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Better Than a Silver Bullet

March 1, 1998
by Alan Joch
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After a decade of PC proliferation and custom software, many healthcare IS managers have nagging doubts about the economic benefits of their computer systems. "If someone says they’re reducing costs, they’re probably lying," says Roger Grimes, regional director of networks and technology for Bonsecours/Hampton Roads, a Virginia healthcare system. "Hospitals may be changing where they’re spending their money--switching from mainframes to PCs. But what they’re saving on mainframe costs is being eaten up on more training and more support for the people using PCs."

Last year, The Gartner Group (Stamford, Conn.) crystallized these doubts with its estimates of "total cost of ownership" or TCO, the maintenance and administration costs for PCs after installation. The research firm said large organizations spend $8,000 or more per year to support each PC. Healthcare technologists quibble with the number--some say a more realistic figure is $1,000 annually--but no one argues that support costs are significant and can sink an IS budget if they go unchecked.

Fortunately, you don’t have to watch TCO expenses spiral out of control. Healthcare organizations can take cost-cutting steps today, some that don’t require any additional expenses but can save as much as 20 percent in support costs. Just don’t rely yet on initiatives like Zero Administration Windows, from Microsoft, or Novell’s code-named ZEN strategy, no matter how many headlines they grab. Healthcare IS managers say these TCO solutions are still too immature to work as advertised. The "thin client" movement, centered around stripped down network PCs that run applications off of a central server, isn’t ready to replace traditional PCs in most healthcare organizations yet, either. "No one is sure a network PC will result in savings," says Steve Ditto, vice president of the network integration services practice for First Consulting Group, Long Beach, Calif. "They’ll require a lot of communications capabilities that would overwhelm most healthcare networks."

Instead of "silver bullets," the real support savings come from a mix of techniques, like standardizing on a limited variety of hardware and software, and tools, like software that lets you monitor PCs and networks from a central workstation. Apply the following five measures judiciously, and you can cut your admin costs by 20 percent to 30 percent--or $200 to $300 per PC per year, experts say.

Step 1

Conduct a comprehensive technology audit
First, gather detailed information about your organization’s hardware and software resources. If you’re like most healthcare organizations, prepare to be shocked by the results. "Our experience shows that most hospitals underestimate by at least 30 percent the actual number of PCs, printers and network ports they have," Ditto says. One First Consulting client thought it had 450 PCs, while an inventory turned up 1,450 computers. The problem: A large amount of hardware and software comes into organizations outside the formal IS purchasing mechanisms, from research grants, for example. But when these systems crash, the IS department is still called to fix them.

Even more glaring is when an inventory reveals an organization is throwing away money in unnecessary software licenses. "One hospital we worked with had 2,000 PCs for 3,000 people, but was paying for 6,000 Novell Netware licenses," Ditto says. "Every time a department bought a server it automatically purchased a multiuser license."

A comprehensive inventory will help you keep these cost drains in check. First, purchase asset-management software, such as IBM Tivoli, Microsoft SMS, Novell ManageWise, or Tally Systems NetCensus, which let you centrally count each networked computer and create a system-resource profile for each box. Next, walk through your organization to count and profile any systems that aren’t connected to the network.

Once you’ve gathered the information, create a central database accessible by your help desk staff that stores a list of applications and system resources for each PC. This information will give help desk people a jump start when a support call comes in and may avert sending a technician to physically inspect the problem PC.

One caution: Many hospitals avoid budgeting for an audit. Doing the job right, however, requires about $100 per PC, whether you hire an outside consultant to do the work or take IS staff away from its regular work to do the count. Either way, look at the cost as an investment. If configuration information exists in a central database, and help desk staff don’t have to physically go to a PC to fix a problem, "it’s like putting $100 back in your pocket each time there’s a problem," says Ditto.

Step 2

Control hardware and software proliferation
Second in importance to a comprehensive inventory is limiting the variety of hardware and software your organization uses. Lack of standardization springs from a cultural attitude that many people have toward the PC on their desktop: It is fair game to be customized with any hardware or software they see fit. To get support costs under control, you’ll have to change this attitude. "I know one organization that has stopped referring to desktop computers as PCs," says Bob Warren, senior manager for First Consulting Group. "Instead, it uses the term ’workstation’ because there’s nothing ’personal’ about the computers."

The issue, he says, is that when a doctor, nurse, or support staff member "customizes" a system with his or her own hardware or software, the IS department inherits a support problem it didn’t expect if there’s a compatibility conflict or a system crash.

For Maryview Hospital, one of three facilities within the Bonsecours/Hampton Roads system, standardization is the key focus of its cost-cutting efforts. The hospital is now integrating its computer system with those of two other hospitals after a recent merger. "The emphasis is on getting like applications on all the desktops, but it’s kind of nightmarish," Laishy Williams, vice president and CIO, admits. Their solution so far: Deploy Windows NT--chosen for its security and stability, as well as the market strength of Microsoft--at each site and hope the single platform will save costs in training, deployment and support.

Grimes, also of Bonsecours/Hampton Roads, suggests that hospitals choose leading hardware and software products that receive wide support by third-party manufacturers and software vendors rather than spending time looking for innovative technologies. "The issue isn’t buying the best technology, it’s avoiding risk," he says.

Step 3

Establish a technology policy that works
Once IS and senior managers have decided on a standard hardware platform, operating system, and software applications, communicate the decision to the entire organization, along with the justification for limiting diversity.

One way to symbolize your new standardization policy is to develop a common user interface within whatever graphical user interface (GUI) you’re running. For example, during your next Windows install, select a limited number of program icons and configuration options, then lock down the implementation so only someone from the help desk can make subsequent changes. "This makes people more aware if they try to do something that’s not standard," says Warren.

To get everyone in an organization to buy-in to your policy you’ll need to wean computer users away from the notion that their PC is their own to customize. But avoid heavy-handed policy memos and enforcement techniques that make IS look like technology dictators. A carrot rather than a stick approach is usually more successful, systems integrators say. Emphasize what benefits users will receive. For example, play up the fact that standardized PCs break less often because there is less chance for hardware and software conflicts. If a problem does occur, it can usually be fixed more quickly when help desk personnel aren’t faced with surprises. An additional incentive: While you’re initiating your new policy, also give people any new services they might be asking for, such as Web access or the ability to send faxes from their PCs, Ditto advises.

Finally, be flexible. You developed the policy to meet the business needs of your organization, so be ready to break the rules when someone demonstrates a business reason why it’s important to do so, says Ditto.

Step 4

Centrally monitor PCs and networks
"If you can remotely access the network so you don’t have to physically go to a problem PC, you’ll save money," Warren says. "That’s especially true if you manage an IDN (Integrated Delivery Network) across a large geographic area. The more you can do centrally, the better off you are."

To help you do this, buy hardware that supports SNMP (Simple Network Management Protocol), which gives IT managers diagnostic and configuration control of any hardware connected to a network. You can use Cisco Systems CiscoWorks, Hewlett-Packard OpenView, IBM Tivoli, or Intel LANDesk to centrally monitor network performance and to peer into the status of any networked PC or workstation. Grimes also uses tools like these for what he calls "proactive monitoring," looking for network bottlenecks as they’re developing rather than after they bring the system to a halt.

One glitch: No single product today will fulfill all your monitoring needs. The problem is that in many healthcare organizations Microsoft applications dominate in desktop PCs while Novell Netware still owns about 80 percent of the network operating system market. "In that mixed environment, you’ll need a patchwork of tools," according to Ditto. "Microsoft Office has monitoring tools built in, Windows has a different tool set, and Novell wants you to use its tools. So at a minimum you’ll be using something different for your applications, desktop operating system, and network operating system."

Nevertheless, the payoff is support efficiency. With remote diagnostic software, three skilled technicians can manage a help desk for as many as 1,000 PCs, estimates Charles Schwenz, national practice leader for IS interim management for Superior Consultant, Southfield, Mich.

Step 5

Pick the right interface engine
The diversity of specialized applications in the healthcare industry presents a data integration problem: If more than one system needs to use the same data, there’s no guarantee that the data is stored in a format that’s understandable by each system. For example, if a lab system needs to send patient tests to radiology, the former system may store the data in HL7 while the radiology system is set up only to read a flat-file format. One costly solution is to hard wire the two systems: Hire programmers to write custom code that automatically translates data formats from one system to the other.

A more flexible solution is to use an interface engine, from such vendors as Healthcare Communications Inc., Software Technologies Corp. or Century Analysis Inc. Interface engines sit between applications and convert data files to specific formats used by your software.

These solutions require extensive set-up and training time, which at a minimum will require about a week of classroom instruction and at a maximum will mean on-site instruction and scripting by a systems integrator. Hardware requirements are also high end. Engine vendors often suggest you dedicate a high-end server for the interface engine. Healthcare Communications Inc. recommends RISC-based workstations from Digital Equipment, Hewlett-Packard, IBM, or Sun running Unix rather than commodity-class Pentiums running Windows NT. "We don’t feel like NT is ready yet for mission-critical work," says Renard Currie, product manager for Healthcare Communications Inc.

How to choose an interface engine? Products are differentiated in four main ways.

First, some less expensive engines are designed to work best in a single, stand-alone hospital, Ditto points out. Others excel in a large enterprise. Even if the marketing literature doesn’t expressly point out such niches, look to pricing for indications of where an engine might work best.

Second, examine the selection of interfaces included in each engine. Some products may have more interfaces for pharmacy data, others may be more laboratory oriented, according to Ditto. Look at your applications and determine which vendors have interface expertise for the programs you use most.

Third, analyze how difficult it is to develop and maintain interfaces within each product. Some engines come with tools and development processes that are austere and difficult to work with. Others are more refined and are thus easier for users to manage.

Finally, consider any reporting tools that come with the engines. How do they implement diagnostics. If an interface fails, you want to know that quickly and know why there was a failure.

Bottom line
IS managers walk a dangerous path trying to deliver the technology a hospital staff needs, while keeping costs and support demands in check. "In the end, users will perceive the success of all of your efforts through the 15-inch screen on their desktops," Warren observes. But standardization and the right set of monitoring tools can keep PCs and networks running efficiently, while reducing support costs by 26 percent to 30 percent, he says.


Save Costs With Training

JOAN DUKE, PRINCIPAL OF HEALTH CARE Information Consultants, Brodbecks, Penn., says one of the best ways to keep support cost low is "training, training, training" so doctors, nurses and support staff at hospitals can be as self-sufficient as possible with their computers. She emphasizes that it’s no longer enough to schedule a single series of classes to teach people a new software application or how to use a new piece of hardware. Training, whether in a classroom, with computer-based programs, or delivered over the Internet, is continuous today.

David Roberts, manager of information system education for the University of Maryland Medical System, Baltimore, prefers to call his efforts "performance support" rather than training because the instruction goes beyond simply teaching people how to use a computer and then letting them loose to do their job. It comes down to teaching people about computers, custom software applications, and the overall business process within the hospital, he says. His favorite tools: A mix of traditional instructor-led classes and computer-based training (CBT) programs.

For example, the facility recently brought online a custom application it calls ProTouch, a clinical order management system that 3,000 staff members interact with using touch-sensitive computer screens. Rather than entering keyboard commands or using mouse clicks, a ProTouch user simply touches menu selections displayed on the screen. Because of the large number of staff to be trained, the trainers decided to hire an outside development firm to create a custom CBT program that people take one to two hours to walk through at their own pace.

The program eliminated the need for a lengthy series of classes that would take people away from their jobs or eat into their personal time. But the development costs weren’t cheap: Coding one hour of training content requires approximately 250 to 500 hours of development time, which can run anywhere from $125 to $250 an hour. By contrast, Roberts estimates that one hour of instructor-led content requires about 50 hours for creation.

When deciding whether to choose instructor training or CBT, look at the size of the audience, the availability of PCs to run computer-based training materials and your training budget, Roberts suggests. When the student body hits 1,000 or more and it has the equipment and technology aptitude to handle CBT, consider that option, otherwise stick with a more traditional classroom approach. And when you have to justify the costs of CBT, remind your financial department that even a multi-thousand-dollar training program can look economical compared to the costs of one-on-one instruction delivered via the help desk if someone makes a support call because they don’t understand the software.

No matter what training materials you choose, make sure that instructors thoroughly understand the facility’s business processes, Roberts advises. "It’s easy for an IT shop to be detached from the clinical side," he observes. "But the key to success in training is for the instructors to know the processes they’re supporting. Besides, it’s on the clinical side that the really cool new applications will be coming."


Alan Joch is a contributing editor to Healthcare Informatics.



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