Use of Information Technology is a Must for Developmental Disabilities Agencies

Current developments are sorely testing the ability of the administrators of our developmental disabilities systems and service agencies to manage the delivery of services and supports efficiently. Consumers and families are spread throughout our communities presenting system access, quality monitoring, and support coordination challenges. The move from program-driven processes to individually driven planning, budgeting, and procurement processes is exponentially increasing the number of plans, budgets, contracts, and related tasks to be managed. The numbers of persons whom states must serve is increasing significantly as an outgrowth of high demand stemming from demographic factors (e.g., the growing number of individuals who live with aging caregivers), wait-list reduction initiatives, and the rush of “waiting list” lawsuits being filed in states across the country. The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, requires agencies receiving Medicaid, Medicare, or private insurance to comply with national standards governing the handling and transmission of electronic billing and records by October 2002. These standards will demand substantial improvements in the information systems of most developmental disabilities agencies.

Information Technology to Date

For a number of years now, developmental disabilities agencies have been taking advantage of low-cost, off-the-shelf packages coupled with the declining costs of personal computers to improve operations. Every agency has some type of accounting software. Most have some form of word-processing software (Microsoft Word, WordPerfect), database software (Dbase, Access), and spreadsheet software (Excel, Lotus) used for clerical, data management, and data-analysis tasks, respectively. Service agencies may also have more specialized packages for fundraising, billing, human resources, consumer management, and the like. State and local administrative agencies have developed a variety of reporting and analysis systems using spreadsheet and data-base packages.

Although these software packages have helped improve the operations of administrative and service agencies alike, the software and personal computer-based systems have definite limitations. The software is not integrated. The software applications do not “talk to one another.” The same data entered in one system must be entered in others, and when the data changes in one system, it may well not change in the others. In other words, time is wasted entering data multiple times, and data grow more inaccurate and inconsistent with time.

The software is inflexible. Data fields, screens, and reports are largely predefined. Where agencies have uncommon data needs, customization is required. This can push the cost of some systems beyond the reach of most agencies.

The personal computer-based systems are expensive to maintain. The computers are often scattered in different agency locations. They may be networked to share printers and other devices, files, and an internet connection. In addition, the hardware may be of different makes and house different software. All add to the time and effort required to maintain the system. As agencies continue to expand their systems, the work and expense involved in troubleshooting system problems and installing software upgrades on these geographically dispersed machines can become prohibitively expensive.

The cost of data capture and cleaning is high

The typical pattern in service agencies is to first record information on paper, periodically transmit the paper to a central office, and then key selected information into specialized software or into the off-the-shelf database management, spreadsheet, word, or other application software used to generate reports. Trained administrative specialists are employed centrally to do the data-checking and cleaning on entry. Sometimes this pattern is due to the absence of personal computers or input devices in the field. Sometimes it is due to the absence of software with the built-in editing capacity needed to assure the integrity of the data entered; still other times, to the fact that the data making-up particular reports comes from a number of nonintegrated computer databases. Clearly, it would be more efficient were information entered only once by the responsible party.

Access is limited

User access to electronic records and other information in a system is oftentimes limited by the availability of personal computers, terminals, or other devices through which staff and others in the field can connect. Agencies cannot afford the software, hardware, training, and maintenance involved in connecting its scattered staff and locations. The demand for broader access is inevitable. Systems will be expected to address not only the internal demands of agency management and staff, but the many demands associated with agency activities and interests that extend beyond its walls. Among them are the demands of consumers and families to review their electronic records as well as information on service agency performance in the interest of informed choice, the need to coordinate and share information with other agencies and individuals involved in serving an individual, the need to obtain Medicaid-eligibility information, service authorizations, and bill for services electronically. There is also the agency's need to order, pay, and account for expenditures for agency goods and services—bank electronically, the desire of oversight agencies to perform “desk” audits of an agency's client records and financial accounts without having to travel on-site, and the need to distribute information of interest to the broader developmental disabilities community electronically.

Functionality is limited

State and area-wide systems, even the newest systems, tend to be long on reporting and financial management capabilities and short on much of the time-saving, front-line functionality needed by developmental disabilities administrative and service agencies. Examples of practical functionality include mailing list management, scheduling, management of facility and vehicle maintenance, fundraising, individual planning/budgeting, billing, work-flow management, the automatic generation of form letters, reminders, etc., triggered by date or events.

Information Technology Today

Information systems have not been as integrated, flexible, functional, user-friendly, and efficient to operate and maintain as they might be. However, the systems coming out today are greatly improved in every one of these respects. Each of these limitations stand to be ameliorated, even erased by key developments in information technology: enterprise systems, input/output devices, fourth generation databases, internet-based software, and application service providers.

Enterprise systems address the problems of system fragmentation and limited functionality. They are a combination of database management software and application software. They are organization-wide, integrated systems with considerable industry-specific or agency-specific functionality. These systems might be built using enterprise resource planning software or by integrating a complement of database and application software packages. The original enterprise resource planning software (e.g., PeopleSoft) was built for manufacturing enterprise. Enterprise software is now available in a number of industries. Enterprise software coming closest to fitting the needs of developmental disabilities agencies is that in the health and behavioral health industries (e.g., MediTech and CMHC). However, the price of this software is still out of the reach of most publicly funded developmental disabilities agencies, and the functionality of especial value to developmental disabilities agencies is wanting.

As enterprise systems grow into the developmental disabilities arena and include the functionality needed to better serve persons with developmental disabilities, they will make sense for more and more developmental disabilities agencies. Depending on the size and nature of an agency, such functionality might include activities such as client management, billing and claims management, mailing list management, staff and client scheduling, fundraising, payroll, human resources, vehicle and equipment maintenance, job shop operation, work flow management, the automatic generation of administrative actions (e.g., form letters and reminders) triggered by dates or events, and performance reporting. Thanks to the open-architecture of the fourth-generation software today, enterprise systems can already be built using a number of different pieces of software: for example, ABRA (human resources management), Great Plains (financial management), Danic Tools (client management), and building bridges to port data from one to another. Over time, given the ongoing consolidation in the software industry, such systems are likely to become the enterprise systems of tomorrow.

Input/output devices address the problems of data capture and access. There are now a number of more expedient means of entering data into the computer than keying. Users can input data from almost anywhere: home, office, and on the road. Users can speak into the computer (or portable microphone) in a conversational manner using voice recognition software, have their words register in whatever software they choose, and expect the computer to comprehend nearly all of it. Service and support staff can record their progress notes in less time than it would take them to key the notes in or write them out.

Documents can be inexpensively scanned in one location and read in another. The image might be attached to a consumer's electronic record for easy reference. This can save the staff time now involved in transporting signed authorizations and proofs from place to place.

Field staff might carry hand-held devices, such as personal digital assistants, mobile phones, or combinations thereof (e.g., communicating Palm Pilots) to write, key, or call in information needed by central office for program management and billing or to update their schedules and access selected consumer information. The information transfer between personal digital assistants and computer may be by wire, even wireless media. However, because of their limited memories, cramped display space, and slow input methods, hand-held devices are still limited in use. Because of the slow data transfer rates possible, and the high price charged to access wireless devices, practical uses for wireless devices are hard to find.

Fourth generation databases address the problems of inflexibility, ease-of-use, and maintenance. Distributed relational databases have become increasingly sophisticated, easier to setup and maintain, and simpler to integrate with application software to produce enterprise solutions. The most popular systems for very large organizations are Oracle and Informix; for mid-size and smaller organizations—the vast majority of developmental disabilities agencies–Microsoft's SQL Server. Not long ago, setting up an Oracle or SQL database would take days and days because the system administrator would have to individually set and test upwards of 50 parameter settings, adjusting as necessary to optimize performance. Today, the database might be set up in a day, maybe two, with the system setting the parameters automatically and dynamically to optimize system performance.

At the same time, the newer client/server application software built to use these databases is written in fourth generation language, object-oriented code, with easy-to-use, icon-based, point-and-click screens—graphical user interface. The fourth generation language allows developers to fashion screens and databases that are extremely flexible. There are already a number of packages that allow agencies themselves to customize the database to meet their ever-changing needs. Users are less dependent on the vendors to make these changes and can customize without the usual risk of losing vendor support. Some of this software is “architected” to fit the needs of a variety of industries and agencies (e.g., Intersystems' Cache). Other software is architected for particular industries (e.g., Danic Tools: health and human services).

Internet-based systems address the problems of system access and maintenance. Internet-based systems are the wave of the future. They use a standard language that allows computers of different makes and models to communicate with one another and to share text, graphics, images, sounds, and video information. These systems can run as virtually a private network over the internet with encryption and firewalls (a security device situated between a private network and outside networks that screens user names and all information that attempts to enter or leave the private network, allowing or denying access or exchange based on pre-set access rules) providing the necessary security. The application (software and database) resides wholly or largely on the server and not on the personal computers. However, anyone, anywhere, with a personal computer browser, internet connection, and proper authority can use the system. The user-interface with internet-based applications is simple and the training, simplified.

Internet-based systems may be web-based or web-enabled. True web-based packages—applications written in open web-based code from the ground-up—are new and still limited in number. Their singular advantage is that users can have full use of the system through any browser. Another advantage is that the software and database reside and execute wholly on the server; the headaches and costs associated with the installation, upgrading, and support of software on the widely distributed personal computers, the many system malfunctions caused by erring personal computer users, and the slowing of system performance over low-speed lines are avoided. The downside is that web-based systems still lack the flexibility and functionality of the fourth generation language systems.

Web-enabled systems are typically fourth generation language systems that have added a web-enabled user interface. The common database resides on the central server and is accessed over the internet via the user interface. All or part of the software still resides on user personal computers, with the attendant headaches and costs mentioned previously. However, technologies are available that enable fourth generation language applications to reside and execute wholly on a central server via remote browser control, just as the web-based applications. There is a cross-application browser licensed by Citrix (a stand-alone Citrix server is required in addition to any servers required for the application software) as well as application-specific browsers licensed by Microsoft, Lotus, Oracle, and other vendors.

Web-based developers are busy adding functionality to their systems and configuring them for the user flexibility needed to compete against their web-enabled counterparts. The web-enabled developers are busy configuring their systems to reside entirely on the server in order to neutralize the access and maintenance advantages of their web-based counterparts. (Microsoft, by far the client/server software in widest use, is going even further to web-enable its software. It is spending $4.4 billion over the next year to develop and begin to introduce its XML-coded, web-based windows system, NET, next year. NET is being designed to web-enable programs written in non-web-based languages, such as C, visual basic, COBOL. Like Java, NET will allow programs to run on many different kinds of computers). Which will prevail? Because agencies look for functionality first, because the web-enabled packages enjoy an established user and associated revenue base, and because the access advantage of the web-based packages has been effectively neutralized by the high cost and limited availability of the high-bandwidth telecommunication lines necessary to support functionally-rich systems, my bet is on the web-enabled packages.

Application service providers address the problems of system maintenance. The development of web-based and web-enabled applications that can be delivered and supported via the internet is leading to the establishment of application service providers. These offerings typically include the installation, operation, upgrades, and support of application software—all for a fixed monthly fee, which can represent significant benefit and savings for agencies. Agencies avoid the hassles and cost of having to recruit and retain technical staff; avoid the risk associated with maintaining and owning malfunctioning, obsolete hardware and software; and avoid having to manage the unforeseen crises that can arise.

At this time, the well-established application service providers are those offering function-specific applications across a number of industries (e.g., accounting, payroll), and those catering to the E-commerce industry. There are a few application service providers assisting the human service and even the developmental disabilities industries, but they are quite limited in scope (e.g., individual plan and note-sharing, time-tracking, billing, training or outcome measurement). Industry-specific (vertical) application service providers offering developmental disabilities enterprise solutions will be arriving in the developmental disabilities arena, but not tomorrow. There are a number of reasons. First and foremost, the industry lacks the established web-based or web-enabled enterprise software that the application service providers must have. A handful of states have commissioned the development of web-enabled reporting and billing systems, but these lack much of the “enterprise” functionality needed by organizations delivering and persons receiving services and supports. Second, most developmental disabilities agencies alone cannot afford what application service providers must charge today to cover the high costs of web-based software, bandwidth (where it is even available), and reliable and secure internet connections. Still, much the same as Mr. Perot's Electronic Data Systems emerged as an application service provider hosting Medicaid information systems, expect to see private entities arise to host developmental disabilities information systems providing the functionality sought by developmental disabilities authorities, providers, consumers, and other system stakeholders. Many developmental disabilities authorities will find this the most economically feasible and administratively manageable approach to system development and operation; so too will smaller service providers who cannot afford to hire information technology staff.

Summary

Agencies must make greater use of information technology in order to serve and support persons with developmental disabilities in keeping with today's individualized, inclusionary policies and in the face of related and growing administrative demands and staffing constraints. Information technology today is much advanced over that available only a few years ago and will continue to improve. Agencies that know or learn how to make effective use of it will benefit themselves and those they serve.

Author notes

Author:John Ashbaugh, MBA, Vice-President, Director of U.S. Operations, Danic Technology, Inc., 2269 Massachusetts Ave., Cambridge, MA 02140.