OASIS will change the future of home care
If you aren’t on computers, you’d better be
Just what can hospital-based agencies expect when they implement the Outcomes and Assessment Information Set (OASIS), as the Health Care Financing Administration now requires?
If yours is a small agency, defined by home care consulting attorney Bill Cabin as one that makes fewer than 30,000 visits a year, and you have been documenting your assessments by hand, expect that to change.
Cabin was the first regulatory affairs director for the National Association for Home Care (NAHC). He predicts agencies will spend money on automation systems to keep up with the data required by OASIS, which has 79 key outcomes indicators. Although the form itself must be completed manually, "This [OASIS] will put significant pressure on the automation process. Agencies will have to buy laptops and hand-held computers, and OASIS will push software companies to develop and market outcomes applications when there may not be a need at this point," Cabin says.
"If you got it [OASIS] automated, it would save time, but I don’t think there’s much of that software out there that interfaces with a hospital’s software," Cabin says. "It will be a big problem for hospital-based agencies."
Indeed, HCFA anticipates a need for computerization. After the proposal becomes a final rule, agencies must incorporate OASIS into their current assessment processes. Later, HCFA plans to publish another proposed rule requiring agencies to report OASIS data electronically.
In the preamble to the OASIS portion of the proposed Conditions of Participation, the agency writes:
"While we recognize that some HHAs already are using fairly sophisticated computer systems to collect and manage clinical as well as financial data, we realize that many HHAs have not begun, or are just beginning, to utilize electronic means of managing clinical and programmatic information. We believe the contributions the OASIS can make to the assessment, care planning, and implementation of performance improvement activities will stimulate more HHAs to move into an electronic format for managing patient clinical information. In fact, we do not envision how an HHA can successfully move to a continuous quality improvement approach without developing and using a computer-based system to manage and use organization and patient-based data."
HCFA goes on to say it believes OASIS will help standardize other clinical record and information systems being developed now. "When we publish these requirements as a final rule, we are committed to sharing data system specifications for the OASIS with the HHA community."
Data collected at three time points
In addition to the push toward computerization, what also appears to be problematic is the extra time and costs associated with collecting data at the three time points designated by HCFA. Data collection is required at the start of care; every 57 to 62 days until and including discharge; and within 48 hours after the patient returns home from a hospital admission for any reason other than diagnostic testing. (A sample of OASIS is inserted in this month’s issue of Hospital Home Health.)
HCFA has calculated the one-time start-up costs of implementation at $2,256 per agency and the ongoing costs at $2,583. HCFA estimates the start-up will take 19.75 hours per agency, which includes time for integration of OASIS into existing assessment forms, staff training, and a learning curve. The ongoing time burden is projected to total 107.4 hours. (See related charts on pp. 54-55.)
"Any estimate of added manpower time translates into dollars," says Cabin. "Also lower productivity. I don’t think they put that in their calculations."
Cabin finds irony in the recent announcement by the Joint Commission on Accreditation of Healthcare Organizations that outcomes will be included in their standard accreditation process for home care agencies by 1998. (See related story in Hospital Home Health, April 1997, p. 41.)
And they wonder why agencies complain’
The Joint Commission, based in Oakbrook Terrace, IL, has approved 19 home care outcomes measurement systems, "none of which are formatted to do OASIS as far as I know," says Cabin. "And they wonder why agencies complain about administrative burdens."
Even though OASIS and the systems required by JCAHO are designed only for data collection, Cabin argues they are "largely academically constructed tools. They’re just not practical in terms of gathering and putting out data. They are comprehensive, but from a clinical standpoint, do you need all that?"
It is not that outcomes are anything new, Cabin concedes, or that the data shouldn’t be collected. He just thinks there are better ways. "Medicare does give deemed status to JCAHO-accredited organizations," he says. "So wouldn’t it be logical to come up with a jointly approved list of multiple vendors, or a single, practical tool?
"Timing is everything," says Cabin. "It’s going to take some time to get software developed to facilitate this. While that’s being done, people will have to use hard copy and this is going to be a nightmare."
For its part, JCAHO approves of the government’s requiring OASIS and doesn’t see any conflict with its outcomes and performance project, called ORYX, that was announced in February.
It’s the way the whole field is going’
"Does OASIS have value? Absolutely," says Margaret VanAmringe, director of the Joint Commission’s Washington, DC office. "We have for the past 10 years have been working toward the day when performance measures could be integrated into the requirements for accreditation. So we would commend any movement by the feds to also require this data."
Adds VanAmringe, "In essence OASIS is very complementary to what we are doing. It’s the way the whole field is going. The first level is to develop the infrastructure capacity to report valid information. Following that, you decide what are most important measures to report. But you have to have infrastructure first. This is moving into the twenty-first century for all of us. It’s not easy. We’re going slowly."
However, Cabin says the whole plan of data collection devised by JCAHO, which has approved 19 different home care data sets (including its own, called Indicator Measurement System), will be too cumbersome. Somewhat tongue-in-cheek, he suggests a simple way to streamline data gathering:
"Why doesn’t JCAHO just mandate its own [data collection system]?" he asks. "If you want JCAHO accreditation, what are you going to do, refuse? The Joint Commission must plan to develop some software to homogenize all this stuff. If they aren’t, then why are they doing it? At least the government has only one."
But reaching any kind of standardization may be difficult, say VanAmringe. "I agree with the concept that there can be some uniformity, but the home care community is a pretty diverse community. Some agencies are doing only infusion therapy, for instance, while some are doing the whole thing. It’s difficult to come up with a set of core measures.
"We’d like to guard against the thought OASIS would be the only basis for a performance measure system, that it would do anything that might interfere and compete with more valuable [quality] indicators. There’s a lot of work being done, and we don’t want to stymie it."
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