a k i n g c o m p a r i s o n more c o s t l y a n d d i f f i c u l t . F i g u r e 2 p r o v i d e s a u s e f u l f r a m e w o r k f o r s u c h c o s t i n g . I t i s e s s e n t i a l t h a t t h e v e n d o r s c l e a r l y d e m o n s t r a t e w h e t h e r t h e y c a n p r o v i d e t h e a p p l i c a t i o n s s i n c e t h i s w i l l f o r m t h e b a s i s o f r e j e c t i o n , a c c e p t a n c e o r p o s s i b l e f u t u r e m o d i f i c a t i o n s . The r e t u r n e d RFPs s h o u l d be e v a l u a t e d by an RFP E v a l u a t i o n Team ( o r s i m i l a r g r o u p ) w h i c h c o u l d be a s u b -c o m m i t t e e o f t h e h o s p i t a l ' s C o m p u t e r A d v i s o r y C o m m i t t e e . 128 T h i s g r o u p ' s r e s p o n s i b i l i t y , i s t o c o m p r e h e n s i v e l y r e v i e w t h e r e t u r n e d RFPs i n o r d e r t o recommend a f i n a l i s t v e n d o r t o t h e C o m p u t e r A d v i s o r y C o m m i t t e e f o r i t s r a t i f i c a t i o n . T h i s p r o c e s s i n c l u d e s m e e t i n g w i t h m a r k e t i n g r e p r e s e n t a t i v e s o f t h e s h o r t - l i s t e d v e n d o r s and s i t e v i s i t s t o i n s t a l l e d s y s t e m s . I t i s a b s o l u t e l y e s s e n t i a l t h a t any u n c e r t a i n t i e s be c l a r i f i e d a t t h i s s t a g e b e c a u s e t h e y w i l l f o r m - t h e b a s i s o f t h e c o s t - s i d e o f t h e CBA. A t t h i s p o i n t i t i s a l s o u s e f u l t o do a p r e l i m i n a r y c o s t a n a l y s i s i f i t c a n be a s c e r t a i n e d t h a t t h e b e n e f i t - s i d e o f t h e CBA i s c o n s t a n t a c r o s s v e n d o r s ; i f n o t , a p r e l i m i n a r y CBA s h o u l d be p e r f o r m e d on e a c h o f t h e s h o r t - l i s t e d v e n d o r s . C r i t e r i a s u c h a s f u n c t i o n a l i t y ( w i l l t h e s y s t e m do w h a t i s r e q u i r e d ? ) , i n t e g r a t i o n ( i s i t t r u l y an H I S ? ) , f l e x i b i l i t y ( i s t h e r e room f o r f u t u r e g r o w t h and m o d i f i c a t i o n s ? ) and c o s t ( i s i t a f f o r d a b l e , g i v e n t h e p o t e n t i a l f o r r e a l i z a b l e b e n e f i t s ? ) s h o u l d be u s e d t o a s s i s t t h e E v a l u a t i o n S u b c o m m i t t e e i n i t s s e l e c t i o n p r o c e s s . C o s t - B e n e f i t A n a l y s i s Once t h e f i n a l i s t v e n d o r h a s b e e n s e l e c t e d , i t i s n e c e s s a r y t o p e r f o r m a d e t a i l e d CBA u s i n g a l l c o s t s a s i d e n t i f i e d a n d s t i p u l a t e d by t h e s e l e c t e d v e n d o r , any o t h e r c o s t s f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l and a l l b e n e f i t s a s e n u m e r a t e d by t h e h o s p i t a l . T y p i c a l l y , t h e v e n d o r -s u p p l i e d RFP r e s p o n s e w i l l n o t i n c l u d e a l l h o s p i t a l c o s t s , f o r e x a m p l e , e l e c t r o n i c e m b o s s e r , i n t e r f a c e s , s t a f f t r a i n i n g / 129 r e l i e f , s t a f f s u p p o r t , h o s p i t a l o v e r h e a d , r e c o r d c o n v e r s i o n s and s o o n . T h u s , i t i s i n c u m b e n t upon the. a n a l y s t t o f u r t h e r i d e n t i f y t h e s e c o s t s and n o t t o t a l l y r e l y on t h e v e n d o r . The v e n d o r h a s an i n t e r e s t i n m i n i m i z i n g t h e a p p a r e n t c o s t s o f t h e s y s t e m a n d , i n f a c t , e x p e c t s t h e h o s p i t a l t o s e e k o u t and a c c o u n t f o r any p e r t i n e n t a d d i t i o n a l c o s t s . T h e r e i s l i t t l e p o i n t i n a s k i n g t h e v e n d o r f o r a s s i s t a n c e i n t h e b e n e f i t c a s e . C a r e m u s t be t a k e n t h a t t h i s p r o c e s s i s a p p l i e d c o n s i s t e n t l y a c r o s s t h e s h o r t - l i s t e d v e n d o r s p r i o r t o s e l e c t i o n o f t h e f i n a l i s t . The CBA s h o u l d be p e r f o r m e d u s i n g t h e g e n e r i c f r a m e w o r k d i s c u s s e d i n C h a p t e r I I I . D e c i s i o n - m a k i n g P r o c e s s Once t h e CBA h a s b e e n p e r f o r m e d and t h e r e s u l t s c l e a r l y d e l i n e a t e d , t h e p l a n n i n g s t a g e r e a c h e s a m a j o r d e c i s i o n p o i n t : t o p r o c e e d o r n o t t o p r o c e e d . I f t h e f o r m e r , s h o u l d t h e w h o l e s y s t e m be c o n s i d e r e d o r j u s t p a r t o f i t ? To some e x t e n t t h i s r e s t s on t h e c o s t - b e n e f i t r a t i o w h i c h , i f f a v o u r a b l e , makes t h e d e c i s i o n - m a k i n g p r o c e s s f a r e a s i e r . On t h e o t h e r h a n d , CBA i s j u s t p a r t o f t h e o v e r a l l p r o c e s s o f p l a n n i n g a n d n o t an end i n and o f i t s e l f . A t t h i s p o i n t , CBA r e m a i n s a p l a n n i n g t o o l t o a s s i s t d e c i s i o n - m a k e r s c h o o s e b e t w e e n t h e two o r i g i n a l c o m p e t i n g a l t e r n a t i v e s ( s t a t u s quo v e r s u s HIS) i n o r d e r t o a l l o c a t e t h e h o s p i t a l ' s s c a r c e f i s c a l r e s o u r c e s . D e c i s i o n - m a k i n g i s a l w a y s f r a u g h t w i t h p r o b l e m s o f 130 c h a n g e , u n c e r t a i n t y and a m b i g u i t y . . The v a l u e o f CBA l i e s i n t h e a b i l i t y o f t h e a n a l y s t t o f i r s t e n u m e r a t e a l l c o s t s and b e n e f i t s r e l e v a n t t o t h e d e c i s i o n - m a k i n g p r o c e s s . T h e n , by u s i n g s e n s i t i v i t y a n a l y s e s , t h e i m p a c t o f u n c e r t a i n t i e s c a n be a s s e s s e d u s i n g v a r i o u s s c e n a r i o s t h a t t h e h o s p i t a l m i g h t e n c o u n t e r . A g a i n , t h e s e r e f l e c t o n l y t h e m o n e t a r y a s p e c t o f t h e d e c i s i o n and s h o u l d be t h o u g h t o f as o n l y o n e • o f s e v e r a l t o o l s a t t h e d e c i s i o n - m a k e r ' s d i s p o s a l . I f t h e CBA i s u n f a v o u r a b l e ( t h a t i s , b e n e f i t s l e s s t h a n c o s t s ) t h e h o s p i t a l m ust r e e x a m i n e t h e i n t a n g i b l e b e n e f i t s t o d e t e r m i n e i f t h e y j u s t i f y t h e n e t c o s t s , o r e x a m i n e t h e i n c r e m e n t a l c o s t s and b e n e f i t s a s s o c i a t e d w i t h s u c c e s s i v e m o d u l e s . P a r t o f t h e d e c i s i o n - m a k i n g p r o c e s s may i n c l u d e c o n s i d e r i n g w h i c h m o d u l e s w o u l d be m o s t a p p r o p r i a t e o r , p e r h a p s , m o s t f a v o u r a b l e f r o m a c o s t - b e n e f i t p e r s p e c t i v e i f o b t a i n i n g f u n d i n g f r o m o t h e r a g e n c i e s i s an i s s u e . T h i s l a r g e l y d e p e n d s on t h e maximum a l l o w a b l e e x p e n d i t u r e l e v e l s , t h e s c o p e o f t h e p r o j e c t and t h e b e n e f i t c a s e o f t h e h o s p i t a l . G o v e r n m e n t A p p r o v a l and F u n d i n g P r o p o s a l The f i n a l s t e p i n t h e a c q u i s i t i o n o f an HIS i n B r i t i s h C o l u m b i a c o n s i s t s o f s e e k i n g g o v e r n m e n t a p p r o v a l a n d s e c u r i n g f u n d i n g v i a t h e MOH a n d / o r t h e R e g i o n a l H o s p i t a l D i s t r i c t (RHD) o r o t h e r s o u r c e s . Of s e e m i n g g r e a t i m p a c t c u r r e n t l y a r e t h e MOH's f u n d i n g g u i d e l i n e s and c o m p u t e r p o l i c i e s d i s c u s s e d e a r l i e r . One o f t h e m o s t d i f f i c u l t h u r d l e s 131 f r o m t h e h o s p i t a l p e r s p e c t i v e i s a d e q u a t e s o u r c e s o f f u n d i n g f o r t h e o n e - t i m e c a p i t a l c o s t s . The c u r r e n t g u i d e l i n e s a l l o w f o r s e v e r a l o p t i o n s w i t h r e s p e c t t o f u n d i n g a n d , d e p e n d i n g on t h e h o s p i t a l ' s f i n a n c i a l s i t u a t i o n , t h e CBA s h o u l d be t e s t e d f o r s e n s i t i v i t y t o d i f f e r e n t f u n d i n g s c e n a r i o s . P e r h a p s r e a l i z a t i o n o f t h e b e n e f i t s t r e a m s h o u l d be t h e s i n e q u a hon f o r r e c e i v i n g a n d r e t a i n i n g f u n d i n g f r o m t h e MOH, RHD o r o t h e r s o u r c e s . I t w o u l d c e r t a i n l y be a b u i l t - i n i n c e n t i v e f o r t h e h o s p i t a l t o p r o v i d e a c c u r a t e b e n e f i t c a s e s a n d f o l l o w t h r o u g h w i t h t h e i r c l a i m s I Of f u r t h e r i m p o r t , h o w e v e r , i s t h e f a c t t h a t B r i t i s h C o l u m b i a h o s p i t a l s h a v e now p a r e d s t a f f i n g l e v e l s down s o f a r t h a t t o e f f e c t f u r t h e r l a b o r s a v i n g s i s v e r y d i f f i c u l t . T h i s n e g a t i v e l y i m p a c t s t h e b e n e f i t - s i d e o f t h e CBA. I n e f f e c t , t h e r e l a t i v e l y e f f i c i e n t h o s p i t a l s c o u l d be a t a c o m p a r a t i v e d i s a d v a n t a g e b e c a u s e t h e i r e f f i c i e n c y i m p l i e s a h a r d e r t i m e j u s t i f y i n g t h e p r o p o s e d H I S s on n e t b e n e f i t g r o u n d s . P a r a d o x i c a l l y , t h e s e a r e t h e v e r y " h o s p i t a l s t h a t r e q u i r e c o m p u t e r i z e d i n f o r m a t i o n s y s t e m s b e c a u s e t h e y h a v e t h e l e a s t , s t a f f t o manage i n f o r m a t i o n . I t i s u n l i k e l y t h a t t h e MOH a p p r o v a l o f and f u n d i n g f o r s u c h s y s t e m s w i l l r e s t on s u c h p e r c e i v e d i n e q u i t y . N o n e t h e l e s s , t h e h o s p i t a l m u s t make i t s b e s t c a s e f o r f u n d i n g a n d , i f t h e r e a r e u n c e r -t a i n t i e s , t h e h o s p i t a l s h o u l d e r r on t h e s i d e o f h i g h e r c o s t s and l e s s e r b e n e f i t s i n o r d e r t o p r o v i d e some c u s h i o n f o r e r r o r i n t h e p o s t - i m p l e m e n t a t i o n s t a g e s . I t w i l l be o f no s u r p r i s e 132 t o t h e MOH t h a t H I S s may g e n e r a t e n e t c o s t s a s o p p o s e d t o n e t b e n e f i t s i n i n d i v i d u a l h o s p i t a l s . I t i s up t o h o s p i t a l s , h o w e v e r , t o m i n i m i z e t h o s e n e t c o s t s by i m p l e m e n t i n g t h e b e n e f i t s ( p a r t i c u l a r l y l a b o r s a v i n g s ) t h e y p u r p o r t w i l l a c c r u e a n d t r a n s l a t i n g them i n t o m o n e t a r y s a v i n g s t h r o u g h o p e r a t i n g b u d g e t r e d u c t i o n s . T h e n , and o n l y t h e n , w i l l t h e MOH g i v e c r e d e n c e t o t h e c l a i m s o f h o s p i t a l s who embark on s u c h p r o g r a m s i n t h e name o f c o s t - j u s t i f i c a t i o n . 133 F o o t n o t e s 1G.B. D a v i s , " S t r a t e g i e s f o r i n f o r m a t i o n r e q u i r e m e n t s d e t e r m i n a t i o n , " IBM System J o u r n a l 21 (January 1982):5. 2 M e l v i l l e H. Hodge, M e d i c a l I n f o r m a t i o n Systems: A Resource f o r H o s p i t a l s (Germantown: Aspen Systems Corp., 1977), pp. 169-70. 134 CHAPTER V I I SUMMARY AND CONCLUSIONS F o r The C h i l l i w a c k G e n e r a l H o s p i t a l The C h i l l i w a c k G e n e r a l H o s p i t a l , by f o l l o w i n g a p l a n n i n g f r a m e w o r k , was a b l e t o i d e n t i f y s e v e r a l p r o b l e m s a s s o c i a t e d w i t h m a n u a l a nd o t h e r s t a t u s quo m e t h o d s o f h a n d l i n g i n f o r m a t i o n . I d e n t i f i c a t i o n o f b e n e f i t s , t a n g i b l e a n d i n t a n g i b l e , h a s b e e n p o s s i b l e t h r o u g h a c t i v e p a r t i c i p -a t i o n b y p o t e n t i a l s y s t e m u s e r s who a r e e x p e r t s i n t h e i r r e s p e c t i v e f i e l d s . I d e n t i f i c a t i o n o f p r i o r i t i e s , f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l , was done i n c o n s u l t a t i o n w i t h t h e u s e r s a n d i n c o n c e r t w i t h p r e v i o u s l y e s t a b l i s h e d h o s p i t a l g o a l s and o b j e c t i v e s . F r om t h e p e r s p e c t i v e o f t h e h o s p i t a l , t h e p r o c e s s o f w o r k i n g t h r o u g h p r o b l e m i d e n t i f i c a t i o n , b e n e f i t i d e n t i f i c a t i o n a n d p r i o r i t y s e t t i n g a n d s o l u t i o n s e n a b l e d s t a f f t o b e t t e r a p p r e c i a t e a n d u n d e r s t a n d how t h e f l o w o f i n f o r m a t i o n w i t h i n t h e h o s p i t a l o c c u r s a n d g a i n a b e t t e r u n d e r s t a n d i n g o f how t h e i r r e s p e c t i v e d e p a r t m e n t a l s u b s y s t e m s f i t i n t h e o v e r a l l H I S . The R F I and RFP p r o c e s s e s p r o v e d t o be e f f e c t i v e m e t h o d s o f n a r r o w i n g down t h e l a r g e number o f p o t e n t i a l v e n d o r s . The s u c c e s s o f t h e RFP p r o c e s s l i e s , t o a l a r g e e x t e n t , i n how w e l l t h e RFP i s w r i t t e n a n d how w e l l t h e v e n d o r r e s p o n d s . W h i l e i t i s v e r y t i m e - c o n s u m i n g t o w r i t e a d e t a i l e d p r o p o s a l t h e r e a r e g r e a t d i v i d e n d s d u r i n g t h e a n a l y s i s 135 o f t h e r e t u r n e d p r o p o s a l s , e s p e c i a l l y i f a s p r e a d - s h e e t h a s b e e n r e q u e s t e d a n d i s p r o p e r l y c o m p l e t e d . D u r i n g t h e e v a l u a t i o n o f t h e R F P s , f o u r m a i n c r i t e r i a m u st be c o n s i d e r e d — f u n c t i o n a l i t y , i n t e g r a t i o n , f l e x i b i l i t y a n d c o s t . I n e s s e n c e , t h e HSP s t a g e o f p l a n n i n g f o r m s t h e b a s i s o f t h e c o s t - s i d e o f t h e a n a l y s i s . Once t h e f i n a l i s t was s e l e c t e d on t h e b a s i s o f t h e f o u r a b o v e - n o t e d c r i t e r i a , t h e f o r m e r ' s a b i l i t y t o meet e a c h a p p l i c a t i o n was o n c e a g a i n t h o r o u g h l y r e v i e w e d by t h e u s e r s . T h i s was t o e n s u r e t h a t any a p p l i c a t i o n t h a t c o u l d n o t be s u p p l i e d was n o t v i t a l t o t h e i n t e g r i t y o f t h e e n t i r e s y s t e m and c o u l d e i t h e r be e l i m i n a t e d c o m p l e t e l y o r m o d i f i e d p r i o r t o i m p l e m e n t a t i o n . Once t h e f o r e g o i n g was c o m p l e t e d , a c o m p r e h e n s i v e CBA was p e r f o r m e d u s i n g s e v e r a l s e n s i t i v i t y t e s t s i n c l u d i n g U.S. e x c h a n g e r a t e s , g r a n t s c e n a r i o s a n d d i s c o u n t r a t e s . As t h e f i n d i n g s i n C h a p t e r V i n d i c a t e , t h e b e s t - c a s e s c e n a r i o f r o m t h e p e r s p e c t i v e o f t h e h o s p i t a l i s when t h e h o s p i t a l o b t a i n s one h u n d r e d p e r c e n t f u n d i n g f o r a l l o f t h e o n e - t i m e c o s t s . To a l l o w a m a r g i n o f s a f e t y , t h e h i g h e r U.S. e x c h a n g e r a t e (1.4) was u s e d a nd t h e l o w e s t r e a s o n a b l e d i s c o u n t r a t e o f t h r e e p e r c e n t . The P a y r o l l / P e r s o n n e l m o d u l e was n o t i n c l u d e d e v e n t h o u g h i t w o u l d h a v e o f f e r e d v e r y s u b s t a n t i a l b e n e f i t s i n t h e l o n g - r u n . The r e a s o n s f o r t h i s h a v e b e e n i d e n t i f i e d e a r l i e r . 136 F o r t h e m o s t p a r t , CGH h a s f o c u s s e d on l a b o r - r e l a t e d b e n e f i t s s i n c e t h i s i s t h e most s i g n i f i c a n t p a r t o f t h e b e n e f i t - s i d e o f t h e a n a l y s i s . I n t h e HSP s t a g e , p o t e n t i a l b e n e f i t s w e r e i d e n t i f i e d by t h e u s e r s on a r a t h e r s u b j e c t i v e b a s i s . As t h e CBA p r o c e e d e d t h e s e p o t e n t i a l b e n e f i t s w e r e f i n e - t u n e d . They w i l l u l t i m a t e l y be t r a n s l a t e d i n t o s a v e d w ork and t h u s d o l l a r s ( r e a l i z a b l e b e n e f i t s ) . I t i s t h e h o s p i t a l ' s f u l l i n t e n t i o n t o e n s u r e t h a t t h e s e p o t e n t i a l b e n e f i t s a r e r e a l i z e d by t a k i n g t h e n e c e s s a r y a c t i o n i n t h e w o r k p l a c e s u c h a s s t a f f r e d u c t i o n t h r o u g h a t t r i t i o n , u s e o f p a r t - t i m e p e r s o n n e l and t h e l i k e . The d e c i s i o n - m a k i n g s t a g e , b a s e d on t h e CBA, was f a i r l y s t r a i g h t f o r w a r d . A s d i s c u s s e d i n C h a p t e r V, a b e n e f i t c a s e i s n o t s u r f a c i n g i n C h i l l i w a c k G e n e r a l ' s p a r t i c u l a r c a s e ; h o w e v e r , f r o m t h e CGH p e r s p e c t i v e i t was n o t a m a t t e r o f how much money c o u l d be s a v e d , b u t r a t h e r how l i t t l e money w o u l d be n e e d e d t o o b t a i n t h e g r e a t e s t number o f a p p l i c a t i o n s t o meet t h e i d e n t i f i e d n e e d s , t h e g r e a t e s t e x t e n t o f i n t e g r a t i o n and t h e g r e a t e s t d e g r e e o f f l e x i b i l i t y . By i m p l i c a t i o n , t h e r e a r e a number o f n o n - c o s t c r i t e r i a t h a t t h e h o s p i t a l d e c i s i o n -m a k i n g team h o l d s o u t a s o f g r e a t e r i m p o r t a n c e t h a n c o s t . N o n e t h e l e s s , t h i s r e s t s on t h e a b i l i t y o f t h e h o s p i t a l t o p a y e i t h e r t h r o u g h u s i n g s u r p l u s o p e r a t i n g d o l l a r s o r s u r p l u s c a p i t a l d o l l a r s and o b t a i n i n g a s much f u n d i n g f o r t h e h o s p i t a l e q u i p m e n t as p o s s i b l e . B e c a u s e t h e CBA was a p p r o a c h e d on t h e 137 c o n s e r v a t i v e , s i d e a c u s h i o n f o r e r r o r e x i s t s . M o r e o v e r , r e a l i z a t i o n o f t h e i d e n t i f i e d b e n e f i t s i s f u n d a m e n t a l t o t h e s u c c e s s o f t h e H I S . A s s u m i n g t h a t t h e MOH p o l i c y g u i d e l i n e s p r e v a i l , t h e h o s p i t a l m ust f a c e e i t h e r a l t e r i n g i t s p r i o r i t i e s t o accommo-d a t e t h e p r i o r i t i e s o f f i n a n c i a l management o r j u s t i f y p r o -c e e d i n g w i t h t h e n o n - f i n a n c i a l p r i o r i t i e s , c ommencing w i t h t h e A d m i t t i n g / D i s c h a r g e / T r a n s f e r / C e n t r a l R e g i s t r y m o d u l e . P a r a d o x i c a l l y , t h i s i s one o f t h e a r e a s p r o d u c i n g t h e l e a s t m o n e t a r y b e n e f i t s . Where t h e MOH h a s i n c l u d e d P a y r o l l / P e r s o n n e l a s p a r t o f t h e f i n a n c i a l management a p p l i c a t i o n s t h i s i s one m o d u l e t h a t CGH h a s i r o n i c a l l y , b u t j u s t i f i a b l y , e l e c t e d t o e x c l u d e f o r t h e t i m e b e i n g , e v e n t h o u g h i t s g r e a t e s t m o n e t a r y b e n e f i t c a s e may l i e i n t h i s a p p l i c a t i o n . P o l i c y and B r o a d e r I m p l i c a t i o n s f o r B r i t i s h C o l u m b i a H o s p i t a l s One o f t h e m o s t c r u c i a l q u e s t i o n s f a c i n g h o s p i t a l s i s w h e t h e r t h e y w i l l be a b l e t o j u s t i f y t h e i r i n f o r m a t i o n s y s t e m s on e c o n o m i c g r o u n d s i n t h e f u t u r e . I f h o s p i t a l s c o u l d s o j u s t i f y i n f o r m a t i o n s y s t e m s , d e c i s i o n - m a k i n g w i l l become f a r e a s i e r . B u t t h o s e h o s p i t a l s who a r e p r e s e n t l y a b l e t o j u s t i f y on e c o n o m i c g r o u n d s a l o n e , c a n do s o l i k e l y b ecause, o f p r e s e n t s t a t u s quo i n e f f i c i e n c y . The c o s t - b e n e f i t c a s e w i l l a l s o be d e p e n d e n t u pon t h e s t a t u s quo s y s t e m s i n any g i v e n h o s p i t a l . H o s p i t a l s who a r e s t i l l t o t a l l y i n t h e m a n u a l mode o f h a n d l i n g i n f o r m a t i o n 138 l i k e l y h a v e more s t a f f and l i k e l y a r e a b l e t o g e n e r a t e more c o n v i n c i n g b e n e f i t c a s e s t h a n t h o s e who h a v e p a r t i a l l y a u t o m a t e d t h r o u g h s t a n d - a l o n e s y s t e m s , t h e r e b y a l r e a d y e f f e c t i n g a r e d u c t i o n o f s t a f f i n t h e d e p a r t m e n t s h o u s i n g t h e s t a n d - a l o n e s y s t e m s . T h u s , t h e c o s t - b e n e f i t p r o c e s s w o r k s a g a i n s t h o s p i t a l s who a r e a l r e a d y r u n n i n g e f f i c i e n t l y , be t h e y w i t h m a n u a l a n d / o r s t a n d - a l o n e a u t o m a t e d s y s t e m s . M o r e o v e r , d e c i s i o n s a r e made on t h e b a s i s o f i n d i v i d u a l h o s p i t a l s . I t i s unknown w h e t h e r i n t e r - h o s p i t a l c o m p a r a t i v e a n a l y s e s a r e done by t h e MOH as p r o p o s a l s a r e r e v i e w e d . I t i s l i k e l y t h a t t h i s i s t h e c a s e e v e n t h o u g h t h e y do n o t h a v e any way o f k n o w i n g e x a c t l y w h a t was i n c l u d e d o r e x c l u d e d i n t h e p r o p o s a l by r e s p e c t i v e h o s p i t a l s o r by t h e c o n s u l t a n t s r e t a i n e d t o do.... t h e s t u d y . What one h o s p i t a l a s s u m e s , a n o t h e r may make e x p l i c i t o r i g n o r e a l t o g e t h e r . A n o t h e r c h a l l e n g e f a c i n g h o s p i t a l s a s t h e y c o n s i d e r i n f o r m a t i o n s y s t e m s w i l l be t h e i m p a c t o f D i a g n o s i s R e l a t e d G r o u p s and t h e n a t i o n a l Management I n f o r m a t i o n S y s t e m s p r o j e c t o f t h e C a n a d i a n H o s p i t a l A s s o c i a t i o n . W h i l e t o some e x t e n t t h e s e a r e i n d e p e n d e n t p r o j e c t s , t h e y a r e i n f o r m a t i o n - b a s e d and o f n e c e s s i t y must i n t e g r a t e w i t h t h e HIS t o be o f v a l u e t o t h e h o s p i t a l and t o t h e u s e r s o f s u c h i n f o r m a t i o n . T h e s e two p r o j e c t s a l o n e w i l l f o r c e h o s p i t a l s t o w a r d s i n f o r m a t i o n s y s t e m s s o o n e r r a t h e r t h a n l a t e r . A n o t h e r m a j o r f a c t o r i s t h a t o f i n t e r - h o s p i t a l i n f o r m a t i o n s y s t e m s . T h i s s u b j e c t i s more o f t e n t a l k e d a b o u t 139 t h a n a c t e d upon, but f o r good r e a s o n . I t i s a complex v e n t u r e r e q u i r i n g extreme c o o p e r a t i o n from p l a n n i n g t h r o u g h implement-a t i o n . The major advantage i s i n reduced system c o s t s o f b o t h hardware and s o f t w a r e ; however, the t r a d e - o f f i s a p o t e n t i a l l o s s o f autonomy by t h e r e s p e c t i v e h o s p i t a l u s e r s . F o r t h i s r e a s o n a l o n e t h i s avenue i s not y e t b e i n g pursued t o o s e r i o u s l y . W h i l e t h i s t h e s i s has concerned i t s e l f o n l y w i t h the p e r s p e c t i v e o f t h e h o s p i t a l , and the r e s u l t s a r e o n l y from t h a t p e r s p e c t i v e , f u r t h e r r e s e a r c h i s r e q u i r e d from the p e r s p e c t i v e o f the MOH, s o c i e t y as a whole and from the p e r s p e c t i v e o f j o i n t h o s p i t a l v e n t u r e s w i t h r e s p e c t t o s h a red i n f o r m a t i o n systems. There i s no q u e s t i o n t h a t c o m p u t e r i z e d i n f o r m a t i o n systems i n h o s p i t a l s are here t o s t a y and, l i k e o t h e r t e c h n o l o g i e s , may t e n d toward r a p i d p r o l i f e r a t i o n . I f t h i s i s the c a s e , d e c i s i o n - m a k e r s must ensure t h a t implemented systems, c e t e r i s p a r i b u s , are t h e l e a s t - c o s t s o l u t i o n s and a b l e t o p r o v i d e the g r e a t e s t b e n e f i t s , b o t h q u a n t i t a t i v e and q u a l i t a t i v e . T h i s w i l l o n l y be p o s s i b l e i f HISs are examined from a m u l t i - p e r s p e c t i v e approach i n c l u d i n g the MOH, s o c i e t y and h o s p i t a l s , j o i n t l y and i n d i v i d u a l l y . These would be u s e f u l t o p i c s f o r f u t u r e r e s e a r c h . A n o t h e r f i e l d o f f r u i t f u l r e s e a r c h i s t h a t o f r e t r o -s p e c t i v e l y e x amining the u t i l i t y o f such systems on d e l i v e r y o f h e a l t h c a r e s e r v i c e s and on h e a l t h s t a t u s , a g a i n from the p e r s p e c t i v e s of t h e MOH, s o c i e t y and h o s p i t a l s . Much tech n o -140 l o g y c o n t i n u e s t o d i f f u s e i n t o t h e h e a l t h c a r e d e l i v e r y s y s t e m w i t h l i t t l e o r no a s s e s s m e n t . T h i s i s e q u a l l y a p p l i -c a b l e t o c o m p u t e r i z a t i o n i n h e a l t h c a r e ; t h u s , p r o g r e s s may be s t i f l e d i n t h i s a r e a . To some e x t e n t i t i s u n f o r t u n a t e t h a t some d e c i s i o n s a r e b a s e d s o l e l y on e c o n o m i c g r o u n d s . P e r h a p s t h i s i s one a r e a w h e r e j u s t i f i c a t i o n s h o u l d n o t be b a s e d s o l e l y on t h e e c o n o m i c p e r s p e c t i v e . I f t h i s t e c h n o l o g y h a d a more d i r e c t i m p a c t on p a t i e n t c a r e a n d p a t i e n t h e a l t h s t a t u s , d e c i s i o n - m a k i n g w o u l d be e a s i e r ; h o w e v e r , c o m p u t e r i -z a t i o n i s o f t e n w r o n g l y p e r c e i v e d a s an a d m i n i s t r a t i v e r a t h e r t h a n c l i n i c a l f u n c t i o n . P e r h a p s t h e g r e a t e s t p o t e n t i a l f o r t a p p i n g b e n e f i t s l i e s i n t h e f u r t h e r i n t e g r a t i o n o f H I S s t o b i o m e d i c a l t e c h n o l o g y , p a r t i c u l a r l y d i a g n o s t i c s y s t e m s w h i c h a r e c h a r a c t e r i z e d by s u c h e q u i p m e n t . Much o f t h e r e c e n t e q u i p m e n t i s a l r e a d y s u p p l i e d w i t h t h e p o t e n t i a l a n d e x p e c t a t i o n o f i n t e r f a c e a b i l i t y t o s u c h s y s t e m s . G e n e r a l l y , i t w o u l d a p p e a r t h a t w h i l e much p r o g r e s s h a s b e e n made i n t h e a r e a o f HIS d e v e l o p m e n t a nd a c c e p t a n c e by t h e h o s p i t a l e n v i r o n m e n t , i t s f u l l p o t e n t i a l i s f a r f r o m b e i n g r e a l i z e d . H o s p i t a l s , b y t h e i r c o n s e r v a t i v e n a t u r e , a r e g e n e r a l l y n o t p r o n e t o b e i n g on t h e l e a d i n g edge o f t e c h n o l o -g i c a l i n n o v a t i o n , u n l e s s t h e r e i s a d i r e c t c l i n i c a l a p p l i c a t i o n . H I S s a r e somewhere i n b e t w e e n p u r e l y a d m i n i s t r a t i v e a n d p u r e l y c l i n i c a l a p p l i c a t i o n s . The g r e a t e s t c o n t r i b u t i o n t h a t e c o n o m i c e v a l u a t i o n c a n make may l i e i n t h e a r e a o f a s s i s t i n g p o l i c y - m a k e r s i n b e t t e r u n d e r s t a n d i n g t h e a d v a n t a g e s o f H I S s 141 I n C a n a d i a n h o s p i t a l s . To d a t e t h e r e h a s b e e n l i t t l e a v a i l a b l e l i t e r a t u r e on s u c h e c o n o m i c e v a l u a t i o n and none on v a l i d a t i o n . H o p e f u l l y , t h i s t h e s i s w i l l f u l f i l l i t s m i s s i o n by p r o v i d i n g t h e b a s i s f o r a p o t e n t i a l f r a m e w o r k t o a s s i s t h o s p i t a l s commence p r o p e r e c o n o m i c e v a l u a t i o n b e f o r e t h e y i m p l e m e n t s y s t e m s a n d , f u r t h e r , w i l l p r o v i d e a b a s i s f o r p o s t -i m p l e m e n t a t i o n e v a l u a t i o n and v a l i d a t i o n . 142 SELECTED BIBLIOGRAPHY American H o s p i t a l A s s o c i a t i o n . 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New York: IEEE Computer S o c i e t y P r e s s , 1984. S c h m i t z , Homer H. " H o s p i t a l I n f o r m a t i o n Systems: Know What You're L o o k i n g F o r . " H o s p i t a l s 56 ( A p r i l 1, 1982):93-7. Shaw, Dean L. "A T o t a l Systems Approach." I n f o s y s t e m s 31 (November 1984):112-14. S h o r t e r , B r i a n and F e r g u s o n , I a n . " I f You Don't Know.Where You're Going Y o u ' l l Never Get There." COACH I/O 8 ( F a l l 1983):27-44. S m i t h , Robert J . "Know T h y s e l f : The S t a r t i n g P l a c e f o r Systems P l a n n i n g . " Computers i n H e a l t h c a r e 5 ( A p r i l 1984):65-6. S t a p l e t o n , W.L. Computer A d v i s o r y Committee. B.C. M i n i s t r y o f H e a l t h , Vancouver, B.C. Telephone C o n v e r s a t i o n , 24 March 1986. S t o d d a r t , G.L. and Drummond, M.F. "How t o r e a d c l i n i c a l j o u r n a l s : V I I . To u n d e r s t a n d an economic e v a l u a t i o n ( p a r t A ) . " Canadian M e d i c a l A s s o c i a t i o n J o u r n a l 130 (June 1, 1984)-.1428-34. S t o d d a r t , G.L. and Drummond, M.F. "How t o r e a d c l i n i c a l j o u r n a l s : V I I . To u n d e r s t a n d an.economic e v a l u a t i o n ( p a r t B ) . " Canadian M e d i c a l A s s o c i a t i o n J o u r n a l 130 (June 15, 1984): 1542-49. 147 S u l k e r s , P a u l . "The Rol e of S e n i o r Management." Vancouver, October 1981. ( T y p e w r i t t e n . ) U.S. Department o f Commerce. O f f i c e of Technology Assessment. The I m p l i c a t i o n s Of C o s t - E f f e c t i v e n e s s A n a l y s i s o f M e d i c a l Technology. Washington, D.C: NTIS, August 1980. U.S. Department o f H e a l t h and Human S e r v i c e s . N a t i o n a l C e n t e r f o r H e a l t h . S e r v i c e s . R e s e a r c h . Methods f o r E v a l u a t i n g C o s t s o f Automated H o s p i t a l I n f o r m a t i o n Systems: F i n a l R e port and E x e c u t i v e Summary, by E r i c a Drazen, A r t h u r D. L i t t l e , I n c . Re p o r t No. NCHSR 80-36. S p r i n g f i e l d , VA: NTIS, March 14, 1980. Warner, Kenneth E. and Luce, Bryan R. C o s t - B e n e f i t and C o s t - E f f e c t i v e n e s s A n a l y s i s i n H e a l t h Care - P r i n c i p l e s , P r a c t i c e , and P o t e n t i a l . Ann A r b o r : H e a l t h A d m i n i s t r a -t i o n P r e s s , 1982. Wo l o t s k y , P a u l and Varone, Americo J . " H o s p i t a l I n f o r m a t i o n Systems P l a n n i n g . " J o u r n a l o f M e d i c a l Systems 7 (August 1983) :379-86. Z i l m , D. Kelowna"General H o s p i t a l , Kelowna, B.C. I n t e r v i e w , 22 May 1985. 149 Hospital Programs Guidelines for Computer Funding Proposals December 1984 r 150 TABLE OF CONTENTS Sec t i on Purpose 1 f u nd i n g Options 2 Procedures 3 Proposal Content 4 Sample Proposal 5 r GUIDELINES FOR COMPUTER FUNDING PROPOSALS 1 5 1 1. Purpose The purpose of the "Computer Funding Proposal" i s to: - describe the system and equipment being requested; - provide costs for hardware, software, Ins ta l l a t i on and operation; - Identify benefits both tangible and intang ib le; - provide a level of de ta i l that is approriate for the cost of the request ( I . e . a submission for $1,000,000 system should contain s i gn i f i c an t l y more de ta i l than for a $30,000 system); - i f one ex i s t s , re late the spec i f i c request to the Information Systems Plan for the hosp i ta l . (In the long term (1986/87), each hospital should have in place a basic long range plan for data processing. I t i s expected that many of the hospita ls w i l l have very s im i la r plans.) 2. Funding Options - A l l computer equipment acquis i t ions sha l l be funded from cap i ta l funds. - Items costing $10,000 or less should be funded from the hosp i ta l ' s Secondary Equipment A l locat ion or other hospital cap i ta l funds. Hospital Programs approval of these items i s not required. - Items costing over $10,000 can be funded in the fol lowing ways: r - 2 - 152 (1) 33 1/3% equipment grant and balance funded as a one time operating to cap i ta l t ransfer (new po l i c y ) . (2) 33 1/3% equipment grant and balance funded by the Regional Hospital O i s t r i c t or other cap i ta l resources (no change). (3) 100% equipment grant based on recovery of operating savings over 2 years. Savings revert permanently to the Min istry of Health (no change). 3. Procedures The fol lowing steps are to be completed 1f a hospita l wishes to acquire computer systems. (1) Determine the f e a s i b i l i t y of the project . Normally th i s requires the completion of a F ea s i b i l i t y Study ( th i s includes a descr ipt ion of the current system, l im i ta t ions and constraints for proposed system, object ives of proposed system, scope of proposed system, analys is of a l te rnat ives , and recommending the most su i table so lu t ion) . The amount of work involved in the Feas i b i l i t y Study i s a function of the cost and complexity of the system. (2) Obtain Board of Trustee approval author iz ing cap i ta l and operating funding associated with the computer project . The actual approval procedures for computer systems w i l l d i f f e r from hospital to hospita l but w i l l include approval of the project (e.g. Computer Steering Committee), approval of cap i ta l funds (e .g . Capita l Appropriations Committee) and approval of operating funds (e .g . Computer Steering Committee). - 3 - 153 (3) If the system costs less than $10,000, and funds are ava i lab le within the Secondary Equipment Grant or other hospital cap i ta l funds, the hospital may proceed with the acqu i s i t i on . (4) If the system cost i s greater than $10,000, the hospita l must: - prepare a Computer Funding Proposal and grant appl icat ion HIA 39 (1f an equipment grant 1s being requested). - submit 1t to the Min is t ry for approval. - 1f approval i s received, proceed with the acqu i s i t i on . 4.0 Proposal Content The level of de ta i l contained in the Computer Funding Proposal is a function of the cost of the equipment. For purposes of explanation the fol lowing levels have been defined: Cost Approval by Proposal level over $10,000 and up Min is t ry 1 to $50,000 over $50,000 and up Min is t ry 2 to $100,000 over $100,000 Min is t ry 3 4.1 Information Required The information required by the Min is t ry , broken down by l eve l , i s : ( - 4 - 154 1 2 3 Information/Level 10.001-50.000 50.001-100.000 100.000 Computer Funding Yes Yes Yes Proposal Typical Size in pages 4 10 15 Feas i b i l i t y Study No Yes Yes Information Systems Plan No No Yes ( i i ) ( i i ) Not required unt i l 1986/87 4.2 Computer Funding Proposal A l l computer funding proposals should include the fol lowing sections: (1) System Requested This section should contain a concise statement of a l l the equipment and software you are planning to acquire or develop and i t s re lat ionsh ip to your Information requirements. (2) Options Evaluation a) This section should describe the systems that were considered pr io r to making a decis ion on the system of choice. I t is ant ic ipated that hospita ls w i l l evaluate systems marketed by at least three a l te rna t i ves . A comparative analys is of costs should be provided in chart format (see sample chart, page 7 ) . b) Please submit a copy of a l l pr ice quotations with the funding proposal. c) Fu l l documentation should be provided to j u s t i f y the system being requested as wel l as to explain the ( f - 5 -reasons for rejecting the competitive system proposals. (3) Anticipated Budget Requirements and Cost Justification: Business Case This section should be prepared in the form of a chart indicating the anticipated costs associated with your planned system. Equipment, software, staffing, facilities and miscellaneous operating costs for each year must be stated using a cost/benefit worksheet like that shown on page 8. This section should also state all the benefits which would be derived from the implementation of the system. All possible benefits should be quantified and compared to the anticipated possible costs. All tangible and intangible benefits should be listed at the end of this section. (The "Net Present Value" method of analysis will be used by the Ministry for review of the submission). (4) Planned Schedule A schedule of proposed activities must be included in this section. (5) Equipment Requirements This section should highlight the type of equipment you anticipate acquiring, including its growth potential. You should indicate the relationship of this equipment to your information systems objectives. If old equipment is being replaced, you should indicate disposal plans. ( ( - 6 - 156 (6) Software Requirements This section should indicate the software system you ant ic ipate i n s t a l l i n g . The re lat ionsh ip of th i s software to the information systems objectives should be indicated. You should also indicate whether the software i s to be developed in-house or acquired from a l te rnat ive sources. (7) Staff ing Requirements The number of staf f members and the i r s k i l l levels w i l l probably change when you acquire computerized systems. Plans for the h i r i ng , re-assignment and re- t ra in ing of staf f should be included in th i s sect ion. (8) F a c i l i t i e s Requirements During the l i f e of the system you may require some major or minor renovations to your f a c i l i t i e s because of the equipment or s ta f f ing required. This information should be included in th is section along with the ant ic ipated costs. (9) Operating Costs This section should contain any ant ic ipated operating costs that may be associated with the system which have not been outl ined in the previous sect ions. COMPARATIVE COST ANALYSIS CHART VENDOR 1 VENDOR 2 VENDOR 3 VENDOR 4' 2 COSTS ($) 1 1 1 1 1 1 1 1 1 1 SALARIES: COMPUTER OPERATIONS OTHER 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 I I I I I PROFESSIONAL/CONSULTATIVE < ' 1 1 i SERVICES ! i 1 i 1 j ^ STAFF TRAINING FACILITIES MODIFICATIONS OFFICE FURNITURE/EQUIPMENT I I I ! MATERIALS ANO SUPPLIES 1 HARDWARE RENTAL/PURCHASE 1 1 1 SOFTWARE DEVELOPMENT/ PURCHASE 1 HARDWARE MAINTENANCE 1 • 1 1 N .. OTHER EXPENDITURES (LIST) ' ! 1 1 1 TOTAL EXPENDITURES I I I ! ! .DOITJONAL COMMENTS CO BENEFITS/COSTS WORKSHEET HOSPITAL 1 19 2 19 3 19 4 19 5 19 C u r r e n t New Change C u r r e n t New C h a n c e C u r r e n t New Chanqe C u r r e n t New Change C u r r e n t New C h a n g e SALARIES:COMPUTER OPERATIONS OTHER PROFESSIONAL/ f "ULTATIVE SVCS S>7TFF TRAINING F A C I L I T I E S MODIFICATIONS OFFICE FURNITURE/ EQUIPMENT MATERIALS AND S U P P L I E S HARDWARE RENTAL/ PURCHASE SOFTWARE DEVELOP-MENT/PURCHASE HARDWARE MAINTENANCE w TOTAL EXPENDITURES OTHER INTANGIBLE COSTS/BENEFITS ( f - 9 -SAMPLE PROPOSAL This section contains a sample proposal for a Dietary System costing $40,000. It is assumed a feasibility study has been completed and internal hospital approval has been received. Computer Funding Proposal Dietary System Sample Hospital A. System Requested Sample Hospital is seeking funding approval for the acquisition of a Dietary System from B.C.H.S.S.S. running on a Micro VAX computer. The Dietary System consists of: Hardware Micro VAX I 0.5 M8 memory 31 MB fixed disk 2 removeable floppy diskettes 2 VT220 terminals 1 LA100 printer $30,000 Dietary Software 10,000 $40,000 The Dietary software interfaces to our existing AOT System extracting pertinent patient dietary and location information. There are plans within B.C.H.S.S.S. to have the system interface to our Materiels Management system { - 10 - 1 6 0 B. Options Evaluation Three a l ternat ives were considered for the Dietary System. The comparative cost analys is chart attached provides a breakdown of the costs for the various a l te rnat i ves . A l ternat ive 1 Acquis i t ion of a Oietary System from B.C.H.S.S.S. running on a micro VAX computer. Advantages: - interfaced to our ex is t ing ADT system. - p lot for Interface to our Materiels Management. - consistent with our arch i tecture. - the overa l l r i sk i s low as the software is presently running in three hospita ls in B.C. - The ADT and Materiels Management systems were acquired from B.C.H.S.S.S. resu l t ing in a greater level of compat ib i l i ty . Disadvantages: - s l i gh t l y higher cost than a l te rnat ive 3. Alternat ive 2 Acquis i t ion of a Dietary System presently be developed by ABC company on Data General hardware. Advantages: - the ABC company has developed various other software packages for hosp i ta l s . Disadvantages: - higher cost than the other two a l te rna t i ves . r - " - 161 - no Interface ex is ts to our ADT/Materiels Management systems. - the appl icat ion i s in development and therefore i s not proven. - inconsistent with our architecture.-- the overa l l r i sk is medium to high as the system is pa r t i a l l y wri t ten but not operat ional . A l ternat ive 3 Custom develop the Dietary system with our own staf f on our ex is t ing VAX 11/750 hardware. Advantages: - our staf f 1s fami l i a r with the Dietary operation at our hosp i ta l . - consistent with our arch i tecture. Disadvantages: - an interface must be developed to our ADT and Materiels Management systems. - the overal l r i sk i s high due to custom development of a system. C. Anticipated Budget Requirements and Cost Ju s t i f i c a t i on The cost/benef i t worksheet attached provides a breakdown of a l l ant ic ipated costs and benefits for implementing the new Dietary System. The fol lowing points should be considered when reviewing the worksheet: - At present there are 3.0 staf f completing the funct ions. With the automated system th i s number w i l l be reduced { - 12 - 162 to 2.0. The system is planned for implementation mid-year which w i l l resu l t in 0.5 s ta f f savings in the f i r s t year and 1.0 in subsequent year. - Implementation costs include: - one week outside consult ing time $ 2,000 - room preparation 100 - hardware 30,000 - software 10,000 $42,000 - At present i t i s estimated that $5,000 worth of meals are spoi led annually, due to patient movement or discharge. Tangible benef i ts: - the system w i l l pay for i t s e l f in less than three years from implementation. - staf f w i l l be reduced by 1.0 F .T.E. - spoi led meals w i l l be reduced by $5,000/year. Intangible benef i ts: - the system w i l l al low for better meal planning. - interfac ing to the ADT w i l l reduce nursing and c l e r i c a l e f fo r t in tracking patient locat ion. - t imely and accurate food production forecast ing w i l l be possib le. r - 13 -Planned Schedule 1984/85 1985/86 Activity: J F M A M J J A S O N D J F H A M receive approval _ order system _ install system _ system test & parallel system in production Equipment Requirement The Micro VAX I was announced by Digital in the Fall of 1983. The hardware can be expanded to eight terminals and 65 MB of fixed disk storage, which will easily meet the Dietary System's long term requirements. The same Operating System (VMS) is used for all VAX line of computers from the Micro VAX at the low end to the VAX 11/785 at the high end. This will allow the software to be transferred to a larger machine in the future, if desired. Software Requirements The Dietary System software is being purchased from B.C.H.S.S.S. as a package. It is presently running in three hospitals in B.C. and the users are very pleased. The software interfaces to our ADT. As well, there are plans to interface it to our Materiels Management System. Staffing Requirements The two staff that will run the system will be trained by B.C.H.S.S.S. as part of the purchase price. The training ( - 14 - 164 will cover the application as well as basic computer operations. B.C.H.S.S.S. is available if additional technical support is required. H. Facilities Requirements Minimal. I. Operating Costs The estimated operating costs are: staff $40,000 suppli es 300 hardware maintenance 3.000 $43,000 A l t e r n a t i v e " ! A l t e r n a t i v e 2 A l t e r n a t i v e 3 COMPARATIVE COST ANALYSIS CHART xwwxk xmmx. mm^ VENDOR «• tfl 1 : . . , . 1 1 1 1 1 - 1 COSTS (5) j j j j SALARIES: COMPUTER OPERATIONS OTHER development 1 i i j j 60,000 (I)' j PROFESSIONAL/CONSULTATIVE i ? ODD I ? nnf) 1 I ! SERVICES • £»UUU , ^ , U U U | j j ""*" STAFF TRAINING | | | | FACILITIES MODIFICATIONS 100 | 100 | | | OFFICE FURNITURE/EQUIPMENT i i i i MATERIALS AND SUPPLIES i l l ! HARDWARE RENTAL/PURCHASE 30,000 j 40,000 | 20,000 (2) | | SOFTWARE DEVELOPMENT/ PURCHASE 10,000 | 15,000 1 1 1 HARDWARE MAINTENANCE ! I I I I ! OTHER EXPENDITURES (LIST) 1 ' 1 1 i % i i i TOTAL EXPENDITURES 4 2 , 1 0 0 | 5 7 , 1 0 0 j 8 0 , 0 0 0 | | ( 1 ) E s t i m a t e d 2 man y e a r s f o r d e v e l o p m e n t a t 5 3 0 , 0 0 0 / y e a r = $ 6 0 , 0 0 0 . ( 2 ) R e l a t i v e c o s t o f h a r d w a r e . HOSPITAL Sample Hospital i 19 84/85 " T ,"585/86 3 ,986/87 14 ,987/88 5 19 88/89 C ' J > l C N t 1 - | V i i - « K C t ( • ! U * i ) i . | o > - ; < ! 40,000 (40,000) i0,000 (40,000) 40.000 (40,000) in.000 40,000) Lp nnn [AO, 60,000 10,000 50,000 60,000 60,000 60.000 ' 60,000 60,000 j 60,000 60,000 ! 60, ^ i r - - * i . j : : j . r i v c 2,000 (2,000) 1 i . i ! i 100 (100) i ! i . t t ' u t H i i . r : - [ ; . - : ' - 1 S T ! j 1 1 1 j 300 (300) 300 (300) 300 (300) j 300 1 (300) 1 1 300 !30,000 (30,000) 1 : 1 1 ' j . 1 r t > t vr -*T / 10,000 (10,000) j • ! 3,000 (3,000) 3,000 (3,000) 3,000 ' (3,000) 3,000 !(3.000) 3 000 I 1 >oiled Meals 5,000 5,000 5,000 5,000 5,000 5,000 5,000 s nnn s nnn 5,< • T O T A L E*PC"S| T ' j ac i 65,000 j 95,400 (30,400) 65,000 • 43,300 21,700 65,000 43,300 21,700 65,000 43,300 21,700 65,000 43,300 21,: Lb I INSTITUTIONAL SERVICES and Regional Hospital D i s t r i c t s In order to a s s i s t hospitals i n planning computer acqu i s i t i o n s , Hospital Programs has developed the following computer "polic ies P r i o r i t i e s In considering requests f o r the approval of computer applications i n hospitals the Ministry w i l l consider the following p r i o r i t i e s . Of highest p r i o r i t y are those dealing with the f i n a n c i a l management of the hospital such as: 1. General Ledger 2. Accounts Payable 3. Financial & S t a t i s t i c a l Reporting (HLTH 1535) 4. Budgeting 5. Accounts Receivable (including M.S.P.) 6. Personnel/Tiinekeeping 7. Materials Management The next l e v e l of p r i o r i t y w i l l be those areas which w i l l continue t o improve the f i n a n c i a l operation of the hos p i t a l and enhance the patient support areas. These w i l l include: 8. Laboratory 9. Radiology 10. Pharmacy 11. Medical Record Abstracting 12. Adrtdttirig/Discharge/Transfer 13. Dietary Production Management 14. Fixed Assets 168 -2-Proposals f o r any of the systems outlined above w i l l be considered f o r c a p i t a l funding by the M i n i s t r y through the normal equipment grant request procedures. At the present time, the Ministry may not be i n a pos i t i o n t o provide c a p i t a l j?unding f o r systems other than those of highest p r i o r i t y . Maximum Acceptable Expenditure Level Hospital Programs i n conjunction with the Systems Development Staff of the Ministry have developed a series of formulas which are designed to indicate the maximum acceptable expenditure l e v e l f o r computers i n hospitals. While these formulas are s t i l l under review we are u t i l i z i n g them to establ i s h the maximum acceptable computer expenditure guideline i n hospitals as follows: major r e f e r r a l hospitals three quarters of one percent of gross operating income craranunity hospitals one h a l f of one percent of gross operating income Where hospitals choose to exceed these expenditure guidelines or to proceed with systems without M i n i s t r y approval the consequences of such action w i l l not be funded. Accounting Treatment In order t o be i n a pos i t i o n t o measure computer expenditures i t i s necessary that these expenditures be uniformly i d e n t i f i e d and reported. The c a p i t a l costs of computers which are purchased s h a l l be recorded i n the c a p i t a l fund and amortized i n the c a p i t a l fund as outlined i n Schedule A attached. ( ( 169 - 3 -The operating and maintenance costs of owned computers together with the costs of computer services provided through service bureaus or the costs associated with leasing a computer s h a l l be paid from operating funds and reported as outlined i n Schedule B attached. The t o t a l computer expenditures f o r each h o s p i t a l w i l l be determined by adding together computer expenditures recorded i n the operating fund and the amortization of the c a p i t a l cost of computer equipment recorded i n the c a p i t a l fund. Ac q u i s i t i o n Alternatives f o r Computers and Computer Services Computer systems/services may be acquired and funded i n any or a l l of the following ways: by the purchase of the service from a service bureau or data centre - such contracts w i l l be paid through operating funds by leasing the equipment such leases w i l l be paid f o r through operating funds by purchasing the equipment purchases s h a l l be paid f o r by the h o s p i t a l from c a p i t a l funds. Hospitals may apply f o r equipment grants i n the normal manner from the province and the Regional Hospital D i s t r i c t . A l l hospitals considering systems/services acquisitions costing more than $10,000 must obtain the approval of the Executive Director of Hospital Programs p r i o r t o entering i n t o any agreement. Such approval w i l l only be granted i f the system proposal meets the stated p r i o r i t i e s of the Mmistry, i s within the guidelines for the hospital and the h o s p i t a l can c l e a r l y e s t a b l i s h that they have selected the most suita b l e product f o r a reasonable price. f ( SCHEDULE A REPORTING AND AMORTIZATION OF COMPUTER PURCHASES REPORTING OF CAPITAL EXPENDITURES: The fol lowing items should be included as cap i ta l cos ts . 1) Hardware (CPU, terminals , p r in te rs , storage devices, etc . ) 2) Software (operating systems), professional too l s (word processing, Lotus 1, 2, 3, e t c . ) , app l i cat ion software (payro l l , general ledger, e tc . ) 3) Training costs 4) Equipment i n s t a l l a t i on fees 5) .Preparation of computer s i t e (cab l ing, w i r ing , ra ised f loor , a i r cond i t ion ing, e tc . ) AMORTIZATION Capital expenditures which to ta l less than $10,000 w i l l be amortized in the cap i ta l fund in the year of acqu i s i t i on . I f the components being acquired are part of a "computer system" the to ta l of these expenditures w i l l be treated as a s ingle unit i r respect ive of the number of s ingle purchases or that the indiv idual items may have cost less than $10,000. For expenditures t o t a l l i n g more than $10,000 the fol lowing formula w i l l be used to ca lcu la te the annual costs to be amortized in the cap i ta l fund. Total expenditures x .0167 for each month the system w i l l be i n s ta l l ed : e.g. for a computer system whose to ta l cap i ta l costs for 1) through 5) above are $300,000, the annual cost would be $300,000 x .0167 x 12 months = $60,120. - The .0167 i s based on a f ive year lease cost . ( ( 172 SCHEDULE B REPORTING OF COMPUTER COSTS IN THE OPERATING FUND OPERATING COSTS Items to be included in operating costs are: 1) Operating s taf f sa lar ies plus benef i ts - Operating s ta f f consist of systems s ta f f including computer programmers and system operations s ta f f . System end users would not be included. 2) Hardware and software maintenance charges 3) Purchased serv ices, e .g. payrol l serv ices , microfiche costs , HMRI/PAS, etc. 4) leasing payments and associated costs A P P E N D I X 3 173 CHILLIWACK GENERAL HOSPITAL SYSTEMS PLANNING PROJECT SEPT 84 LEGEND: (x) Major resp o n s i b i l i t y ana decision-making X Major involvement in the process / Some involvement in the process PROCESSES c •n 0 01 01 01 01 0 0 X Laundrv/Linen tc c a c u: i c c tf. r-r-l M S <y CJ 1 D c •r-01 r-= > i u ra E u 2 ft i .c cr C 0 rH 0 ra ft Laboratory Pastoral Care 1 Plant & Maintenance Food Services Personnel & Payroll Community Resources 1 Purchasing/SSD 1 Social Work Services | Long Term Care Admitting/Swbd Finance/Bus. Office Health Records 1 Physical Medicine 1 Radiology 1 Nursing Admin. 1 Administration J Medical staff 1 PATIENT ADMINISTRATION: 1.1 Patient i d e n t i f i c a t i o n X .< X / / / X X X X X / 1.2 Admi s s ion/book ing « X X X $ / X X 6 ) 1.3 Census control X X X / / / X X / X K X / X X / / 1.4 U t i l i z a t i o n review X X / / X X X X ® 1.5 Abstracting X X / @ COMMUNICATION: 2.1 Order Entry / ® £> ? V X X X X X / x X $ 2.2 Worklist control <$ CX> X $> © X X X ® X (» X 2.3 Results reportinq fx? C*> X X Ov s> / X TREATMENT PLANNING: 3.1 Assessment/History Taking <f> c?> X X X 3 X ® 3.2 Care preparation u> x X X y X X X X X I 3.3 Evaluation & C l a s s i f i c a t i o n w © X X / X X ^> X X QUALITY ASSURANCE: 4.1 Health Care Audit !» GO 63 X X X $ 4.2 Environmental Control <£ ® CS5> <Z> ® ® X X X X X X X 5) X 4.3 Quality Control ® xc1 2> 3> (X) £> ® 3 X 4.4 Standards Management 2> ® O ® a ® ® (33 CX) ro MATERIELS MANAGEMENT: 5.1 Purchasing X X X 3) x X 'x; X : CP X X X X X X X 2 X 5.2 Production Control X X> / s> X 3> X 5.3 (Supplies) Inventory Control S> X X cS) x X 2> S> ® X X X X S X 5.4 Capital Equipment Control S> & X S> G> S> < ^ ® / <® <2 <Z cS c£i c£ ® FACILITY MANAGEMENT: 6.1 Ma intenance •X x x x <£ X © X / X X X 6.2 Operations x X X y PERSONNEL ADMINISTRATION: 7.1 Applicant Tracking ® x (5 & SJ ® <£ CS CS) Q> <S X 7.2 S k i l l s , Privileges Control x X x X X K <? X X © X X (??> 7.3 Personnel Management > X X x K X X X ® ® <2> X <2> <? (£> 7.4 Position Control <£> a S> ® & X ® c3> & <8 c3 X 75''. Time Reportinq and Analysis X x ® (2) / •X) © <£ ® ® CS •?>' STAFFING MANAGEMENT • . " ... 8,1 Staff Schedulina <£ X X, @ (S <2 ® (5 ® c?5 (S © C3 2> © <£ TO X ^) ®v —i_ M U c t U I v ic iI iuCltrnien L. ' ' RESEARCH AND PLMTNTNG X X. A X X X X X X X < C5 @ <5 PUBLIC RELATIONS MANAGEMENT X X x X X X K ® X X X X X x X X X MESSAGE MANAGEMENT 5P ® (% X fx Ts> Cx FINANCIAL SERVICES: 13.1 Budget & Financial Control X x X x X X X X ® X X X X ® X X < < X 13.2 Accounts Payable Management X. x X X X X X X X X X X X X 13.3 Accounts Receivable Management X / X ® X Cx> (? (K C\ c^ ; X (*> X X 13.4 Resource Costing x X X / V X X X ® X X X 13.5 S t a t i s t i c s Management X K x X x X X G> X X X Q£ @ X < 5 X X (£. <£ APPENDIX 4 17 CHILLIWACK GENERAL HOSPITAL OCTOBER 3, 1984 PROCESS DEFINITIONS 1.0 PATIENT ADMINISTRATION The Patient Administration process deals with the information associated with administratively c o n t r o l l i n g the patient's case or encounter with the h o s p i t a l . The process includes the subprocesses of patient i d e n t i f i c a t i o n , admission/booking, census c o n t r o l , u t i l i z a t i o n review and abstracting. 1.1 PATIENT IDENTIFICATION This subprocess controls information regarding basic biographic and demographic data on each patient encountering the h o s p i t a l . The main objective i s to ensure that each patient appears only once in the patient i d e n t i f i c a t i o n index, or r e g i s t r y , regardless of the reason (inpatient, emergency, etc.) f o r the encounter. Basic data includes name, sex, date of b i r t h , address, telephone .number, p r o v i n c i a l health number, next of k i n , area of b i r t h , • language, l a s t date of update and, most important, a c e n t r a l h o s p i t a l medical or health record number. Functions include the r e g i s t r a t i o n of new p a t i e n t s , update and display of e x i s t i n g p a t i e n t s . Access to t h i s data may be v i a patient's name (exact s p e l l i n g or p h o n e t i c a l l y ) , medical record number or p r o v i n c i a l health insurance number. Reports produced from t h i s information could include a demographic d i s t r i b u t i o n report, and a back-up master l i s t i n g of a l l r e g i s t e r e d p a t i e n t s . 1-2 ADMISSION/BOOKING The Admission/booking subprocess r e l a t e s to the c o n t r o l of treatment and resources information, including beds, waiting rooms, OR rooms, describing each case or encounter with the h o s p i t a l , regardless of the type of patient (inpatient, emergency, e t c . ) . The information c o n t r o l l e d describes the time and type of service for each case, and u t i l i z e s information from the patient i d e n t i f i c a t i o n process to i d e n t i f y each p a t i e n t . Basic information includes the expected and actual date/time of 175 admission/arrival, service area, admitting/attending or consulting physician, a r r i v a l information, type of patient (emergency or elective) and insurance/payment data. Specialty information includes date/time of accident, i s o l a t i o n information and whether the appointment was on-time/late. Functions include the admission/documentation of inpatient, outpatient and emergency encounters, p r i n t i n g of associated forms, checking and updating of insurance data, and updating of patient/physician information. Access to t h i s information could be v i a patient i d e n t i f i c a t i o n access methods, encounter/case number, or patient location/nursing census. Reports could include the admission/discharge/transfer l i s t , OR l i s t , emergency l i s t , appointment l i s t , nursing s t a t i o n census, clergy reports, census summaries by u n i t and service (both d a i l y and monthly). Daily appointment l i s t by service and physician, and waiting l i s t a n a l y s i s . 1.3 CENSUS CONTROL This subprocess deals with the reservation, assignment and tracking (transfer) of patients while in h o s p i t a l . Basic information includes current and previous l o c a t i o n , date and time of movement, status of beds, pending discharge, discharge status, and discharge data. Functions include display of nursing unit census, ambulatory r o s t e r s , a v a i l a b l e beds by service. Access to t h i s information could be v i a e x i s t i n g p atient i d e n t i f i c a t i o n functions, or v i a admission/booking functions. Reports include census l i s t i n g s , a v a i l a b l e beds and patient-days s t a t i s t i c s . 1.4 UTILIZATION REVIEW Deals with the review of a current patient's LOS and condition, together with assessment of an extended LOS and coordinating external resources i n order to plan a discharge. Basic data, .includes expected date of discharge, discharge needs f o r discharge planning, date of last/next review. Reports include a l i s t of patients scheduled f o r discharge or a l i s t of patients scheduled f o r another review. 1.5 ABSTRACTING 176 The Abstracting subprocess i s a summarization of data c o l l e c t e d i n patient treatment areas. Information from the patient i d e n t i f i c a t i o n and admission/booking processes are used to produce the abstract. In B r i t i s h Columbia t h i s abstract generally meets the requirements of the Hospital Medical Records I n s t i t u t e . I t also includes discharge summaries, O.R. notes, P.A.R. notes and transfe r summaries f o r other agencies. In addition to information from patient i d e n t i f i c a t i o n , admission booking, procedures, physician and diagnosis information i s also c o l l e c t e d . Reports from the Abstracting subprocess includes discharge s t a t i s t i c s by service, physician, procedure, diagnosis, time, area, or combination thereof, or optional data as requested by h o s p i t a l . 2.0 ORDER COMMUNICATIONS The Order Communications process deals with the communication of medical information, both treatment and diagnostic, between the patient treatment areas and the support a n c i l l a r i e s of the h o s p i t a l . This process includes the subprocesses of order entry, worklist c o n t r o l , r e s u l t entry. 2.1 ORDER ENTRY The Order Entry subprocess enables the display and communication of a l l patient r e l a t e d orders on a nursing unit or patient treatment area. The objective of the order entry process i s to ensure complete and accurate information for order communication to ei t h e r diagnostic or treatment departments, including integration with nursing care procedures. Functions include the display, entry, v e r i f i c a t i o n , c o r r e c t i o n , c a n c e l l a t i o n , updating of a l l orderable procedures (including requests to borrow or review patient charts or x-ray f i l m s ) , along with the i n d i c a t i o n or required data for each procedure. Information may be pr i n t e d i n ei t h e r the a n c i l l a r y or the nursing u n i t . A key function of the order entry function i s the a b i l i t y to review and v e r i f y information. Basic information includes procedure name, s t a r t date/time, and date/time, frequency, ordering physician, entered by, v e r i f i e d by, performing department and category of order. Textual order comments are also included. Specialty information includes ..strength, dosage and route. Accurate information from the patient i d e n t i f i c a t i o n and admission/booking processes i s a pr e r e q u i s i t e . Access to order entry i s v i a the patient i d e n t i f i c a t i o n or the census co n t r o l . Reports or documents produced by t h i s process include r e q u i s i t i o n s , f l a s h cards, standard l a b e l s and order l i s t s . 2.2 WORKLIST CONTROL 1 7 7 The Worklist Control subprocess u t i l i z e s information from the order entry process to support c l e r i c a l service and care planning. Functions include the production of work station reports, c o l l e c t i o n schedules, and work status reports. The main f a c t o r of the Worklist Control sub-process i s the control of the order status, from u n v e r i f i e d order through to completed and documented r e s u l t . Worklist Control c l o s e l y interfaces with the r e s u l t entry. Access to t h i s subprocess i s via patient i d e n t i f i c a t i o n , department, order type of r e q u i s i t i o n number, or date and time by pa t i e n t . Functions include the recording o f a completed t e s t , cancelled procedure and in d i c a t i o n of management control data. The key function of worklist control i s the tracking and status checking of any order from entry through to completion and reported. Status i n d i c a t i o n s should include a l l major stages in the order l i f e c y c l e . 2.3 RESULT-ENTRY The Result Entry subprocess deals with the entry of both textual and numerical information as a r e s u l t of the performance of a diagnostic procedure. Reports produced from t h i s subprocess include radiology impressions, cumulative laboratory summaries and interim laboratory r e s u l t s , medication p r o f i l e s , therapy and dietary documents, and nursing care plans, as described under the care planning process. Information from the patient i d e n t i f i c a t i o n subprocess i s used to accurately return r e s u l t s . Information from the order entry process describes the procedure. Basic information for the r e s u l t entry process indicates date/time performed, performing/entering technologist, reading/staff physicians, fee code, date/time r e s u l t entered, numerical and textual information. A r e s u l t i s entered for each occurrence of a procedure according to order entry information such as frequency and duration. Textual information may be entered by the r e s u l t entry process v i a ei t h e r standard phrases, pre-selected standard paragraphs or word processing c a p a b i l i t i e s . Numerical r e s u l t s may be entered by either selected values, d i r e c t entry by technologist, or v i a connection to instrumentation. Access to the r e s u l t entry subprocess i s by patient i d e n t i f i c a t i o n or census control information, performing department or r e q u i s i t i o n number. Functions include the r e s u l t entry c a p a b i l i t i e s of text and numerical data, production for interim and f i n a l r e s u l t s at both a n c i l l a r y and nursing locations updating of interim r e s u l t s , and display of a l l r e s u l t s by department or patient. 3.0 TREATMENT PLANNING 178 Deals with the assessment of patient treatment needs, preparation of a treatment or a care plan, followed by the evaluation of the plan. The documentation of a patient l i s t i n g would be included i n assessment, and evaluation could include c l a s s i f i c a t i o n of patients. 3.1 HISTORY TAKING AND ON GOING ASSESSMENT Deals with the i n i t i a l recording of health h i s t o r y and ongoing documentation of assessment notes regarding the patient current health problems. 3.2 CARE PLAN PREPARATION Deals with the preparation and updating of a plan of care to deal with patient health problems documented during assessment. 3.3 EVALUATION AND CLASSIFICATION Deals with the charting of patient progress r e l a t i v e to care plans, and the c l a s s i f i c a t i o n of the patient to determine the resources required and the patient's condition. 4.0 QUALITY ASSURANCE This process deals with the measurement of outcomes versus standards to monitor q u a l i t y of work performed. Included as subprocesses would be health care audit, environmental c o n t r o l , q u a l i t y control and standards management. 4.1 HEALTH CARE AUDIT Deals with the retrospective r e t r i e v a l (random or complete) of departmental records or patient charts based on predetermined c r i t e r i a , and comparison of these records/charts against standards. 4.2 ENVIRONMENTAL CONTROL Deals with the recording of d e f i c i e n t s t r u c t u r a l standards (e.g. b u i l d i n g d e f i c i e n c i e s ) and follow-up c o n t r o l . Areas covered may include f i r e prevention, sec u r i t y , r a d i a t i o n p rotection and i n f e c t i o n c o n t r o l . 4.3 QUALITY CONTROL 179 Deals with the comparison of r e s u l t s versus standards to ensure the current accurate service functioning, e.g. equipment, instrumentation. 4.4 STANDARDS MANAGEMENT Deals with the establishment and recording of required l e v e l s of operation and protocols in the areas of patient care, resource management and administration, the establishment and documentation of ho s p i t a l and departmental p o l i c i e s and procedures. A key function i s the a b i l i t y to extract textual information on keyword or phrase basis, and to produce documents and manuals v i a text processing. 5.0 MATERIELS MANAGEMENT This process considers the a c q u i s i t i o n , production c o n t r o l , i d e n t i f i c a t i o n and maintenance of supplies and c a p i t a l equipment. 5.1 PURCHASING Process of ordering and obtaining materials and/or services necessary to carry out the hospital's operational functions, and ensuring favourable cost with q u a l i t y and service. The process includes tracking of the request from order-entry to f i l l i n g by purchasing, current out-standing orders by department are supported. 5.2 PRODUCTION CONTROL Deals with the monitoring of work-in-progress which processes raw materials and produces f i n i s h e d goods. 5.3 SUPPLIES INVENTORY CONTROL Process of est a b l i s h i n g a supply of materials needed to carry out services, ensuring that appropriate l e v e l s of materials are av a i l a b l e and d i s t r i b u t e d as requested. 5.4 CAPITAL EQUIPMENT INVENTORY CONTROL Process of recording the re c e i p t , i d e n t i f i c a t i o n and tracking, and possibly the recording of preventative maintenance of c a p i t a l inventory items such as o f f i c e equipment, kitchen equipment and patient r e l a t e d equipment. 6.0 FACILITY MANAGEMENT 180 This process deals with the management of bui l d i n g s , grounds, b u i l d i n g services and equipment to support the operation of the h o s p i t a l . This may include some c a p i t a l equipment. 6.1 MAINTENANCE Deals with the preventative and on-going maintenance of the bui l d i n g s , grounds, b u i l d i n g service equipment and other c a p i t a l equipment. 6.2 OPERATIONS Deals with c o n t r o l l i n g and monitoring of the b u i l d i n g service equipment. 7.0 PERSONNEL ADMINISTRATION This process deals with the r e q u i s i t i o n and recruitment of s t a f f , monitoring of s k i l l s and p r i v i l e g e s , p o s i t i o n control and general personnel management, including p a y r o l l r e l a t e d functions. 7.1 APPLICANT TRACKING Deals with the request f o r recruitment and the tracking of applicants versus the request, through to f i l l i n g the p o s i t i o n . 7.2 SKILLS, PRIVILEGES CONTROL Deals with the recording of s k i l l s , award recognition, q u a l i f i c a t i o n s and p r i v i l e g e s of s t a f f (employees, a u x i l i a r y members, board members, volunteers, medical s t a f f ) i n order to ensure up-to-date and accurate records. 7.3 PERSONNEL MANAGEMENT Deals with the recording of personnel data including demographics, ben e f i t entitlement and u t i l i z a t i o n (e.g. sick or vacation use), union a f f i l i a t i o n , s e n i o r i t y , performance evaluations and other labour r e l a t i o n s matters. 7.4 POSITION CONTROL 181 Deals with the monitoring of authorized posi t i o n s against authorized incumbents, including c l a s s i f i c a t i o n s , contract l e v e l , F . T . E . value, status. 7.5 TIME REPORTING AND ANALYSIS Deals with the c o l l e c t i o n and entry of time for hours worked, paid or unpaid, and producing for a given period a pay cheque and/or labour d i s t r i b u t i o n a n a l y s i s . 8.0 STAFFING MANAGEMENT The process deals with the preparation of s t a f f i n g schedules or rotations for approved p o s i t i o n s , assignment of ad d i t i o n a l s t a f f to account for workload or r e l i e f s i t u a t i o n s and the recording of time, based on these schedules and assignments, in order to produce a pay cheque. 8.1 STAFF SCHEDULING Deals with the creation and maintenance of s t a f f schedules or rotations for approved posi t i o n s within contract guidelines to meet baseline coverage. 8.2 WORKLOAD MANAGEMENT Deals with providing s t a f f with s k i l l requirements to meet unexpected workload changes. 9.0 RESEARCH AND PLANNING Deals with the documentation and ana l y s i s subsequent to research into alternate procedures, equipment and organization. Inherent in the process i s the a b i l i t y to extract and analyze information from patient, personnel, and resource ( f a c i l i t y and f i n a n c i a l ) data bases. Modelling and forecasting may be components. 10.0 PUBLIC RELATIONS MANAGEMENT Deals with the documentation and extraction of data r e l a t e d to correspondence, complaints, acknowledgements and fund-raising. 11.0 MESSAGE MANAGEMENT 182 Deals with the process of handling messages (not order entry related) which would include the switching, tracking and l o c a t i n g within the h o s p i t a l . In many instances t h i s i s presently covered by telephone, paging systems, interdepartmental memos and messengers. 12.0 FINANCIAL SERVICES This process deals with the c o l l e c t i n g , recording and disbursing of funds for day-to-day operational functions of the h o s p i t a l . 12.1 BUDGET AND FINANCIAL -CONTROL Deals with the establishment of budgets (hospital and departmental), and the comparison of actual costs/revenues with forecasted costs/ revenues. 12.2 ACCOUNTS PAYABLE MANAGEMENT Deals with the paying f o r supplies, services and equipment received. 12.3 ACCOUNTS RECEIVABLE MANAGEMENT Deals with the c o l l e c t i o n and re c e i p t of funds f o r services rendered by the h o s p i t a l . 12.4 RESOURCE COSTING Deals with the analysis of a l l costs involved i n providing a service. 12.5 STATISTICS MANAGEMENT Deals with the c o l l e c t i o n , a n a l y s i s , and d i s t r i b u t i o n of data r e l a t i n g to costs, revenue and performance (present or past) of services, departments or the h o s p i t a l as a whole. 183 APPENDIX 5 CHILLIWACK GENERAL HOSPITAL SUMMARY OF PROBLEMS I D E N T I F I E D THROUGH HSP STUDY OCTOBER, 1984 A d m i n i s t r a t i o n I n a b i l i t y t o manage and f o r e c a s t f i n a n c i a l , p h y s i c a l a n d human r e s o u r c e s due t o p o o r u t i l i z a t i o n m e a s u r e m e n t t o o l s . D i f f i c u l t y a c c e s s i n g and f o r e c a s t i n g c o s t c o m p a r a t i v e s t a t -i s t i c a l d a t a f r o m a l l ' d e p a r t m e n t s due t o m a n u a l e r r o r p r o n e f o r m a t o f r e p o r t i n g . R e p o r t s a r e n o t t i m e l y a n d t h e r e f o r e n o t r e l i a b l e a n d o f t e n n o t u s e f u l ( s t a t i s t i c a l a n d f i n a n c i a l ) . D i f f i c u l t y a c c e s s i n g a n d a n a l y z i n g t i m e l y i n f o r m a t i o n f r o m e x t e r n a l s o u r c e s ( e . g . FCRHD, m u n i c i p a l i t y , n a t i o n a l , T e l i -d on I n f o ) i n f l u e n c i n g d e c i s i o n - m a k i n g i n t h e o p e r a t i o n o f t h e h o s p i t a l . I n a b i l i t y t o c o s t / f o r e c a s t d i f f e r e n t s c e n a r i o s i n o r d e r t o make d e c i s i o n s i n r e g a r d t o h o s p i t a l o p e r a t i o n s . T h i s i s a c c e n t u a t e d by l a t e and i n a d e q u a t e b u d g e t i n f o by t h e M.O.H. D i f f i c u l t y a c c e s s i n g and a n a l y z i n g u p - t o - d a t e h o s p i t a l - w i d e i n v e n t o r i e s due t o l a c k o f c o n t r o l o f d e c e n t r a l i z e d m a t e r i a l s management s y s t e m . C u r r e n t s t a t u s o f e q u i p m e n t l i s t a n d f u n d i n g o f same i s h a r d t o t r a c k ( i . e . o u t s t a n d i n g PO commitment s t a t u s ) . E x c e s s i v e v o l u m e , d e t a i l and r e p e t i t i o n o f r e q u i r e d r e p o r t i n g i n f o r m a t i o n t o e x t e r n a l a g e n c i e s i s t i m e c o n s u m i n g a n d f r u s -t r a t i n g due t o l a c k o f o p p o r t u n i t y t o p r e s e n t i t i n any o t h e r way. D i f f i c u l t y i n m a i n t a i n i n g a n d a c c e s s i n g m e d i c a l s t a f f a d m i n -i s t r a t i v e m a t t e r s s u c h a s p r i v i l e g e s , p o l i c i e s , p r o c e d u r e s , r u l e s a n d r e g u l a t i o n s . D i f f i c u l t y i n m a i n t a i n i n g a n d a c c e s s i n g h o s p i t a l - w i d e p o l i c i e s a n d p r o c e d u r e s . E x c e s s i v e v o l u m e o f c l e r i c a l w o r k ; s c h e d u l i n g o f m e e t i n g s , s p a c e , e q u i p m e n t , e t c . i s t i m e c o n s u m i n g . 184 Current method of message management i s slow and e r r o r - p r o n e . Admitting/Switchboard R e p e t i t i o u s r e c o r d i n g of p a t i e n t demographic data on repeat v i s i t s . When emergency v i s i t t r a n s f e r r e d to i n p a t i e n t or day ca r e , e t c . d u p l i c a t i o n of r e c o r d i n g of p a t i e n t demographic data takes p l a c e . Incomplete e s s e n t i a l i n f o r m a t i o n f o r a l l c a t e g o r i e s of p a t i e n t s due to p h y s i c a l l a y o u t and a c c e s s i b i l i t y to p a t i e n t . I n c o r r e c t data and sometimes i n c o r r e c t l y f i l e d p a t i e n t index cards; r e q u i r e s need to v e r i f y or repeat i n f o r m a t i o n a l r e a d y recorded. I n i t i a l l y recorded i n c o r r e c t data gets perpetuated to many departments. Much time spent on a d v i s i n g other departments of e r r o r s , changes and updated i n f o r m a t i o n and u n c e r t a i n t y remains t h a t a l l departments a f f e c t e d have been n o t i f i e d and t h a t they have a l l updated t h e i r l i s t s . I n c o r r e c t ADT i n f o r m a t i o n and census data from ward r e p o r t s causes f r u s t r a t i o n , wasted time, e t c . to Switchboard, A d m i t t i n g , Business O f f i c e and Hea l t h Records. Uncoordinated d i s c h a r g e procedure causes l o s s e s i n c o l l e c t -a b l e p a t i e n t revenue and time-consuming e f f o r t on p a r t of v e r i f i c a t i o n c l e r k . Volume and mechanics of message management through switch-board. C e n t r a l S t e r i l e Department No c o n t r o l over d i s t r i b u t i o n of stock c r e a t i n g s p o r a d i c demands on department. Not n o t i f i e d of supply shortage by Supply & D i s t r i b u t i o n and Li n e n Departments c r e a t i n g workload.. s c h e d u l i n g problems. Lack of communication between wo r k - r e l a t e d departments causing s c h e d u l i n g problems. 185 Community R e s o u r c e s G e t t i n g u p - t o - d a t e d i s c h a r g e / t r a n s f e r i n f o r m a t i o n f o r I n f o r m a t i o n B o o t h o r TV R e n t a l s . A c c e s s t o s t a t i s t i c a l i n f o r m a t i o n f o r a l l a r e a s o f S e r v i c e L e a g u e , A u x i l i a r y a n d J u n i o r V o l u n t e e r s . F i n a n c e / B u s i n e s s O f f i c e L a c k o f i n t e g r a t e d s y s t e m w i t h i n B u s i n e s s O f f i c e c a u s e s d u p l i c a t i o n o f p a p e r w o r k ( e . g . when p a t i e n t d e m o g r a p h i c i n f o r m a t i o n c h a n g e s ) . I n a c c u r a t e d o c u m e n t a t i o n f r o m A d m i t t i n g / S w i t c h b o a r d b e c a u s e o f m i s i n f o r m a t i o n , c l e r i c a l e r r o r s , o r l a c k o f i n f o r m a t i o n l e a d s t o d i f f i c u l t y i n p r o c e s s i n g r e c o r d . D e l a y s i n b i l l i n g and p a y m e n t s due b e c a u s e o f t h e s e e r r o r s . Time c o n s u m i n g a nd e r r o r - p r o n e m a n u a l s y s t e m i n A c c o u n t s R e c e i v a b l e . F o o d S e r v i c e s C o m m u n i c a t i o n s y s t e m i s i n a d e q u a t e , i m p a c t i n g on a l l o t h e r p r o b l e m s . P r o d u c t i o n s h e e t s : i n c o m p l e t e and i n a c c u r a t e i n f o r m a t i o n f r o m w a r d s ; c o m p l e x i t y o f i n f o r m a t i o n ; t o o t i m e c o n s u m i n g t o c o m p i l e ; e r r o r s l e a d t o c o s t l y f o o d w a s t a g e and s t a f f t i m e . D i e t l i s t s : i n c o m p l e t e and i n a c c u r a t e i n f o r m a t i o n f r o m w a r d s ; c h a n g e s n o t c o m m u n i c a t e d i n a t i m e l y f a s h i o n , e.g. d i e t c h a n g e s , D/T; a d m i s s i o n s ; n o u r i s h m e n t e r r o r s . R e c o r d k e e p i n g i s n o t c e n t r a l i z e d c a u s i n g r e c o r d d u p l i c a t i o n , e r r o r s , i n a c c e s s i b i l i t y , s t a f f t i m e w a s t a g e , s p a c e c o n s t r a i n t s . Menus: l a s t m i n u t e c h a n g e s c a u s e r e w r i t i n g o f t h e r a p e u t i c and i d e n t i f i e r menus ( e i t h e r t r u e c h a n g e s o r human e r r o r ) . T r a n s c r i b i n g e r r o r s a n d t i m e i n v o l v e d i n p r e p a r i n g menus. P o o r i n v e n t o r y c o n t r o l s y s t e m : v o l u m i n o u s p a p e r w o r k , human e r r o r / " e y e b a l l " o r d e r i n g , d i f f i c u l t y i n g e t t i n g u p - t o - d a t e v e n d o r p r i c e s . f o r g o o d s . 186 I n - h o u s e c a t e r i n g : u n p r e d i c t a b i l i t y o f demand, c h a n g e s n o t c o m m u n i c a t e d i n t i m e l y f a s h i o n . L o s s o f p o t e n t i a l r e v e n u e i n c a f e t e r i a . H e a l t h R e c o r d s The c u r r e n t m a n u a l a d m i t t i n g p r o c e s s p e r p e t u a t e s p a t i e n t i n f o r m a t i o n e r r o r s and c a u s e s e x c e s s i v e t i m e t o be s p e n t by H e a l t h R e c o r d s s t a f f i n i d e n t i f y i n g and c o r r e c t i n g t h e s e e r r o r s . I n a c c u r a t e i n f o r m a t i o n on u n i t r e p o r t s c a u s e s e x c e s s i v e s t a f f t i m e i n c o r r e c t i n g t h e s e e r r o r s a n d d e l a y s c e n s u s d i s t r i b u t i o n . C u r r e n t m a s t e r p a t i e n t i n d e x f i l e s y s t e m r e s u l t s i n c l e r i c a l e r r o r s s u c h a s m i s f i l i n g w h i c h c a u s e s s t a f f t o s p e n d e x c e s s -i v e t i m e l o c a t i n g c h a r t and i n d e x c a r d . The c u r r e n t n o n - i n t e g r a t e d p a t i e n t e n c o u n t e r s y s t e m c r e a t e s m a j o r d i f f i c u l t i e s i n o b t a i n i n g c o m p l e t e p a t i e n t r e c o r d s . H o u s e k e e p i n g L a c k o f n o t i f i c a t i o n o f p a t i e n t d i s c h a r g e s / t r a n s f e r s . L a b o r a t o r y D e l a y s i n o r d e r e n t r y a n d r e s u l t s r e p o r t i n g due t o awkward p a p e r f l o w . E x c e s s i v e t i m e s p e n t on m a n u a l l y m o n i t o r i n g q u a l i t y c o n t r o l p r o c e d u r e s . Human e r r o r i n O.E./R.R. s u c h a s t r a n s c r i p t i o n , l o s t r e q u i s i t i o n " r e p o r t s a n d i n - t r a n s i t l o s s e s . I n c o m p l e t e o r d e r s a n d m i s - s c h e d u l i n g o f l a b t e s t s . T e c h n o l o g i s t s s p e n d t o o much t i m e on r e s u l t s t r a n s c r i p t i o n and v e r b a l t r a n s m i t t a l o f r e s u l t s . D i f f i c u l t y i n l o c a t i n g i n p a t i e n t s due t o t r a n s f e r o f i n c o m -p l e t e d a t a . 187 L a u n d r y / L i n e n Time r e q u i r e d by d e p a r t m e n t h e a d t o c o m p i l e o p e r a t i n g s t a t i s t i c s . L o n g Term C a r e L a c k o f i n t e g r a t e d i n f o r m a t i o n f o r e a c h r e s i d e n t . L a c k o f a c c e s s i b i l i t y o f i n f o r m a t i o n f o r e a c h r e s i d e n t . L a c k o f c o n c i s e c h r o n o l o g i c a l summary o f h i s t o r y o f e a c h r e s i d e n t . M e d i c a l S t a f f D i a g n o s t i c r e s u l t s r e p o r t i n g i s t o o s l o w ; f o r m a t i s n o t e a s i l y r e a d a b l e ; f o r m a t i s n o t c u m u l a t i v e ; a c c e s s i b i l i t y i s d i f f i c u l t o u t s i d e o f n o r m a l h o u r s due t o d i s t r i b u t i o n e r r o r s and g e o g r a p h i c l a y o u t o f h o s p i t a l . N o n - i n t e g r a t e d p a t i e n t r e c o r d s c a u s e s i n c o m p l e t e p a t i e n t a s s e s s m e n t . L a c k o f t i m e l y i n p a t i e n t l i s t i n g s . C l i n i c a l r e p o r t i n g / r e f e r e n c e r e t r i e v a l i s d i f f i c u l t t o a c c e s s , n o t c u r r e n t o r n o t know i f c u r r e n t . L a c k o f d i a g n o s t i c d e p a r t m e n t ( s ) w o r k l i s t s u c h as p a t i e n t s c h e d u l i n g . E x i s t i n g m a n u a l message management s y s t e m i s e r r o r - p r o n e and s o m e t i m e s s l o w . N u r s i n g A d m i n i s t r a t i o n P r e s e n t m a n u a l and u n c o o r d i n a t e d i n f o r m a t i o n h a n d l i n g s y s t e m r e s u l t s i n h a m p ered d e c i s i o n - m a k i n g . R e q u i r e d i n f o r m a t i o n i s a b s e n t , i n c o m p l e t e , i n a c c u r a t e , i n a c c e s s i b l e and s l o w . T h i s i s b o t h i n t r a - a n d i n t e r - d e p a r t m e n t a l . T h i s r e s u l t s i n c o s t l y d e c i s i o n s and p o o r r e l a t i o n s h i p s w i t h o t h e r d e p a r t -m e n t s r e g a r d i n g s u c h i n f o r m a t i o n , a s c o n d i t i o n r e p o r t s , c e n s u s and s t a t i s t i c a l i n f o r m a t i o n . R e p e t i t i v e n a t u r e o f r e p o r t i n g m e c h a n i s m i s t i m e c o n s u m i n g an d e r r o r - p r o n e . 188 P r e s e n t m a n u a l s t a f f i n g s y s t e m r e s u l t s i n i n a c c u r a t e s c h e d u l e s ; c h a n g e s n o t c o m m u n i c a t e d b e t w e e n d e p a r t m e n t s ; l a c k o f s t a n d a r d f o r m a t f o r r e q u e s t s f o r c h a n g e s . L a c k o f a c c e s s t o w o r d p r o c e s s o r r e s u l t s i n s l o w n e s s o f p r o d u c i n g t y p e d m a t e r i a l s ( i n c l u d i n g p o l i c i e s a nd c h a r t i n g p r o c e d u r e s , e t c . ) and c i r c u l a t i n g u p d a t e d i n f o r m a t i o n . L a c k o f i n t e g r a t e d i n v e n t o r y s y s t e m . I n a b i l i t y t o h a v e i m m e d i a t e a c c e s s t o a w o r k l o a d i n d e x r e s u l t i n g i n i n a p p r o p r i a t e d e c i s i o n - m a k i n g a t u n i t , c a r e c o o r d i n a t o r a n d a d m i n i s t r a t i v e l e v e l . L a c k o f c o o r d i n a t e d h o s p i t a l - w i d e i n s e r v i c e e d u c a t i o n s y s t e m s s u c h a s : l i b r a r y r e s o u r c e s a r e l i m i t e d ; m a n u a l m o n i t o r i n g o f s t a f f u t i l i z a t i o n o f s e r v i c e s i s t i m e c o n s u m i n g ; u n a b l e t o a s s e s s l e a r n i n g n e e d s ; m e c h a n i s m f o r u n i t - b a s e d p r o g r a m s and r a p i d f e e d b a c k ; no c e n t r a l i z e d - a c c e s s i b l e s t o r a g e . ; l a c k o f s e l f - p a c e d l e a r n i n g o p p o r t u n i t i e s . N u r s i n g - G e n e r a l P r e s e n t m a n u a l s y s t e m o f p r o c e s s i n g and r e t r i e v i n g l a b o r -a t o r y o r d e r s i s t i m e c o n s u m i n g , e r r o r p r o n e and r e p e t i t i o u s . R e p o r t s a r e o f t e n d i f f i c u l t t o a c c e s s , n o n - c o m p a r a t i v e and n o t i m m e d i a t e l y c u m u l a t i v e . P r e s e n t m a n u a l s y s t e m o f p r o c e s s i n g d i e t a r y o r d e r s i s r e p e t i t i v e , e r r o r p r o n e and t i m e c o n s u m i n g . D e m o g r a p h i c , b i o g r a p h i c and c l i n i c a l i n f o r m a t i o n n e e d e d t o i n i t i a t e c a r e i s o f t e n d i f f i c u l t t o a c c e s s , n o t t i m e l y and o f t e n i n c o m p l e t e . P r e s e n t d r u g i n f o r m a t i o n i s d i f f i c u l t t o o b t a i n ( h o u r s o f s e r v i c e ) , s l o w t o a c c e s s and t i m e c o n s u m i n g . P r e s e n t t i m e k e e p i n g s y s t e m i s t i m e c o n s u m i n g and e r r o r p r o n e . P r e s e n t s y s t e m o f s c h e d u l i n g r e l i e f s t a f f i s t i m e c o n s u m i n g , e r r o r p r o n e , d i f f i c u l t t o m a i n t a i n i n c l u d i n g s u c h f a c t o r s a s : w h e r e l a s t w o r k e d , when, how l o n g , q u a l i f i c a t i o n s , p r e f e r e n c e s , r e c o r d i n g o f h o u r s w o r k e d and a v a i l a b i l i t y . P r e s e n t l i b r a r y s y s t e m i s i n a d e q u a t e i n c l u d i n g no a c c e s s t o l i s t o f e d u c a t i o n a l m a t e r i a l s , b o o k s , p e r i o d i c a l s , a u d i o -v i s u a l p r o g r a m s , l o c a t i o n o f e q u i p m e n t and r e f e r e n c e s . 189 I l l - d e f i n e d d e c e n t r a l i z e d , s t o c k d i s t r i b u t i o n s y s t e m c a u s e s c o n f u s i o n a n d t i m e w a s t a g e . P r e s e n t s y s t e m o f c o m p i l i n g s t a t i s t i c s i s t i m e c o n s u m i n g . P r e s e n t s y s t e m o f t r a n s m i t t i n g ADT i n f o r m a t i o n i n t e r d e p a r t -m e n t a l l y and o u t s i d e i s s l o w and t i m e c o n s u m i n g . P r e s e n t m a n u a l s y s t e m o f c a r e p l a n p r e p a r a t i o n and u p d a t i n g i s t i m e c o n s u m i n g , s l o w and o f t e n o m i t t e d . R e p e t i t i o u s i n f o r m a t i o n d i s t r i b u t i o n i s t i m e c o n s u m i n g . i n c l u d i n g c l i n i c a l s u m m a r i e s , d i s c h a r g e , t r a n s f e r , b a s i c d e m o g r a p h i c i n f o r m a t i o n and d a i l y r e p o r t s . D i f f i c u l t t o a c c e s s p o l i c i e s a nd p r o c e d u r e s . N u r s i n g - S p e c i a l P r e s e n t m a n u a l s y s t e m f o r p r o c e s s i n g and r e t r i e v i n g o f l a b o r a t o r y o r d e r s i s t i m e c o n s u m i n g , e r r o r p r o n e and r e p e t i t i o u s . R e p o r t s a r e o f t e n d i f f i c u l t t o p r o c e s s , n o n - c o m p a r a t i v e and n o t i m m e d i a t e l y . . c u m u l a t i v e . P r e s e n t m a n u a l s y s t e m f o r p r o c e s s i n g d i e t a r y o r d e r s i s r e p e t i t i o u s , e r r o r - p r o n e and t i m e c o n s u m i n g . I n f o r m a t i o n n e e d e d t o i n i t i a t e c a r e i s o f t e n d i f f i c u l t t o a c c e s s , n o t t i m e l y and o f t e n i n c o m p l e t e , l o s t o r i n c o r r e c t . P r e s e n t d r u g i n f o r m a t i o n i s d i f f i c u l t t o o b t a i n ( h o u r s o f s e r v i c e ) , s l o w t o a c c e s s and t i m e c o n s u m i n g . No a c c e s s t o d r u g i n v e n t o r y w i t h c r o s s - r e f e r e n c e s . P r e s e n t t i m e k e e p i n g s y s t e m i s t i m e c o n s u m i n g and e r r o r - p r o n e . P r e s e n t s y s t e m o f s c h e d u l i n g r e l i e f s t a f f i s t i m e c o n s u m i n g , e r r o r - p r o n e and d i f f i c u l t t o m a i n t a i n i n c l u d i n g w h e r e l a s t w o r k e d , when, how l o n g , q u a l i f i c a t i o n s , p r e f e r e n c e s , r e c o r d -i n g o f h o u r s w o r k e d and a v a i l a b i l i t y . P r e s e n t l i b r a r y s y s t e m i s i n a d e q u a t e i n c l u d i n g : no a c c e s s t o l i s t o f e d u c a t i o n a l m a t e r i a l s , b o o k s , p e r i o d i c a l s , a u d i o -v i s u a l m a t e r i a l s , l o c a t i o n o f e q u i p m e n t and r e f e r e n c e s . I l l - d e f i n e d d e c e n t r a l i z e d s t o c k d i s t r i b u t i o n s y s t e m c a u s e s c o n f u s i o n and t i m e w a s t a g e . P r e s e n t m a n u a l s y s t e m o f r e g i s t e r i n g p a t i e n t i n f o r m a t i o n i n OR, OBS and E m e r g e n c y i s t i m e c o n s u m i n g . 190 P r e s e n t s y s t e m o f c o m p i l i n g s t a t i s t i c s i n OR, OBS, ICU and E m e r g e n c y i s t i m e c o n s u m i n g . P r e s e n t s y s t e m o f t r a n s m i t t i n g ADT i n f o r m a t i o n i n t e r d e p a r t -m e n t a l l y and o u t s i d e i s s l o w and t i m e c o n s u m i n g . P r e s e n t s y s t e m o f b o o k i n g and s c h e d u l i n g OR, E m e r g e n c y and o t h e r p r o c e d u r e s i s s l o w , t i m e c o n s u m i n g , f r u s t r a t i n g a nd i n c o r r e c t . P r e s e n t m a n u a l s y s t e m o f c a r e p l a n p r e p a r a t i o n and u p d a t i n g i s t i m e c o n s u m i n g , s l o w and o f t e n o m i t t e d . P a s t o r a l C a r e I n c o m p l e t e i n f o r m a t i o n s u c h as r e l i g i o u s d e n o m i n a t i o n , on c e n s u s l i s t . D e l a y i n r e c e i v i n g c e n s u s l i s t . No n o t i c e o f d i s c h a r g e s / t r a n s f e r s . C l e r i c a l s t a f f h a v e no a c c e s s t o w o r d p r o c e s s o r . P a t h o l o g y I n c o m p l e t e r e q u i s i t i o n s s u c h a s d a t e o f b i r t h and c a s e h i s t o r y ( i n p a t i e n t , o u t p a t i e n t ) . I n t e r n a l c r o s s - r e f e r e n c i n g i d e n t i f i c a t i o n . A m b i g u i t i e s on i n d e x c a r d s f o r new and e x i s t i n g p a t i e n t s . Time c o n s u m i n g r e t r i e v a l o f w o r k l o a d s t a t u s i n c l u d i n g : i n c o m p l e t e and w h e r e ; c o m p l e t e and w h e r e . P e r s o n n e l / P a y r o l l I n c o m p l e t e , o l d and f r e q u e n t l y i n a c c e s s i b l e p e r s o n n e l i n f o r m a t i o n . Known and unknown e r r o r s i n t i m e k e e p i n g . Known and unknown e r r o r s i n b e n e f i t s a d m i n i s t r a t i o n . R e t r i e v a l a nd a n a l y s i s o f i n f o r m a t i o n f r o m g e n e r a l f i l e i s s l o w , e r r o r — p r o n e , i n a c c e s s i b l e a nd d i f f i c u l t t o u p d a t e . E m p l o y e e t e r m i n a t i o n , f i l e s a r e i n a d e q u a t e l y p u r g e d and o c c u p y t o o much s p a c e . 191 P h a r m a c y S l o w t r a n s m i t t a l o f d o c t o r s ' o r d e r s . Too much t i m e s p e n t p r e p a r i n g p u r c h a s e o r d e r s and p o s t i n g i n v o i c e s t o P u r c h a s i n g . Too much demand on e x i s t i n g c o m p u t e r t e r m i n a l . L a c k o f c o n s e n s u s f o r p u r c h a s i n g o r d e r f o r m a t . P h y s i c a l M e d i c i n e M a n u a l s y s t e m o f r e t r i e v i n g c l i n i c a l and s t a t i s t i c a l i n f o r -m a t i o n i s h i n d e r i n g t h e e f f e c t i v e n e s s o f t h e d e p a r t m e n t i n c l u d i n g m i s s i n g p o t e n t i a l r e f e r r a l s ; m a n a g i n g w o r k l o a d v o l u m e s and w o r k l o a d m e a s u r e m e n t s ; m o n i t o r i n g q u a l i t y a s s u r -a n c e ; u n a b l e t o do r e s o u r c e c o s t i n g . Time c o n s u m i n g a nd u n o r g a n i z e d i n v e n t o r y c o n t r o l s y s t e m . M a n u a l h a n d l i n g o f r e q u e s t s f r o m o u t s i d e a g e n c i e s / i n - h o u s e r e q u e s t s i s t i m e c o n s u m i n g a nd e r r o r - p r o n e . C u r r e n t m e t h o d o f e n t e r i n g p a t i e n t d o c u m e n t a t i o n i s r e p e t i t i o u s , t i m e c o n s u m i n g a nd e r r o r - p r o n e . D e p a r t m e n t n o t n o t i f i e d o f p a t i e n t ADT s t a t u s . D e l a y i n t y p i n g r e p o r t s . P l a n t a n d M a i n t e n a n c e Time i n v o l v e d i n c l e r i c a l f u n c t i o n s . L i m i t e d p r e v e n t i v e m a i n t e n a n c e p r o g r a m . No c e n t r a l i z e d m e t h o d o f t r a c k i n g i n v e n t o r y i n f o r m a t i o n and h i s t o r i c a l m a i n t e n a n c e o f b u i l d i n g , b u i l d i n g s e r v i c e a n d o t h e r c a p i t a l e q u i p m e n t . . I n c o m p l e t e r e p a i r r e q u i s i t i o n f o r m s and d e l a y s i n r e c e i v i n g many o f them. N o t n o t i f i e d o f a l l n e w l y p u r c h a s e d e q u i p m e n t . 192 Purchasing/Supply & D i s t r i b u t i o n Inventory a n a l y s i s : month-end p r i c i n g of goods i s s u e d versus i n v e n t o r y l e v e l s c r e a t e s month-end c l e r i c a l l o g jam. I n a b i l i t y to c o r r e l a t e p r i c e i n c r e a s e s w i t h i n v e n t o r y items causes i n c o r r e c t r e p o r t i n g to business o f f i c e : and i n c o r r e c t f i n a n c i a l b a l a n c i n g . I n a b i l i t y to p r e d i c t f l u c t u a t i o n s i n workloads through h o s p i t a l . Purchase order r e q u i s i t i o n s i n a c c u r a t e and incomplete. Radiology Inaccurate and incomplete p a t i e n t demographic and c l i n i c a l i n f o r m a t i o n from other departments i n h o s p i t a l and other o u t s i d e sources causes e r r o r s and d u p l i c a t i o n i n Radiology f i l e s . Manual t r a n s p o r t a t i o n of r e s u l t s r e p o r t i n g i s too slow c a u s i n g too much c l e r i c a l and t e c h n i c a l time being spent on f i n d i n g and communicating the r e s u l t s . Untimely and e r r a t i c nature of bookings causes i n e f f i c i e n t use of c l e r i c a l and t e c h n i c a l s t a f f time. Delay i n r e c e i p t of orders from n u r s i n g u n i t s causes d e l a y i n procedures. Too much time i s spent i n c o m p i l i n g and m a i n t a i n i n g the p a t i e n t index c a r d f i l e . Too much time spent c o m p i l i n g d a i l y s t a t i s t i c a l data. Inadequate n o t i f i c a t i o n of p a t i e n t ADT s t a t u s . R e p e t i t i o u s r e c o r d i n g of p a t i e n t data. D i f f i c u l t y i n l o c a t i n g f i l m s out of department. D i f f i c u l t y o b t a i n i n g and c o r r e l a t i n g o u t s i d e r e s u l t s with in-house. D i f f i c u l t y r e t r i e v i n g h i s t o r i c a l / c l i n i c a l i n f o r m a t i o n f o r q u a l i t y assurance. . . . . 193 S o c i a l Work S e r v i c e s - I n s u f f i c i e n t a nd i n c o r r e c t s o c i a l a nd d e m o g r a p h i c i n f o r m a -t i o n on p a t i e n t c h a r t . - D e l a y and i n a c c e s s i b i l i t y o f p a t i e n t d a t a p a r t i c u l a r l y e m e r g e n c y p a t i e n t s . - R e t r i e v i n g p a t i e n t i n f o r m a t i o n f o r r e s e a r c h / p r o g r a m e v a l u a -t i o n t i m e c o n s u m i n g and d i f f i c u l t . - L a c k o f n o t i f i c a t i o n o f p a t i e n t ADT s t a t u s . - R e p e t i t i o u s r e c o r d i n g o f p a t i e n t i n f o r m a t i o n . - No a c c e s s t o w o r d p r o c e s s i n g . 194 APPENDIX .6 CHILLIWACK GENERAL HOSPITAL SUMMARY OF BENEFITS (TANGIBLE AND INTANGIBLE) I D E N T I F I E D THROUGH HSP STUDY OCTOBER, 1984 A d m i n i s t r a t i o n Time s a v i n g i n a s s e m b l i n g i n f o r m a t i o n f o r s e n i o r management r e v i e w . I m p r o v e d a b i l i t y t o m o n i t o r t h e i n t e r n a l a n d e x t e r n a l e n v i r -o nments a nd p l a n / m a n a g e s t r a t e g i c a l l y . P o s s i b l e a d m i n i s t r a t i v e s t a f f s a v i n g s r e s u l t i n g i n c o s t -a v o i d a n c e . B e t t e r / i m p r o v e d a b i l i t y t o a l l o c a t e f i n a n c i a l , p h y s i c a l a n d human r e s o u r c e s c o u l d r e s u l t i n i m p r o v e d p r o d u c t i v i t y a n d s a v i n g s i n many d e p a r t m e n t s . I m p r o v e d a b i l i t y t o e v a l u a t e p r o g r a m e f f e c t i v e n e s s ( i n c l u d i n p r o s p e c t i v e l y ) . F a s t e r a n d more a c c u r a t e d e c i s i o n - m a k i n g and c o m m u n i c a t i o n . A d m i t t i n g / S w i t c h b o a r d I m p r o v e d a n d i m m e d i a t e a c c e s s t o p a t i e n t d a t a w i l l e n a b l e t i m e s a v i n g i n a d m i t t i n g p r o c e s s . G r e a t e r d e p e n d e n c e on p a t i e n t d a t a b e i n g a c c u r a t e and com-p l e t e i n a l l d e p a r t m e n t s . D e f i n i t e b u t h a r d t o d e f i n e t i m e s a v i n g s i n S w i t c h b o a r d , A d m i t t i n g , B u s i n e s s O f f i c e a n d H e a l t h R e c o r d s . G e n e r a l l y l e s s f r u s t r a t i o n i n d e p a r t m e n t a l f u n c t i o n s and p r o c e d u r e s . M essages, w i l l be h a n d l e d i n a more t i m e l y a n d a c c u r a t e f a s h i o n . 195 C e n t r a l S t e r i l e D e p a r t m e n t D e p a r t m e n t w i l l r u n more e f f i c i e n t l y , f o r e x a m p l e , i n c r e a s e d s t e r i l i z i n g l o a d s . C o u l d p l a n t o u s e a l t e r n a t e / s u b s t i t u t e s u p p l i e s t o c a r r y on w o r k l o a d . • Community R e s o u r c e s I n f o r m a t i o n B o o t h w i l l r u n more e f f i c i e n t l y . I m p r o v e d p u b l i c r e l a t i o n s . I m p r o v e d r e v e n u e . M ore a c c u r a t e a n d u p - t o - d a t e p r o f i l e o f Community R e s o u r c e s e n a b l i n g b e t t e r p l a n n i n g , v o l u n t e e r r e c r u i t m e n t a n d a d m i n -i s t r a t i v e r e p o r t i n g . F i n a n c e / B u s i n e s s O f f i c e I m p r o v e d t u r n - a r o u n d t i m e f r o m a g e n c i e s r e s p o n s i b l e f o r payment. Reduce r e j e c t i o n s by t h i r t y - f i v e p e r c e n t . S t a f f t i m e s a v i n g s . B e t t e r u s e o f p e r s o n n e l r e s o u r c e s f o r o r i e n t a t i o n , v a c a t i o n , s i c k r e l i e f a n d o t h e r s . F o o d S e r v i c e s Ward and d i e t a r y s t a f f t i m e s a v i n g s . L e s s raw and p r o c e s s e d f o o d w a s t a g e . B e t t e r u s e o f s t a f f t i m e . P a t i e n t s a t i s f a c t i o n ( g e t s r i g h t f o o d a t r i g h t t i m e i n r i g h t p l a c e ) . I m p r o v e d p a t i e n t s a f e t y . B e t t e r u s e o f s t a f f t i m e . S a v i n g s i n p a p e r and p r i n t i n g c o s t s ( i n v o l v e s s i x d o c u m e n t s ) . 196 C o u l d r e d u c e a n n u a l i n v e n t o r y . P r o d u c e more a c c u r a t e m e a l d a y c o s t s w h i c h may i m p a c t r e v e n u e s . S i m p l i f i e s p r i c i n g o f p r o c e s s e d f o o d s i n , f o r e x a m p l e , h o s p i t a l c a f e t e r i a . I n c r e a s e d r e v e n u e . H e a l t h R e c o r d s S t a f f t i m e s a v i n g s . C e n s u s p r e p a r e d a nd d i s t r i b u t e d more q u i c k l y . C o u l d p r o v i d e more t i m e l y a n d c o m p r e h e n s i v e p a t i e n t r e c o r d r e t r i e v a l r e s u l t i n g i n h i g h e r s t a n d a r d o f c a r e . H o u s e k e e p i n g More e f f i c i e n t u s e o f o n - d u t y s t a f f ( h o u s e k e e p i n g and n u r s i n g ) . W i l l c o n t r i b u t e t o some f u t u r e c o s t - a v o i d a n c e . I n c r e a s e d s t a f f m o r a l e . L a b o r a t o r y R e d u c t i o n i n LOS o f some p a t i e n t s . R e d u c t i o n i n some s u r g i c a l c a n c e l l a t i o n s . C o u l d s a v e t e c h n o l o g i s t t i m e and p r o v i d e f o r more r e l i a b l e q u a l i t y c o n t r o l and s y s t e m o f D e l t a c h e c k s . R e d u c t i o n i n number o f r e p e a t p r o c e d u r e s . R e d u c e s p a t i e n t a n x i e t y . B e t t e r u s e o f t e c h n o l o g i s t t i m e r e s u l t i n g i n r e d u c t i o n i n number o f t e s t s s e n t o u t a n d i n c r e a s e i n number o f t e s t s s e n t i n . L a u n d r y / L i n e n R e d u c t i o n o f t i m e r e q u i r e d p r o v i d i n g m u l t i p l e u s e c a n be made o f d a t a t o p r o d u c e s t a t i s t i c s . 197 L o n g Term C a r e P o t e n t i a l s t a f f t i m e s a v i n g s . B e t t e r u t i l i z a t i o n o f s t a f f . I m p r o v e d r e s i d e n t c a r e . P o t e n t i a l m o n e t a r y s a v i n g s i n c l u d i n g : l e s s WCB c l a i m s , i n c r e a s e d s a f e t y t o r e s i d e n t s and l e s s s t a f f o r i e n t a t i o n t i m e due t o s h o r t e r t i m e r e q u i r e d . M e d i c a l S t a f f C o u l d r e d u c e r e p e a t o r d e r s . C o u l d r e d u c e some p a t i e n t s ' LOS. I n c r e a s e s commitment t o e f f i c i e n t r e s o u r c e u t i l i z a t i o n . I m p r o v e s m o r a l e o f p a t i e n t s a n d p h y s i c i a n s . R e d u c e d r e s o u r c e u t i l i z a t i o n i n L a b o r a t o r y a n d R a d i o l o g y , f o r e x a m p l e . A s s u r e s c o n t i n u i t y o f p a t i e n t c a r e a n d i m p r o v e d p a t i e n t r e l a t i o n s . I m p r o v e s p a t i e n t c a r e and r e d u c e d p h y s i c i a n a n d h o s p i t a l c u l p a b i l i t y . N u r s i n g A d m i n i s t r a t i o n S t a f f t i m e s a v i n g s . D e c i s i o n - m a k i n g more a p p r o p r i a t e and t i m e l y . P o t e n t i a l c o s t s a v i n g s . I m p r o v e d i n t r a / i n t e r d e p a r t m e n t a l r e l a t i o n s h i p s . I m p r o v e d q u a l i t y a s s u r a n c e . I m p r o v e d p a t i e n t c a r e . G r e a t e r c o n s i s t e n c y o f n u r s i n g c a r e . S t r o n g e r i n t e r d i s c i p l i n a r y s e n s e a nd more a p p r e c i a t i o n o f t h e h o s p i t a l o r g a n i z a t i o n . 198 - More e f f e c t i v e and c o s t - e f f e c t i v e t e a c h i n g methods. - Pr o v i d e s a g r e a t e r v a r i e t y of programs. Nursing - General - S t a f f time savings. - Improved p a t i e n t s a t i s f a c t i o n . - Improved r e l a t i o n s h i p s between departments. - Improved p a t i e n t care and s a f e t y . - Improved s t a f f morale. - More up-to-date nurses r e s u l t i n g i n improved p a t i e n t c a r e , improved p a t i e n t t e a c h i n g and p o t e n t i a l monetary savings (through in-house t r a i n i n g ) . - Decreased f r u s t r a t i o n . - Improved q u a l i t y assurance. Nursing - S p e c i a l - S t a f f time s a v i n g s . - A b i l i t y to i n i t i a t e a p p r o p r i a t e care sooner. - Improve p a t i e n t - n u r s e - d o c t o r r e l a t i o n s h i p . - Improve p a t i e n t s a f e t y . - B e t t e r r e l a t i o n s h i p between n u r s i n g a d m i n i s t r a t i o n and s t a f f on n u r s i n g u n i t s . - B e t t e r o p p o r t u n i t y f o r s t a f f to p a r t i c i p a t e i n e d u c a t i o n a l programs. - Improved a c c e s s i b i l i t y to s t a f f and p a t i e n t t e a c h i n g t o o l s . - Improved use of res o u r c e s l e a d i n g to p o t e n t i a l monetary sav i n g s . 199 P a s t o r a l C a r e More t i m e c a n be s p e n t w i t h c l i e n t s . P r i o r i z e c l i e n t s n e e d i n g t o be s e e n . P r o v i d e t i m e l y l i s t s t o c o m m u n i t y c l e r g y t h e r e b y i m p r o v i n g m o r a l e , p u b l i c r e l a t i o n s and q u a l i t y o f c a r e . P a t h o l o g y S a v i n g s i n c l e r i c a l t i m e . B e t t e r u s e o f P a t h o l o g i s t t i m e . B e t t e r and more t i m e l y s t a t i s t i c a l i n f o r m a t i o n f o r i n t e r n a l p u r p o s e s , f o r e x a m p l e , a c c u r a t e d o c u m e n t a t i o n o f b i o p s i e s . P e r s o n n e l / P a y r o l l More a c c u r a t e and u p - t o - d a t e r e p o r t s . P r o b l e m s c o u l d be a c t e d on more q u i c k l y . B e t t e r u s e o f a l l s t a f f . C o s t s a v i n g s . G r e a t e r e m p l o y e e a w a r e n e s s o f b e n e f i t s . R e d u c t i o n o f e m p l o y e r l i a b i l i t y . P e r s o n n e l f u n c t i o n s c o u l d be r u n more e f f i c i e n t l y . S p a c e w i l l be s a v e d . P h a r m a c y I m p r o v e d p a t i e n t c a r e , e s p e c i a l l y w i t h t i m e l i n e s s o f m e d i c a t i o n d i s t r i b u t i o n . S t a f f t i m e s a v i n g s . F l e x i b i l i t y o f s c h e d u l i n g and w o r k l o a d s . I m p r o v e s p u r c h a s i n g p r o c e s s . 200 P h y s i c a l M e d i c i n e D e p a r t m e n t s t a f f t i m e s a v i n g s . B e t t e r u t i l i z a t i o n of. s t a f f . B e t t e r f o r e c a s t i n g o f p a t i e n t t r e a t m e n t p r i o r i t i e s and r e s o u r c e c o s t i n g . R e d u c t i o n i n p o t e n t i a l e r r o r s i n p r o c e s s i n g r e q u e s t s , f o r i n f o r m a t i o n . B e t t e r q u a l i t y a s s u r a n c e ( e s p e c i a l l y r e l a t e d t o c h a r t i n g ) . T i m e l i n e s s o f r e p o r t s i n c r e a s e s q u a l i t y o f c a r e . P l a n t a n d M a i n t e n a n c e S a v i n g s i n d e p a r t m e n t h e a d and s t a f f t i m e . More d e t a i l e d w o r k l i s t s a n d i m p r o v e d w o r k l o a d management. L e s s e q u i p m e n t b r e a k d o w n s . R e d u c t i o n i n e q u i p m e n t d o w n t i m e . D e c r e a s e d t u r n a r o u n d t i m e f o r r e p a i r s . I m p r o v e d c o o r d i n a t i o n w i t h P u r c h a s i n g d e p a r t m e n t . P u r c h a s i n g / S u p p l y & D i s t r i b u t i o n S t a f f t i m e s a v i n g s . Work u p - t o - d a t e . More a c c u r a t e f i n a n c i a l r e p o r t s . A l l o w D i r e c t o r o f S & D more t i m e t o n e g o t i a t e b e t t e r d e a l s w i t h v e n d o r s . S t r e a m l i n e p a p e r f l o w f r o m p u r c h a s e r e q u e s t t o a c c o u n t s p a y a b l e . . . . M i n i m i z e s t o c k - o u t s a nd d e l a y s i n p a t i e n t t r e a t m e n t . P o t e n t i a l s a v i n g s i n c o m m u n i c a t i o n - and t r a n s p o r t a t i o n c o s t s f o r u n e x p e c t e d r e q u e s t s . 201 - D e c r e a s e d t u r n - a r o u n d t i m e . - C o s t s a v i n g s i n r e t u r n i n g i n c o r r e c t g o o d s . R a d i o l o g y - S a v i n g s i n c l i n i c a l t i m e . - More t i m e l y b a s i s f o r d e c i s i o n - m a k i n g f o r p a t i e n t c a r e . - W i l l s a v e r e a d i n g r e p o r t s on t e l e p h o n e . - More e f f i c i e n t u s e o f t i m e . - More e x p e d i e n t o r d e r c o m m u n i c a t i o n p r o c e s s . - S a v i n g s i n f i l i n g t i m e . - More a c c u r a t e f i l i n g s y s t e m . <-• S a v i n g s i n c l e r i c a l t i m e . - B e t t e r u t i l i z a t i o n o f t e c h n o l o g i s t t i m e . - M i n i m i z a t i o n o f d e l a y s i n p a t i e n t p r o c e d u r e s a nd r e p e a t R a d i o l o g y p r o c e d u r e s . - I m p r o v e d q u a l i t y a s s u r a n c e o f i n - h o u s e r e s u l t s r e p o r t i n g . S o c i a l Work S e r v i c e s - Time s a v i n g s . - More e x p e d i e n t i n t e r v e n t i o n s . - More e f f i c i e n t a n d e f f e c t i v e u s e o f s o c i a l w o r k s k i l l s . CHILLIWACK GENERAL HOSPITAL REQUEST FOR PROPOSAL MAY, 1985 202 TABLE OF CONTENTS PAGE THESIS 1. I n t r o d u c t i o n 1 203 2. C h i l l i w a c k G e n e r a l H o s p i t a l P r o f i l e 4 206 2.1 C u r r e n t 4 206 2.2 F u t u r e 6 208 3. G e n e r a l R equirements o f t h i s R e quest f o r P r o p o s a l 9 211 3.1 C o n d i t i o n s 9 211 3.2 Canadian u s e r s l i s t 10 212 3.3 P r e s e n t a t i o n / s i t e v i s i t s t i m e t a b l e 10 212 4. T e c h n i c a l C a p a b i l i t i e s o f P r o p o s e d Systems 11 213 4.1 S o f t w a r e 11 213 4.2 Hardware 11 213 4.3 S e c u r i t y 11 213 4.4 D a t a I n t e g r i t y 11 213 5. C o s t s / B e n e f i t s / F i n a n c i n g 12 214 5.1 One-time systems c o s t s 13 214 5.2 Hardware 1 i n s t a l l a t i o n c o s t s 13 215 5.3 S o f t w a r e i m p l e m e n t a t i o n and i n s t a l l a t i o n c o s t s 13 215 5.4 T r a i n i n g c o s t s 13 215 5.5 C o n v e r s i o n c o s t s 13 215 5.6 On-going maintenance c o s t s 13 215 5.7 F u t u r e m o d i f i c a t i o n s c o s t s 14 216 5.8 P r o j e c t e d t a n g i b l e and i n t a n g i b l e b e n e f i t s 14 216 5.9 F i n a n c i n g o p t i o n s 14 216 6. I n s t a l l a t i o n / I m p l e m e n t a t i o n / L i v e T i m e t a b l e and R e s p o n s i b i l i t i e s 15 217 7. Pe r f o r m a n c e b o n d s / w a r r a n t i e s / c o n t r a c t 15 217 8. E v a l u a t i o n methodology and t i m e t a b l e 16 218 9. V i d e o D i s p l a y T e r m i n a l s and P r i n t e r s 16 218 10. D e t a i l e d Systems A p p l i c a t i o n s 18 220 203 1. INTRODUCTION Recognizing that h o s p i t a l s t a f f spend, as a conservative estimate, approximately 25% of t h e i r working time processing information and that the current manual methods of handling or processing information could be made more e f f e c t i v e and e f f i c i e n t through computerization, the Board of Trustees of the Chilliwack General Hospital approved formation of a Hospital Systems Planning Project Team i n the F a l l , 1984. The Project Team, comprised of senior management of the h o s p i t a l and representatives of the B r i t i s h Columbia Health Association used a modified version of a Business Systems Planning methodology and adapted i t to our h o s p i t a l environment. This methodology has f a c i l i t a t e d and fostered the concept of p a r t i c i p a t i v e planning throughout the organization and the Project Team f e e l s i t accomplished i t s mandate for t h i s stage of planning. P a r t i c i p a t i n g s t a f f have been very cooperative and candid. Their input i s i n t e g r a l to the success of t h i s study and, indeed, to the ultimate success of proposed solutions through computerization. Through a general s t a f f o r i e n t a t i o n meeting, questionnaires and interviews, the Project Team was able to gain an o v e r a l l understanding of the degree of involvement of various departments i n information processing a c t i v i t i e s . More importantly, major problems and benefits (tangible and intangible) were i d e n t i f i e d , documented and analyzed. Following t h i s , a prospective evaluation, using the major components of cost-benefit analysis combined with a structured p r i o r i t y ranking approach, was undertaken. This enabled the Project Team to rank p r i o r i t i e s according to f i n a n c i a l b e n e f i t s , intangible b e n e f i t s , technical importance/sequencing and f i t with h o s p i t a l goals. O v e r a l l p r i o r i t i e s were then ranked. 204 The study, which was completed November, 1984, v e r i f i e d that the current manual methods of handling information are i n e f f e c t i v e and i n e f f i c i e n t , although t h i s i s not unique to the Chilliwack General Hospital. If the i d e n t i f i e d problems can be solved, thus leading to greater effectiveness and e f f i c i e n c y i n information processing, the h o s p i t a l w i l l r e a l i z e s i g n i f i c a n t b e n e f i t s . The solutions to these problems and attainment of i d e n t i f i e d b enefits are possible through modular computerization of the i d e n t i f i e d manual information processing problems. Because there has been a high l e v e l of user p a r t i c i p a t i o n the l i k e l i h o o d of successful implementation i s greatly enhanced. I t was beyond the scope of the report to investigate the pros and cons of the four general approaches to t e c h n i c a l planning of computerized information systems: in-house; turnkey; shared service; and f a c i l i t i e s management. I t was our i n t e n t i o n that the contents would f a c i l i t a t e discussion and decisions with respect to the most appropriate way to approach technical planning and the implementation of the best system. Equally, the report d i d not address the four general approaches to systems implementation: non-integrated stand-alone; modular; d i s t r i b u t e d processing; and t o t a l , f u l l y integrated systems. Again, i t was intended that the contents would f a c i l i t a t e discussion and decision-making with respect to the best approach to technical implementation of the systems. The report, along with i t s recommended staging of computerized solutions, was approved by the Board of Trustees i n December, 1984. Patient r e g i s t r a t i o n and tracking, f i n a n c i a l and c l i n i c a l a p p l i c a t i o n s were the highest p r i o r i t i e s . The applications that must be addressed i n 205 t h i s proposal include: 1. Central Registry/Admission, Discharge, Transfer 2. Outpatient Registration 3. Accounts Payable, General Ledger, Accounts Receivable 4. C l i n i c a l Laboratory/Pathology 5. Radiology 6. Pharmacy 7. Food Services 8. A l l Nursing Units/Emergency/ Operating Room/Day Care Surgery/ Ambulatory Care/Nursing Admin. 9. Extended Care Unit 10. Health Records/HMRI 11. Pastoral Care 12. S o c i a l Work Services 13. Physical Medicine 14. Administration 15. Medical S t a f f 16. Housekeeping 17. Payroll/Personnel 18. O f f i c e Automation/Word Processing 19. Parkholm Lodge Intermediate Care F a c i l i t y 20. Future modules ( i n t e r f a c e a b i l i t y only) Address and COST OUT IN FULL these a p p l i c a t i o n as complete modules Address and COST OUT these a p p l i c a t i o n as in t e r f a c e s to CR/ADT, order e n t r y / r e s u l t s / commun/AR/AP/GL and medical records. DO NOT COST OUT appl i c a t i o n s designated as future c a p a b i l i t i e s Address these applications as future c a p a b i l i t i e s only. DO NOT COST OUT 206 2. CHILLIWACK GENERAL HOSPITAL PROFILE 2.1 Current The Chilliwack General Hospital i s a general community h o s p i t a l 100 km east of Vancouver, which serves an area population of approximately 60,000 people. We are situated i n the Fraser Cheam Regional Hospital D i s t r i c t i n which the Fraser Canyon Hospital i s also located. Our current rated capacity i s 181 acute care beds and 95 extended care beds. (Additionally, Parkholm Lodge i s p h y s i c a l l y attached to the h o s p i t a l and houses 90 intermediate care beds; however, i t i s not included i n the present proposal). The h o s p i t a l employs approximately 430 f u l l - t i m e equivalent s t a f f and has an annual operating budget of approximately $16 m i l l i o n . Some $35,000 i s currently spent annually on data processing a c t i v i t i e s l a r g e l y associated with the Computer Services of the B r i t i s h Columbia Health Association (BCHA). These a c t i v i t i e s include Payroll/Personnel, Data Entry Programs such as Accounts Payable, General Ledger and Medical Services Plan Accounts Receivable. We also subscribe to the Hospital Medical Records I n s t i t u t e (HMRI) Medical Abstracting Program through BCHA. We have word processing a b i l i t y (IBM Displaywriters) i n Health Records and Administration. P a y r o l l i s p i l o t i n g an Alternate Time Code (ATC) Data Entry System i n conjunction with BCHA using the IBM PC. The Business O f f i c e uses an IBM PC for D i r e c t Data Entry for Accounts Payable/General Ledger/Medical Services Plan - Accounts Receivable. An IBM XT has jus t been acquired for Pharmacy as part of a revised Drug D i s t r i b u t i o n System. An IBM PC has been recently i n s t a l l e d i n Health Records to f a c i l i t a t e automated patient medical record abstracting with HMRI. Administration uses an IBM AT f o r cen t r a l i z e d RJE for Payroll/Health Records, Finance and micro-based decision support. We are also considering subscribing to the BCHA "Information Centre" using structured Query Language (SQL). This w i l l allow us query and reporting c a p a b i l i t i e s using our data i n the BCHA mainframe computer system f o r Medical A b s t r a c t s / U t i l i z a t i o n , Finance and P a y r o l l . 207 SUMMARY OF INPATIENT, OUTPATIENT, DAY CARE AND EMERGENCY VISITS TO THE CHILLIWACK GENERAL HOSPITAL FOR THE PERIOD APRIL 1, 1984 - MARCH 31,1985 PATIENT DAYS Acute Care 47821 Extended Care 34778 Newborn 3397 ADMISSIONS Acute Care 6171 Extended Care 59 Newborn 836 DISCHARGES Acute Care 6164 Extended Care 59 Newborn 833 AVERAGE LENGTH OF STAY Acute Care 7.6 Newborn 4.1 % OCCUPANCY Acute Care 80.6 Extended Care 100.3 Newborn 56.4 EMERGENCY/AMBULATORY CARE INPATIENT DIAGNOSTIC/THERAPEUTIC Emergency v i s i t Laboratory v i s i t s Laboratory tests Radiology exams Ultrasound exams Ps y c h i a t r i c Day Care v i s i t s 1828 Diabetic Day Care v i s i t s 278 D i e t e t i c Counselling 373 Physiotherapy v i s i t s 4747 20881 6253 15000 (est.) 5563 1348 Radiology exams Ultrasound exams Laboratory tests Pathology specimens Physiotherapy atten-dances Occupational Therapy attendances 6080 333 66000 (est.) 1500 (est.) 8933 2027 208 2.2 Future The Chilliwack General Hospital i s currently awaiting approval from the Ministry of Health to proceed with construction of a $26 m i l l i o n Phase I Redevelopment Project which replaces the majority of our e x i s t i n g acute care beds, Operating Rooms, Recovery Room, Radiology, Emergency, Ambulatory Care, Doctors' Lounge, Admitting/Switchboard, Purchasing, Supply & D i s t r i b u t i o n and Central Supply Department. As well, there w i l l be p r o v i s i o n for a Physical Medicine S a t e l l i t e department, expanded B o i l e r Plant and expanded Food Services department. The following excerpt from our Master Plan w i l l a s s i s t you i n understanding the proposed growth pattern of the h o s p i t a l . Thus, the vendor must appreciate and account for the eventual r e l o c a t i o n of video display terminals and p r i n t e r s i n the affected departments/areas. 2 0 9 OUTLINE OF MASTER PLAN There are three phases. The $26 m i l l i o n p r o j e c t r e f e r s to Phase I only. Phase One This includes a l l the work p r i o r to new construction and r e l o c a t i o n such as: changing Menholm Street and adding to the ICU. Then, i n order to o f f - l o a d the beds and diagnostic services so that renovation can take place, the major piece of new. work i s commenced. This contains a l l acute Nursing service beds, Emergency, Obstetrics/Nursery, Operating Rooms, PAR, Radiology, Ambulatory Care, Admitting/Switchboard, Main Lobby/Entrance, Purchasing/Supply & D i s t r i b u t i o n . The renovation of several e x i s t i n g areas occurs simultaneously. When the new block i s completed, beds, surgery and the other departments are relocated. Phase Two This i s divided into four stages or can be completed as one whole program up to the projected requirements. The f i r s t stage of work generally includes renovation to vacated areas and r e l o c a t i o n of such departments as S o c i a l Work Services, Administration and s t a f f f a c i l i t i e s . The next stage includes new construction by adding to areas which have been relocated i n the e a r l i e r stage to provide for departments such as Laboratory, Pharmacy, Psychiatry, C l i n i c a l Data Centre and Medical S t a f f . The t h i r d stage includes renovation and r e l o c a t i o n of further vacated spaces to accommodate Physical Medicine and Occupational Therapy, Respiratory Technology and Dental/Head Unit. The f i n a l stage provides for expansion to Food Services, P s y c h i a t r i c Day Care and Extended Care i f appropriate. Phase Three A l l the work i n Phase Three i s the expansions of departments to carry the h o s p i t a l workload to the cap-off phase. I t would be developed as a series of stages at a l a t e r date but include such new construction as additions to the Inpatient B u i l d i n g , Laboratory, Food Services, Radiology, Emergency, Physical Medicine/Occupational Therapy, plus f i l l i n g of shelled spaces f o r ICU/CCU, S u r g i c a l Day Care, Outpatient C l i n i c s , s t a f f f a c i l i t i e s and Central Supplies. 2 1 2 3.1.6 The proposal must be developed using the same methodological framework, numbering and sequencing as t h i s document i n order to f a c i l i t a t e comparative evaluation of the proposals. 3.1.7 The vendor must include an executive summary including the major components of t h i s proposal. 3.1.8 This i s a Request f o r Proposal only and i n no way obligates the Chilliwack General H o s p i t a l . 3.2 Canadian Users L i s t 3.2.1 The vendor must supply a l i s t of Canadian h o s p i t a l s currently using a l l of the applications i n the proposed t o t a l l y integrated system ( A r t i c l e 1, Items 1-10) . 3.3 Presentation/Site V i s i t s Timetable 3.3.1 Vendors who have been s h o r t - l i s t e d following our evaluation process must arrange f o r presentations and/or s i t e v i s i t s to take place during the period June 28, 1985 - July 10, 1985 i n c l u s i v e . ( S h o r t - l i s t e d vendors w i l l be advised by telephone by June 27, 1985). TECHNICAL CAPABILITIES OF PROPOSED SYSTEMS 4.1 Software 4.1.1 Describe operating systems 4.1.2 Describe a p p l i c a t i o n systems 4.1.3 Describe future developmental plans and out l i n e what major modules you intend to market within the next 5 years 4.2 Hardware 4.2.1 Describe computer room design considerations 4.2.2 Describe video display terminals and p r i n t e r s required for these applications 4.2.3 Describe upgradeability 4.2.4 Comment on response times during peak periods 4.2.5 Describe future developmental plans 4.3 Security 4.3.1 Describe methods used to ensure c o n f i d e n t i a l i t y and security of information 4.4 Data Integri t y 4.4.1 Describe techniques used to ensure i n t e g r i t y of the data base COSTS/BENEFITS/FINANCING In order to a s s i s t us i n evaluating the proposals, please consolidate the following items into a spread sheet summary over a f i v e (5) year span, A p r i l 1, 1985 - March 31, 1990. Use categories i d e n t i c a l to those below and break down the items as much as possible. Do not provide costs of future applications r e f e r r e d to i n A r t i c l e 1 -Items 11-18. 5.1 One time systems costs (show taxes separately where applicable) 5.1.1 Software 5.1.1.1 Operating Systems 5.1.1.2 Applications 5.1.1.3 Interfaces 5.1.1.4 Any other 5.1.2 Hardware 5.1.2.1 Uninterruptable power supply 5.1.2.2 Terminals 5.1.2.3 Pri n t e r s 5.1.2.4 Embossers 5.1.2.5 Interfaces to Lab equipment 5.1.2.6 Any other 5.1.3 Licenses 5.1.4 Communications ( i n t e r n a l and external to the hospital) 5.1.4.1 Multiplexers 5.1.4.2 Modems 5.1.4.3 Wiring 5.1.4.4 Any other 215 5.2 Hardware i n s t a l l a t i o n (include l i k e l y b u i l d i n g renovations) 5.2.1 In-house, one-time i n s t a l l a t i o n s t a f f support (describe l i k e l y duties f or each p o s i t i o n , anticipated number of FTEs and expected remunerations at current B.C. wage rates) 5.3 Software implementation and i n s t a l l a t i o n 5.4 Training 5.4.1 Training (include a l l relevant t r a v e l requirements, manuals and audiovisual aids) 5.5 Conversion costs 5.5.1 Conversion from manual to computerized health records index. We wish to convert our e n t i r e f i l e of approximately 87,000 cards generated over the past 28 years ( describe how t h i s w i l l occur). 5.5.2 Conversion from current automated f i n a n c i a l system to new one (describe how t h i s w i l l occur). 5.6 On-going maintenance (software and hardware) 5.6.1 Lease l i n e costs, i f applicable 5.6.2 Monthly phone costs for data transmission and on-going voice communication 5.6.3 Computer room services ( e l e c t r i c a l , mechanical, plumbing, etc. ) 5.6.4 In-house, on-going s t a f f support (describe l i k e l y duties for each p o s i t i o n , number of FTEs, expected remuneration at current B.C. wage rates) 5.6.5 Vendor and/or t h i r d party support 5.6.6 Describe service f a c i l i t y arrangements and proximity to hos p i t a l 5.6.7 Comment on need f o r and l o c a t i o n of spare equipment/parts 216 5.7 Describe p o l i c y regarding costs of future modifications/ enhancements a f t e r implementation of i n i t i a l a p p l i c a t i o n s 5.8 Describe projected tangible and intangible benefits based on previous accomplishments i n s i m i l a r l y sized Canadian community general h o s p i t a l s 5.9 Describe financing options a v a i l a b l e to the h o s p i t a l INSTALLATION/IMPLEMENTATION/LIVE TIMETABLE AND REQUIREMENTS 6.1 Describe l i k e l y timetable f o r each stage and module (see Table 2) 6.2 Describe vendor manpower and other r e s p o n s i b i l i t i e s f o r each stage and module 6.3 Describe h o s p i t a l manpower and other r e s p o n s i b i l i t i e s f o r each stage and module 6.4 Describe the o r i e n t a t i o n / t r a i n i n g programs supplied by vendor f or each stage and module TABLE 2 STAGE I ADT, Central Registry, Health Records/HMRI, Outpatient Registration G/L, A/P, A/R Anticipated implementation period 8 months STAGE II C l i n i c a l Laboratory/Pathology Order Entry/Reporting/Communications 8 months STAGE III Radiology, Pharmacy Food Services 12 months PERFORMANCE BONDS/WARRANTIES/CONTRACT (Software and Hardware) 7.1 Describe performance assurances and system warranties. Attach samples 7.2 Attach sample contracts 7.3 Attach copy of most recent corporate f i n a n c i a l statement 2 EVALUATION METHODOLOGY AND TIMETABLE 8.1 Following the June 21, 1985 deadline f o r receipts of the RFPs, the ho s p i t a l ' s Computer Advisory Committee w i l l evaluate each proposal i n d e t a i l using the methodological framework contained herein. Thus, i f each vendor follows t h i s framework, the evaluation process w i l l be more accurate and greatly expedited. 8.2 S h o r t - l i s t e d vendors w i l l be selected and contacted by telephone by June 27, 1985. 8.3 On-site demonstration/presentations and/or s i t e v i s i t s must take place during the period June 28, 1985 - Jul y 10, 1985 i n c l u s i v e . ' 8.4 A f i n a l i s t w i l l be selected by Jul y 11, 1985 and a recommendation made to the Board of Trustees of the Chilliwack General Hospital for consideration. VIDEO DISPLAY TERMINALS AND PRINTERS 9.1 Please comment on number and d i s t r i b u t i o n of video display terminals, e.g. departmental need f or stand-alone applications i n addition to routine work performed on integrated system and data base. 9.2 Please comment on number and d i s t r i b u t i o n of p r i n t e r s 9.3 Please comment on adequacy of l i s t below. This l i s t represents our understanding of our needs at t h i s point i n the pro j e c t . A need for the fine-tuning of the numbers i s recognized and expected once the proposals are evaluated and a f i n a l i s t i s selected. 219 VIDEO DISPLAY TERMINALS Computer Room Admitting/Booking O f f i c e / Switchboard Finance/Business O f f i c e Laboratory Radiology Pharmacy Food Services Nursing/Extended Care Health Records Pastoral Care S o c i a l Work Services Physiotherapy Medical S t a f f (Lounge and Library) Housekeeping PRINTERS Simple dot high speed matrix/high forms speed forms 4 9 15 2 2 3 27 2 1 1 1 2 2 2 5 1 2 2 25 2 1 1 1 2 Total's 71 47 DETAILED SYSTEMS APPLICATIONS 10.1 The following applications represent our understanding of our needs at t h i s point i n the pr o j e c t . A need f or fine-tuning of the applications i s recognized and expected once the proposals are evaluated and a f i n a l i s t i s selected. 10.2 Please review each item. Following each section i s a space e n t i t l e d "comments". In t h i s space please note which item(s) you cannot supply and any other comments you wish to make regarding the a p p l i c a t i o n s . I f there are no comments we w i l l assume you can meet without q u a l i f i c a t i o n a l l of the applications as stated. 10.3 Please return t h i s e n t i r e section as completed with your response. 2 2 1 ADMISSION, DISCHARGE, TRANSFER, CENTRAL PATIENT INDEX, MEDICAL RECORDS 1. A b i l i t y to f l a g i n d i v i d u a l s admitted to a s p e c i f i c bed charge category who wish to change to the f i r s t a v a i l a b l e of another bed charge category , e.g. i n d i v i d u a l s occupying a p r i v a t e wishing to transfer to a semi-private or vice versa and to have t h i s information indicated on the nursing u n i t bed p r o f i l e . 2. A b i l i t y to indicate "Do Not Move From Preferred Accommodation" for non-paying patients who have been placed i n p r i v a t e or semi-private for medical reasons, e.g. dying, i s o l a t i o n , d i s r u p t i v e , odor, etc. 3. A b i l i t y to NOT automatically assign bed charge category according to semi or pri v a t e rooms , i . e . an override c a p a b i l i t y . 4. A b i l i t y to provide a transf e r bed function and cost adjustment. 5. A b i l i t y to l i n k t h i s function with Accounts Receivable. 6. A b i l i t y to communicate pa t i e n t t r a n s f e r and discharge to "need to know" areas (Lab, Pharmacy, Food Services, Health Records, Radiology, Housekeeping, Doctors' Lounge, Switchboard, Cashier, Accounting, S o c i a l Services, Physical Medicine, Care Coordinators' o f f i c e , Pastoral Care and others). 7. A b i l i t y to p r i n t or display summaries and occupancy s t a t i s t i c s by t o t a l h o s p i t a l , nursing unit, physician, etc. on a continuous basis d a i l y , weekly, monthly and annually. Time of admission should be available i n these s t a t i s t i c s . 8. A b i l i t y to provide n o t i f i c a t i o n to Admitting O f f i c e of a patient scheduled for surgery at the time the appointment i s made. Although t h i s may be redundant f o r our purposes since ADT i s Admitting, so we should have a l l t h i s information at our f i n g e r t i p s . 9. A b i l i t y for Housekeeping to n o t i f y Admitting Department of "bed ready" rooms status. 10. A b i l i t y to pre-admit patients f o r an unlimited period p r i o r to admission and admit those patients from the pre-admit f i l e without rekeying data. 11. A b i l i t y to reverse or change admissions, discharges and transfers done i n error without d i s t o r t i n g s t a t i s t i c s . 12. A b i l i t y to delete both cancelled admissions and cancelled previously pre-admitted s u r g i c a l patients without d i s t o r t i n g s t a t i s t i c s . This would also include cancelled outpatients and emergency patients. 222 13. A b i l i t y to automatically assign the next sequential h o s p i t a l number and to override t h i s capacity i f necessary. 14. A b i l i t y to reuse cancelled admission numbers. 15. A b i l i t y to assign a "down time" h o s p i t a l number for manual input of patient admitting data at some time a f t e r the patient admission. 16. A b i l i t y to r e t r i e v e a patient's p r i o r v i s i t information. 17. A b i l i t y to access p r i o r and current admission, t e s t r e s u l t s and r e f e r r a l s , information obtained from other departments such as S o c i a l Services, O.T./P.T., etc. to t i e i n with Discharge Planning in the future. 18. A b i l i t y to record the date, and i d e n t i f i c a t i o n of operator making changes to the patient f i l e information and a summary of the changes made. 19. A b i l i t y to admit newborns using mother's admission information. 20. A b i l i t y to maintain up to 5 physician/patient per admission on the patient p r o f i l e . 21. A b i l i t y to enter "pending" discharges and transfers as "pending" bed a v a i l a b i l i t y . 22. A b i l i t y to d i s t i n g u i s h between discharges and deaths i n sending notices and maintaining s t a t i s t i c s . 23. A b i l i t y to open and close beds on-line. 24. A b i l i t y to add and delete nursing s t a t i o n s . 25. A b i l i t y to provide census reports on demand, and with the a b i l i t y to tailor-make the census to our needs. i . e . u n i t census and h o s p i t a l census cu r r e n t l y being done by i n d i v i d u a l units and Health Records r e s p e c t i v e l y . 26. A b i l i t y to specify a patient type and r e l a t e t h i s type with a charge and i n t e r n a l charge number f o r agency b i l l i n g , e.g. "P" number received from ambulance service dispatcher to b i l l P r o v i n c i a l Ambulance Service. 27. A b i l i t y to n o t i f y physicians of p a t i e n t l o c a t i o n , messages, meetings, appointments, etc. 223 28. A b i l i t y to r e t a i n and p r i n t a Medical Waiting L i s t . 29. A b i l i t y to produce embossed cards f or a l l Inpatients, Day Care Patients and selected Outpatients. 30. A b i l i t y to display and p r i n t alphabetic p a t i e n t l i s t i n g i ncluding l o c a t i o n by nursing u n i t . 31. A b i l i t y to f l a g and p r i n t out inpatients the day before they reach t h e i r "expected date of discharge". 32. A b i l i t y to generate a "Religion L i s t " , i . e . a l i s t by r e l i g i o n , ward, room, patient name and indi c a t e "out of town" p a t i e n t s . 33. A b i l i t y to l i s t by ward patients requesting v i s i t s from community clergy. 34. FUTURE CAPABILITY to generate microfiche of patient record information. COMMENTS RE ABOVE SECTION OUTPATIENT EMERGENCY DEPARTMENT AND DAY CARE REGISTRATION 1. A b i l i t y to automatically assign the next sequential h o s p i t a l number and override t h i s c a p a b i l i t y i f necessary. This should include numbering for d i f f e r e n t types of patients separately, i . e . emergency patients, day care surgery patients, etc. with a d i f f e r e n t numbering sequence, i . e . d i f f e r e n t stacks of numbers. 2 . A b i l i t y to admit outpatients from Outpatients, Emergency, Day Care f i l e s without rekeying data. 3 . A b i l i t y to generate standard v i s i t charges for c l i n i c and emergency patients that can be transferred d i r e c t l y to the Accounts Receivable. 4. A b i l i t y to book outpatient v i s i t s f o r Ambulatory Care and to p r i n t a copy of the booking l i s t . 5. A b i l i t y to p r i n t and/or display s t a t i s t i c s and summaries by selected data f i e l d s , i . e . time of admission, type of patient, etc. i n order to develop s t a f f i n g schedules and q u a l i t y assurance. 6. A b i l i t y to delete or change Day Care, Outpatient or Emergency admission without d i s t o r t i n g the s t a t i s t i c s . COMMENTS RE ABOVE SECTION 227 FINANCIAL ACCOUNTS RECEIVABLE - INPATIENTS 1. A b i l i t y of automatic b i l l i n g based upon bed designation. 2. A b i l i t y to adjust b i l l i n g to r e f l e c t bed a v a i l a b i l i t y , e.g. lower b i l l i n g rate for patient i n pr i v a t e bed awaiting a semi-private. 3. A b i l i t y to report number of patient occupying beds without charge even though (s)he may be i n preferred accommodation. A b i l i t y to state reason for occupancy. 4. A b i l i t y to adjust b i l l i n g to account for proportions paid by various agencies (e.g. Workers' Compensation, DVA, etc.) 5. A b i l i t y to provide statement of charges due at time of patient discharge. 6. A b i l i t y f o r the system to handle multiple and miscellaneous charges such as telephone c a l l s , s p l i n t s , etc. 7. A b i l i t y f o r the system to c a l c u l a t e charges as follows: 7.1 Per diem charge - length of stay x rate (for the patient type) 7.2 Co-insurance charge - length of stay x rate (for the patient type) 7.3 Room d i f f e r e n t i a l - stay i n the room x room rate; however, a patient i s not charged i f preferred accommodation i s due to a medical reason, nor i s (s)he charged for accommodation which (s)he has not requested 7.4 Above charges calculated automatically from ADT dates 7.5 Non-resident surcharge calculated automatically 7.6 Miscellaneous charges added as applicable 7.7 Patient may have more than one agency responsible f o r payment of the account 8 A b i l i t y reverse or correct any charges. 9. A b i l i t y to correct ADT dates. 10. A b i l i t y to correct p r i o r periods shown i n the current period receivable/ revenue and s t a t i s t i c s ( i . e . closed month not reopened). 11. A b i l i t y to make corrections i n current period but to use 2 28 rates from previous periods. 12. A b i l i t y to ca l c u l a t e new charges and reverse o l d charges when t r a n s f e r r i n g from one agency to another. 13. A b i l i t y to handle b i l l i n g of multiple agencies. 14. A b i l i t y to d i s t i n g u i s h between residents and non-residents. 15. A b i l i t y f o r system to in t e r f a c e , on-line, to the ADT and ce n t r a l patient index and to have access to the following information: 15.1 Maximum room d i f f e r e n t i a l patient agrees to pay 15.2 Agency responsible f o r room d i f f e r e n t i a l 15.3 Addition I.D. numbers up to 15 alpha-numeric d i g i t s 15.4 F i n a n c i a l l y responsible person and address 15.5 Agency responsible f or per diem 16. A b i l i t y f o r the system to handle r e t r o a c t i v e transfers from one payment r e s p o n s i b i l i t y to another, where the t o t a l revenue changes as a r e s u l t . 17. A b i l i t y for system to record deposit c o l l e c t e d upon admission. 18. A b i l i t y to b i l l f o r long stay p a t i e n t s . 19. A b i l i t y to b i l l upon discharge for accounts outstanding. 20. A b i l i t y to r e b i l l f o r patients or agencies from whom payments are not received f or up to 90 days. 21. A b i l i t y to b i l l agencies on s p e c i a l forms. 22. A b i l i t y to prepare s p e c i a l b i l l i n g reports required by b i l l i n g agencies. COMMENTS RE ABOVE SECTION ACCOUNTS RECEIVABLE - OUTPATIENTS 1. A b i l i t y for the system to accommodate charges that vary by paying agency rather than by the service provided. 2. A b i l i t y for the system to provide for Day Care Services where the charges are as follows: 2.1 Set by the government 2.2 Primary charge paid by B.C. Hospital Programs for e l i g i b l e patients 2.3 Paid by Department of Veteran A f f a i r s (DVA), Workers' Compensation Board (WCB), Indian A f f a i r s , S o c i a l Welfare, S e l f , RCMP and agencies from other provinces 3. A b i l i t y f o r system to provide f o r Laboratory and Radiology where charges are as follows: 3.1 Set by Medical Services Plan (MSP) 3.2 Paid by MSP for insured services 3.3 Paid by i n d i v i d u a l p a t i e n t s , DVA, WCB, S o c i a l Welfare and agencies from other provinces 4. A b i l i t y for the system to provide f o r other services and charged as follows: 4.1 Charges for B.C. residents approved but not paid f o r by BCHP 4.2 Hospital Board determined non-resident charges to be paid by the patient 5. A b i l i t y to c a l c u l a t e charges f o r : ' 5.1 Fee code for most service provided by HSP. Each fee divided into a technical and p r o f e s s i o n a l component 5.2 Fee code remaining services determined by h o s p i t a l s t a f f 5.3 N o n - Canadian re s i d e n t s ; automatic surcharge added or d i f f e r e n t f l a t rates can apply. F l a t rate plus mis-cellaneous charges such as lab, x-ray, meds, s p l i n t s , etc. 6 . A b i l i t y to provide for b i l l i n g s to multiple agencies. 7. A b i l i t y of on-line v e r i f i c a t i o n of MSP numbers using check d i g i t c a l c u l a t i o n . 231 8. A b i l i t y of on-line v e r i f i c a t i o n of doctor's number, fee code, date, etc. 9. A b i l i t y of on-line v a l i d a t i o n of b i l l i n g agencies ( i . e . MSP b i l l not processed without v a l i d MSP number, no b i l l i n g permitted to MSP for day care services, etc. 10. A b i l i t y to enter a l l transactions and then prompt for missing patient information. 11. A b i l i t y to correct patient information. 12. A b i l i t y to d i f f e r e n t i a t e betwen optional and required information. 13. A b i l i t y to a l t e r patient MSP number i f t h i s i s to be used as the patient ID. 14. A b i l i t y to automatically t r a n s f e r s e l f charges to MSP b i l l i n g when patient supplies correct b i l l i n g number (and vice versa). 15. A b i l i t y to prepare MSP b i l l i n g s by tape or on-line. 16. A b i l i t y to receive and process MSP tapes on-line for r e c o n c i l i a t i o n of charges. 17. A b i l i t y to b i l l on s p e c i a l forms used by b i l l i n g agencies. 18. A b i l i t y of s e l f b i l l i n g s p e c i f y i n g the outpatient department service received from as well as t e s t / s e r v i c e performed and showing balance forward, new charges and payments. 19. A b i l i t y to r e b i l l patients and agencies from whom payments are not received. 20. A b i l i t y to b i l l other h o s p i t a l s and c l i n i c s with a monthly invoice with d e t a i l s regarding a patient's treatment and services performed. 21. A b i l i t y to interface with the outpatient r e g i s t r a t i o n module and provide the following information on-line: 21. 1 Diagnosis 21. 2 Agency(s) to b i l l 21. 3 Fee code 21. 4 Date of service 21.5 Number and type of services 232 21.6 F i n a n c i a l l y responsible person and address 21.7 Other ID number for WCB, DVA, etc. 22. A b i l i t y of on-line inquiry of statement of account showing a l l charges and payments for s e l f p a t i e n t s . 23. A b i l i t y to r e b i l l delinquent accounts f or a l l agencies. 24. A b i l i t y to generate a w r i t e o f f review and writeoff. 25. A b i l i t y to specify i n d i v i d u a l accounts which are not to be r e b i l l e d and/or written o f f . 26. A b i l i t y to state, on r e b i l l i n g , the status ( i . e . a r e b i l l of the b i l l and the amount overdue. 27. A b i l i t y to p r i n t a message on the age of an account or the number of the previous b i l l i n g . 28. A b i l i t y to p r i n t several d i f f e r e n t messages on one b i l l i n g run. 29. A b i l i t y to transfer r e c e i p t s from- outpatient to inpatient receivables. COMMENTS RE ABOVE SECTION MISCELLANEOUS RECEIVABLES 1. A b i l i t y to provide accounts to the b i l l which are calculated externally (e.g. i n p a y r o l l ) . 2. A b i l i t y to provide more d e t a i l e d descriptions of "services" (items being b i l l e d ) required than for patient b i l l i n g . 3. A b i l i t y to provide automatic statements once a month. 4. A b i l i t y to have items b i l l e d quarterly. 5. A b i l i t y to prepare invoices for selected accounts. 6. A b i l i t y f o r refund cheque run to update cash, payables, receivables and G/L. CASH RECEIPTS 1. A b i l i t y to batch cash by cash page and date. 2. A b i l i t y to post to inpatient, outpatient and miscellaneous accounts. 3. A b i l i t y to receive cash that cannot be i d e n t i f i e d . 4. A b i l i t y f o r d i r e c t entry of cash r e c e i p t information by the cashier's or mail receipt area. 5. A b i l i t y to day-end t o t a l cheques and cash and to p r i n t out re c e i p t information to balance to bank deposit. 6. A b i l i t y to enter cash from other areas of the h o s p i t a l (e.g. emergency). 7. A b i l i t y of on-line correction of a l l input e r r o r s . 8. A b i l i t y to maintain an audit t r a i l of corrections. 9 . A b i l i t y to handle an MSP cheque received on a separate date from the remittance l i s t to c r e d i t suspense account (DR cash CR suspense). 10. A b i l i t y to handle a remittance l i s t on tape from MSP (except for some manual b i l l i n g ) . 11. A b i l i t y to handle remittance l i s t to debit suspense account f o r MSP (DR suspense CR r e c e i v a b l e s ) . 235 12. A b i l i t y to process p a t i e n t refunds. 13. A b i l i t y to l i s t patients whose accounts are overpaid. 14. A b i l i t y to i n t e r f a c e to accounts payables for cheques to patients. 15. A b i l i t y to interface with General Ledger to post cash receipts to the G/L. COMMENTS RE ABOVE SECTION REPORTS 1. A b i l i t y to maintain an audit t r a i l of a l l f i n a n c i a l trans-actions by batch. 2. A b i l i t y to maintain an audit t r a i l of a l l postings to G/L. 3. A b i l i t y to maintain an audit t r a i l of patient master information updates. 4. A b i l i t y to provide d a i l y census reports. 5. A b i l i t y to generate an inpatient long stay report ( i . e . l i s t a l l patients i n h o s p i t a l over 30 days). 6. A b i l i t y to t r i a l balance by agency f or inpatient, outpatient and miscellaneous receivables. 7. A b i l i t y to purge "old" patients to hi s t o r y tapes. 8. A b i l i t y to r e t r i e v e these "old" p a t i e n t s . 9. A b i l i t y to p r i n t out any account. WRITE-OFFS 1. A b i l i t y to l i s t the old accounts under a s p e c i f i e d agency, with s p e c i f i c d o l l a r l i m i t s and age l i m i t s or number of b i l l i n g s . 2. A b i l i t y to have automatic wri t e o f f or wr i t e o f f to c o l l e c t o r . 3. A b i l i t y to suspend i n d i v i d u a l accounts from w r i t e o f f s . 4. A b i l i t y to l i s t accounts paid d i r e c t l y to h o s p i t a l that are i n c o l l e c t o r ' s hands (by c o l l e c t i o n agency). STATISTICS For i n patient s t a t i s t i c s , does the system handle: 1. A b i l i t y to gather s t a t i s t i c s f o r government reporting. 2. A b i l i t y to feed s t a t i s t i c s to the management reporting module. 3. A b i l i t y to provide number of b i l l i n g s of accounts i n categories les s than $10, $10-$20, $20-$50, etc. 4. A b i l i t y to provide number and amount of accounts by revenue type e.g. co-insurance, room d i f f e r e n t i a l s . Eor outpatient s t a t i s t i c s , does the system handle: 1. A b i l i t y f o r d o l l a r s b i l l e d vs d o l l a r s c o l l e c t e d for each outpatient revenue area to pinpoint bad debt problems. 2. A b i l i t y to handle d o l l a r s of p r o f e s s i o n a l fees vs t e c h n i c a l fees b i l l e d to each outpatient area. 3. A b i l i t y to provide number of b i l l i n g s of amounts i n categories l e s s than $10, $10-$20, $20-$50, etc. 1. A b i l i t y f o r d a i l y census to provide a summary by inpatients i n each ward, number i n paid p r i v a t e beds, number in paid semi-pri v a t e beds and t o t a l . 2. A b i l i t y f o r d a i l y census to provide the beds held. 3. A b i l i t y f o r monthly census to provide the number of patient days by paying agent. 4. A b i l i t y f o r monthly census to provide information to complete government form HIA35. 5. A b i l i t y f o r monthly census to provide p a t i e n t days by service (wards grouped). 1. A b i l i t y f o r the system to provide tables f or the following: CENSUS TABLES 1.1 Inpatient per diem rates 1.2 Inpatient co-insurance 1.3 Room rates 1.4 Outpatient services - fee codes, rates for t e c h n i c a l professional component 1.5 Agency codes 1.6 Aging c r i t e r i a 1.7 Doctor table 1.8 Debit/credit codes 1.9 Automatic agency b i l l i n g (inpatients) 1.10 Transaction codes 1.11 Report parameters that change infrequently 1.12 Security l e v e l to be assigned 1.13 Other (please l i s t ) 2. A b i l i t y f o r table maintenance to be handled on i n d i v i d u a l entries or a serie s of entries by users. 3. A b i l i t y for printouts of tables a v a i l a b l e on demand. 4. A b i l i t y for table entries to be dated when updated (especially r a t e s ) . 5. A b i l i t y f o r h i s t o r i c a l rates to be stored. SECURITY AND CONTROL 1. What l e v e l s of security are a v a i l a b l e : 1.1 By user 1.2 By function 2. Does the system provide control t o t a l s and audit t r a i l s f o r : 2.1 B i l l i n g s 2.2 Cash receipts GENERAL 1. A b i l i t y to l i s t the module names on which you based your responses to t h i s a p p l i c a t i o n c h e c k l i s t . Indicate whether the module i s your packaged software or i s based on another hospi t a l ' s (or company's) system. COMMENTS RE ABOVE SECTION 241 ACCOUNTS PAYABLE Includes features common to the "BCHA Interdata" program as well as: 1. A b i l i t y to prepare cheques by vendor. 2. A b i l i t y to prepare d a i l y cheque run by vendor. 3. A b i l i t y to prepare tapes/invoices to various agencies (e.g. Workers' Compensation, MSP). 4. A b i l i t y to interface with inventory program. 5. A b i l i t y to prepare p u b l i c bodies information act reports. 6. A b i l i t y to interface with Radiology, Laboratory, Materiel Management, Pharmacy, Central Supply. Interfacing with Materiel Management: 1. A b i l i t y to maintain a common vendor f i l e . 2. A b i l i t y to mail cheques to a purchase address which i s d i f f e r e n t than the address on the vendor f i l e . 3. A b i l i t y to have the l a t t e r address appear i n the vendor master f i l e . 4. A b i l i t y to have address above automatically used by the accounts payable system. 5. A b i l i t y to p r i c e , at the time of receipt, from the p r i c i n g information on the purchase order. 6. A b i l i t y f o r inventory and non-inventory items to be d i s t r i b u t e d from one purchase order. 7. A b i l i t y to match, on-line, receiving and purchase order information. 8. A b i l i t y to report quantity and p r i c e variances. 9. A b i l i t y to r e j e c t an invoice i f p r i c e variances are beyond user set parameters. 10. A b i l i t y for materiel management system to provide f o r a l l o c a t i o n of p r o v i n c i a l sales tax to appropriate items and f r e i g h t where priced. INVOICE PROCESSING 1. A b i l i t y to process invoices where there i s no purchase order i n the following ways: 1.1 Multiple expense entries made by one invoice 1.2 P r o v i n c i a l sales tax and f r e i g h t be al l o c a t e d to item c o s t ( s ) . 2. A b i l i t y to process one time vendor invoices i n the preparation of the "Public Bodies Report" which l i s t s payments to a l l suppliers. 3. A b i l i t y to excuse payments that should not be included i n t h i s report, e.g. patient refunds. 4. A b i l i t y to modify/delete invoices a f t e r entry. 5. A b i l i t y to modify/delete a f t e r payment. 6. A b i l i t y to handle debit and c r e d i t memos. 7. A b i l i t y to e d i t for duplicate invoices. 8. A b i l i t y to handle prepaid expenses over a user s p e c i f i e d time period. 9 . A b i l i t y to handle cash discounts. 10. A b i l i t y to report on discounts not taken. 11. A b i l i t y to assign a high payment p r i o r i t y code for invoices with discounts. 12. A b i l i t y to enter a recurring invoice and generate a cheque on a monthly, quarterly, or other time sequence. 13. A b i l i t y to p r i n t a report at the time such cheque i s prepared. 14. A b i l i t y to interface with a general ledger system. 15. A b i l i t y to interface with an accounts receivable system with respect to producing refund cheques for p a t i e n t s . 16. A b i l i t y to enter and validate next period's transactions before c l o s i n g the current period. 17. A b i l i t y to override due dates and generate payments on the following c r i t e r i a : 17.1 On demand 17.2 A l l invoices through a c e r t a i n date 17.3 A l l invoices f o r a s p e c i f i c vendor 243 18. A b i l i t y to hold invoices at the vendor l e v e l . 19. A b i l i t y to make p a r t i a l payments f or s p e c i f i c vendors and for a l l vendors. 20. A b i l i t y to suppress cheque preparation to vendors with zero or negative balances due. 21. A b i l i t y to produce a proposed cheque l i s t p r i o r to running the cheques. 22. A b i l i t y to make changes to the proposed cheque run. 23. A b i l i t y to prepare one cheque per vendor, l i s t i n g multiple • invoices on the remittance advice. 24. A b i l i t y to a l l o c a t e consecutive cheque numbers f or each bank account. 25. A b i l i t y to have separate cheque runs f o r each bank account. 26. A b i l i t y to prepare the cheque r e g i s t e r during each payment cycle to control a l l cheques generated during the period. 27. A b i l i t y to enter annual cheques. 28. A b i l i t y to enter a manual cheque regarding an invoice not on f i l e . 29. A b i l i t y to enter spoiled cheques to maintain co n t r o l over pre-numbered cheque forms. 30. A b i l i t y to record discounts to be recorded when manual cheques are entered. 31. A b i l i t y to provide an independent r e g i s t e r f o r manually written cheques. 32. A b i l i t y for above r e g i s t e r to show the debt d i s t r i b u t i o n for each cheque. 33. A b i l i t y to generate a schedule of invoices by due date for each vendor. 34. A b i l i t y to produce a report of invoices due with user-determined selected time periods. 244 35. A b i l i t y to provide a vendor h i s t o r y including: 35.1 Vendor number 35.2 Vendor name/address 35.3 Cheque address 35.4 Telephone number 35.5 Contact 35.6 Month-to-date/year-to-date purchase d o l l a r s and volumes. 35.7 Date of l a s t purchase 35.8 Amount paid year-to-date 35.9 Public Bodies Report support 36. A b i l i t y to move a vendor h i s t o r y to a new vendor number and name when a vendor changes i t s name. 37. A b i l i t y to recompute sales tax. 38. A b i l i t y to prepare a monthly summary report of purchases, tax status, and sales tax paid. (e.g. purchase journal) 39. A b i l i t y to provide a cheque r e c o n c i l i a t i o n feature from cancelled cheque information. 40. A b i l i t y to generate bank r e c o n c i l i a t i o n reports. 41. A b i l i t y to make available year-to-date transaction d e t a i l by account, by vendor, on-line and by P.O. outstanding. 42. A b i l i t y to apply journal e n t r i e s to the general ledger on a d a i l y , weekly or monthly basis. 43. A b i l i t y to maintain vendor contracts. 44. A b i l i t y to prepare vendor l a b e l s . 245 45. A b i l i t y to generate the following reports: 45.1 Month-end aged t r i a l balance at cu t - o f f date t i e d to Accounts Payable co n t r o l account balance at month-end f o r : 45.1.1 Summary by vendor 45.1.2 D e t a i l by vendor 45.2 Alphabetic vendor l i s t s 45.3 Numeric vendor l i s t s 46. A b i l i t y to generate l i s t of payments (invoices/vouchers) due by a s p e c i f i e d date of aged category; vendor and grand t o t a l s . 47. A b i l i t y to l i s t vendors with c r e d i t balances. 48. A b i l i t y to produce cheques i n U.S. funds and clear invoices f o r which foreign money orders have been obtained. 49. A b i l i t y to produce an inventory audit t r a i l , which indicates a l l a c t i v i t y f o r the month on a l l or selected catalogue items. 50. A b i l i t y to produce an inventory usage report r e f l e c t i n g q u a ntities and d o l l a r s . 51. A b i l i t y to report on a l l non-inventory items and services, including d e b i t / c r e d i t memos and any other charges to a department not included i n the inventory usage report. 52. A b i l i t y f o r the system to provide reasonable e d i t s over such entries as: 52.1 Invoice date 52.2 Due date 52.3 General Ledger date 52.4 Amount of cheql^e A b i l i t y to provide input e d i t s such as 53.1 Duplicate batch number 53.2 V a l i d catalogue (stock) numbers 53.3 V a l i d vendor number 53.4 V a l i d purchase order number 53.5 Other (specify) 54. A b i l i t y f o r the system to use average costing. COMMENTS RE ABOVE SECTION 247 GENERAL LEDGER 1. A b i l i t y to include the p r i n t i n g of revenue and management accounts on a monthly basis. 2. A b i l i t y to include those provided by the current "BCHA Interdata" version. CHART OF ACCOUNTS 1. A b i l i t y to provide f o r a f l e x i b l e coding structure to enable s p e c i f i c a t i o n of the maximum number of d i g i t s to the G/L code and the l e v e l that can be coded. 2. A b i l i t y to designate the following a t t r i b u t e s to each account: 2.1 Expense/revenue/asset/liability 2.2 Fund 2.3 Division/department/cost centre 2.4 Dollars or s t a t i s t i c s 2.5 Various groupings of accounts to handle other reporting requirements 2.6 Various groupings of cost centres to allow d i f f e r e n t " r o l l u p s " according to reporting needs 2.7 An account code independent from reporting structure 2.8 S p l i t a G/L account f o r reporting purposes (e.g. al l o c a t e overhead to cost centres based on user defined formulas) JOURNAL ENTRY 1. A b i l i t y to provide for manual journal e n t r i e s f o r a l l postings not coming from a sub-system. 2. A b i l i t y to provide for entry and retention i n the G/L, f o r audit purposes, the following data: 2.1 Journal entry number 2.2 Journal entry date - may be p r i o r year i f adjusting p r i o r year, or else must be current year and current of future accounting period ( e f f e c t i v e date - date of entry) 2.3 Description (20-30 characters) 2.4 Dr accounts (maximum number) 2.5 CR account(s) (maximum number) CASH RECEIPTS 1. A b i l i t y to record the following: 1.1 Date of rec e i p t 1.2 Receipt number 1.3 Received from and on behalf of 1.4 Purpose 1.5 G/L account number 1.6 Amount 2. A b i l i t y to allow for reversals. 3. A b i l i t y to l i s t by date. SUB SYSTEM INTERFACE 1. A b i l i t y to provide f o r automatic i n t e r f a c e s with the following sub-systems: 1.1 Accounts Receivable^ 1.2 Cash receipts 1.3 P a y r o l l 1.4 Materiel Management (including s e t t i n g up an estimated payable) 1.5 Accounts Payable 1.6 Admission/discharge/transfer and r e g i s t r a t i o n 2. A b i l i t y to validate data from sub-system and exception reporting 3. A b i l i t y for postings to be summarized by: 3.1 Account number 3.2 Source 3.3 Period (using posting date) PROCESSING PROCEDURES 1. A b i l i t y to generate on demand t r i a l balance and/or G/L summary and/or statement of expense and revenue preliminary to month-end close o f f . 2. A b i l i t y to produce t r i a l balance and G/L summary at month end. 3. A b i l i t y to r e t a i n h i s t o r i c a l d e t a i l s on alternate computer readable media i f disk storage i n s u f f i c i e n t to r e t a i n on the current f i l e . 4. A b i l i t y f o r G/L system to be updated and balanced on a d a i l y basis. 5 . A b i l i t y to maintain a d e t a i l e d suspense account for i n v a l i d or out-of-balance e n t r i e s . 6. A b i l i t y to provide a d a i l y record of transactions including volume, source and amount. YEAR END PROCEDURES 1. A b i l i t y to close o f f year end and post forward to next year before a l l adjustments are through and a f t e r sub-systems s t a r t to post new year. 2. A b i l i t y f o r year end adjustments to be posted to both l a s t and current year. 3. A b i l i t y to run f i n a l year end close several months a f t e r year end. 4. A b i l i t y at the f i r s t year end close, to post forward asset and l i a b i l i t y balances, p r o f i t / l o s s figures and zero revenue and expense accounts. MANAGEMENT REPORTS 1. A b i l i t y to prepare reports f o r comparison of budget to actual expenditure for the following: 1.1 Hospital 1.2 D i v i s i o n 1.3 Department 1.4 Cost centre 1.5 S t a t i s t i c s and d o l l a r s on same report (where applicable) 1.6 Both revenue and expense accounts 2. A b i l i t y to produce balance sheets. 3. A b i l i t y to prepare a p r o f i t and loss statement. 4. A b i l i t y f o r year to date and/or monthly figures to appear for actual and budget as designated by user. 5. A b i l i t y to produce exception reports where tolerances are exceeded, either by expense type or by cost centre. 6. A b i l i t y for the non inventory usage report to include journal entries and current charges and c r e d i t s . 7. A b i l i t y for above reports to be a v a i l a b l e on demand basi s . 8. A b i l i t y to design own reports and report groupings. 9. A b i l i t y to p r i n t reports i n user s p e c i f i e d order. ACCOUNT ANALYSIS FUNCTIONS 1. A b i l i t y to explore any summary figu r e on any management report. 2. A b i l i t y to s e l e c t an account or a range of accounts, date(s) and source code(s) for d e t a i l p r i n t i n g of postings s a t i s f y i n g the selected parameters and sorted as s p e c i f i e d by user. 3. A b i l i t y to generate statement of changes i n f i n a n c i a l p o s i t i o n work sheets for work c a p i t a l and for cash. 4. A b i l i t y to generate projected year and f i n a n c i a l statements during the year based on year to date actual r e s u l t s plus remaining periods budget data. BUDGET 1. A b i l i t y to enter budgets for both s t a t i s t i c s and d o l l a r s . 2. A b i l i t y to provide f o r f l e x i b l e budgeting (using user s p e c i f i e d formulas and parameters and global change c a p a b i l i t i e s ) . 3. A b i l i t y to assign monthly amounts by G/L number upon data entry. 4. A b i l i t y to automatically c a l c u l a t e from l a s t year's volumes and d o l l a r s using percent assigned upon data entry for a l l or selected G/L accounts. 5. A b i l i t y to assign annual amount by account number to be spread evenly throughout year. 6. A b i l i t y to change amount (above) as required, throughout year. 7. A b i l i t y to have budget, volumes and d o l l a r s , to appear on management reports as designated by user, with automatic variance c a l c u l a t i o n . 8. A b i l i t y to store and use more than one budget for a given year or years. 9. A b i l i t y to provide online entry, enquiry and e d i t s . 10. A b i l i t y to input/modify next year's budget before end of current year. CAPITAL AND OTHER FUNDS 1. A b i l i t y to handle multiple funds which include: 1.1 Cash receipts posting to separate bank account 1.2 Accounts payable to separate G/L 1.3 Cheques generated are posted to separate bank account 1.4 Accounts receivable has user designed invoices 1.5 Equipment and depreciation l i s t i n g to include: 1.5.1 Description of asset 1.5.2 Purchase (receiving) date 1.5.3 S e r i a l number and user assigned control number 1.5.4 Quantity and cost 1.5.5 Who uses equipment 1.5.6 Asset l i f e expectancy 1.5.7 Current month and year to date depreciation (type of c a l c u l a t i o n determined by user) 1.5.8 Disposal date 1.5.9 Interface to G/L - purchase and depreciation ( c a p i t a l fund ledger) FILES AND TABLES 1. A b i l i t y f o r control G/L chart of accounts by user. 2. A b i l i t y to a l t e r management report groupings during f i s c a l year. 3. A b i l i t y f o r user design and modify report formats. 4. A b i l i t y for the G/L protect against an out-of-balance condition with sub-systems and with annual e n t r i e s . 5. A b i l i t y to handle 12-14 month period f i s c a l year. 6 . A b i l i t y to handle multiple h o s p i t a l s . COMMENTS RE ABOVE SECTION LABORATORY 1. A b i l i t y to int e r f a c e with: 1.1 Admission/discharge/transfer 1.2 Indirect interface from an automated instrument (e.g. Astra 8, RA 1000, Corning 178, Coulter Counter) through an intermediate b u f f e r 1.3 Central Patient Index 1.4 Outpatient Registration 2. A b i l i t y to support the entry of r e s u l t s by terminal. 3. A b i l i t y to receive ward generated lab requests and be able to record the time and date of request. 4. A b i l i t y to monitor duplicate t e s t s ordered within a user s p e c i f i e d period of time. 5. A b i l i t y to process ward generated enquiries and return status of ordered tests (to eliminate phone c a l l s ) . 6 . A b i l i t y to p r i n t out lab tes t s on wards and store the r e s u l t s . 7. A b i l i t y to prepare walking l i s t (specimen c o l l e c t i o n l i s t ) f o r accessioning s t a f f together with appropriate l a b e l s . 8. A b i l i t y to prepare worklists f o r various work, areas and instruments. 9. A b i l i t y to add to generated w o r k l i s t s . 10. A b i l i t y to r e p r i n t work l i s t s with t e s t r e s u l t s . 11. A b i l i t y to report r e s u l t s i n conventional and/or S.I. units with appropriate reference ranges. 12. A b i l i t y to add various i n t e r p r e t a t i v e comments to reports (code phrase comments and free form formating). 13. A b i l i t y to search f i l e s for previous work done on patients (archiving). 14. A b i l i t y to sort p a tient r e s u l t s out by patient name, ordering doctor or ward. 15. A b i l i t y to p e r i o d i c a l l y review status of ordered t e s t s . 255 16. A b i l i t y to maintain active patient records: inpatients -60 days, outpatients - 6 months. 17. A b i l i t y to charge a l l laboratory tests upon completion (interface with Accounts Receivable). 18. A b i l i t y to pre-access a l l t e s t s for morning c o l l e c t i o n . 19. A b i l i t y to have immediate access to patient information to an extent determined by h o s p i t a l p o l i c y . 20. A b i l i t y to r e g i s t e r and r e t a i n lab data on selected patients for longer periods. 21. A b i l i t y to c l a s s i f y laboratory orders (e.g. STAT, ASAP, Pre-Op, Routine). 22. A b i l i t y to produce laboratory u t i l i z a t i o n reports by t e s t , and/or physician and/or diagnosis. 23. A b i l i t y to date and time a completed laboratory report. 24. A b i l i t y to provide a hard copy of a l l laboratory r e s u l t s within the laboratory (completed report). 25. A b i l i t y to allow v e r i f i c a t i o n of a l l r e s u l t s before they are released. 26. A b i l i t y to transmit STAT r e s u l t s immediately a f t e r v e r i f i c a t i o n . 27. A b i l i t y to provide cumulative r e s u l t s reporting f o r a complete patient's stay i n i n t e l l i g e n t format. 28. A b i l i t y to compare t e s t r e s u l t s with previous r e s u l t s of the same procedure (e.g. reasonable l i m i t s check). 29. A b i l i t y to provide a q u a l i t y c o n t r o l package (Shewhart, Levey-Jennings) . 30. A b i l i t y to provide for workload recording by s h i f t , day, month, year, year to date and previous year and year to date (DBS units, number of t e s t s , number of p a t i e n t s ) . 31.. A b i l i t y to provide for instrument maintenance schedules. 32. A b i l i t y to perform s t a f f scheduling. 33. A b i l i t y to record s t a f f time (time book). Interface with personnel/payroll. c 34. A b i l i t y to generate pr i n t e d Lab r e s u l t s at l e a s t for major pieces of automated equipment (Astra 8, RA 1000, Corning 178, Coulter Counter) and produce cumulative reports. 35. A b i l i t y to provide f or word processing f or maintenance of: 35.1 Methods manuals 35.2 Doctor's l i s t s 35.3 Patient i n s t r u c t i o n , etc. 35.4 Autopsy and s u r g i c a l reports 36. A b i l i t y to provide f or computer as s i s t e d i n s t r u c t i o n . COMMENTS RE ABOVE SECTION MICROBIOLOGY 1. A b i l i t y to enter and p r i n t r e s u l t s on wards and to allow for i n t e r p r e t i v e comments (free t e x t ) . 2. A b i l i t y to enter and store microbiologic reports by patient name and h o s p i t a l number, ward l o c a t i o n ( s ) , organism(s) i s o l a t e d and s u s c e p t i b i l i t y pattern when required, f o r user defined period. 3 . A b i l i t y to generate i n f e c t i o n c o n t r o l information with reference to culture reports ( s i t e and organism(s) i s o l a t e d ) , h o s p i t a l demographic information and h o s p i t a l procedure, e.g. surgery by type, c a t h e t e r i z a t i o n , intravenous administration, in h a l a t i o n therapy. 4. A b i l i t y to generate a n t i b i o t i c s u s c e p t i b i l i t y p r o f i l e s at any time f o r the past 12 month period. 5. A b i l i t y to inventory and track long-term, in-house cultures, e.g. blood cultures. 6 . A b i l i t y to inventory and track long-term r e f e r r e d out cultures e.g. tuberculosis cultures. COMMENTS RE ABOVE SECTION TISSUE PATHOLOGY 1. A b i l i t y to log specimens with sequential yearly accessioning numbers including departmental p r e f i x . 2 . A b i l i t y to provide, upon patient return v i s i t , instant r e t r i e v a l of patient i d e n t i f i c a t i o n information, previous accession number(s) and diagnosis. 3. A b i l i t y to r e t a i n on-line p a t i e n t i d e n t i f i c a t i o n information, e.g. name, date of b i r t h , sex, date of biopsy and diagnosis for user s p e c i f i e d time period. 4. A b i l i t y to accept patient c l i n i c a l h i s t o r y , s u r g i c a l procedure at specimen l o g - i n . 5. A b i l i t y to enter previous biopsy diagnostic reports f i l e d manually. 6. A b i l i t y to provide f o r fre e - t e x t and pre-defined comments for gross and microscopic d e s c r i p t i o n , comments, English diagnosis and coded diagnosis. 7. A b i l i t y to accept SNOP, SNOMED or user-defined coding systems. 8. A b i l i t y to search for user selected items, e.g. diagnosis, biopsy s i t e , sex, age range, doctors, and to provide data content and comparative studies. 9. A b i l i t y to provide above f o r autopsy reports and to allow for multiple diagnoses. 10. A b i l i t y to calculate work load s t a t i s t i c s . COMMENTS RE ABOVE SECTION RADIOLOGY 1. A b i l i t y to maintain a basic patient scheduling system. 2. A b i l i t y to provide accurate patient l o c a t i o n information on an immediate basis. 3. A b i l i t y to provide n o t i f i c a t i o n to "need-to-know" areas (e.g. Food Services) that a patient i s scheduled f o r Radiology services. 4. A b i l i t y to provide status and/or r e s u l t s reporting to various "need-to-know" areas from the request through to f i n a l report. 5. A b i l i t y to i d e n t i f y and locate previous Radiology procedures performed on a patient and give bag #, signed out, and by whom, date. 6. A b i l i t y to produce a monthly notice f o r overdue f i l e loans by Doctors. 7. A b i l i t y to p r i n t a log a l p h a b e t i c a l l y three times per day of patients seen through-out the day including: 7.1 Patient name 7.2 Physician 7.3 Diagnosis 7.4 Medical Record number 7.5 Procedure(s) performed 8. A b i l i t y to n o t i f y and i d e n t i f y STAT orders that must be performed on an immediate bas i s . 9 . A b i l i t y to provide STAT ' r e s u l t s reporting to c r i t i c a l care areas. 10. A b i l i t y to generate radiology reports including procedures schedules, s t a t i s t i c a l / u t i l i z a t i o n reports, demand and supply report. 11. A b i l i t y to produce a patient f i l e including basic demographic information, f i l m f i l e status, types of exams, radiology reports, reason f o r examination, etc. 12. A b i l i t y to relay p a t i e n t preparation protocols f o r Radiology exams. 263 13. A b i l i t y to input l i s t of e x i s t i n g patients names/number and get associated bag #. 14. A b i l i t y to prepare labels f o r films and f i l e s . 15. A b i l i t y to p r i n t outstanding t e s t l i s t s . 16. A b i l i t y to provide for f i l m f i l e / c h a r t l o c a t i o n using. 17. A b i l i t y to provide l i s t i n g of films signed out with i n d i v i d u a l and loc a t i o n d e t a i l . 18. A b i l i t y to control and monitor Radiology stock. 19. A b i l i t y to provide l i n k with Accounts Receivable f o r b i l l i n g procedures. 20. A b i l i t y to provide l i n k with stores inventory. 21. A b i l i t y to produce bag # of deceased patients and i n a c t i v e f i l e s for removal. 22. A b i l i t y to provide standard reports and standard r e s u l t s statements to allow each Radiologist to have unique set of standards. 23. A b i l i t y to develop schedules f o r procedures and p r i n t d a i l y schedules. 24. A b i l i t y to schedule order f o r future days and generate r e q u i s i t i o n on the appropriate day. 25. A b i l i t y to produce month end reports on: 25.1 Total a c t i v i t i e s by subdepartment (e.g. Nuclear, Echo, CT, Heart Cath, Angio, Radiology, Ultrasound) and by exam and by units (standards) < 25.2 F i n a n c i a l reports (fee for service) f o r Radiologists 25.3 MSP b i l l i n g for h o s p i t a l 26. A b i l i t y to interface with C l i n i c a l Laboratory and Pathology to c o r r e l a t e s u r g i c a l , p athological and r a d i o l o g i c a l r e s u l t s . 27. FUTURE CAPABILITY to run Quality Control procedures. COMMENTS RE ABOVE SECTION PHARMACY LABELS - ACUTE 1. A b i l i t y to put the following information on l a b e l : 1.1 Bed 1.2 Patient name 1.3 Prescribing physician 1.4 Drug name (generic, brand) 1.5 Drug form (capsule, etc.) 1.6 Strength 1.7 Directions (sig) (User defined table and free form) 1.8 Issue date 1.9 Unique p r e s c r i p t i o n or u n i t # (consecutive; 5 characters,-multiple p r e s c r i p t i o n per #, sort by date) 1.10 Pharmacist's i n i t i a l s 1.11 A l e r t i n s t r u c t i o n s 1.12 Stop date - programmed to automatically put i n a c e r t a i n # of days which can be overriden 2. A b i l i t y to specify the number of l a b e l s at the time of p r e s c r i p t i o n . 3. A b i l i t y to specify up to 99 l a b e l s , the d e f a u l t determined at the time of i n s t a l l a t i o n . 4. A b i l i t y to have multiple s i z e s and multiple formats. LABELS - EXTENDED CARE 5. Same as Acute but with card number (x of y) f o r b l i s t e r pack. 6. A b i l i t y to produce la b e l s with 2 formats for each order. 266 7. A b i l i t y to set up Cancer/T.P.N./I.V. Admixture labels with the following information provided from the patient p r o f i l e (or data base): 7.1 Same as Acute PLUS 7.2 Up to 20 drugs per l a b e l 7.3 Bag number instead of card number 7.4 Expiry date 8. • A b i l i t y to cal c u l a t e based on user-defined formula, and p r i n t conversions on lab e l s (e.g. on a TPN l a b e l , where x mg = y ml where y ml i s calculated from x mg according to user-defined formula). 9. A b i l i t y to generate user-defined custom l a b e l s . 10. A b i l i t y to integrate with Accounts Receivable, Accounts Payable, inventory control f o r : 10. 1 Pharmacare b i l l i n g f o r Acute and Extended Care patients and community patients 10. 2 B i l l i n g WCB/DVA/IA / Cancer Control Agency of B.C. 10. 3 Inventory control and reorder points entered by Pharmacy. A b i l i t y to generate the following drug i n t e r a c t i o n data: 11. 1 Two l e v e l s of a l e r t desired; contact Doctor before releasing; release then investigate 11. 2 Standard i n t e r a c t i o n s 11. 3 Source of i n t e r a c t i o n information 11. 4 Integration with Laboratory, Radiology, Dietary orders 11. 5 Remote update and/or user update of drug i n t e r a c t i o n data through'third party agencies (e.g. DPIC, Drug and Poison Information Centre, St. Paul's Hospital, Vancouver) 267 12. A b i l i t y to have a system for i n t e r n a l inventory c o n t r o l for up to 2,000 d i f f e r e n t items with the following information on each item (master f i l e ) : 12.1 DIN 12.2 Primary vendor (name, address, contact, phone) 12.3 Secondary vendor 12.4 Key 12.5 Description/package si z e 12.6 Unit cost 12.7 Quantity on hand 12.8 Reorder l e v e l 12.9 Reorder quantity 13. A b i l i t y to p r i n t out a l i s t of inventory items due for reorder. 14. A b i l i t y to keep a transaction f i l e with the following information: 14.1 Lot number 14. 2 Expiry date 14.3 Who or where issued (patient Rx or ward stock) 14.4 PLUS relevant information from master f i l e l i s t 15. A b i l i t y to generate a patient p r o f i l e with the following information: From ADT: 15.1 Name 15.2 Patient # 15.3 Room & bed 15.4 I n s t i t u t i o n name 15.5 Birthdate 268 15.6 Sex 15.7 Surface area 15.8 Height 15.9 Weight 15.10 Admitting diagnosis 15.11 A l l e r g i e s 15.12 Date of Admission 15.13 Physician responsible 15.14 Pharmacare plan and # 15.15 CCA.B.C. 15.16 W.C.B. 15.17 Other conditions, diagnosis, a l l e r g i e s 15.18 Present medications 15.19 Comments (2 lines) p r e s c r i p t i o n s 16. A b i l i t y to read bar code and produce bar coded l a b e l where needed. 17. A b i l i t y to generate order information (entered at Pharmacy) with the following c h a r a c t e r i s t i c s : 17.1 A b i l i t y to create a new order using a previous p r e s c r i p t i o n 17.2 A b i l i t y to r e f i l l an p r e s c r i p t i o n 17.3 A b i l i t y to generate orders from ward stock (inpatient p r o f i l e ) which w i l l not reduce inventory or generate labels .17.4 A b i l i t y to generate p r e s c r i p t i o n s i n the usual way which i s to reduce inventory, and p r i n t l a b e l s 269 18. A b i l i t y to generate the following reports: 18.1 Drug u t i l i z a t i o n report 18.2 Narcotic and co n t r o l l e d drug report 18.3 B i l l i n g s CCABC, Pharmacare 18.4 S t a t i s t i c s (month-end) - ( f i n a n c i a l drug usage and by cost centre) 18.5 Purchase orders 18.6 Extended Care resident medication p r o f i l e 18.7 Medication administration record (Acute Care d i f f e r e n t from E.C.) 18.8 Drug p r o f i l e a v a i l a b l e to ward by order entry/ reporting module 18.9 Custom reports (e.g. workload s t a t i s t i c s ) 18.10 Table l i s t s - drug formulary, inventory 19. A b i l i t y to perform data entry with the following features: 19.1 Automatic generation of p r e s c r i p t i o n number (with overwrite c a p a b i l i t y ) 19.2 To fi n d a patient p r o f i l e and h i s t o r y : 19.2.1 Inpatient/outpatient/community p a t i e n t 19.2.1 Patient # 19.2.2 Rx # 19.2.3 Name 19.3 B u i l d p r o f i l e or obtain from ADT 19.4 Enter orders - single, r e f i l l s 19.5 Batch r e f i l l s f o r Extended Care 19.6 Use DIN number, keyword or f i r s t 2 to 3 l e t t e r s or drug name l i s t 19.7 Use number or name to i d e n t i f y physician 270 19.8 Enter l a b e l information (e.g. type of l a b e l format, number of labels required) 19.9 Date (system generated) 19.10 Password security 20. A b i l i t y to perform pharmacokinetic c a l c u l a t i o n s . 21. A b i l i t y to place orders to pharmacy from nursing stations and Extended Care. 22. A b i l i t y to continue use of our e x i s t i n g modified u n i t dose (controlled dosage system) using b l i s t e r cards. COMMENTS RE ABOVE SECTION 272 FOOD SERVICES 1. A b i l i t y to prepare and p r i n t i n d i v i d u a l menus for patients. 2. A b i l i t y to record and e d i t standard menus. 3. A b i l i t y to in t e r f a c e to a document reader for the purpose of entering and subsequent processing of completed patient menus. 4. A b i l i t y to prepare from p a t i e n t menus, tray preparation cards d e t a i l i n g a l l items on each p a t i e n t tray to a s s i s t i n checking trays for completeness. 5. A b i l i t y to t a l l y menu selec t i o n s for preparation of quantities f o r cook's work sheets. 6. A b i l i t y to receive notices through order entry/communications of meals to be held and of any changes i n d i e t r e q u i s i t i o n s . 7. A b i l i t y to prepare l a b e l s f o r s p e c i a l nourishments to attach to items on dietary trays sent to nursing wards at non-meal times. 8. A b i l i t y to input and store recipes. 9. A b i l i t y to adjust recipes f o r varying number of c l i e n t s . 10. A b i l i t y to prepare purchase orders from non-stock food items. 11. A b i l i t y to cost recipes and menus. 12. A b i l i t y to f l a g patient f o r whom d i e t review i s required. 13. A b i l i t y to provide f o r nu t r i e n t a n a l y s i s . 14. A b i l i t y to prepare and p r i n t patient and di e t a r y service evaluation and provide a summary of s t a t i s t i c s of the responses. 15. A b i l i t y to l i s t patients on each nursing u n i t by pa t i e n t name, room number, d i e t , etc. 16. A b i l i t y to produce f i n a n c i a l budgets for patients and non-patient food costs. 17. A b i l i t y to interface with "smart" cash r e g i s t e r s f o r on-line costs and inventory c o n t r o l . 18. A b i l i t y to monitor perpetual inventory, c o n t r o l costing and forecast product requirements. 273 19. FUTURE CAPABILITY to reconcile invoices with goods received and p r i c e s charged. 20. FUTURE CAPABILITY to f l a g items for which there i s a user defined discrepancy between invoice p r i c e and P.O. p r i c e . COMMENTS RE ABOVE SECTION ORDER ENTRY/REPORTING/COMMUNICATION 1. A b i l i t y to enter and v e r i f y orders on-line and generate or modify standing orders from nursing stations or Admitting. 2 . A b i l i t y to hi g h l i g h t (flag) duplicate procedures/orders requested for a patient based upon pre-defined c r i t e r i a . 3. A b i l i t y to n o t i f y a n c i l l i a r y departments of requested procedures that would a f f e c t those departments and/or services, namely: 3.1 Radiology 3.2 Pharmacy 3.3 Food Services 3.4 Materiel Management 3.5 Laboratory 3.6 Physical Medicine/Occupational Therapy 3.7 Enterostomal Therapy 3.8 Respiratory Technology 3.9 General/Emergency 3.10 Switchboard 4. A b i l i t y to p r i n t outstanding orders r e f l e c t i n g current status 5. A b i l i t y to review previously ordered tests/procedures, displayed by time, date. 6. A b i l i t y to int e r f a c e with stand-alone automated system on a real-time basis. 7. A b i l i t y to enter messages f o r a s p e c i f i c l o c a t i o n or general broadcast i n d i c a t i n g time frames for dis p l a y . 8. A b i l i t y to automatically change patient c l a s s i f i c a t i o n s from emergency to inpatient when assigned room/bed. 9. A b i l i t y to automatically change p a t i e n t c l a s s i f i c a t i o n when moved within Extended Care Unit or to acute h o s p i t a l and back 276 10. A b i l i t y to access patient information on the system using: 10.1 Patient name 10.2 Patient l o c a t i o n 10.3 Patient unit number 11. A b i l i t y to enter t e s t r e s u l t s on-line and update order status. 12. A b i l i t y to p r i n t t e s t r e s u l t s immediately f o r standard orders or for orders generated i n s p e c i f i c l o c a t i o n s . 13. A b i l i t y to update or modify t e s t r e s u l t s and immediately p r i n t at patient l o c a t i o n . 14. A b i l i t y to review status of tests/procedures ordered for in d i v i d u a l patients: 14.1 Procedure requested 14.2 Specimen obtained 14.3 Procedure/test performed - r e s u l t pending 14.4 Result/report generated 15. A b i l i t y to cancel or change p a t i e n t orders. 16. A b i l i t y to provide a d e t a i l e d audit t r a i l of a l l transactions generated throughout the network. 17. A b i l i t y to provide security and user password techniques to r e s t r i c t unauthorized access to the system. 18. A b i l i t y to interface a l l pertinent data elements to the f i n a n c i a l system. 19. A b i l i t y to store and display a l l orders placed f o r a patient during a length of stay. Orders should be retained f o r a minimum period of time a f t e r discharge based upon user defined procedure retention c r i t e r i a . 20 A b i l i t y to generate s t a t i s t i c s . 21. FUTURE CAPABILITY f o r small "banking" a p p l i c a t i o n f o r Extended Care Unit, to include: 21.1 A b i l i t y to l i n k to Business O f f i c e Resident Trust Accounts i n order to have current balance and give residents funds f o r outings, etc. 277 21.2 A b i l i t y to f l a g and update resident valuables 21.3 A b i l i t y to a c t u a l i z e expenditure from Resident A c t i v i t y Fund (Social Diversional) 22. FUTURE CAPABILITY to run nursing care plan COMMENTS RE ABOVE SECTION NURSING ADMINISTRATION 1. A b i l i t y to generate s t a t i s t i c a l information and run on e x i s t i n g IBM-AT microcomputer. 2. A b i l i t y to run nurse care plan a p p l i c a t i o n f o r each nursing u n i t . 3 . FUTURE CAPABILITY to access t o t a l Patient Care Units (PCUs) fo r each nursing unit i n order to assess workload i n r e l a t i o n to bed a l l o c a t i o n . 4. FUTURE CAPABILITY to run s t a f f scheduling f o r each nursing u n i t and interface with e x i s t i n g IBM Displaywriter. COMMENTS RE ABOVE SECTION HEALTH RECORDS/HMRI 1. A b i l i t y to interface to the present HMRI abstracting computer and software or the pro v i s i o n of a separate abstracting program which r e t r i e v e s patient data from the data base. This should provide the abstracter with patient data selected from the ADT system without having to rekey i t . 2 . A b i l i t y to construct and keep current an incomplete chart l i s t f o r Doctors. The l i s t w i l l document which charts are yet to be completed for each doctor and w i l l be c i r c u l a t e d to physicians on a per i o d i c basis. 3 . A b i l i t y to track a patient's medical record l o c a t i o n inside and outside Health Records. 4. A b i l i t y to interface the ADT system with the IBM Displaywriter word processors i n the steno pool to provide the stenos with patient data selected from the ADT system without having to rekey i t . COMMENTS RE ABOVE SECTION PASTORAL CARE 1. A b i l i t y to int e r f a c e with CR/ADT. COMMENTS RE ABOVE SECTION SOCIAL WORK SERVICES 1. A b i l i t y to interface with CR/ADT, order entry/reporting/ communication, AR/AP/GL, Medical Records. 2. A b i l i t y to i d e n t i f y demographic and diagnostic i n d i c a t o r s for p r o f i l i n g 'high r i s k S o c i a l Work c l i e n t s on admission. 3. A b i l i t y to i d e n t i f y high r i s k c h i l d r e n upon admission (Emergency, Outpatient or Inpatient) and generate a high r i s k C h i l d Abuse Registry. 4. A b i l i t y to generate departmental s t a t i s t i c a l information. 5. FUTURE CAPABILITY to perform the following: 5.1 Problem c l a s s i f i c a t i o n p r o f i l e 5.2 Referral d i s p o s i t i o n s 5.3 Workload measurement system 5.4 M e d i c a l / c l i n i c a l h i s t o r y p r o f i l e COMMENTS RE ABOVE SECTION PHYSICAL MEDICINE 1. A b i l i t y to interface with CR/ADT, order entry/reporting/ communication, AR/AP/GL, Medical Records. 2. A b i l i t y to generate departmental s t a t i s t i c a l information. COMMENTS RE ABOVE SECTION ADMINISTRATION 1. A b i l i t y to download s t a t i s t i c s and budget information to a stand-alone microcomputer and i n a format compatible with Lotus 1-2-3, Symphony or s i m i l a r e l e c t r o n i c spreadsheet analysis. 2. A b i l i t y to interface with e x i s t i n g IBM-AT micrcomputer. 3. FUTURE CAPABILITY to provide communications module to include the following: 3.1 Report writing 3.2 Messaging 3.3 Interface with e x i s t i n g IBM Displaywriters word processing for management information and medical s t a f f administration information such as cred e n t i a l s p r i v i l e g e s , etc. COMMENTS RE ABOVE SECTION MEDICAL STAFF 1. A b i l i t y to l i s t and p r i n t patients at any video d i s p l a y terminal and re t r i e v e the following information: 1.1 Medical orders f o r today 1.2 Medical orders since admission 1.3 Current medication orders 1.4 Orders f o r s p e c i f i c date 1.5 Orders by type (laboratory, radiology, etc.) 1.6 Patient diagnoses 1.7 Patient admitting data 2. A b i l i t y to enter medical orders at any video d i s p l a y terminal. 3. A b i l i t y to l i s t attending/consulting physician census at any video display terminal. 4. A b i l i t y to access toxicology reference at any video display terminal. 5. A b i l i t y to access drug information at any video d i s p l a y termina 6. A b i l i t y to access poison control index at any video display terminal. 7 . A b i l i t y to access medical data banks f or current journal information. 8. FUTURE CAPABILITY of l i s t i n g meeting schedules by physician. COMMENTS RE ABOVE SECTION HOUSEKEEPING 1. A b i l i t y to interface with CR/ADT. COMMENTS RE ABOVE SECTION PAYROLL/PERSONNEL 1. FUTURE CAPABILITY to i n t e r f a c e with e x i s t i n g BCHA payroll/personnel system and/or a b i l i t y to provide stand-alone system. COMMENTS RE ABOVE SECTION PARKHOLM LODGE INTERMEDIATE CARE FACILITY Parkholm Lodge provides intermediate care services to ninety (90) residents and provides an Adult Day Care Program f o r twenty (20) people per day. The f a c i l i t y employs approximately f o r t y (40) f u l l - t i m e equivalent s t a f f and has an annual operating budget of approximately $2 m i l l i o n . The budgetting and accounting a c t i v i t i e s are e n t i r e l y separate to the a c t i v i t i e s of the Chilliwack General Hospital; however, services such as Administration and Food Services are purchased from the Chilliwack General H o s p i t a l . 1. FUTURE CAPABILITY to int e r f a c e AR, AP, GL, Food Services and Pharmacy applications of the Chilliwack General Hospital with Parkholm Lodge. COMMENTS RE ABOVE SECTION INTERFACEABILITY WITH FUTURE MODULES 1. FUTURE CAPABILITY to interface with preventative maintenance/environmental monitoring and control modules. 2. FUTURE CAPABILITY to interface with materiel management module(s). 3. FUTURE CAPABILITY to interface with s t r a t e g i c management/ decision support modules. 4. FUTURE CAPABILITY to int e r f a c e with OR and other scheduling module(s). COMMENTS RE ABOVE SECTION PUBLICATIONS - ADDENDUM Lindstrom, R.R. Lindstrom, R.R. Lindstrom, Ronald Lindstrom, Ronald Lindstrom, Ronald "The Concept of Synergy i n Leukemogenesis." The Canadian Journal of Radiography, Radiotherapy and Nuclear Medicine 6 (May 1975):96-107. "Hospital-Wide Education: The Challenge for Adult Educators." Dimensions i n Health Service 54 (July 1977) :33-5. "Quality Control i n Diagnostic Radiology." Dimensions i n Health Service 55 (July 1978):30-1. "Designing a Shared Radiology Quality Assurance Program." Dimensions i n Health Service 56 (January 1979):16-7. "Implementing a Shared Quality Assurance Program." Dimensions i n Health Service 56 (March 1979):32-4. Lindstrom, Ronald "R.T. or not R.T.? That i s the question." Dimensions i n Health Service 58 (July 1981):22.
Thesis/Dissertation
eng
Health Care and Epidemiology
Vancouver : University of British Columbia Library
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Graduate
A general framework for predictive economic evaluation of computerized hospital information systems and an application to a British Columbia hospital
Text